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Ashley Solomon, Psy.D is a psychologist who specializes in the treatment of eating disorders, body image, trauma, and serious mental illness.

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14 Oct

Eating Disorders in the Ivory Tower: How Colleges Can Help or Hurt

Ideas to Consider 2 Comments by Ashley @ Nourishing the Soul

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{image credit :: Matt Katzenberger}

It’s easy to romanticize the college experience. When someone mentions my alma mater, my heart flutters a bit as I recall the excitement of a new syllabus (I am not being ironic, just so you know — I really am a nerd), meeting friends for lunch in the student union, warm spring days spent sitting on my porch curled up with a good… book.

But college isn’t a time of frivolity and freedom for everyone. And even those among us who had a great college experience face our challenges. A deeper look back quickly brings to mind all the things that made this transitionary time challenging: I was alone in a relatively huge place without anyone or thing that was familiar. I didn’t know who I was or exactly what I wanted to become. I was anxious about running out of money and scared I wasn’t wearing the right thing.

Of course, I wasn’t alone. I was surrounded by thousands of other students in the same exact boat, trying to navigate these choppy, unchartered waters. But most people weren’t talking about their fears of fitting in or getting lost in the shuffle. They were too busy drowning their anxieties in the alcohol that was suddenly copiously available or perfecting their AIM away message to sound just busy but available (read: cool) enough.

And, as a recent Huffington Post piece explored, there may be another reason that college kids aren’t talking about their feelings: they don’t want to get kicked out. The story looks at the way that universities are handling college mental health, staring by highlighting the experience of Rachel Williams who faced an eating disorder while at Yale.

The piece struck me because this is an issue that I face on a very regular basis as a psychologist. I’m constantly face to face with students who have been asked to leave their universities, chosen to take a leave, or soon facing the decision (their own or the school’s). I’m also often asked by universities to help provide a recommendation for whether a particular student should be on a medical leave.

What’s been fascinating to me sitting on this side of the couch is that there is so much variability in the way that universities handle issues of mental health. I’ve worked with students who have been in a strong place of recovery for a significant period of time, but their university won’t let them return until a specified period of time has passed. This is often a semester, but has been as long as a year. Other students I’ve treated have been essentially ignored at their schools, despite our best efforts to enlist the help of the university to grant a leave or provide services.

It begs the question of whether there is a best practice for universities in addressing students with eating disorders. While nothing formal exists for the field of eating disorders, it’s heartening to know that 55 universities very recently signed up to take part in The Jed & Clinton Health Matters Campus Program, a program evaluating mental health services on campuses. The universities will take part in self-assessments and commit to improving their practices.

I can only hope that one of the outcomes of such an initiative is to develop effective ways of managing individuals with eating disorders on college campuses. With prevalence rates of eating disorder symptoms nearing 20%, it’s not an issue that can be ignored.

Further, it’s not an issue that can be addressed with a one-size-fits-all approach. Taking the stance that students with eating disorders cannot continue with academic pursuits can be short-sighted. We have to consider the particular student and the potential impact of having them step away from their university. For some students, college can be incredibly helpful in the process of recovery, providing a source of focus and meaningful activity outside of the disorder and the chance to socialize and interact with people not trapped in the grips of their own disorder. Some students find that leaving school sends them into a spiral of depression and anxiety, feeling like all they have left in their lives is their eating disorder.

Of course, this is not the case for all students. Many very much need to step away from the school environment in order to give themselves a chance to really reflect and focus on their recovery process. College campuses aren’t exactly known for promoting great eating and health habits, and the stress of academics can sometimes make it impossible to participate fully in one’s own treatment. For students with severe eating disorders, taking time off to address their health — just as they would do with another health condition — can be life-saving.

The point is that protocols are nice in theory, but cannot forget to take into account the individual needs of individual students. While campus suicides and other deaths are heart-wrenching for a school, colleges also cannot react to student mental health concerns from a place of fear. This only leads to further stigmatization, which students with mental illness already face on a daily basis.

If you struggled with mental health issues during college, how did you university handle things? What kinds of practices do you think would be most effective in getting students the services they need? 

10 Jun

Could Naming Your Eating Disorder Help or Hurt?

