Understanding the new link between social media and mental health

 I have been following the general public's reactions to this news about social media and its impact on eating disorders and mental health. And what I am seeing is that the real point is not truly being understood. For example, read the comments on the KSL article posted 12/9 on the topic.

Yes, it's well known that social media of any type has a questionable impact on mental health. Some research shows that social media can have a positive impact. Examples that I see of this in my practice is patients reporting interactions on pages designed to be support groups, or promote positive body image, or sharing podcasts that support therapy goals. These are clearly all positive places on social media. And, research backs this up. The study that I focused on, which looked at a number of studies (what is called a meta-analysis) showed that those who actively engage in social media, defined as talking to others on Messenger, for instance generally have a positive experience with social media. But those who "passively" use social media tend to have a negative experience. Examples of this are simply looking at others' content, perhaps hitting "like," or maybe commenting, but not directly communicating with others, tend to have more negative experiences. So, that covers what we have known for a while about social media; it can be positive, or it can be negative, BASED ON CHOICES THE USER MAKES.

The reason that was in bold, even though that makes it seem like I'm yelling, is the need to make this very, very important point:

What we now know is that the social media platforms use algorithms that push upon young users content which is harmful. Meaning, what the teen is exposed to goes beyond what they are choosing to view. An algorithm is deciding what they should see, and the suggestions that are presented have the potential to be very damaging.

But, what does that mean? Truly the best example is the stories coming from various congressional members. They are going in and creating fake profiles of 13 year old girls, and then watching what happens on that profile. I believe the first to do it was Senator Richard Blumenthal, and now Utahan Mike Lee is reporting having done the same thing. 

And what are they finding? See this quote from yesterday's KSL article: "Why did following Instagram's top recommended account for a 13-year-old girl cause our Explore page to go from showing relatively innocuous things like hairstyling videos to content promoting body dysmorphia, the sexualization of women and content otherwise unsuitable for a 13 year old girl?" Lee asked Mosseri. "What happened?" https://www.ksl.com/article/50308196/sen-mike-lee-to-instagram-youre-the-new-tobacco-whether-you-like-it-or-not

But then you read KSL comments, and people get hung up on each government official's overall political leaning and the generic understanding of social media. This means people are missing the point!

And the longer parents go missing the point, the more kids might well be exposed to the content that is pushed upon their children by an artificial intelligence algorithm. 

Now, anyone can go to my Facebook page and see that I "got off" (as defined by having I believe 9 FB friends) Facebook (the only social media I have ever had) weeks ago, after months, likely years, of knowing it was toxic to me. I have no problem with others knowing I have social anxiety. And, for me, social media worsened social anxiety. Did it also provide a form of communication/connection? Sure. But more so it worsened my social anxiety, and let's be honest, social anxiety is not that much fun. So, I finally...finally...decided to stop my exposure to it; not an easy task in our society. I now really only see what horse-related companies are having sales, and for me, that is the perfect use. ;)

Is social media all bad? Absolutely not. But do we all need to better understand how it works and how it might impact us? I would argue the answer to that is a resounding yes! I fear all the news coming out is simply not sinking in, and for social media to eventually improve, it needs to sink in. 

Pardon me while I leap off my soapbox. 

More on Social Media

Given the last post, the next logical question is "What can I do, as a parent?"

This is, of course, a very tricky question, as we knowing parenting teenagers is tricky in general. But, I have found that teenagers do best when things are simply explained to them in straightforward terms. Especially once a teenager has developed an eating disorder, it is common to walk on eggshells around them, never knowing when the next explosion might occur...whether that is an explosion of anger, or tears. 

But, as a professional, I never tiptoe. I just don't. And I have found that all clients, teens included, appreciate this the vast majority of the time. Teens are looking for direction. Sure, they want to believe they know all the things, but in the end, they also seek guidance from trusted adults. So, my suggestion is this:

First, explain what you have learned about social media and what they might have been exposed to. The response to this will vary, I'm sure, based on the stage of recovery from the eating disorder. Those later in recovery might easily volunteer what they have been exposed to, while those more protective of the eating disorder might deny. They might want the continued exposure, so they can learn ways to improve their eating disorder behaviors. 

