A Treatment Refresher

While I do have several new posts on the way, I want to highlight a couple of older Grey Thinking posts (some are several years old!  I bet you were not reading GT two years ago) that talk specifically about treatment, your attitude toward treatment, recovery expectations, etc.  While there are a couple of people that I have in mind when it comes to the subject of these posts, I think that everyone can use the refresher.

You as your own case manager
Originally Posted: 01/01/2009

I wish that all these guys were going to stay clean, I really do. I’ve just seen it so many times that I can tell when someone’s really willing to do whatever it takes and when someone’s willing to do what they think it should take. And it’s just not going to work like that, unfortunately.

–Shelly, Celebrity Rehab with Dr. Drew 2

Wanting to want to recover
Originally Posted: 06/12/2008

Motivation to change implies an intention–weak or strong–to change one’s behavior. However, AN patients may at the same time both wish to recover and be highly resistant to change their behavior. Therefore, we suggest that assessment of motivation in these patients should include not only their motivation to change, but also their different wishes to recover which do not necessarily imply a behavioral intention.

Dr. Drew should treat eating disorders
Originally Posted: 07/01/2008

There are a lot of components of addiction treatment that I believe in and think are important, and should be applied to eating disorders:

1. Recovery is a lifelong, daily process
2. Denial, and not necessarily that you have a problem, but that you need help
3. The importance of personal accountability
4. There’s no magic cure
5. The disorder should be taken as seriously as any potential fatal disease

Do not pass Go, Do not collect $200
Originally Posted: 12/09/2008

“I don’t want to play the rehab game anymore”

– Jeff Conaway, Celebrity Rehab 2

I think that recovery can feel like a game at first because it is so different from the rest of your life. It’s nice to have others care about your wellbeing and there’s something about treatment that gives you permission to take care of yourself. Plus, there is so much positive reinforcement (gold star for following your meal plan over the weekend!). All of this doesn’t sound so bad… and I do believe you can make progress — even with this mindset.

When does the game end? Personally, I think this is when the disorder starts to feel threatened. There is something scary about recovering, and suddenly it doesn’t sound like a great idea anymore.

“I don’t want to play the rehab game anymore”

– Jeff Conaway, Celebrity Rehab 2

I think that recovery can feel like a game at first because it is so different from the rest of your life. It’s nice to have others care about your wellbeing and there’s something about treatment that gives you permission to take care of yourself. Plus, there is so much positive reinforcement (gold star for following your meal plan over the weekend!). All of this doesn’t sound so bad… and I do believe you can make progress — even with this mindset.

When does the game end? Personally, I think this is when the disorder starts to feel threatened. There is something scary about recovering, and suddenly it doesn’t sound like a great idea anymore.

It’s not about what you are doing

Since I have a serious Dr. Drew Pinsky addiction (irony intended), I was really sad when his podcast was cancelled.  Thankfully, Celebrity Rehab 2 and Sober House came out shortly after the podcast ended, so I was able to watch those repeatedly for awhile. When VH1 stopped running CR2, I read his books.  Now, having exhausted all of those Dr. Drew resources, I am listening to Loveline.  This kills me a little bit, for several reasons:

1. It’s called Loveline
2. Half of it is sex talk
3. I have to pay $5 a month for it!

Still… It’s Dr. Drew, so I have to do it.  There are calls about addictions and psychological issues, and listening to his responses to those questions is worth my $5.

Dr. Drew had a particularly great quote today:

“It’s not what you’re doing, it’s what you’re missing – and you deserve better.”

The quote was not in relation to alcoholism or eating disorders, but it really hit home with me.  Yes, you need to get better because it’s important to take care of yourself, people care about you, you should care about you, you want to be healthy, it’s pathological, etc.  But also, when you are wrapped up in the ED you are missing life.  Maybe that’s semi-intentional; maybe you’re avoiding life.  You might think you’re just coping with life in an unhealthy manner, but you really are missing it.

