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"Recovered?
What's That!" When I introduce myself as leader of the ANAD group, I say that I have recovered from eating disorders. I often get the same reaction from the new members in the group: "Is it possible to recover fully? How do you know when you are recovered? You don't think about food all the time!" Total recovery to me means that food, eating, and weight eventually become "non-issues". I tell my clients that we have to take the "power" out of food and turn it back into, well, food. Total recovery means being able to eat without feeling guilt, remorse, despair, panic, self-hatred, etc. After I eat I forget about it! It becomes a non-issue! I can get on with the rest of my life. At this point I usually get quizzical looks: "You mean you can eat ice cream or pizza and not feel bad afterwards? That's fine for you, but I can't stop eating! I can't have those foods." Part of the recovery process involves learning how to eat like a "normal eater". Normal eaters eat foods like ice cream and pizza. Normal eaters eat three meals and a snack or two a day. Normal eaters eat when they are hungry and stop when they are full - most of the time. Normal eaters do not panic at the sight of pizza! When I was in college there was a woman in my class who would bring a slice of left-over pizza for lunch every Tuesday. This truly amazed me at the time, because the words "left-over" and "pizza" never went together in my vocabulary before! And she brought it EVERY Tuesday! I got up my courage and as nonchalantly as I could I asked her about it - how could she have pizza every Tuesday and feel OK about it? She told me that she and her husband had pizza every Monday night and always had left-overs for the next day. At the time I wondered how she could "control" herself having pizza so often. She explained that since she knew she was going to have pizza on Monday and the next and the next… it was no big deal! She had taken the power out of the pizza and turned it back into, well, food. This story illustrates that when we give ourselves "true permission" to have a food, we do not have to "control" it. Total recovery involves learning how to give ourselves "true permission": "Yes I can have that and I can have it again too". This is opposed to "sort of permission": "Well, OK, I'll have it this one time, but never again!" (You know the consequence of "sort of permission": "Since I can never have it again, I better eat it all and then some!") The consequence of "true permission" is that we do not feel deprived and can trust that there will always be enough and that we will always be able to get our share. How do we learn how
to give ourselves "true permission"? Everyone is going to come
up with their own solution to this. One approach is to buy food in such
large quantities that you could not possibly eat it all. This can be expensive
and very very scary. Another way is to start by allowing yourself one
"treat" a day. I, myself, took the middle road by starting with
a scary food: peanut butter. I decided one day that if I wanted peanut
butter I was going to have peanut butter! I had peanut butter for breakfast,
lunch, and dinner. On the first day, I just relished it like a greedy
little child! On the second day, I found that I could relax a bit and
get in touch with the taste and texture. The third day, I still liked
it but the enjoyment was beginning to wear off. On the fourth day, I ate
it but did not really want it. By the fifth day, I rebelled and refused
to eat it! I craved a salad! I couldn't believe it! To see peanut butter
and think, "No, thanks." Peanut butter had been turned back
into, well, food! Amy Grabowski "Why
is Starting Psychotherapy so Hard?" Why is starting psychotherapy so hard? Whether it is one's first attempt, or second or third, for some-perhaps even most-beginning the process of psychotherapy can be a daunting prospect. It is not uncommon that people consider starting therapy long before they actually take the first step. Usually one is experiencing some sort of pain or confusion and it oftentimes needs to become fairly acute before she is willing to take action; therefore, many people find themselves starting the process of therapy when they are in the middle of a crisis. This can contribute to feeling overwhelmed by the changes that come with adding this important relationship to one's life. The first layer of concern tends to be around the nuts and bolts of arranging therapy. What if I can't afford the fee? What if I can't fit it into my schedule? What if I don't have the emotional energy to do this? These are all valid concerns. Therapy costs money-even if you negotiate a reduced fee or attend a low-fee clinic or you have excellent health insurance benefits. There isn't any way around the fact that you pay for therapy. You might imagine that it would be easier if therapy didn't cost money, but the truth is that money is an important part of the process of therapy-and not just because