I'm guessing I don't need to say a lot about what to do if your teen is open about what they have experienced. Listen to what they have to say, and then ask them how they want to respond, rather than telling them what they should do. We all know that works better with teenagers, and humans in general.

If they are resistant, that probably is answer in and of itself; it likely means they are guarding the information on their social media. At that point, you have a couple options: 1) keep trying to talk to them, or 2) notify their treatment team. Reality is, sometimes teenagers are more willing to talk calmly to their treatment team than their parents, unfortunately.

As I stated previously, right now, we don't know well enough what teens have been exposed to via social media, but it is likely that more and more of that information will become clear over the coming months. Remember, the majority of clinicians are not aware of this new information about social media exposure. Your child's providers will be better able to help as they are made aware of your child's specific exposures. 

 

Parents: What You MUST Know About Social Media

As most of us know, a whistleblower, Frances Haugen, recently testified in front of Congress regarding her knowledge of some of the dangerous actions taken by Facebook, Instagram and WhatsApp. Whereas her testimony covered a number of topics, most relevant to my work is the fact that it appears these companies use artificial intelligence (AI) to push diet and eating disorder content to young girls and young women. The extent of this is likely to continue to unfold over the coming months, but for now, what we know is that, in spite of this testimony and news coverage, it continues to happen.

For years, eating disorder providers have known that social media is risky for those with eating disorders. Studies have repeatedly shown that involvement with social media correlates to worsened body image, which is a precipitating factor for the development of eating disorders. As a result, providers have worked with adolescents and young adult to try to alter their usage patterns. We have recommended parents monitor for concerning content, and we have worked directly with patients to choose to change the accounts they follow, with an emphasis on following more positive messaging.

But, what we have not known is that, regardless of how we encourage our patients to use a different approach in their intentional use of social media, the AI algorithms have forced upon these same individuals content that is not within their control. THIS is what is so important for parents, and providers, to understand at this time. In short, simply being a certain age and gender is the trigger for being bombarded with pro-diet and pro-ED content, and there is nothing the user can do to change this.

Since this news came out, I have spoken to a few providers, including some at the top of the field, regarding their understanding of social media and its impact on those with EDs. And what surprised me was that NONE of them knew about this new finding, the impact of this algorithm. And we all agreed, this changes things in a massive way. No longer can we focus solely on encouraging patients to change their choices online, as simply doing that will not stop the barrage of eating disorder and diet content. So, what do we do now? There's not an answer to that question, but I pose some ideas below.

I have dug into the research on social media and eating disorders, knowing none of it has yet to address this new information. But here are some key takeaways:

1. In 2021, the overall social media (SM) usage rate in the US was 74%. In the EU, 88% aged 16-24 use SM. Globally, the SM platforms with the highest number of user are Facebook (2.449m), WhatsApp (2B), Instagram (1B) and TikTok 800M (Statista, 2020)
2. From 2014-2017, Facebook usage in adolescents 12-18 increased from 47% to 75.1% of users. A 2018 study showed highest use for adolescents was Instagram. (Clinical experience says that use of TikTok is also very high.)
3. In one study, 61.3% of females sought body image related products on SM. Engagement with health, beauty and physical health accounts have been shown to correlate with an increased drive for thinness.  Finally, increased time on SM was associated with lower self-esteem about appearance, which was related to increase dietary restriction. 
4. SM usage was positively correlated with body image dissatisfaction, and also with restricting, bingeing, purging, laxative and diuretic use, and drive for muscularity. 
5. Social media use increased pathology in those with lower self-esteem and higher social comparisons. Passive FB use, defined as viewing others' content, without posting one's own, and intensity of use, were linked to social comparison and poor self-esteem. Both of these were then linked to depressive and anxiety symptoms, which often underlie eating disorder behaviors. 
6. Longitudinal research has shown: Greater social media usage predicted greater body dissatisfaction and increased appearance-related discussions with peers 18 most later. Body dissatisfaction did NOT predict SM usage, meaning that SM, instead, negatively impacts BI. 

