Wednesday, September 10, 2014

But, What Do YOU Want?

I'm guessing this won't come as a surprise to anyone, but sometimes there are a number of power struggles involved in our lives. A good number of us really don't like to be told what to do. And, sometimes, this can become a challenge in therapy, as sometimes, the best intended suggestions can end up feeling like we are telling our clients what to do.

As you might guess, this is a not uncommon phenomenon with teenagers. Teenagers do not want to be told what to do! At least most of the time... So, being the therapist to a teenager carries the risk of just being the next adult in line to have authority worthy of bucking. And the last thing a therapist wants to create is
a power struggle.

So, I often find myself asking clients what they want for themselves, who do they want to be? What are their values, morals, and beliefs? And, in going down this path, I find that it's not uncommon that the client actually wants the same thing that the person they are defying wants. The client actually wants to be a good student, a good worker, reliable, trustworthy, and to have good relationships. So, for example, rather than continuing to battle the parent over grades, the focus can change to the reality that the client wants to be a good student, or wants to be respected by teachers, or wants a particular job some day.

Of course, this can also be applied directly to eating disorders. What does the eating disorder client want more? To be thin? To feel in control? To be numb? To have good relationships? To enjoy life? To have integrity? To be honest?

If you will identify what you truly want, you can then measure your behaviors against that. Is what you are doing in any given moment consistent with your long-term desires? If yes, fantastic! If no, you have to decide whether this means your desire has changed, or something is overriding it. And, you have to distinguish between what you want in that moment, versus in the big picture.

This way, it no longer matters what anyone else wants, and whether you want to follow their direction; it only matters that you are pursuing what you want.

Update, a long time coming

Today, I was asked to write a blog post. Now, I asked the requestor to give me a topic, and her ever-helpful response was, "I dunno; you are the one with a PhD." Well, thanks for that help! ;) So, I will write two blog posts, in a flurry of posting!

First, an update:

Equine therapy session formally began on June 1, and it has been a wonderful thing to be a part of. Violet was added to the herd mid-June, and has been a wonderful addition. It is amazing what can happen with horses present. Often, my clients miss the grin I get on my face when they turn to see what one of the horses has just done that is perfectly timed. It is phenomenal to watch the horses work their magic, and I feel very honored to be a part of these sessions. Sometimes, it's a client learning a new skill with the help of an equine partner; other times, it is the horse and client standing forehead to forehead in silence. Throwing rocks has also become a favorite pastime, and fortunately, my corral has no shortage of rocks. There's just something to standing in nature, next to these beautiful animals, that is amazing; I love it.

In the downtown office, Angela Hicks is hard at work building up her practice, taking on a number of eating disorder clients. I am so thankful to have her on board to help decrease wait times for clients seeking treatment. It is so hard to tell someone with an eating disorder that they have to wait on a wait list, so it feels very good to be able to get people in quickly. And, it's fun to have a partner in crime!

So, that's the update. Now on to a post about a specific topic, in spite of receiving NO HELP from the person requesting a post!!! ;)

Friday, May 30, 2014

What Does the Body Hold?

One of the reasons I have become committed to equine psychotherapy is the fact that it requires the use of the body, rather than simply talking. But, why is this so important? Well, most clients with eating disorders are very intelligent; they don't suffer from an inability to use their brains, even if their actions are not the most rational. The average eating disorder client can easily talk for an entire hour about all of their thoughts and beliefs, but can make it through that hour almost completely avoiding emotion. It's a challenge for us therapists, as our job is, you know, to talk. So, it's easy to get caught up in talking brain to brain, leaving out emotions, and the body.


And maybe this sounds kind of "woo-woo," but I think it is true that our bodies hold onto emotions. Think of how many physical ailments can be linked to emotions. Headaches and stomachaches are easily seen as sometimes being the result of emotions. I have become very interested in Peter Levine's work with trauma, and he is probably the foremost person to convince me that our bodies hold suppressed emotion.