You’re missing:

1. Close relationships with friends
2. Many normal social situations (getting pizza, going out for lunch, meeting for a drink, getting ice cream for no reason)
3. Good experiences (as well as bad experiences) that shape you as a person

I can think of a lot of things that I “missed”

1. Close relationships with HS friends
2. Trying anything new (for most of my life)
3. Getting ice cream with friends
4. A lot of summer cookouts
5. Trips I wouldn’t go on because there would be too much food or b/c I was depressed & wanted to stay home
   (okay, this is a depressing list so I’m going to stop here)

I think that eating disorders are as much about avoiding life as they are hurting yourself.  First there is all the time that you spend wrapped up in the disorder.  You’re isolating, avoiding events with food, and spending 90% of your day thinking about food and weight.  You have no idea what is going on around you.  And then there’s treatment, which takes up even MORE time… because along with the continuing disordered behavior (it’s not going to go away overnight), you now also have a dietitian, a therapist, a doctor, a psychiatrist (and this is assuming that you don’t really put your life on pause to go to a residential or partial hospitalization program).  You are spending your free time in treatment.  And I don’t know about you, but when I’m working on tough stuff in therapy, I have a harder time dealing with the rest of life.  When I’m upset about whatever my therapist said two hours ago, the last thing I want to deal with is a presentation that’s due tomorrow.  So yes, even in recovery, you are avoiding / escaping / missing (whatever you want to call it) your life.

It’s kind of ironic when you think about it.  You spend so much time in therapy trying to change behaviors, discussing why you are coping with life via your ED, identifying unhealthy aspects of your career and relationships, etc.  However… how much time do you spend talking about what you’re missing?

And for awhile, this is the point.  Maybe something in your life is not okay.  Maybe there is too much on your plate, maybe you are in a bad relationship, maybe you do need to change your job, maybe you are killing yourself trying to please everyone else in your life–whatever.  One of the best things about residential (I think) is that you don’t have to deal with the real world while you’re in treatment.  I can just focus on myself and what I need to be doing without the constant stress and anxiety of bills, relationships, responsibilities, work, money, and the list goes on.

However, I am not new to treatment, and neither are several of my friends.  And while I do worry about their health and their symptoms, what really makes me sad is what the ED takes away from them.  For one friend, it takes away time and energy that she would rather be spending with her children.  For another, it limits her career because work has to be planned around the ED and ED treatment.  Another friend has to put relationships, summer plans, and a lot of the life that she has created in the past year on the side right now to get more intense help.

All of these friends are making the right choices to work on the eating disorder and to get the help that they need!  Absolutely.  Friend #1 can’t take care of her family if she isn’t taking care of herself, Friend #2 won’t be able to put the energy and concentration into the job that career that she really wants until she is healthier, and Friend #3 won’t be able to maintain that life if she doesn’t do intensive treatment.  My point is, though, that what saddens me the most about these friends is not their concerning ED symptoms, but all the things that they are missing out on in their lives.  They’re such wonderful people and are meant to do so much more in the world than they can with this eating disorder.  They deserve so much more out of life than this eating disorder, and that’s why I hope they can get better.

It's not about what you are doing

Since I have a serious Dr. Drew Pinsky addiction (irony intended), I was really sad when his podcast was cancelled.  Thankfully, Celebrity Rehab 2 and Sober House came out shortly after the podcast ended, so I was able to watch those repeatedly for awhile. When VH1 stopped running CR2, I read his books.  Now, having exhausted all of those Dr. Drew resources, I am listening to Loveline.  This kills me a little bit, for several reasons:

1. It’s called Loveline
2. Half of it is sex talk
3. I have to pay $5 a month for it!

Still… It’s Dr. Drew, so I have to do it.  There are calls about addictions and psychological issues, and listening to his responses to those questions is worth my $5.

Dr. Drew had a particularly great quote today:

“It’s not what you’re doing, it’s what you’re missing – and you deserve better.”

The quote was not in relation to alcoholism or eating disorders, but it really hit home with me.  Yes, you need to get better because it’s important to take care of yourself, people care about you, you should care about you, you want to be healthy, it’s pathological, etc.  But also, when you are wrapped up in the ED you are missing life.  Maybe that’s semi-intentional; maybe you’re avoiding life.  You might think you’re just coping with life in an unhealthy manner, but you really are missing it.