An important detail in reviewing this research is the differentiation between correlation and causation. Many of the studies have shown correlation between SM usage and ED pathology. But, correlation is NOT causation. So, to clarify, the correlations above show that those who use social media more, also have higher levels of body image dissatisfaction and Ed pathology, but it cannot say that the SM uses CAUSES ED pathology. However, this is where we can bring in clinical experience, and clinical experience backs this research; many clients report that their social media use played a major role in their eating disorder development and maintenance. As a result, most, if not all, ED treatment centers terminate the usage of social media while in their treatment centers, and recommend limited to no use upon discharge. 

Fortunately, there is some data that is able to look at causative factors. The few experimental studies have shown that young adult men and women who were exposed to images of same-sex "attractive" strangers in mock SM profiles reported poorer body image than those exposed to "unattractive" strangers, and exposure to “fitspiration” images taken from IG led to a more negative mood and body dissatisfaction than did exposure to appearance neutral control images. These data reinforce the reality that exposure to problematic images on SM significantly contribute to ED pathology.

This is all research conducted at the time before we were truly aware of the impact of these AI algorithms. So, all of this data that has been based on the content that users voluntarily seek is only exacerbated by the new reality, which is that increasing amounts of this content is actively pushed upon teens and young adults, AND the SM companies know that and, to this day, have not changed it. 

Yes, to this day, users report that this content is still pushed upon this age group. 

This changes the landscape for parents and providers. No longer is it as simple as encouraging our children and patients to choose wisely what they follow on social media. No, now we have to explain the reality that, simply due to their demographics (age and gender) this content is forced upon them each time they use SM. 

Fortunately, as I have started to explain this to the girls and women I work with, the main response is anger. Nobody with an ED wishes it upon anyone else, so the women I work with are enraged about this reality. (I will add, some have indicated that TikTok is the worst offender, so I'd recommend to all of those with EDs...well, and probably everyone in general, but that's another post...to get off of TikTok.) And, I believe, that rage in the mind of the highly intelligent and powerful girls and women with eating disorders can then result in change. But we must get the word out. Talk to everyone you know about this situation...from parents, to teachers, to providers, to teens and young adults. Everyone needs to unite in the fight against this attack from SM companies; an attack based in increasing income to advertisers, seemingly without worry about the impact on these girls and women. Moving forward, providers will start to get a sense of how much this newly recognized exposure has impacted those with eating disorders, but for now, it is important that those working with individuals with eating disorders know that this is something to look at. 

And yes, men are exposed to it also, just not at the same rates, it seems.

For Parents: First Few Weeks

Recovery from an eating disorder is a confusing process. Some improvements happen quickly, and others take much longer. And unfortunately, while you are waiting for those improvements that take longer, conflict around food continues in your home. That conflict is hard for you and your child with an ED, and it is also hard for your other kids. One of the things I monitor as families provide treatment at home is when siblings are starting to be overly impacted by the conflict, or by the ED itself. It can feel like everything evolves around food and the ED, and there's some truth to that. The ED is so loud and overwhelming in your child's head that of course it kinda leaks out everywhere, over all of you. 

Let's start with the things that can improve quickly. Fortunately, many medical concerns can resolve quite quickly with improved intake of food and water. Orthostatic hypotension, blood pressure, heart rate, and lab values can all correct quickly, and most often do. (That is most true for patients who are not purging in any way. If intake improves, but purging continues, these values can remain unpredictable, and ongoing weekly monitoring is needed until purging ends. Fortunately, purging is not as common in teens as it is in adults.) For reference, teenagers that are hospitalized for issues related to vitals and labs often find all the issues corrected in just a few days; food and water is an amazing healer! Patient will also report improved thinking processes and energy with just a week of sufficient intake, and overall, they seem to be happier, though they tend to be very hesitant to admit any of these things. Medical risk decreases significantly, as long as ED behaviors do not continue. 

