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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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Tag: psychotherapy

10 Jul

Where are the fat eating disorder therapists?

Ideas to Consider 5 Comments by Ashley @ Nourishing the Soul

A few weeks ago, a wanted-to-be scientist name Rachel Fox, bravely shared the fat-shaming she’s endured during her years as an undergraduate science major at a prestigious university. The overt and covert discrimination by the scientific community has led her to make the decision to say goodbye to the field altogether.

Her story should make us angry. Not only on her behalf for another human to have to endure insensitivity and harassment based on size, but also for ourselves. We’ve just lost a potential brilliant scientist because our society is so bigoted that we can’t see talent beyond a jean size. She could have been the next scientist to cure a terminal illness or discover a new planet. What if Jonas Salk or Stephen Hawking were told to avoid milkshakes and made to feel less than?

Fox’s op-ed piece left me reflecting on where else larger people are missing. I started to look around at my own field and wondered… how many aspiring therapists have changed course because they didn’t feel welcomed by the community?

In the field of eating disorders, I’d anecdotally suggest that there is a disproportionate number of clinicians with smaller bodies, as compared to the general population. I can take educated guesses as to why this might be. One reason might be that of fields in psychology, those with histories of their own eating disorders are perhaps drawn to working with this population. And while the vast majority of clinicians with their own histories of eating disorders are fully recovered, they may continue to be more aware of their own body size and possibly engage in some weight-control practices. More optimistically, it could be argued that these clinicians may be disproportionately smaller because they tend to be more mindful about their eating, practicing what they preach and not using food in unhealthy ways.

But the cynic in me wonders if there is not something more disheartening going on. Are we losing therapists of larger body sizes because they are not feeling welcomed into this field?

There is some research to suggest that this may have some validity. For starters, patients with eating disorders are often considered to be much more highly attuned to others’ weight and shape, including those of their therapists. While some with eating disorders claim that they “judge” only their own bodies, many others acknowledge feeling hyperaware of others’ bodies and even making assumptions about their therapists based on body size. A recent study (Rance, Clarke, & Moller, 2014) examined patients’ perceptions of therapists bodies and found that some patients assessed a fat therapist as less trust-worthy and more likely to lose control. This study asked patients to report on their experiences, but often the beliefs, assumptions, and feelings are less overt and conscious. It’s not difficult to imagine how a patients’ weight bias, particularly in the midst of an eating disorder in which weight and shape’s importance often gets elevated, can create a seemingly hostile environment for a therapist.

I wonder, though, if more of that hostility and distrust doesn’t actually come from within our own ranks, however. A study by Puhl, Latner, King, and Luedicke (2013) reveled weight bias among eating disorder professionals. In fact, 56% of us reported having observed our colleagues express negative comments about obese individuals. If more than half (and I’d suggest it’s actually much more than half) of us observe these behaviors occurring — and are we addressing them? — it’s easy to imagine how uncomfortable a fat therapist might feel in that setting.

Just as in the STEM field, the eating disorder realm is full of assumptions about what professionals should be doing with food. Insiders and outsides, explicitly and implicitly, seem to assume that someone who treats eating disorders should be of a middle-of-the-road weight, or even thin. If someone deviates from this, the assumption becomes that they must not really know how to manage a relationship with food. Thus, how in the world could they teach or inspire someone else to do the same?

Obviously — or, apparently, maybe not so obviously, these assumptions are unfounded. But they permeate our experience in this field and it’s easy to see why we don’t observe as much diversity in body shape and size among therapists.

Perhaps the best thing that we can do to avoid losing talent and diversity is to become ever more aware of own stereotypes and biases. Once we can acknowledge these, we can take more conscious steps to not allow them to guide our decision making and treatment of others in our field.

Do you think people of larger sizes are underrepresented in the eating disorder field? Why or why not?

 

**Please note that I don’t believe that there are not fat eating disorder therapists. I personally know many. I do believe that there aren’t as many as one might expect and that there are reasons for this…

10 Jun

Could Naming Your Eating Disorder Help or Hurt?

Ideas to Consider 163 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?

16 Dec

Don’t fall asleep in the cockpit

Ideas to Consider No Comments by Ashley @ Nourishing the Soul

planes

{image via pinterest}

Perhaps it’s not the best idea to start reading an article about plane crashes while 36,000 feet above the earth, but I wasn’t allowed to turn my laptop on yet and I had already finished my book. So it was The Atlantic article or SkyMall, and I’d already finished my Christmas shopping.

The article, appearing in the November 2013 issue, highlighted the perils of automation, the practice of turning over previously human-controlled tasks to the likes of computers. It started with the stories of two horrific aviation disasters in which the autopilot failed and the real live human pilot failed too.

The first accident involved a flight some of us might remember hearing in the news in 2009. On a flight from Newark to Buffalo, the automatic controls failed as the plane approached it’s destination, leaving the pilot to step in to take over control of the plane. In a state of “startle and confusion,” according to the investigation, the pilot pulled back on the yoke instead of forward, actually causing the plan to stall, spin out of control, and crash into a house. Everyone on board died, in addition to a person on the ground.

This and several other examples demonstrate a harrowing truth: while automation can make our lives simpler and, in many ways, better, it carries with it the risk of making us as humans complacent, and maybe even dumber. Essentially, when we begin to rely so heavily on computers to run our world, we lose the practice and knowledge necessary to know what’s going on and how to do the tasks ourselves.

