You’ve decided to start therapy and you’re feeling a little nervous. Who is this random person to whom you’re supposed to spill your guts? Between the closed doors, tight lips, and vows of confidentiality, therapists can sometimes seem quite mysterious. But really, we’re just human beings with relationships, feelings, and – yes – problems.

At the risk of losing my therapist club card, I’m here to let you in on a few things you might have wondered about the person across from the couch.

1. Yes, she thinks about you when she’s not working. 

I find that my patients wander in and out of my mind a lot, whether it’s hearing about a treatment approach that I think could be useful in our work together or hearing a song that they mentioned a boyfriend once sang to them. Some therapists talk about “turning it off” when they lock up at night, and to some degree we do. We really are not “analyzing” everything that stranger says over cocktail wieners at our neighbor’s retirement party. But to think that we could know another so intimately and not find ourselves thinking (and yes, worrying) about them when we’re off-duty would be naive.

2. Sometimes, she wants to tell you to stop being crazy.

I once knew a therapist who had a stamp that printed the word “CRAZY!” in bright red ink. He actually never used it with patients (thankfully!), but he kept it on his desk, sitting there as a reminder that at times we all do things that fall in that category. All therapists have at one point or another wanted to tell (or shout at) a patient that they were about to do something totally stupid or were completely overreacting. A good therapist considers why that might be the case and helps the person reflect on their own behavior or thought processes.

3. She has her own set of “issues.”

As much as some might make you want to believe that it’s to the contrary, therapists are just as flawed as the non-therapist world. In fact, the majority of therapists I know are or, at the very least, have been in therapy. And I don’t know about you, but I think it’s much better that way. It’s impossible to escape life without a few bumps and bruises. I’d rather my therapist be aware that she needs support like the rest of us and be working through her “stuff” in her own therapy rather than on me. (If your therapist starts unloading his problems on you, head for the door!)

4. She might want to be friends with you.

It’s not unusual to have the desire to want to hang out with your therapist outside of your sessions. I mean, you’ve decided this person is trustworthy and likable enough to share your deepest fears. Why wouldn’t you want to grab coffee and watch The Voice with her? The truth is, we feel the same way sometimes. However, a good therapist likes her patients enough to want to spend time with them, but also clearly respects the boundaries of the relationship. Remember, the relationship is about you and your needs, not hers.

5. She cares about you.

The therapeutic relationship is an interesting one. It’s incredibly intimate and it involves the exchange of money. Strange, right? My patients sometimes ask if I care about them - truly care about them – given that they pay for therapy.  The answer is unequivocally yes. I absolutely care about them. If I didn’t, I would not only become complacent about my work (and thus ineffective), but I would definitely have gone into the wrong field. Therapists aren’t automatons who listen to someone’s woes without being affected. A good therapist, in my opinion, feels your experiences deeply and is able to separate himself enough to help you work through them.

Are there things you’ve wondered about your therapist? 

Loved ones of those with eating disorders can find themselves feeling confused and helpless when treatment just doesn’t seem to be working, A psychologist, eating disorder expert, and a personal role model, Dr. Dana Udall-Weiner shares a bit of her wisdom here on NTS today about this difficult juncture in the recovery process.

When family members first learn that their loved one has an eating disorder, most are quick to ask an obvious question:  What’s the treatment?   Which is usually followed by another obvious question:  How long will it take?

Given that we’re talking about conditions with intimidating, Greek-derived names like Anorexia, it’d be easy to assume that medical and mental health professionals have this whole treatment thing figured out.  You’d think that all that data would lead us to a well-established treatment protocol—one administered consistently, reliably, invariably to patients around the world.  Something like an antibiotic for the food-impaired psyche.

Yet the reality is less constant and less comforting: Anorexia, Bulimia and Binge Eating Disorder are conceptualized and treated in various ways.  In the story of eating disorder treatment, there is a loosely organized narrative, with many disparate threads.

You can imagine the disappointment and frustration most people feel when they learn this stark fact.  You may have felt that way, too.

Though we’re learning more all the time, eating disorder research is still in its infancy.

Here’s what we know:  Eating disorders most likely develop due to a multitude of factors which include genetics, ongoing biological processes, and environmental influences.  They are not “caused” by mom’s poor body image or dad’s vegetarianism; they are not inevitable in the children of adults who meet diagnostic criteria.  But there is evidence for heritability:  People are more likely to develop an eating disorder when a first-degree relative has one.  And we know that parental eating patterns, as well as attitudes about weight, impact children—for better or worse.

Here’s the good news:  There are some treatments that seem to be relatively good at reducing eating disorder symptoms.  But the most important word in that sentence is relatively.  Relative to other treatments, Cognitive Behavioral Therapy is fairly effective for Bulimia and Binge Eating Disorder.  Relative to other treatments, Family-Based Therapy is fairly effective for adolescents with Anorexia.