However, as all of this medical progress is being made, the anxiety around food increases. The best way to think of it is to look at fear in general. Imagine something you are afraid of, and how you respond to it. Most likely, you avoid it. However, avoiding it only serves to continue, and potentially increase, your fear of it. So, for your child, he/she is fearful of food, and has avoided it. Now we are shutting down that option, and as you can imagine, fear shoots up. Without fail, those with EDs become convinced they will rapidly gain weight as a result of what we have them eat. They won't, but we cannot easily convince them of that, so don't even try to do so very hard. We just have to wait. And, what I have noticed over all these years, is that it takes about two weeks, on average, for that fear to peak and decrease. In two weeks time, we are able to prove that they can eat way more than they thought and barely gain any weight. We were not able to talk them out of their fear, but their body proves the fear to be wrong. Now, if only EDs were so easily convinced, right?? Treatment could then just be done. But, nope; they are very annoying disorders and they hang on as long as they can. The EDs "job" is to convince its host that we are all lying, and only it is telling the truth; it's truth is that food is bad and your child will gain lots of weight, among other things. And the only thing that can disprove that....is time. 

So, your job is to outlast that obnoxious ED. While your child is screaming at you about what you are serving for dinner, you want to try to remember it is the ED screaming, not your child. And so you do your best to get mad at the ED for them, because they are not ready to be mad at it yet. You will want to closely watch your phrasing and express anger at the ED, not your child. Your child is frightened, though is not acting like the scared kid you might be used to. No, the fear is coming out as aggression and cruelty at times. But, it is not your child; it is the ED. And, of course, sometimes you just want to back down and serve something easier, or otherwise negotiate with the ED. But in those moments, if you have the resources within you (you won't always; we all have bad days), you want to stand up to that ED and make it clear it will not get to win, in that moment, or in the future. 

But what do you do if the disorder has become too aggressive for you to stand, or is impacting siblings too much? First, you want to make sure the other kids are getting attention too. I know, I just told you you have to work EVEN HARDER. Believe me, I know this is not fair. At all. But your best protection against your other kids potentially learning that the way to get more attention is to be sick, is to make sure they get attention for being well. This makes your job even harder as I know you are tired. So, it doesn't have to be big stuff. Just little moments to show that you have not forgotten about them in the mess of the ED. And, if this level of ED chaos continues, we then start to look at whether a higher level of care is necessary. And that's not because you or your child failed; we just know there are some EDs that are really nasty, or maybe you are a single parent, and the expectation of managing the ED at home becomes too much. For many teens, once they realize their parents actually will send them to treatment, they are able to rein in some of the ED acting out a bit more, and it becomes more manageable at home. But for others, there are excellent treatment centers that can step in and help out until the brain is more healed. 

I know this might sound more pessimistic, but I want to make sure you realize you are not alone in this battle and in how difficult it is. It is very difficult. But stay the course. Follow what the treatment team recommends, and recognize that it is unfortunately a bit of a waiting game. But recognizing that it just takes time can also be empowering. I know it's a cliche, but you do have to look at recovery as a marathon, not a sprint. There's a sprint off the starting line, just to get all the medical stuff managed, and the treatment team put together, but from there, it's about persistence...just putting one foot in front of the other until you reach the end. And the end does exist. I promise. Otherwise, I could never do this job. 

For Parents: The Initial Session

 So, you are about to do the first session with your son or daughter, and you don't know what to expect; or, you just finished it, and have no idea what just happened! ;) I thought my best approach would be to kind of walk through what is typically addressed Day 1.

My first job, even though I'm a psychologist, is to assess your child's physical state. I might do weird things like take his/her pulse, and I will annoyingly grill you on your child's most recent vitals, labs, etc. As I have explained before, I have a bit of an odd job, given my training. I'm trained in talk therapy, right? But, in eating disorder treatment, what comes first is physiology. So whereas you come in potentially expecting me to to dig into your child's thoughts and emotions, this is not going to be the priority at this stage, and hopefully this post will help explain why.