You’re missing:

1. Close relationships with friends
2. Many normal social situations (getting pizza, going out for lunch, meeting for a drink, getting ice cream for no reason)
3. Good experiences (as well as bad experiences) that shape you as a person

I can think of a lot of things that I “missed”

1. Close relationships with HS friends
2. Trying anything new (for most of my life)
3. Getting ice cream with friends
4. A lot of summer cookouts
5. Trips I wouldn’t go on because there would be too much food or b/c I was depressed & wanted to stay home
   (okay, this is a depressing list so I’m going to stop here)

I think that eating disorders are as much about avoiding life as they are hurting yourself.  First there is all the time that you spend wrapped up in the disorder.  You’re isolating, avoiding events with food, and spending 90% of your day thinking about food and weight.  You have no idea what is going on around you.  And then there’s treatment, which takes up even MORE time… because along with the continuing disordered behavior (it’s not going to go away overnight), you now also have a dietitian, a therapist, a doctor, a psychiatrist (and this is assuming that you don’t really put your life on pause to go to a residential or partial hospitalization program).  You are spending your free time in treatment.  And I don’t know about you, but when I’m working on tough stuff in therapy, I have a harder time dealing with the rest of life.  When I’m upset about whatever my therapist said two hours ago, the last thing I want to deal with is a presentation that’s due tomorrow.  So yes, even in recovery, you are avoiding / escaping / missing (whatever you want to call it) your life.

It’s kind of ironic when you think about it.  You spend so much time in therapy trying to change behaviors, discussing why you are coping with life via your ED, identifying unhealthy aspects of your career and relationships, etc.  However… how much time do you spend talking about what you’re missing?

And for awhile, this is the point.  Maybe something in your life is not okay.  Maybe there is too much on your plate, maybe you are in a bad relationship, maybe you do need to change your job, maybe you are killing yourself trying to please everyone else in your life–whatever.  One of the best things about residential (I think) is that you don’t have to deal with the real world while you’re in treatment.  I can just focus on myself and what I need to be doing without the constant stress and anxiety of bills, relationships, responsibilities, work, money, and the list goes on.

However, I am not new to treatment, and neither are several of my friends.  And while I do worry about their health and their symptoms, what really makes me sad is what the ED takes away from them.  For one friend, it takes away time and energy that she would rather be spending with her children.  For another, it limits her career because work has to be planned around the ED and ED treatment.  Another friend has to put relationships, summer plans, and a lot of the life that she has created in the past year on the side right now to get more intense help.

All of these friends are making the right choices to work on the eating disorder and to get the help that they need!  Absolutely.  Friend #1 can’t take care of her family if she isn’t taking care of herself, Friend #2 won’t be able to put the energy and concentration into the job that career that she really wants until she is healthier, and Friend #3 won’t be able to maintain that life if she doesn’t do intensive treatment.  My point is, though, that what saddens me the most about these friends is not their concerning ED symptoms, but all the things that they are missing out on in their lives.  They’re such wonderful people and are meant to do so much more in the world than they can with this eating disorder.  They deserve so much more out of life than this eating disorder, and that’s why I hope they can get better.

The dark side of inpatient stays

‘But I ask myself if an eating disorder unit is the best place for an impressionable young girl to be,’ says Deanne Jade. ‘As any inpatient will tell you, a specialist unit is the best place to learn how to be really, really good at anorexia.’ They also breed their own subculture.

— Still at war with our bodies

Oh, what a statement! This article is a couple of years old, but I still think it’s bold to suggest that the “highest level of care” for eating disorders actually makes people sicker. Everyone’s inpatient experience is different… but there is a lot of truth to this statement.

What about inpatient stays can make people sicker?

1. Exposure to the sickest of the sick. You know who these people are… the frequent flyers who have the most severe symptoms and often are the most manipulative and/or resistant to change.
2. Picking up other ED symptoms that you didn’t originally have. It’s not unheard of for a restricting anorexic to pick up purging after treatment.
3. Competition among eating disorders. This ranges from being the thinnest, eating the least, and having the most inpatient stays to comparing “worst BP episode” and visits to the ER.
4. Unhealthy modeling. Everyone around you is doing a great job of modeling ED-behaviors.. but other than the staff, there’s not a lot of “healthy eating” modeling going on.
5. Negative attitude toward treatment. If you weren’t originally treatment-resistant, there’s nothing like being surrounded by a group of girls who don’t want to be there to kill your motivation.
6. No life outside of the eating disorder. This is such a catch 22 of ED treatment… by making your recovery first and putting everything else on hold, your whole day revolves around the ED–which is kinda want the eating disorder wants. There’s no stress of school or work because all you’re doing is eating and sitting in eating disorder therapy.