Ideas to Consider 238 Comments by Ashley @ Nourishing the Soul

On the heels of a wonderful #aedchat, I’ve been spending a lot of time thinking about the concept of externalizing eating disorders. (If you missed the tweetchat, you can read the entire transcript here.) To grossly over-simplify, externalizing an eating disorder refers to the technique of considering the eating disorder as a separate entity from one’s self.

Jenni Schaefer, author of Life Without Ed, is often credited as being the first to really popularize this idea. In her book, now ten! years old, she talks about assigning her eating disorder the name Ed and coming to think of Ed as an abusive boyfriend, one that she loathed but was also afraid to leave. Jenni shares over the course of the book how creating this distance between herself and the eating disorder allowed her to garner the strength to begin fighting back, eventually making real change and forging a path to recovery. Creating “Ed” was a starting point for her in changing the way she saw herself and the disorder.

Many other therapeutic traditions have adopted a similar approach. Narrative therapy teaches individuals to reconceptualize their disorders garner a new sense of strength and the power to rewrite their stories. to In Family Based Treatment, for instance, practitioners introduce the eating disorder as a separate entity, a grave disease, to patients and families. The rationale is that the family needs to be united against this “intruder.” Indeed, many families come to this on their own. They observe how this awful “being” has seemed to come to posses their child, leaving at times a shadow of their loved one’s former self in its wake.

In my own work, I’ve heard from countless individuals how externalizing their eating disorder helped them begin to distinguish between their own thoughts and those of the eating disorder. Over time they began to recognize their true (“healthier”) self as distinct from this disorder who’s goal was to trick and deceive them. Once they were able to recognize this distinction, they could begin to attend more to the true self, letting the Ed or Ana or Mia fade further into the background (or kicking him or her to the curb).

While I observe how powerful an intervention this can be, I do find myself concerned that it has become almost an expected part of the treatment process. When one group member in an eating disorder group I run expressed that this didn’t resonate for her, other members told her that she would “get there” and seemed to indicate this as a sign of her not being further along in recovery.

Eating disorders can be so insidious and I think externalizing and visualizing them can be helpful in undermining their strength. But this doesn’t work for everyone. And not only that, I think there are some potential costs that come for some with treating the eating disorder as a separate entity. Hearing Dr. Kelly Vitousek talk at a conference a couple of years ago, I was struck by a number of these costs.

For one, I worry that it oversimplifies a very complex and nuanced issue. One of the issues that we continually challenge in eating disorder treatment is the practice of dichotomous (“black and white“) thinking, and creating two selves – healthy/sick or good/bad — seems to perpetuate that approach. It could be more powerful, in some cases, to consider the complexity of the disorder and acknowledge that the traits we may associate with each “self” — e.g. perfectionism with the anorexia — are not solely good or bad. Those traits are part of the person himself or herself and can be used in pursuit of more or less workable goals.

Further, while they are painful and destructive, eating disorders often emerge initially as a means of self-protection and safety. For some, a the world has become too dangerous or chaotic or unpredictable and the eating disorder serves an important function. To separate it from one’s self and villainize it could prevent one from fully acknowledging the role the eating disorder has played.

Some individuals end up feeling invalidated by this approach, that what they think or feel is treated by others as “just Ed talking” versus him or her. When I once remarked to a patient of mine that it felt like “Ed” was the loudest person in the room and I wished I could hear her instead, she became very upset and reminded me that she was the person behind all of the words, and it was important that I hear them all, not dismissing any because they were “Ed’s.” It was an important learning moment for me, and I’m cautious, even when a patient externalizes her own disorder, to not treat what is shared in that way.

And finally, could seeing the eating disorder as distinct from one’s self impair accountability? I’ve observed this go various ways with individuals with whom I’ve worked. I do think there can be a risk is over-externalizing, to the point where an individual feels that they are actually powerless over this much stronger being. The person feels that he no longer has any control, so why bother? It requires energy to fight a monster, and if someone is physically malnourished and weakened by the symptoms, they could feel unable to take on Ed, finding it easier to submit.

The bottom line is that this is an intervention that should be used judiciously. It’s not a one-size-fits-all approach, and one has to consider the individual or one’s self before determining if creating an “Ed” is the right way to go.

Have you used this technique in your work or recovery? If so, what was your experience?