Eating disorders, especially those that have resulted in weight loss, are brain AND body disorders. Weight loss and/or starvation (you can have either or both), impact their brain heavily. It changes the way your child thinks, and the way he/she behaves. You have likely noticed they have become more anxious, more depressed, more obsessed (particularly on food and weight, of course), and they explode in anger like they never have before. There's a good reason for this. In short, the part of the brain that is impacted is the frontal lobe; that is the part of the brain that is responsible for rational thinking, impulse control and decision-making. I think it always helps a bit when I say it's the part of the brain impacted by substance use also. We expect somewhat chaotic, irrational behavior from those using drugs, but we don't expect it from the overly compliant kids/teens that end up with EDs. So, it is helpful to realize that that part of the brain is "hijacked." And therefore, our primary job is to repair that part of the brain.

In addition, what we know about kids and teens is that they tend to get sick very quickly, and they tend to recover very quickly. In all my years of doing this, I have rarely had to refer an adult for admission for medical monitoring. In kids and teens, this is more common. One of the tricks with kids and teens is that we have to look not only at the amount of weight lost, but also the amount of weight they should have gained during the time of their ED, but didn't. I realize that didn't make complete sense. Basically, kids and younger teens are supposed to be gaining weight all the time. So, when they lose weight, say 10 pounds, they not only "lost weight" but also "failed to gain." So, let's say they lost weight on the scale in six months; but, during that six months, they were also supposed to gain 5# naturally. So, at the time of the assessment, they have actually "lost" 15 pounds. Adults only have to look at weight loss, as they don't have the "failure to gain" variable. 

In either case, the weight loss impacts the frontal lobe, and so we sees the symptoms I listed above. And, those exact symptoms, and the brain impairment, make it so insight-oriented therapy is not really possible at this stage. Emotions other than anger and fear are often shut down. The primary answer you hear to most questions is "I don't know." And often they don't know; their brains need healing. 

And that means weight gain. Many therapists want to avoid talking about weight gain, because it upsets the client. And it does, very much. But, I approach working with teens by respecting their intelligence and their ability to understand science. I separate them from their eating disorder, and what i have found over the years is that, yes, the eating disorder has a meltdown about hearing about weight gain, but your smart child can understand why the brain needs to be repaired. Admittedly, they would prefer their brain could repair without weight gain, but sadly, I'm a therapist, not a magician. ;) So, we are left with weight gain as the cure.

So, initially, you will find this talk therapist mostly asking about medical indicators, and also asking the same questions the dietitian asks; what does food intake look like, what does energy expenditure look like, etc. And then I'll start to explain what I explain here in this post, and more. The goal is for both patient and parents to understand where we start, what the focus must be, and it gives me a sense of how willing the kid/teen is to consider engaging in treatment at home. I will often explain that there are two paths to treatment: one is treatment at home, with parents providing the structure, and the other is treatment in a treatment center, with the treatment providing structure. Kids/teens (and adults with EDs) like to make up path #3, which is something, "I'm fine, I"ll do what I want." Um, no. That's a mythical path; one of the two actual paths must be chosen. 

The main task for parents and teens leaving that first session is this: 1) contact providers you have been referred to to create a full treatment team, getting in as soon as possible, 2) follow dietary recommendations, starting immediately (willingness to do so helps determine which of the two paths we will end up on), 3) separate the patient from the ED (asking parents and teen both to get mad at the ED while making it clear there is no anger toward the patient him/herself), and 4) for parents, begin to learn about Family Based Treatment, from the resources provided in my previous post. 

That's kinda it. That's really all we can do in that first hour, unless there's a need for a medical intervention immediately. I know it's hard to walk out not having all the answers from any of us on the treatment team, but trust that those answers will come and you will make your way through this, one day at a time. 