As as for “breed[ing] their own subculture”… well, I’ve always said that there is an eating disorder world. You make friends in treatment. After discharge, you keep up and talk about how everyone is doing… is so-and-so back in treatment? I heard so-and-so is doing really poorly. Because you’ve given up school or work to go into treatment, the most interesting things going on in your life are your therapy and nutrition appointments. Everyone talks to each other about their appointments. You send each other cards. You continue doing the same arts and crafts that you were doing inpatient. Everyone’s lives are still consumed by the eating disorder so no one is doing great. It’s all very dysfunctional.

This is not true to everyone’s experience (not even necessarily to mine) and often residential treatment is the level of care that someone needs to get better and make progress in his/her recovery. My own inpatient stays were KEY to my recovery. However, negative stuff does go around in treatment. It’s kind of the dark side of inpatient treatment that people don’t talk about very often.

“All we’ve done is make a girl cry”

From an Episode of House, MD: Episode 3-12, One Day, One Room

In case you haven’t seen it, a girl has been raped and refuses to talk about the trauma. These are the last lines of the episode.

CUDDY: She’s gonna be okay.
HOUSE: Yeah, it’s that simple.
CUDDY: She’s talking about what happened. That’s huge. You did good.
HOUSE: Everyone will tell you… that that’s what we gotta make her do. We have to help her, right? Except we can’t. We drag out her story. Tell each other that it’ll help her heal. Feel real good about ourselves. But all we’ve done is make a girl cry.
WILSON: Then why did you…?
HOUSE: Because I don’t know.

Doesn’t this sound like the promise of therapy? That if you show up and talk about stuff that sucks, you’ll be okay? That’s at least the initial illusion that I had (similar to my inpatient treatment illusion — that you go away for a couple of months and come back okay).

So I went and I talked and I cried and I did not leave feeling okay. In fact I left feeling worse than before, and it took months (maybe years) to get back to my beginning neutral (apathetic) state. And I’ll admit that I had more insight than I began with, but if anything that just made some things in life harder for me (i.e.: particular relationships).

And then, after grieving my loss of hope that I would someday get over this, I moved onto accepting that “I just can’t be helped” (is that progress? probably not). It wasn’t really a “this is hopeless, there is not point in trying for the rest of my life,” defeat-like acceptance, though… but more of a “I am never going to work through this so I need to do my best to just ignore it” acceptance.

And that worked okay, because I finished school and formed meaningful relationships and functioned as a self-sufficient adult. But… then I went back and found a therapist. Why?

Well…. I don’t know. Because things weren’t quite right and I didn’t have any better ideas.

"All we've done is make a girl cry"

From an Episode of House, MD: Episode 3-12, One Day, One Room

In case you haven’t seen it, a girl has been raped and refuses to talk about the trauma. These are the last lines of the episode.

CUDDY: She’s gonna be okay.
HOUSE: Yeah, it’s that simple.
CUDDY: She’s talking about what happened. That’s huge. You did good.
HOUSE: Everyone will tell you… that that’s what we gotta make her do. We have to help her, right? Except we can’t. We drag out her story. Tell each other that it’ll help her heal. Feel real good about ourselves. But all we’ve done is make a girl cry.
WILSON: Then why did you…?
HOUSE: Because I don’t know.

Doesn’t this sound like the promise of therapy? That if you show up and talk about stuff that sucks, you’ll be okay? That’s at least the initial illusion that I had (similar to my inpatient treatment illusion — that you go away for a couple of months and come back okay).

So I went and I talked and I cried and I did not leave feeling okay. In fact I left feeling worse than before, and it took months (maybe years) to get back to my beginning neutral (apathetic) state. And I’ll admit that I had more insight than I began with, but if anything that just made some things in life harder for me (i.e.: particular relationships).

And then, after grieving my loss of hope that I would someday get over this, I moved onto accepting that “I just can’t be helped” (is that progress? probably not). It wasn’t really a “this is hopeless, there is not point in trying for the rest of my life,” defeat-like acceptance, though… but more of a “I am never going to work through this so I need to do my best to just ignore it” acceptance.

And that worked okay, because I finished school and formed meaningful relationships and functioned as a self-sufficient adult. But… then I went back and found a therapist. Why?

Well…. I don’t know. Because things weren’t quite right and I didn’t have any better ideas.

It’s not just genetics

One of these days, I will start a “Grey’s take on the Maudsley Method” series. Not because I think that it’s wrong or right, but just because I think it’s really interesting and have a lot to say about it.

In the meantime though, I want to highlight a quote from Laura Collins’ article, “The size of the trigger or the speed of the bullet?”

