Nike: Just Do It!

Eating disorders are often so hard to understand for those who have not had one. Parents, friends and family often find themselves becoming so frustrated with their loved one who has an eating disorder because they can't understand why their loved one won't "just do it." They find themselves saying things like, "Come on, just eat!" or "If you wanted to get better, you'd do it." And, granted, some people with eating disorders don't want to get better at that moment, so maybe they really are not trying very hard, but at the same time, really, who chooses to have an eating disorder? And I think that is such a hard concept to work through when you are not the one struggling with this disorder. On the outside, it looks like a choice, it looks like something that could "easily" be changed by "just eating." So, what I try to help family and friends understand is that there is pretty much nothing rational about an eating disorder; thus, applying rational thought processes to the disorder just doesn't work very well. Oh, how tempting it is to rationalize with someone with an eating disorder, thinking, "if I can just get him/her to see the truth, she'll change!" But it is not that simple....

Eating disorders are (brace yourself for psychobabble) what is called ego-syntonic. What this means, basically, is that the ED helps the person in some way. Depression is usually ego-dystonic. People don't really want to have it, and when someone with depression comes into my office, they want me to help them get rid of it. EDs (and substance abuse, and self-harm), on the other hand, are "helping" the person. They help the person manage their emotions when they are so scared to face them straight on. They give the person an identity when he/she might feel invisible instead. They serve many, many purposes, which vary from person to person.

So, unfortunately, someone with an ED comes into my office partly wanting me to help them get rid of their disorder, and partly wanting to keep it so they feel safe. Many have what is called the "anorexic wish:" Please help me get over this disorder without gaining any weight. They don't want to have the disorder anymore, but they are terrified of weight gain, and honestly, they are terrified of life without the ED.


So, hopefully, now it makes more sense how the "just do it" approach doesn't work as well as we might hope. We can all relate to having emotions override rational thought, and how we act in those situations. So, for those with EDs, their fear overrides almost all rational thought on the subject. So, keep talking to your loved one rationally, but don't expect it to dramatically change their actions right then. It takes a lot to override fear. Early in treatment, "just do it" doesn't work.

Though my patients would tell you I have been known, much later in treatment, to threaten that they must wear Nike clothes all the time to remind them that there does indeed come a time when, in recovery, you have to "just do it." But that is another post.

The "perfect patient"

Many patients with eating disorders also have a significant problem with perfectionism. They want to be perfect, or the best, at most of what they do. And, for some, this includes being your "perfect patient." What does the perfect patient do? He/she tells you what you want to hear, acts as though everything is fine, and desperately wants your approval. So, whereas their morals may be against lying, they just might lie to you, just to make sure you are okay with them; their fear is to make you mad. 

But, unfortunately, the "perfect patient," in my experience, rarely gets better. After all, what you want to hear is rarely what is really going on. What is really going on is incredible pain, torture, a horrible battle with an eating disorder. There's nothing pretty about this. And soon you start to see evidence of the "perfect patient." The concrete data (ie, weight, vitals, etc) doesn't match what the patient is reporting. The smile is strained and often barely held. You find there is not much depth to conversations. And, most of this is simply because your approval, acceptance, is what is so desired.

So, the "perfect patient" must learn that you will approve and accept them, even if everything isn't, well, so perfect. It become a challenge to balance the need for high expectations, which I believe are necessary for full recovery, with challenging the presentation as a "perfect patient." It is a challenge to balance the need for following a meal plan 100% with a patient's desire to tell you they did it when they didn't, just so you won't get mad. Really, I guess it all comes down to honesty and authenticity, and the trust that is built from keeping high expectations while also encouraging honesty. It is a balance, indeed. I also thinks this links to the patient's need to learn that, even if you do get upset with them (read: their eating disorder), you can work through it. They don't need to fake you out for you to be okay with them. You can simultaneously be upset at their eating disorder behaviors, and like them as a person. Said another way, you can dislike their ED, while liking them just fine. This is often a hard concept as the ED has become so ingrained as a part of the patient. But, separation is key. 

I'm pretty sure nobody has ever said that recovery from, or treatment of, an eating disorder is very easy. It is hard, but oh-so-rewarding work.

Secrets

There is a saying in addiction treatment that goes, "Secrets keep you sick." I first heard this phrase while working in a substance abuse RTC here in Salt Lake. There was a lot of focus in this program on secrets, letting secrets out, etc. This was such a powerful thing to be introduced to, and something I have carried with me since. I only wish I had been aware of this concept in the work I had done prior to working at this facility.