In short, Levine argues that we can use animal models to understand human trauma. (Disclaimer: this is my interpretation of his writings.) Levine specifically uses whiplash injuries as one of his examples. He indicates that many people who experience low speed car accidents that result in whiplash report physical symptoms that surpass what one would expect from the low speed rear-ending. This is where he brings in animal models. He argues that animals, who can be under pretty constant threat from predators, don't demonstrate trauma. Now, I don't know if this was his example, or just what I ended up using as an example, but think of a deer in the headlights. It is frozen, but then bounds off into the woods. Well, apparently, if we were to follow that deer, we would eventually find it shaking in the woods. And, Levine indicates that this shaking is the release of the emotion from the body.

Now, back to the car accident. Humans get into a low speed car accident, and then get out, get their insurance, call the cops, call loved ones, etc., and the emotion they might be feeling gets blocked by this flurry of acting. His argument is that if we were to stand on the side of the road, and allow our bodies to release the emotion, we would be less likely to have the effects of trauma. I am confident this is dramatically oversimplifying his stance, but this is the basics. He has written a number of books on trauma, any of which would provide more in-depth information on this concept.

So, now, back to the clients with eating disorders. Not everyone with an eating disorder has a clearly definable trauma history; that is not my stance. But, eating disorders do serve to block emotion. Rather than feel about something, you focus on food in some way or another. That effectively blocks the emotion inside your body. Often emotions are numbed completely and clients will report really not feeling anything anymore. But it's still there. The extent of blocking varies from person to person, but I'm arguing that, in order to achieve recovery, and general psychological health, the emotion(s) must be released. There are many avenues for achieving this, sometimes even including simple talk therapy. But, if the emotions are NOT being released through talk therapy, it might be time to look for something to add to you therapy work. Dance therapy, yoga, art therapy, physical movement, and equine psychotherapy are all possibilities; and I'm sure there are many more I've not listed. But the bottom line is this: Release the emotion from your body. Trust it will not consume you. And, in fact, understand it is consuming you more when you block it than when you release it.

Tuesday, May 27, 2014

Why Equine Therapy...and What is it Anyway??



Hmm, I have run into an unexpected difficulty in marketing Shadow Mountain Equine Psychotherapy (from this point forward, known as SMEP). As it turns out, the vast majority of people think equine psychotherapy means I am therapizing the horse. Hmm, quite a problem! So, to be clear, no, I am not a horse whisperer; whereas I am known to talk to horses, (and all animals...and myself...) they do not, in fact, talk back to me!

So, how to get out there that equine psychotherapy (aka, horse therapy, equine therapy, equine assisted psychotherapy, equine facilitated psychotherapy) is this very powerful form of talk therapy that simply uses horses as a co-therapist? This is proving to be tricky here in Utah. In Colorado, where I am primarily training, you can't hardly take a footstep without tripping over an equine psychotherapist, and the field is pretty well understood, I believe. In Utah (and on airplanes, it appears!), it is assumed I think I'm a horse whisperer. Umm, no.

Therefore, I guess I am left trying to describe some of the work. Work that oftentimes seems pretty indescribable, or at least difficult to represent how powerful it can be. In my office, I work hard to make sure I am not just talking to clients using their brains. While there is some benefit to cognitive therapy, the risk is that the highly intelligent people I work with will simply "overthink" themselves or their lives, but not necessarily make the changes they are wanting. So, I work to help clients experience, feel, and understand what is actually happening in their bodies. If you think about it, each emotion we have has at least one physical sensation that goes with it. Over time, you might have become really good at blocking the physical sensations (much as you maybe have become good at blocking the sensations of hunger and/or fullness), but I promise they are still there. The risk is that, in the office, clients will just think really hard about what they are feeling, which, in the end, often is not really feeling at all.

Now, let's translate that out to the pasture/stall/wherever the horse is. So much emotion can be elicited simply by being around horses, and my task is to help you "feel into" your experience, rather than think about it. There's more to experience in a pasture than in an office. Every sense can be triggered, and in different ways each time; in comparison, my office looks, smells, and feels basically the same each time. Getting into emotion, sensation and feeling is simply "easier" in the pasture.