the therapist needs to make a living, although of course this is the case. The fact that money exchanges hands sets up the relationship as a professional one. Some people find that this helps to establish a boundary, allowing them to feel safe enough to share some of their most intimate thoughts and feelings. Some people find themselves having negative feelings about paying for the service. This is not an uncommon reaction and optimally will lead to an open discussion with the therapist, hopefully revealing a deeper understanding of the specific meaning this has for the client. Money is a part of our lives and having it enter into the treatment relationship is important and necessary. Scheduling can also seem like an obstacle, especially at first. When is it a good time to go to therapy? If I go at the beginning of the day, will I be worn out? If I go in the middle of the day, will it be disruptive? Will I be tired if I go at the end of the day? Perhaps the client has a demanding work schedule or limited child care. And don't forget travel time to and from therapy, which includes the hassles of parking or waiting on public transportation. There are also the limitations of the therapist's schedule to add to the mix. It might seem like the stresses of arranging therapy could make one feel worse instead of better! Though it may be hard to imagine getting used to a weekly or more than weekly appointment time, in fact there is a rhythm that develops. Therapy becomes a regular part of one's week, ideally contributing to a feeling of cohesiveness. Everyone has limits to how much energy they can expend. It seems that some imagine therapy will leave them emotionally drained. While I would never suggest that psychotherapy is easy, I would say that it shouldn't be depleting. It is hard work and therefore demands energy but also provides an opportunity for deep satisfaction. No one's therapeutic experience is exactly like another's and so it is impossible to predict how any one individual will feel, but therapy can very often lighten one's load at the same time as it demands energy. If one is struggling with the practical issues in arranging therapy-money, scheduling, allotment of emotional energy-it may be that one is also struggling with these very same issues in other areas of one's life. In therapy, one has the opportunity to talk about these things and perhaps understand them better. However, further exploration might reveal that the client does not struggle with these issues elsewhere, but was in fact frightened about starting therapy without being fully aware of it and that this created difficulties getting started. Once the practical arrangements have been settled upon, sometimes there are more complicated worries that come up. What if I don't like my therapist? What if therapy doesn't work? What if it does! What if I get worse? What if I get worse before I get better? The anxiety experienced around the idea of beginning this new, intimate and unusual relationship is understandable. I believe that it is really important to like and trust your therapist; however given all of the potentially confusing feelings around starting therapy, it is possible that one could be unclear about whether she did or didn't like her therapist. Unless you have a particularly negative impression of the therapist that becomes obvious to you in the first meeting, I usually recommend trying a therapist at least three times. There is a lot of information that needs to come out at the beginning and this can make it hard to get a feel for how you and the therapist are "clicking." I advise people to begin by going to a reliable source for a referral-such as a friend or a reputable organization-in order to narrow down the search. Even so, some people end up trying more than one therapist before they find the right fit. Obviously people come into psychotherapy with expectations. Doubtless these will change as the therapy gets underway and change again and again throughout the duration of the treatment. Anticipating this can cause a fair amount of anxiety and that is why it is important to find a therapist with whom you feel as comfortable as possible. Specific questions about what one can expect are essentially the work of an individual's therapy and cannot be addressed in general terms, except to say that the relationship with the therapist will ideally help the client to tolerate the unknowns in the beginning and to tolerate the "knowns" further down the road. To be sure, therapy isn't for everyone. It requires a real investment of resources and there are some people who simply can't make this kind of commitment for a variety of reasons. But I find it interesting that many in our current society view going into therapy as indicative of some sort of personal weakness on the part of the client, when it seems to me to be the opposite. Taking the risk in starting a relationship with a therapist, making the effort to understand oneself in deeper ways and facing painful feelings indicates courage and strength and a special kind of optimism. Susan Bachman, MSW, LCSW "Should