Over the years, it seems I have developed a somewhat uncanny ability to tell when someone is keeping a secret that is impeding their treatment. For some, I am sure this skill is quite irritating, but for many others, I can see the relief on their faces when I bring up the concept of holding onto secrets. Before going farther, I should probably better define what I mean by a secret.

There's the obvious definition of a secret. Something you hold onto and don't tell anyone else. So, something you did, something that happened to you. And these can be powerful secrets. But, sometimes "emotional secrets" can be even more powerful. What I mean by this term is those emotions we feel, but don't tell anyone about. It's the emotions about events that we cannot escape and that we, for whatever reason, are too scared to tell anyone else about. Sometimes, we have told people the details of an event, so in that way, it is no longer a secret, but if we hold onto emotions about that event, suddenly it is still a secret. It's a hard concept to explain, but for those who you holding secrets, I am sure you know what I mean.

Secrets make people "act twitchy," as I often so clearly describe it. They generally avoid becoming emotionally connected, vulnerable, and when you ask a question, sometimes you can tell there's something not being said. They have emotional reactions to things that you can't quite understand. In many ways, it is hard to describe how to tell someone has a secret, and fortunately, most people don't need this skill. But, when clinicians have the ability to tell a secret is there, they can help the patient eventually feel safe enough to let it out.

When it comes to eating disorders (or substance abuse, or self-harm), secrets will often lead the person to "need" the symptom to cope. This might be a strange concept to those of you who have not experienced one of these behaviors. How could someone "need" the symptom of a disorder? Well, when the emotions linked to a secret are so strong, and you are trying so hard not to let that secret out, the symptom serves as an excellent distraction, a way to avoid, and a way to keep others at arm's length.


So, let's try an example. Let's say Suzie Q has an emotional secret. She feels extreme guilt about something she did a year ago, but that guilt makes it so she doesn't want to tell anyone because who knows what others will think of her. But, as she goes through her days, she thinks of this thing she did, and she feels badly. You can look at her sometimes, and see she seems to be lost in her own head, and she is thinking about that thing she did that she cannot tell you about. Sometimes that guilt becomes overwhelming and she almost cannot stand it, but then she engages in her ED. It doesn't matter the symptom; really, they all serve the same purpose. And as she engages in that symptom, she is distracted from that guilt, and maybe even feels better, because she is punishing herself. The guilt decreases for the moment. The problem is that the guilt always comes back, and it will until she is able to "work through" the guilt. So, the need for the ED symptom remains.

Now, I can't say everyone with an ED has secrets. That would be unfair to draw such a broad stroke. But, if you have secrets that you have not told your treatment team about, maybe start by at least writing the secrets out; this way, you have at least admitted them to you. And, then, as you feel safe (not that it will ever feel TOTALLY safe to tell a secret), tell your team. Let them help you talk through it. And, fortunately, in my experience, once this happens, you will feel better. If it is your loved one that has secrets, I wouldn't try to force the secrets out....that is too scary and will be met with resistance. But, let your loved one know you are there to listen and to support whenever he/she is ready to talk.

On Anger....

I have heard a few times recently, "I don't really feel anger very much." Sometimes, of course, this is followed by statements about how and why anger is invalid, unnecessary, unacceptable. Now, ask the parents of a teenager with an eating disorder, and sometimes you will find there is plenty of anger being expressed. But the problem is that the vast majority, if not all, of the anger being expressed is about food, rather than about what really angers him/her.

However, I have noticed that, a lot of the time, those with eating disorders, especially anorexia, are seen as fragile, breakable, in need of being treated with kid gloves. I see it very differently. In my experience, behind a lot of eating disorders is a good amount of anger, but the individual does not feel anger is okay, so the anger leaks out in ED symptoms. In many ways, eating disorders are even somewhat aggressive disorders. Now, the actual person is not aggressive, but the disorder creates a level of aggressiveness.

Now, some would say that someone with an eating disorder is not in control of their behaviors and their actions, and sometimes that is true, but in my experience, it is not true as often as maybe providers assume. Certainly eating disorders dramatically impact brain functioning, but I'm not sure it is in such a way that the patient no longer has control over his/her actions. 


So, back to the aggressiveness. Again, I want to be clear that I am NOT stating that those with eating disorders are intentionally aggressive. But, if you think of the behaviors, I think the anger behind them becomes more evident. Eating disorders require a lot of defiance; defiance of of bodily needs, others' expectations, treatment recommendations. They are not passive disorders, and thus, in my opinion, to treat them passively, rather than more directly confronting the disorder, may do a disservice to the person suffering with the disorder.