Sadly, this tells you very little about your loved one, and how he or she will respond to treatment.   And that’s the bad news.

During treatment, some individuals very quickly gain insight about why their difficulties began.  For example, many Anorexics will tell you that they actually didn’t feel particularly fat before the eating disorder began to eat away at their lives; rather, they were experiencing something overwhelming—either external circumstances or their own internal response–which seemed impossible to tolerate or control.  The answer, they found, was to restrict their caloric intake; this, at least, seemed to grant them a sense of mastery over their bodies (and lives).  But even an insight as profound as this does not guarantee weight restoration or recovery; for this, the individual actually needs to eat.

The act of eating, however, is never as simple as piling food on a fork and directing it toward a waiting mouth, just as refraining from vomiting is never as simple as avoiding a toilet.  These behaviors have meaning, and they become part of a set of behaviors around which the individual organizes her life.

So why isn’t treatment more successful at getting people to abandon these worn out patterns?

Treatment can stall for a laundry-list of reasons which include: physiological factors (either associated with the eating disorder, or co-occurring and unrelated); psychological factors, including undiagnosed or untreated conditions; attitudes and beliefs about recovery; therapeutic factors that relate to the type of treatment being conducted, the setting in which it takes place, or to the therapist; and environmental factors, which include things like family influence and the media.

But regardless of why your loved one may have plateaued in treatment (or even failed to leave the starting gate), you can take important steps like these to right her course and encourage recovery:

1. Learn all you can about eating disorder treatment in order to determine whether your expectations are realistic.
2. Share your concerns with the treatment team and ask how they think things are going.
3. If necessary, get a second opinion; consult with another medical or mental health professional to get feedback about whether your loved one’s experience is typical or cause for alarm.
4. Think about whether environmental factors might be reinforcing the eating disorder.  Some things to consider:  Is your loved one participating in activities—such as ballet or gymnastics—in which a thin body is idealized?  Is she benefiting from the eating disorder in any way, such as getting attention from parents or increased respect from peers?
5. Talk with her directly to see whether or not she thinks she’s making good progress; it could be that her decision to refrain from “fat talk” with friends represents a major accomplishment in her eyes, even if she’s made little progress in changing her eating patterns.
6.  Educate yourself about which eating disorder symptoms are most dangerous, so that you can assess how she’s doing, make informed decisions about her care, and accurately communicate your concerns with her treatment team.  For example, poor body image is generally less worrisome than vomiting after meals.

In some ways, eating disorder treatment can feel like the Wild West—vast, loosely mapped, and ruled by contending factions who each want to stake their claim.  But even on stretches of unmarked trail, we generally know how to steer (willing) people toward health and wholeness.

It is not enough.  It is what we have.  And with additional years of ongoing research, our cartography skills will only improve.

If you’d like to learn the specifics about why treatment fails, as well as why research findings don’t always apply to your child, please watch my video, “When Treatment Stalls or Fails: Why Your Child May Not Be Getting Better.”  You can find it on my website, ED Educate, (www.EDEducate.com). 

If you’ve been following the apparent outbreak of a tic disorder in a New York high school, you know that investigators there have ruled out environmental causes linked to the school itself. Parents, outraged by the Tourette’s sydrome-like symptoms that have plagued twelve teenage girls in the past several month, are demanding answers. Unsatisfied by the lack of results from school investigators, public health officials, and the victim’s own doctors, they recently brought in the Erin Brokovich team to explore the test the ground water and more.

Health officials are now calling the illnesses with which the young women are presenting conversion disorders. Conversion disorders are psychiatric illnesses in which a person experiences physical symptoms without a physical cause. People with conversion disorder can demonstrate things like blindness, lack of muscle function, paralysis, or seizures.

Parents are reportedly not satisfied with this explanation for their daughters’ and community members’ illnesses. Indeed, watching video of the young women unable to talk, write, or function normally is disturbing, and it’s easy to see how the Le Roy High School community would be frustrated.

As I watched the Today Show’s interview with a few of the young women and their mother’s, you could see the visible vehemence when Dr. Nancy Snyderman suggested that the root of these issues could be psychological. The parents and teenagers quickly denied that this was possible, their justification that they weren’t under any stress and that their symptoms were real.

The thing is, the symptoms in a conversion disorder are real too. The person truly is experiencing tics, or muscle weakness, or difficulty walking. They really do seize – anyone can watch. These individuals are not making up their symptoms (that happens when someone malingers), and their development is not in the person’s conscious awareness.

This last piece is the rub, of course. If it’s not under conscious control, the person isn’t aware that there’s a psychological cause, and so there’s no way for them to deny or disprove it. Patients sometimes say things like, “But I just know something’s really wrong. I just know!” And the thing is, they’re right. There’s something wrong, really wrong. The only difference between the symptoms of conversion disorder and the symptoms of a physical illness is in the treatment. Conversion disorder symptoms are not going to respond, at least not long term, without psychological help.