I Take Medication?" Medication can be an important adjunct to therapy and other healing interventions. When considering medications, there are many factors to evaluate. It is important to thoroughly assess one's symptoms and how much the symptoms are interfering with functioning and everyday responsibilities. It is important to consider one's current symptoms in the context of one's history and to evaluate to what degree and frequency these symptoms have been present in the past. One's medical status is another critical variable to be evaluated to ensure that a medical condition is not contributing to the picture since medical conditions can masquerade as psychiatric conditions. Drug and alcohol use can also make it difficult to ferret out what symptoms are due to substance effects as opposed to primary psychiatric conditions. Many people with an eating disorder have other psychiatric diagnoses. Sometimes these diagnoses precede the eating disorder and may contribute to the development of the eating disorder. Other times these diagnoses occur secondarily as an outgrowth of contending with an eating disorder. Coexisting diagnoses commonly include mood disorders, anxiety disorders and substance abuse. Depression is seen very frequently and medications can help to diminish symptom frequency, intensity and duration. Common medications include the selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Zoloft, Luvox, Paxil and Celexa. SSRIs can also be helpful in managing irritability, anxiety and mood lability that often accompany depression. If one has mood changes that alternate more clearly between states of depression and mania or hypomania, then a diagnosis of bipolar disorder is more likely and a mood stabilizer is the treatment of choice. Other non-SSRI antidepressant medications such as Wellbutrin, Effexor, Serzone and Remeron are also available if the SSRIs are not preferable. Finally, there are antidepressant medications that predate the SSRIs that are available and well suited for particular patient profiles. Anxiety can take many different forms. In brief, the anxiety disorders that commonly coexist with eating disorders include panic disorder, social phobia, obsessive compulsive disorder, generalized anxiety disorder and post-traumatic stress disorder. Panic disorder involves panic attacks. Panic attacks are abrupt, discrete episodes of intense anxiety and physical symptoms that often appear without an identifiable trigger and diminish within minutes. Social phobia involves impairment in social situations due to preoccupations with being seen critically or harshly by others. Obsessive compulsive disorder involves repetitive, intrusive, anxiety provoking thoughts that seem to be beyond one's control and/or repetitive rituals to help manage anxiety. Eating disorders have been conceptualized by some as being on the obsessive compulsive spectrum because of the obsessional ideation involving body image and size and compulsive rituals such as purging or exercising that need to be consistently followed. Generalized anxiety disorder involves consistent and pervasive anxiety and worry accompanied by poor concentration, irritability, fatigue and muscle tension. Post-traumatic stress disorder involves having experienced or witnessed a traumatic event with helplessness that is then reexperienced and accompanied by avoidance of related trauma stimuli and a state of heightened alert. Many of the aforementioned antidepressant medications are also equally powerful in ameliorating anxiety. Other common antianxiety medications include the benzodiazepine class (such as Valium, Klonopin, Ativan and Xanax) and Buspar, a nonbenzodiazepine. Benzodiazepines must be closely monitored as consistent usage can contribute to dependence and tolerance. There are other medications that have been found serendipitously to have antianxiety properties that are also frequently prescribed. As mentioned above, eating disorders have been conceptualized on the obsessive compulsive spectrum. Obsessive compulsive symptoms have been found to respond well to SSRIs in particular and may require higher dosages than that prescribed for other forms of depression or anxiety. This treatment strategy has also proven useful for eating disorders and is often utilized as one treatment option. In some studies, SSRIs in higher dosages have helped to diminish the anxiety provoking thoughts and behaviors as well as decrease relapse rates. As always, every person must be evaluated individually and the chosen treatment should be based on what the person and prescribing physician feel is the best fit. If you have any questions or wish to schedule an appointment, please feel to contact me at 773-929-6262, voicemail ext 6. Sandra Sheinin, MD "Dialectical