The part that's indescribable is the work the horses do. Mind you, horses are not really trained to be therapy horses. I cannot, as far as I know anyway, teach them what to do. They do what they do, and it's kind of amazing. Things I have seen:

  • A donkey come up and repeatedly head-butt a woman who was talking about being pushed   around in her relationship.
  • A yearling come and rest her chin on the head of someone squatted down, crying.
  • A horse come through and repeatedly violate the boundaries of someone talking about.....having a hard time setting boundaries. 
  • An active, fidgety horse stand stock still, not moving a muscle, while a woman leaned on him and cried.
  • Many, many horse hugs....provided by the horse, not the human.
These are things that cannot really be described, and can only be understood when witnessed. These are the unsolicited actions of horses. I won't pretend to know why the horses act in these ways. I don't know what they do and don't understand. I just know I have seen it over and over, and thus believe in what they do, and the power it has with people. 

I worry that people see equine therapy as "woo-woo" or as not having sufficient backing. Honestly, the second is likely true, as there is little data to back it up right now. Many of us are working on that problem. But, I have no doubt that if we could hook biofeedback machines to clients working horses, we would see significant changes in heart rate, blood pressure, etc, as clients learn to use their relationship with horses to create calm, happiness, and connection. Someday the research will get there. 


In the meantime, all I can say is that I am one science-minded woman...and I believe in equine psychotherapy. 

Monday, May 12, 2014

Shadow Mountain Equine Psychotherapy and the return of Angela Hicks, PhD!

Hi everyone! It has certainly been a long time since I have posted. A lot has been going on! Some major changes have happened around here, all for the good! The major news is that the week of June 1, I will begin to offer equine psychotherapy to clients with, and without, eating disorders. I have previously posted on how I see equine psychotherapy being relevant in the treatment of eating disorders, so I will not rehash that.

What is interesting is that there are virtually no equine psychotherapy options in the Salt Lake valley. I'm aware of a couple programs that offer hippotherapy, which is more designed to treat physical disabilities, though I understand some small amount of psychotherapy might be done at these facilities.

I feel strongly about the approach I am using in providing equine facilitated psychotherapy. What is emphasized is the clients' relationship with the horse, and using that connection to help facilitate change. Some other approaches use horses to complete certain tasks, such that the client can learn something. Unfortunately, this can take the client out of relationship with the horse. Therefore, in the approach I am using, the horse will not be forced to do anything other than be a horse. It is very hard to explain the power of equine psychotherapy; it really is something that must be seen.

So, I hope you will all check out my new website: shadowmountainequine.com. I am excited to get this phase of my work started, though my availability will be limited. I am very thankful to Keystone Equestrian Horsepark for their support of this venture. Check them out at keystoneteam.com

The other major change is that Dr. Angela Hicks is returning to part-time work with me! I am very excited about this, and welcome her back with open arms. She is completing her final stage of training to receive her PhD in Counseling Psychology; this will be her second PhD! So, she will have limited availability until the fall, but then will be back full force! Welcome back, Angela!


Thursday, December 5, 2013

Weighing versus Intuitive Eating

Often, weighing yourself is a big part of having an eating disorder. Sometimes many, many times a day. That number on the scale, and the one inside your pants, comes to drive how you feel, what you do, how you eat, and how you view yourself. Suddenly, that number on the scale seems to be driving everything.

But, it feels reassuring. It feels comforting to know what is happening with that number (though, let's be honest, only as long as it is not going up!). Your eating disorder is reassured by that illusion of control. So, it is hard to let go of the behavior. I have had numerous new patients argue with me that seeing their weight helps, not hurts--mostly because the client is too scared to not know the number. Being weighed by us is often a significant area of stress, and sometimes conflict.

And, of course, this is another area of great debate in the field. Should we show weights or hide weights. Do they hurt, or do they help? And how do you know from patient to patient?

At UCED, we do blind weights, for those with whom we need to do weights. Why? Because we also teach intuitive eating. And, weighing yourself and becoming an intuitive eater are pretty much diametrically opposed (which is why we do not weigh people who are practicing intuitive eating). But why is it so unlikely to work if you both weigh yourself and try to become an intuitive eater? Intuitive eating is based on trusting your body and learning to follow your body's cues. The goal is to eat when you are hungry, stop when you are full, and eat a variety of foods.

Enter, the scale. You jump on that "wonderful" little thing and it gives you a number. What if that number is higher than you want it to be? Chances are you will automatically change your eating behavior to compensate. You will restrict the amount you are eating, or the range of foods you allow yourself. And, as we have covered before, that restricting has a very high chance of then leading you to overeat. And the cycle of disordered eating continues. You are quickly taken right away from from following your body's cues, and intuitive eating has gone out the window.