17 Feb

Could a recovery app help you beat an eating disorder?

Ideas to Consider 10 Comments by Ashley @ Nourishing the Soul

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When people talk about how hard eating disorder treatment is, it’s not often the actual sessions with a therapist or dietitian or the meal group they’re attending that they’re talking about. It’s usually the time in between session that poses the biggest challenges for individuals working their way into recovery. And while the meetings with providers can help guide someone on the right path, it’s generally the time outside of those meetings that make up the steps to real recovery. That’s when real life happens.

Real life is hard work, and it’s the stuff that challenges all the plans and commitments made in the safety of a therapist’s office. Whether it’s developing a plan to utilize a coping skill or practicing mindful eating at each meal, memory and motivation can easily wane when someone finds himself on his own.

That’s why both professionals and recovered people alike decided that there had to a better way to help people stay connected and committed to their goals. If only there was a device that was nearly always with you that could track data and send alerts… and maybe it could even make calls too? Oh, yes! Your mobile phone!

Many individuals with eating disorders are downloading a secret weapon in their battle against their eating disorder. Tucked between their Instagram account and Candy Crush are mobile apps that are helping these individuals stay on track. There are a number of apps out there, but some of the most popular include Take Control, Recovery Record, and Rise Up + Recover.

How do they work? They harnass several of the factors that we believe are important to recovery and make them completely mobile. They center heavily around the concept of self-monitor, meaning that users can document things like what they ate for each meal, if they engaged in any eating disorder behaviors, and if they were able to practice copings skills. Many of the apps will offer positive reinforcement — a virtual high-five — when, for example, someone practices mindful eating.

Some apps allow that accountability extend to an individuals providers’ as well, allowing their progress and struggles to be seen in real-time by their therapists or dietitians. This can not only save time in the next session, but it gives more accurate and thorough information to the people who need it.

Apps can also help track your moods, eating patterns, and other factors and alert you if you are at high risk to engage in binge eating, for example. Many people with eating disorders report feeling that the time before a binge episode feels like their on “autopilot,” so getting a notification that to proceed with caution and reminder to go engage in some self-care could help stave off the behaviors before they begin.

Most of the app creators caution that they apps are most helpful in conjunction with traditional treatment, at least right now. A team at Drexel University will soon be studying if these apps could replace certain aspects of treatment at some point. In the meantime, though, apps can provide a great avenue of additional and unique support outside of the therapy room.

Nothing is a panacea, of course, and one of the issues that these apps’ developers are facing is that users sometimes abandon them not long after downloading. That’s where, I believe, using them as a tool in your ongoing treatment will help. When your therapist is checking in and helping facilitate the use, retention is likely to improve. And just like in therapy, it’s up to the individual to be honest and open when logging meals or determining the trigger for a purging episode.

But for individuals who are ready and willing and confront their eating disorder, apps can provide an effective, efficient, real-time tool.

Have you ever used a recovery app? If so, what was your experience like? If not, would you ever consider it? 

 

**If you weren’t able to join me for the recent AED TweetChat on recovery apps, you can read the transcript here.

03 Feb

Trigger Warning: Are These Warnings Really Helpful?

Ideas to Consider 3 Comments by Ashley @ Nourishing the Soul

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{image credit :: World Bank Photo Collection}

Amanda Marcotte, a writer over at Slate, recently 2013 the “Year of the Trigger Warning.” She points out that trigger warnings have proliferated across the blogosphere in the past year, expanding their reach in the type of sites on which they appear and content from which they attempt to protect readers. Marcotte highlights the outrage that was met by Shonda Rhimes when the show she created, Scandal, failed to provide a warning to viewers of a rape that was depicted on the show. Rhimes eventually acknowledged the purported mistake and tweeted, “I agree that a trigger warning would have been a very good and responsible thing.”

So what’s a trigger warning? While they’ve been used widely in the feminist blogosphere, trigger warnings aren’t particularly common in more mainstream media. They refer to the act of alerting a reader or viewer of material that could be potentially evocative and create distress. They often appear briefly but boldly at the start of a post or other media and list the specific content that might be disturbing to some individuals. Example: [Trigger Warning: Suicide, Rape]

Some suggest that trigger warnings are more common among feminist writers and artists because there is an increased attunement in these communities to the pervasive effects of trauma. The idea, it seems, is that these warnings allow individuals to make more informed and conscious decisions about what they are prepared to ingest. If someone has recently gotten clean from drugs, for instance, they may choose not to read an article with detailed descriptions of substance abuse.