Starting a New Series for Parents Providing Treatment for Low Weight EDs at Home

 I realized yesterday that I have a higher than average percentage of teen clients at this point, and one of the biggest challenges in treating teens is that my job is to teach parents how to treat an eating disorder. This is no small feat for parents, as where, in that mythical parent school, did you supposedly learn how to treat an eating disorder?! And yet, here you are, living with an eating disorder that has taken over your child. It is a terrifying position to be in, and it will be one of the most difficult things you have ever done. But, it is also possible, effective, and, in the end, can be rewarding. I promise I'm not just saying that; this comes from years of helping parents do this exact thing.

The hardest thing about suddenly living an eating disorder is the reality that they hijack your child and turn him/her into someone you don't always recognize. Kind, well-behaved, honest kids begin to lie, manipulate, call you names, and express their hatred. My goal is to try to explain how the ED works, what essentially is likely going on in your child's head, so maybe the nonsensical can start to make just a bit more sense. Other resources, however, include Lock and LeGrange's "How to Help Your Teenager Beat an Eating Disorder," and AroundTheDinnerTable.org.

The idea of Family Based Treatment, which, to me, amounts to creating an ED treatment center in your home....no big deal, right?!....is to keep teenagers out of higher levels of care and allow them to remain at home with their families (even when they say they hate you). There are pros and cons to FBT and to treatment centers, and both are very good options. I won't try to speak for the creators/advocates of FBT, and I will fully confess that I do not follow closely how Lock and LeGrange described the treatment. I use the tenets that I have found work, and adapt the rest. For example, FBT initially called for no involvement from a dietitian, and I have never agreed with that. Due to the changes that happen during refeeding, I have always felt expecting parents to know what to do 100% with food was too high an expectation. I believe they have since loosened that messaging, but this is just an example of ways in which I have adapted the approach over the years.

I fully agree with the basic tenet that eating disorders CAN be treated outpatient, and I absolutely believe every patient should be given the opportunity to give it a try. I do not believe in a patient being diagnosed and immediately sent to a treatment center, unless that is what the patient wants. Many, many patients and families have succeeded at home, but it is definitely a lot of work. And parents need a lot of support as they experience a lot of unexpected hostility and anger from their child. I always take into account when that hostility and anger becomes too much either for parents or for siblings, and that becomes grounds for referral to a higher level of care when necessary. 

If your child is referred to a higher level of care, it is not failure on your part! Some eating disorders are unbelievably nasty, and sometimes, overcoming them at home is simply too high an expectation. One of the key parts of eating disorder treatment is empathy not only for your child, but also for yourself. And, eventually, I will work with teens to recognize how much they need to empathize with their parents and the terror they have experienced while watching their child suffer. Good news...all the teens so far have come around to recognize how hard their parents worked, how scared they were, etc. Your kid may hate you now, but it's not forever!

Some of the things I will talk about in this series have been addressed previously, but I still am going to go over these things again, just so it is all in a string. If you are reading this and have something you want me to address, please feel free to email me at whoytphd@gmail.com, as I don't necessarily check for comments here (I know, I'm a poorly behaved blog writer. I thoroughly enjoy sharing this information; I do not thoroughly enjoy social media!😉) These blogs will also be sans pictures and images and the like, simply for the purpose of conserving my time! I hope you find this series to be helpful!!!

Tenacity and Facing Fears

The other half of my life (and it does feel like it takes 50% of my time!) is being an equestrian. As I share with my clients often, I too was gifted a healthy dose of anxiety, which I address through multiple paths. One of those paths is riding horses. I can have a million thoughts going through my head, but riding demands enough of my brain to, you know, remain on the horse, that it forces out all the other thoughts. Well, that is not COMPLETELY true. Part of my anxiety is social anxiety, so that still comes up when I am involved specifically in my sport, which is dressage. (Most people have no idea what it is, and I cannot easily explain what it is, soooo ask Google?) But I definitely have to battle a health amount of social anxiety as I fumble around in this sport.