But, more importantly, in order for one to recover, he/she must deal with the underlying anger. It must be safe for him/her to express anger and that emotion must be accepted. I often encourage patients to get angry with me, which sounds kind of strange I am sure, but my goal is to make it clear it is okay to show anger, even anger at me. And I'm sure if you could ask the patients I work with, they will likely all confirm that I REALLY annoy them at some point, if not frequently. The key is, you must get past the anger at food, at treatment, at feeling controlled, and get to the "real" anger, the anger that comes from your experiences.


So, find a relationship where it's okay to be angry, and express away! For many patients I have worked with, as they have learned to express anger, they have found they have less need for their ED symptoms.

One week vacation!

Just a note that Within Four Walls will be going on a one-week vacation, starting today. We hope to see you all back here in a week. Please feel free to leave any comments asking for topics to be addressed upon our return!

The "War on Childhood Obesity"

I was asked to post on this topic, and first I wanted to research a bit more on the government's stance. First, on a government website, I found the announcement that a research task force has been developed, which seems quite reasonable. Then, however, I found an article (http://abcnews.go.com/GMA/Health/michelle-obama-childhood-obesity-initiative/story?id=9781473&page=2#.T_ZKbI64LzI) on Michelle Obama's push for the Childhood Obesity Task Force. And, a couple quotes caught my eye:

"I have set a goal to solve the problem of childhood obesity within a generation so that children born today will reach adulthood at a healthy weight," the text of the president's memorandum reads.


Perhaps this is a bit blunt, but this seems like such an ignorant statement. I am pretty sure the president is saying that the "healthy weight" is an average or below average weight. Of course, in reality, what do those terms even mean? But, anyway, I am pretty sure the president is not recognizing that weights are normally distributed, which is represented below.


***See bottom of post for a brief explanation on normal distribution.***


If we assume weights are normally distributed, it means that some people are naturally very thin, and some people are naturally obese. This is where people's brains start scrambling. But, we all know someone who is naturally very thin. So, if you can accept that some people are naturally very thin, then you kind of have to accept some people are naturally obese.


So, back to the president's statement.... I'm pretty sure he is not accepting that some people's "healthy weight" actually falls within the obesity range. There is so much more that can be said about this, but to do so would make this particular post far too long, so let me know if you'd like to hear more. Next:


"To help parents, the first lady said she's working with the Food and Drug Administration and major food manufacturers and retailers to make it easier for parents to identify healthier foods by placing nutrition labeling on the front of the package."


Oh my! Who knew the problem was the location of the nutrition facts. Really? Enough said.


Now, this is just one article, so I realize it's not fair to base all my thoughts on this. So, more globally, I am concerned about any messages that identify good foods and bad foods, or healthy foods and unhealthy foods. This type of mindset violates the tenets of Intuitive Eating, which again is a whole 'nother post. But, to identify foods as "bad" or "unhealthy" just creates shame around eating those foods. And, even worse, sending the message that being "above average" in weight is "wrong" is horrifying, potentially creating long-lasting shame and self-hate.


I think there is much more benefit to teaching the benefits of carbs, proteins, fats, fruits and vegetables, than demonizing any specific types of food, and teaching how to read food labels, which, last I heard, are not even terribly accurate anyway. I don't have the citation, but last I heard, the FDA allows up to 20% error in a food label, which means if something says it has 100 calories, it could have anywhere from 80 to 120. How's this for a nutrition label, though?? (I suppose it should be placed on the front of the baby?)

In short, I think it is going to be very hard to skillfully teach about food in a school setting. The teacher will be biased by what he/she believes about food and pass on these biases. Now, if we could get a dietitian who teaches Intuitive Eating to go into every school and teach those concepts, that'd be awesome, but not practical. So, in the end, I cannot say what should happen. I just feel confident that demonizing food and being "above average weight" is NOT the way to go. And, as the last post addressed, making exercise about weight change ruins the fun of it, which, sadly, may decrease a kid's willingness to do it. So, I'm not sure the Obamas have hit the mark very well at all. I will hold out hope that the Task Force will receive information from researchers who truly understand the genetic, biological and psychological factors that impact obesity.