Trigger warnings are all too common in the eating disorder community as well, at least in the community that is recovery-focused. There seems to be an expectation of curtesy among individuals with eating disorders and those who write about them to alert readers if the content could be disturbing or “triggering” to others.

But there remain a couple fundamental issues when it comes to trigger warnings that, to me, feel unresolved.

First, what does the term “trigger” even mean? Is it a noun or verb or both? It strikes me as an interesting word choice that has evolved to have so much meaning. The first definition listed by Merriam Webster for the word “trigger” refers to the lever that one finds on a gun to fire it. I think there’s a bit of irony there in using a word that refers to force and violence when talking about something evoking difficult or unwanted feelings.

The second definition reads, “something that causes something else to happen.” And this is where I struggle with the concept of triggers. From my vantage point, I see the idea of “triggers” referring to things that evoke strong emotions in the “triggered” person. Perhaps other uncomfortable experiences like re-enactments or flashbacks could occur to.

But I often hear the idea of triggers being used to refer to something that, like the definition says, “caused something else to happen.” But the truth is, it takes a multitude of factors for any given behavior or event to happen. Specifically, something that “triggers” one person to engage in self-harm may have no impact on someone else.

The chain events is more complicated than the idea of “triggers” allows. Take eating disorders, for examples. We sometimes use the analogy of eating disorders being like a gun. Genetics shape and mold the gun, the environment loads the gun, and certain events (e.g. bullying, dieting) pull the trigger. But if there was no gun to start with, or if it hadn’t been loaded, pulling the trigger would be impossible or non-eventful.

I personally feel that there may be an over-reliance on this concept. I think it over-simplifies the situation and externalizes the root of the feelings (e.g. “Seeing her eat that pizza triggered me to binge,” rather than considering what you were feeling prior to seeing her eat that, how hungry you were, the availability of binge food, etc.).

Back on the issue of trigger warnings in media, the other issue that is yet unresolved is the very basic question of whether these warnings are actually helpful or effective. For one, I think many people who may be most vulnerable to content (and who could potentially benefit from avoiding reading the post) are often the same people who will read it. This is part because there’s the fact that we are all a little rebellious (who doesn’t at least want to press that button that says not to press it…).

This is also because these are individuals who are emotionally struggling and often in need of support and relating. Personally, whenever I’ve struggled with something difficult, I’ve found myself seeking out stories of others going through the same thing. It made me feel less alone. Misery loves company, after all… So when they come across an article about something they personally have experienced (e.g. death of a friend, physical abuse, miscarriage), they may be more inclined to read it, even if they may be too emotionally vulnerable to do so.

Spending so much time recently turning this idea over and over in my head, I did a review of the research. I figured that that would help me better assess the utility of trigger warning. But it turns out that there’s really nothing out there that I could find addressing this issue. Basically, we don’t know if and how trigger warnings impact readers or viewers. I’d actually love to start doing some research on this, as it’s fascinating to me.

So we are left to rely on our own intuition. It could be that trigger warnings become a slippery slope of individualized censorship, or they could be protective of individuals who are too vulnerable in the moment for exposure to certain things.

I don’t have a firm answer, as I think this issue isn’t black and white and I like to consider what the data tells us before being more decisive on an issue (and there’s none! at least not that I’ve found — if you can, please let me know!).

I will say that I fear trigger warnings might be an example of falsely satisfying our own sense of altruism but not actually helping people. One writer had some interesting questions that he asked about trigger warnings, but summed up that he supposed they couldn’t harm anyone. I think it’s possible that they could (even while helping others). Perhaps perpetuating the idea of “triggers” could be harmful in and of itself, as it takes away from the complexity of given issues. Perhaps it gives us a false sense of security, or even keeps people in a pattern of avoiding things that would ultimately be helpful to have exposure to and work through (with a trained therapist, in many cases, of course).

But what do you think? Should writers include trigger warnings? Have they been helpful for you? 

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