I started riding horses in 2013. I mean, I had ridden horses occasionally before, but never in any type of informed way. So, I started riding February of 2013, and by May bought my first horse (advisable? Probably not....but she stole my heart.) I rode Daisy for a year, and started conducting equine assisted psychotherapy with her as my co-therapist. Then another horse was coming into the barn; I took one look at her picture and somehow just knew that she would be an excellent co-therapist, and also that she was meant to be mine. I cannot explain it; it just seemed true. When she arrived, it only became more clear to me, though my husband, reasonably so given the cost of horses, was less convinced. ;) But here's the kicker: Violet had never been backed (often referred to as "broke"). Nobody had ever ridden her. So, sure, that's a great plan....let's take the brand new rider and have her buy an unbacked horse. Yep, great idea. (Hint: it's not a great idea and literally nobody advised this.) Neither of my horses now were typical dressage horses, but someone did say that V could like make it to Grand Prix (the highest level of the sport). So, stubborn ol' me decided that the really bad idea was still what was going to happen, and I bought her a couple months later, and she was started under saddle in spring/summer 2014. 

This pic is an example of the early not-very-good riding. I basically am just sitting up there hoping for the best!

I started to train in dressage in early 2016, and first showed in summer 2016. Let's just say it's been a rough road. Perhaps the main thing I learned from Violet was...how to not fall off...and persistence. That horse can change directions at the speed of light and so from seemingly Day 1, I just had to figure out how to stay on. I had a number of near falls where I literally would be shooting off her side, but would hook my boot under the saddle and pull myself back on her, because, let's be honest, hitting the ground hurts. I have no doubt that everyone watching the debacle of new rider riding new horse was thinking, "What does she think she's doing up there? She has no idea what she's doing." It was true! I didn't have any idea what I was doing. Normal, sane people buy horses that already are trained; that wasn't me. I was just stubborn, I guess.

This pic illustrates getting the job done, but not competently. Leaning forward, horse unhappy.

In 2018, I took a huge risk and started bringing Violet out to San Diego so she and I could train with high level riders....international riders.....another massive challenge to the social anxiety. "Hi, don't mind me over here on the small horse (dressage riders are generally tall, and on tall horses) and no, I don't really know how to ride, just to be clear!" My very first ride in San Diego, I had to go into a ring with an Olympian and the next-in-line for the Olympics. Right. "Don't mind me. No, really, don't look at me. Please." By that time, I had made it up to showing third level, which wasn't too bad, and also means nothing to anyone who doesn't do dressage! (I tried to figure out how to explain the levels 

to my mother the other day, and this is what I came up with. You start out as a high school athlete (Training level and first level), then you become a college athlete (2nd and 3rd level), and then you make it to the minor leagues (PSG and I1), and then you are in the big leagues (Grand Prix). And then those who really excel in the big leagues go to the Olympics.) But I was a college athlete that had never been really taught how to do the sport correctly; I just kinda fumbled through doing it on a fairly fancy horse and so did acceptably enough, but I was not doing it correctly. Then I started training with Emma Weinert, an international Grand Prix rider. I returned to San Diego this winter to train with Emma, and then life happened and suddenly we were looking at moving somewhere, so we might as well consider San Diego so I could work with Emma full-time. 

Fast forward to this weekend. I had spent two years (Nov 2018 to now) trying to learn how to ride correctly, and did not advance up the levels as I worked on that. It was a lot of work as I had to completely change how I rode in order to do it correctly. But I had gotten lucky, and did indeed have a very talented horse, who also is quite unpredictable. 2020 happened, and horse shows were no longer a thing, so my focus was on trying to advance to PSG (Prix St Georges, if you are super bored and want to google), which I have equated to the "minor leagues." My eyes were set on a show called Spooktacular, which was 10/31-11/1/2020. We were gonna do it, no matter what, I thought. Then life threw enough barriers that by 10/27/20, I was being thrown around on horseback and said sadly, "I can't take this (extremely wild animal) into the ring this weekend." Violet had ulcers and had become aggressive and violent. I had given up about 40% and then started Google Image-ing "Persistence." I couldn't really find any quotes I liked, but one thing led to another and I found quotes about "Tenacity" and that is what felt right. And also seemed to describe what one with an eating disorder must have in order to recover. 