An eating disorder is not a sign of deep wounds, but some people do have deep wounds, and it makes recovery harder.

I’m curious — this this a “duh” statement for everyone treated with the Maudsley Method? Because it basically goes against all of my inpatient and outpatient treatment, formal education, and research. Just to quote a few of the institutions, professionals, and resources I’ve had experience with:

“Eating disorders are serious health- and life-threatening physical disorders that usually stem from some underlying emotional cause.” – The Renfrew Center

“Genetics make the gun, environment loads it, and that an experience of unbearable trauma is what actually pulls the trigger.” – Lui, Aimee. Gaining: The Truth About Life After Eating Disorders.

“Eating disorders are real, treatable medical illnesses with complex underlying psychological and biological causes.” – National Institute of Mental Health

If you don’t see my point by now… it’s that I have always been told, eating disorders are not about the food. They’re a symptom, coping mechanism, etc. of something else.

That said, I don’t think that everyone has trauma… I’m not a fan of repressed memory therapy, because I think a lot of it is made up (or generated in the process).  Ruminating on traumatic events prolongs mental illness.  You can’t change what happened to you when you were three.  This is all true… but I also think that some people are using food to subconsciously avoid feelings/situations related to previous trauma, and in those cases, they need to be resolved in therapy.

I like Aimee Lui’s perspective on the matter.  You NEED the genetic component to develop and eating disorder.  They don’t really just happen to people.  Even if you have the genetic component, though, growing up in a wonderful environment can be protective.  I refuse to believe that you just inherit the anorexia gene and you’re doomed for a life haunted by an eating disorder (and if that’s the case, then I should never have children given my family history).  There IS a strong genetic component… but in all these genetic studies, you also have to consider environment!  Chances are, these kids are growing up with semi-similar relationships as their parents did.  There are just too many variables.

Anyway, I think that given genetics, environment CAN be enough… but for many people, it’s the unbearable stressing event that pushes them over the edge.  Those are the people with the trauma history.  So, regardless of whether or not you have a history of trauma, you at least have underlying relationship/environment issues to address

It's not just genetics

One of these days, I will start a “Grey’s take on the Maudsley Method” series. Not because I think that it’s wrong or right, but just because I think it’s really interesting and have a lot to say about it.

In the meantime though, I want to highlight a quote from Laura Collins’ article, “The size of the trigger or the speed of the bullet?”

An eating disorder is not a sign of deep wounds, but some people do have deep wounds, and it makes recovery harder.

I’m curious — this this a “duh” statement for everyone treated with the Maudsley Method? Because it basically goes against all of my inpatient and outpatient treatment, formal education, and research. Just to quote a few of the institutions, professionals, and resources I’ve had experience with:

“Eating disorders are serious health- and life-threatening physical disorders that usually stem from some underlying emotional cause.” – The Renfrew Center

“Genetics make the gun, environment loads it, and that an experience of unbearable trauma is what actually pulls the trigger.” – Lui, Aimee. Gaining: The Truth About Life After Eating Disorders.

“Eating disorders are real, treatable medical illnesses with complex underlying psychological and biological causes.” – National Institute of Mental Health

If you don’t see my point by now… it’s that I have always been told, eating disorders are not about the food. They’re a symptom, coping mechanism, etc. of something else.

That said, I don’t think that everyone has trauma… I’m not a fan of repressed memory therapy, because I think a lot of it is made up (or generated in the process).  Ruminating on traumatic events prolongs mental illness.  You can’t change what happened to you when you were three.  This is all true… but I also think that some people are using food to subconsciously avoid feelings/situations related to previous trauma, and in those cases, they need to be resolved in therapy.

I like Aimee Lui’s perspective on the matter.  You NEED the genetic component to develop and eating disorder.  They don’t really just happen to people.  Even if you have the genetic component, though, growing up in a wonderful environment can be protective.  I refuse to believe that you just inherit the anorexia gene and you’re doomed for a life haunted by an eating disorder (and if that’s the case, then I should never have children given my family history).  There IS a strong genetic component… but in all these genetic studies, you also have to consider environment!  Chances are, these kids are growing up with semi-similar relationships as their parents did.  There are just too many variables.

Anyway, I think that given genetics, environment CAN be enough… but for many people, it’s the unbearable stressing event that pushes them over the edge.  Those are the people with the trauma history.  So, regardless of whether or not you have a history of trauma, you at least have underlying relationship/environment issues to address