I admittedly have no idea about the origin of the symptoms among these New York teenagers, and I would never purport to know. But what I am very aware of is the cultural backlash against the idea that our minds can produce physical symptoms.

It’s actually a bit dismaying to see how negatively people react to this idea, and how vehemently they deny it. I want to ask these individuals where they think all physical issues originate – in our brains! Why is it so unimaginable to think that psychological stress could create physical symptoms?

Our brains regulate our hormones and every function of our body, and yet we tend to see our minds as distinct from our bodies. The effects of this disconnect are far-reaching. I think that this contributes to everything from fertility issues to the flu to problems with our sexuality to distorted relationships with food. This is not to say that that all of these things have only psychological bases – certainly, that’s not the case. But we often fail to see how our psychological functioning influences these processes, and in doing so miss out on a real chance of improving our health.

My hope is that, regardless of what is determined to be the cause of these Tourette’s sydrome symptoms in New York, the parents will encourage their children to seek psychological treatment. Even if the cause is environmental, these young women could likely benefit from support around the trauma of the past several months.

you might be as outraged as the community.

{image via pinterest; originally found at The Quilted Castle}

Despite having been one half of hundreds of therapeutic relationships over the years, I work hard to remember that for many individuals who sit down in my office, this could be the first time that they’ve entered into this experience.

I recognize that making the decision to go to therapy isn’t an easy one. It usually comes on the heels of deciding that something significant in one’s life isn’t working as she thought it should. Sometimes what isn’t working is incredibly profound, and touches nearly all aspects of her life. Or it may seem on the surface to be minor, trivial even – but hits on such valued parts of an individual’s life so as to push them into my office. Whatever the reason that someone decides to enter treatment, it’s a big decision and one that is never taken lightly.

So if you’re that person – you’ve decided to allow a trusted professional to help you make important changes in your life – you might want to know what to expect. While sitting down in a stranger’s chair is never easy, per se, being armed with an understanding of the process is key to developing the trust that is vital to the process.

Here’s what you can – and should – expect when starting therapy:

1. You’ll be asked why you’re there. It may sound obvious, but the therapist will want to get a thorough understanding of what brings you to treatment. Even if you’ve alluded to “relationship issues” on the phone, he will want to hear in your own words (and in more detail) how you think about the problem, and why you’ve chosen to get help now. Even if you think that certain parts are irrelevant, share them. It helps the therapist to help you if he has a richer context in which to understand the issue that concerns you.

2. You’ll be told about your rights as a patient. The therapist will spend some time letting you know about what you can expect from her and the process of therapy. She’ll likely explain that you can expect your information to remain confidential and secure, unless you are at risk of seriously hurting yourself or someone else. She should generally also let you know things like her fees, cancellation policy, how you can access your records, and more. The specifics will be based on the laws of your area and the specifics of her profession.

3. You’ll learn about the nature of the therapy relationship. The therapeutic relationship is quite different than other relationships that we are used to. When you think about it, it can actually seem a little strange. You’re pouring your heart out to a person who just met you recently and you know nothing about. But certain therapeutic boundaries are in place for a reason. You should be able to trust that you will not have to take care of your therapist’s needs and feelings. You’ll learn, likely quickly, what your therapist’s style is when it comes to this. Some may disclose some personal information about themselves, and you’ll need to decide what you feel comfortable with.

4. You’ll learn about the therapist’s approach. There are more styles and approaches of therapy than we could possibly discuss here, but they often fall along a continuum of directiveness. Some therapists will take a more active approach, asking you to do things like monitor and challenge thoughts and feelings and experiment with changing your behavior. Others will spend time helping you to develop insight into your patterns of functioning and work to provide a new relationship experience via the therapy itself. Others will do a bit of both. While it’s not always important to know precisely how things are working (in fact, it can sometimes steer you off course to get caught up in the details), you should check in with yourself to determine how comfortable you are with the therapist’s style.

5. You’ll be invited to ask your own questions. I encourage you to use this space to really be a savvy consumer. Questions that can be helpful to ask include: What kind of license do you have to practice? Do you have a supervisor or will you be consulting about my case? Have you worked with others who have my issue? What can I expect from therapy? Can I call you between sessions if I need to? How will I know if things are improving? If the therapist avoids these questions or doesn’t give you the answers you are looking for, I suggest proceeding cautiously.

It’s important to remember that the effectiveness of therapy is based heavily (very heavily, in fact) on the therapeutic relationship, so it’s vital to feel a good fit is in place. If you don’t initially, however, that might not mean the therapist isn’t for you; it could mean that you need to give the process time. Unless there is a significant issue, I always encourage patients to give a therapy relationship at least a few weeks for trust and rapport to develop. If these things don’t happen, I urge you to seek a therapist who will meet your needs. Remember, this is your treatment and your mental health.

If you’ve been to therapy, what has your experience been like? What would you ask a new therapist?