***Normal Distribution: Okay, statistics is a bit hard to blog on, but here's the basics. Imagine all the weights for all the women in the US who are 5'5" tall are on the graph above. All those dots would be within the blue line above....meaning between the blue line and the graph line along the bottom. So, the vast majority of dots would be near the middle, and that is why the curve is higher there; the height of the curve represents the number of dots. The middle would be the average weight for women 5'5" tall. But, out at the very ends, where the blue line is very close to the graph line, there would still be weights graphed there. 

Exercise is healthy, right?

Oh, if I could count the number of times I say the phrase,

"Yes, exercise is good for you. Until it's an eating disorder symptom, and then it's bad for you." 

Or,

"Yes, exercise is a good way to reduce anxiety, until it's an eating disorder symptom, and then it only serves to increase anxiety."


Exercise is the "socially acceptable way of purging." Really, using exercise to "get rid of food" is no different than any other form of purging. But, wow, we sure do give people a lot of attention for exercise, seemingly irregardless of situations where it is clear someone's exercise is not healthy, or they are not healthy. Of course, often exercise is a really good thing. But not always. And it shouldn't ever be about appearance.

Although our society is incredibly confused on this point, the intent of exercise is not to control weight or change appearance! If you really look at it physiologically, it's pretty simple. Exercise does NOT make you lose weight. Physiologically, exercise.....makes you hungrier! So, yes, you can lose weight by exercising. But, you also will have to not eat enough to support the exercise, for this to happen. If you follow hunger and fullness cues, exercise will just make you eat more.

So, it frustrates me that our society ruins exercise by making it all about weight loss. There are so many other purposes for exercise. Why do you exercise? (Please, no "to lose weight"s or "to change my appearance"s.)

And, please, rather than complimenting someone who exercises on their appearance, find something else to compliment. Let's try to override society's skewed view of exercise!

Relationships replace eating disorders

Treating eating disorders is difficult work, for both patient and provider. In reality, eating disorder treatment is a relatively new field, and the body of knowledge is growing exponentially each year. As a result, at times, we will seek advice from experts across the nation regarding how to approach a certain clinical situation. A few months ago, in response to one of these requests for suggestions, a number of conflicting ideas came in regarding how to broach a client's limited progress and difficulty adhering to treatment recommendations. And as all these ideas flew back and forth, there was one comment, quite simple really, that made it all make sense to me.

Now, I have no hope of getting the quote correctly, and unfortunately don't even remember who said it, but the bottom line was this....

As long as our clients believe in us as providers, whatever approach we take, within reason, is          likely to "work." 


And this confirms my belief about therapy, which is that, primarily, what we have to offer is a relationship. And then that relationship has power. And that power can join with the patient to create recovery from an eating disorder. I have seen patients with severe eating disorders symptoms choose to stop engaging in their eating disorder largely because a relationship finally matters enough to overpower the eating disorder. Sometimes, that relationship is with us as providers. Other times, it is with a child, a spouse, a family member.

I firmly believe relationships help replace eating disorders. Unfortunately, relationships are also what so often frighten those with eating disorders. Or probably all of us, really. So, what seems simple, is anything but.

But, overall, the idea that relationships can replace eating disorders this is good news, because we can all offer relationships, whether we are trained in doing so, or are a friend or family member.

And I thank all of my clients for offering me a relationship with them. There is no greater honor.

Tell Us Your Thoughts on Providers

Recently, on the Academy of Eating Disorders listserv, someone posted a reference for an article regarding the ideal characteristics for a clinician treating eating disorders, from the clients' perspective. I am waiting patiently to receive my copy of the journal, but thought this would be an interesting question to throw out to those of you who have participated in any type of eating disorder treatment.

I will confess, I tried to collect this same data. Sort of. About 18 months ago, I was training a group of therapists in eating disorder treatment, and decided to see if I could get our patients to anonymously tell us what they found most helpful about our approach, so then I could share this with the therapists-in-training. This was not a high-tech, experimental design, unfortunately. I put an empty tissue box in our waiting room, with a sign above it, asking for patients to put in their answers. It was a miserable failure.
I did my best to not take it personally.

So, I could speak to what we think works well in interacting with our clients, but reality is that we are biased by our own beliefs, and our clients are somewhat biased by their experience with us. As this blog moves along, of course, you will begin to see our views and beliefs on what has worked with the patients with whom we work. But first, we are interesting in your thoughts....

So, what characteristics have been important to you in your treatment providers?

I hope this does not become another empty tissue box. That would be so embarrassing! Though perhaps not as embarrassing as this.