That night, I threw one final hail Mary in the form of very expensive medication at her, followed by another dose first thing on Wednesday, and somehow it magically made her sane (it really shouldn't work THAT well, especially since she had been on a less expensive version of the exact same medication). I cautiously thought, "well, maybe?" The next day, Thursday, she was okay again, and I thought, "Well, I guess so?!" And Friday we left for the show, where she also was good. BUT, we had never actually practiced for our "minor league" debut, as she had been that aggressive horse for the past three weeks. Just the next inadvisable thing in line, I guess! Somehow, I had confidence that it'd be fine. That was quite misguided confidence, I'll have you know! ;)

It was basically fine....if you don't have social anxiety, perhaps. I did ride into the show ring on both Saturday and Sunday. We completed the tests without any major issues other than that tiny rear in the back corner of the arena on Saturday (just to be clear, at no point does a dressage test call for the horse to rear, whether tiny or large, so that's a bit of problem). The judge skewered us in her written comments; my social anxiety took off at a gallop! I pondered dropping out of the show for the next day. Some kind friends talked me off the ledge, and we gave it a go again on Sunday. Was it significantly better? Yes, and no. No rearing is always a plus, of course, so that was cool. But again, I knew our score would not be particularly desirable. But this time, the judge's comments were fair and constructive, so the low score was way more tolerable. We had survived. We had done the inadvisable, and we had received a lot of encouragement along the way, and I would not have experienced those things if I had listened to my anxiety and bailed. There were some really cool moments, and a lot of errors. But, we had made it in the ring, she stayed in the ring, I stayed on the horse, and we played the sport in the most basic of senses, on a much larger stage than we had ever been in, with huge room for improvement. Let's just say we wouldn't be chosen as a starter in the minor leagues. We need a bit more practice. ;)

What, you might be thinking, does any of this have to do with eating disorder treatment. Well, let's go back to that Tenacity quote: 

This quote drove me from Tuesday on in the battle to make it to something quite unimportant in the scheme of life...a horse show. This same quote, in my opinion, describes the experience, the process, of eating disorder treatment and recovery. The patients I work with must trust that we, as the treatment team, can share a game plan and a strategy, while they bring the strength and the determination. And it is hard to feel strong while fighting an eating disorder. It is hard to feel determined when there's a nasty voice in your head saying to give up, to not listen nor believe in the game plan. The statistics about eating disorder recovery present as "seemingly insurmountable odds," and certain the ED voice in your head feels insurmountable. But the odds are NOT insurmountable. As I say frequently, I could not do this job if my clients did not recover. I'm not crazy (Hmm, to those of you who know me, keep your opinions to yourself, LOL!). Ok, I am kinda crazy. But I'm not willing to work every day to treat something that is untreatable. Everyone can get better. I don't doubt that for one second. But it sure takes a ton of persistence, stubbornness, and tenacity.

Same message for anxiety. Anxiety also convinces us that thing that are not true, are true. My anxiety convinced me I was being judged left, right, and center. I mean, I was technically being judged...by the judge....but I eventually realized all the witnesses were not judging me as harshly as *I* was judging me. So, simmer down, brain. Anxiety almost led me to not go back in the ring on Sunday, but in the end, I would then be a hypocrite as I allowed anxiety to stop me from facing the fear of judgement. And, sure enough, Day 2 wasn't as bad as Day 1. And even it was terrible and everyone judged me harshly, let's be honest, for me, as an amateur, it's "just a horse show." And lots of times the things we are fearful of are just not that big a deal in the long run; our brains are lying to us. And the only way past, is through. You must prove your anxiety wrong, and it is wrong the vast majority of the time. Whether that is proving that eating x,y and z won't make you gain x amount of weight, or whether failing on x activity does not make you a failure at life. Eating disorders lie, anxiety lies, and you can be tenacious enough to prove that to be true.