Behavior Therapy" From joy and love to hatred and disgust, emotional experiences are part of everyone's life. However, some people are more sensitive to emotion than others. They experience feelings quickly and intensely, and take more time to "recover" from strong emotions. Reasons for this sensitivity may include biological causes, as well as growing up in a family where one's feelings were ignored or dismissed as unreasonable. Emotionally invalidating family experiences deprive us of the opportunity to learn the skills we need to cope with strong, sudden emotion in healthy ways. Instead we may seek temporary solutions to emotional pain through behaviors that are destructive to our bodies, our relationships, and our lives, such as self-injury, disordered eating, or substance use. These solutions come with their own set of problems that eventually add to a sense that one's life is out of control. Dialectical Behavior Therapy (DBT), developed by Dr. Marsha Linehan, provides an opportunity to gain the skills necessary for identifying, experiencing and regulating emotions, in order to interact more effectively with ourselves and others. There are two components to DBT: skills training group and individual therapy. In skills training group, lectures and discussions focus on managing emotions, learning to be more effective in relationships, and learning techniques for tolerating distress. Individual therapy focuses on staying motivated, understanding how and why problem behaviors occur and identifying alternative, more skillful ways of coping. The overall approach to therapy is called "dialectical" because it seeks balance between opposites -- such as acceptance and change, validation and challenge, rigidity and flexibility. Underlying DBT is the practice of "mindfulness." Drawn from the Zen tradition of meditation, mindfulness is about attending to the moment, without judgment or impulsivity. DBT recognizes that everyone works hard at finding solutions to the problems in their lives. It is not designed to take away the solutions that you already have, many of which are probably very effective. Instead, DBT can help you find more and possibly better ways of solving problems than what you are doing right now, especially if what you are doing does not seem to be working for you. Cindy Butler, Ph.D. Cindy will be joining our team in June, 2002, as a post-doctoral trainee. Cindy received her Doctorate in clinical psychology from DePaul University. She recently completed advanced training through Northwestern University's Department of Psychiatry, with an emphasis on Dialectical Behavior Therapy. Cindy will be offering individual psychotherapy and a DBT group, which will be co-led by Kathleen Check. For more information about the DBT group, please call Kathleen at ext 4. "The
Art Within" The brush moves across the page and creates vivid imagery. Hands shape the soft clay into shapes and figures. The tools of art-making and other forms of creativity allow constant self-expression. Often, the words that describe our emotions become stuck inside. The process of art therapy encourages our thoughts to emerge in a safe and tangible manner. By building, painting or creating in group or individual sessions, we can establish positive connections with ourselves, others and our surroundings. Artistic ability is not necessary to fully appreciate the benefits of moving the brush or shaping the clay. We all possess the creative ability within us to participate in art therapy. Internal thoughts and sensations externalize via a safe and supportive environment, producing a somewhat cathartic escape. Kathy Mattea once said that we should all, "dance like no one is watching." When we express ourselves without boundaries, possibilities become limitless. The wildness and wonder surface as our hidden creative pleasures push our otherwise protected selves. The exposure can be freeing. Through the process, some of us may discover our talent for painting flowers or sculpting the human form. Others may use the art-making as a time to breathe, away from daily stressors. During the session, the therapist facilitates and guides the participants. However, the therapist allows clients to find their own way through the session. Art holds a power and when used as a tool, expressions flow. I believe in this power, as it has been a strength in my life many times. I now want to share this passion of mine with you, as we create together using various materials. I am currently a student at the Adler School of Professional Psychology and am in the Masters of Counseling: Art Therapy Program. I believe that everyone has the ability to participate in the creative process and the benefits constantly amaze me. Together we can create, inspire and discover art-making. Lisa Cohen, Art Therapy Student Intern Lisa is available for individual and group art therapy for those who want a visual way to express and explore issues. Participants must also be in individual counseling (not necessarily at The Awakening Center). No Charge; one time material fee of $25 requested. For more information contact Lisa at ext 7.
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