So, what do we recommend? I highly recommend getting rid of your scale in the most glorious fashion possible. I have had patients confirm that scales don't bounce when dropped from significant heights and they do shatter when hit with another solid object! Send your scale out with a bang! Or, give it to a loved one so they can make it disappear. Take it to your therapist/dietitian/doctor. Or, put it in the garbage yourself, and wave good-bye.

Think of the freedom that can come when your mood and behavior is not dictated by a number on a scale. We are all much more than a number, and the number says absolutely nothing about us as people.

Monday, December 2, 2013

UCED's Treatment Approach for Adolescents with Eating Disorders

For the past couple years, there has been a lot of research going into, and professional debate regarding, the appropriate treatment of adolescents with eating disorders. Eating disorder treatment, and the mental health field in general, is a hard field when it comes to finding concrete answers as to what is the best approach for treatment. In general, the focus is on identifying empirically/research supported treatments, and then using clinical judgement and skill to identify what will work best for a particular individual.

Recently, most of the focus in treatment of adolescents has been on Family Based Treatment (FBT), which is also known as Maudsley Method. Lock and LeGrange are the main forces behind FBT here in the US, and there are ongoing trials continuing to assess this treatment approach. The mindset behind the approach is keeping adolescents at home, rather than sending them to inpatient/residential treatment centers. Treatment centers certainly have their benefits and are needed in some cases, but our stance here at UCED is that every adolescent (and adult) should first be able to try outpatient treatment at home, prior to being sent to an inpatient/residential program.

One of the major tenets of FBT is the idea that parents know how to feed their children. If you go back in the history of the understanding of EDs, unfortunately, you will find a lot of blame on parents and families. The field as a whole no longer has this attitude towards families, but some long-held beliefs are hard to get past. Fortunately, FBT has shown that many adolescents can get better at home, with their families. However, as with any therapeutic approach, one size does not fit all.

Our approach with adolescents is to first give the teenager a chance to show they have the motivation to get better on their own. So, first we give them the opportunity to make healthy choices regarding food, with the support of their parents. A surprising number of teenagers actually will choose to get better without invasive intervention--a testament to the maturity of these young men and women, and their awareness that the ED is not serving them well. Because adolescents live at home and are supported primarily by their parents, in addition to friends, we involve parents in therapy frequently; typically every other session, although some teenagers choose to have their parents involved in every session. This approach, which teenagers typically are not thrilled to hear about initially, allows us to avoid the risk of the ED "splitting" the treatment team and the parents. Fortunately, most teenagers quickly realize family therapy isn't THAT BAD and come to accept it pretty quickly. (Sometimes parents end up disliking it more than the teenagers!)

If, with this structure, the teen remains unable to do what he/she needs to do in terms of food and activity, we transition to more of an FBT approach, which provides the parents with much more say in what the child is eating and doing. This is a tough transition for some teenagers, as the last thing they want is for parents to tell them what to do! However, on the flip side, this can provide motivation to do what they need to with food, so they can regain some control. This approach is often difficult for parents because they find themselves feeling pulled to "go easy" on their teen, which unintentionally ends up as negotiating with the eating disorder and allowing it to get away with ED behaviors. Therefore, parents need a lot of support in supporting their teens during this phase of treatment. Fortunately, there are a number of resources for parents in this situation; some include:

  • aroundthedinnertable.org
  • maudsleyparents.org
  • feast-ed.org
Finally, there are some teenagers whose ED is so deeply entrenched that inpatient/residential treatment is what is needed. Fortunately, there are very solid adolescent treatment programs in the US, many of which use the FBT approach. At that point, we will help facilitate the teen's admission to a treatment program, and provide ongoing support for the family, as there is still work to be done to make for a successful transition back home.

It is terrifying to have a teenager with an eating disorder. Parents spend a lot of time blaming themselves and trying to figure out what they did wrong. Eating disorders are not so simple as to be caused by one thing, including parents and families. But, by working together, the teen and parents can rid the family of the eating disorder, and strengthen their bonds.