While we might be happy to turn over many of these tasks – say, washing our clothes by hand or performing long division – there are effects we can’t ignore to losing the knowledge necessary to complete them ourselves.

I found myself considering how this phenomenon applies to my own work.  While computers don’t play a major role in my clinical work with patients yet, I see our flavor of “automation” at play in the manualized treatments that are increasingly becoming the preferred way of delivering therapy.

For those unfamiliar with the concept of manualized treatment, it refers to therapeutic approaches that are outlined in the form of a manual, with specific interventions and sequences of the interventions defined for the practitioner. Across diagnoses, manualized treatment has taken hold.

What manualized treatment treatment offers, and which can be invaluable to those struggling with mental health concerns, is a time- and data-tested approach to the illness. Creating more formulaic interventions allows researchers to study these treatments, much like we would study a medication, and see what works and what doesn’t. This can ensure that therapists aren’t out there doing voodoo treatment on people with serious mental disorders. Standardization – and automation – can improve outcomes.

But what this article left me thinking about was the times when it doesn’t. Being outside the walls of the ivory tower and working day to day with individuals struggling with eating disorders, I see on a daily basis how our “automatic controls” can fail. While a computer can be programmed to measure and assess wind speed, altitude, and obstructions, they cannot yet (fortunately, in my humble opinion) account for every variation of human experience.

The therapy protocols can’t tell you how to respond when your patient, with whom you’ve been working on reducing binging and purging, walks in and tells you her mother passed away last night. They can’t give you instruction on what to do when your patient gets so upset with you that he tells you he hates you and wants to kill you. The have no advice on how to navigate your patient’s unexpected pregnancy or sudden attraction toward you or even how to handle your own urge to reach out and give your patient a hug.

What I fear in our age of increasing reliance on manualized treatment – automation, in a sense – is that we as clinicians will end up like the pilots when we encounter something unexpected. We’ll startle and become confused, and have no idea how to proceed. The article references important research that tells us the failure to regularly practice and adapt prevents true learning leads to mistakes – sometimes dangerous ones.

Allow me to state clearly that I am not dismissing the importance of evidenced-based treatment. It is crucial that we continue to deconstruct and critically evaluate the treatment we are offering those in our care. What I am suggesting is that we can’t lose our humanity in the process. We have to practice doing it without the book, learning to sit with another human being and allowing them to bear witness to their experience. I don’t think that this piece of our work can be undervalued without serious consequences.

While I am a huge proponent for the advancement of technology in addressing mental health concerns, I hope that we don’t see a day where the therapist’s couch is replaced by the one in someone’s condo. Just as interesting and compelling as the developments technological science is the research that is telling us how human connection changes and rewires our brains.

We already know that a large part of the healing power of therapy can be attributed to the relationship. I hope that digital interventions and manualized treatment find ways to augment these healing effects, rather than detract from them. Therapists are pilots, steering a powerful human relationship across turbulent skies. We cannot fall asleep in the cockpit.

12 Nov

Can we treat binge eating and anorexia together?

Ideas to Consider 3 Comments by Ashley @ Nourishing the Soul

If I had a nickel for every patient with anorexia that has told me that their doctor has remarked, “I wish you could teach some of my overweight patients your tricks,” well… I’d have more nickels than I’d know what to do with.

Unfortunately, physicians aren’t the only ones who often see these two groups as opposite. Many of us think of the  underweight and overweight as existing on opposite ends of some wide spectrum: one group has an eating disorder and consumes too little, the other consumes too much. The fat can learn something from the thin, they surmise. Just don’t take it too far, of course.

In reality, people who eat too much or too little likely share space on one end of a different spectrum, with those who have a balanced relationship with food on the opposite side.

As a recent New York Times article points out, the recent inclusion of binge eating disorder (BED) in mental health’s diagnostic manual may help bridge the gap in how we think about these two groups. As we begin to recognize and understand BED, we start to see the many similarities the disorder shares with its more familiar counterparts, anorexia nervosa and bulimia nervosa.

But what happens when you treat these disorders together?

When I first started treating eating disorders, I thought it was important to have more diagnosis-specific programming. Would a larger person really want to sit in a room with someone underweight and talk about their body shame? Would someone underweight panic to face a person that they fear they will look like if they begin eating properly? Like some others in our field, I worried that the anxieties and differences in these groups would be a barrier to them really being able to benefit from treatment.

I felt that each population deserved their own specific programming that would target their specific eating issues. We could work on refeeding those who needed to regain weight and we could help those who overeat to learn how to feel comfortable eating less.

And then I learned a thing or two.

What I discovered was that the work was incredibly similar. Both groups were using food in a way that was not in line with their health, well-being, and values. They were using as a tool to manage their difficult experiences and feelings – whether they were restricting or binging wasn’t really the point.

Similarities in their personalities and struggles emerged quickly too. Both groups tended to be perfectionistic and have high standards for themselves. They both were known as caretakers and supporters to others among friends and family. In the midst of helping others, both groups tended to forget and deny their own needs. And both groups tended to be very critical of themselves and place a really high value on weight and shape.

The research tells us that those who continue to place a high value on weight tend to relapse, and I realized that lessening the power that weight wielded was the work that all of these patients needed to do.

Further, they all needed to eat. While the assumption might be that those who binge eat or are of a larger size just eat all the time, that isn’t the case. In fact, most of those I see who binge eat cycle between eating too little food and then eating a large amount. So, like the patients with anorexia, those with binge eating need to learn to eat full, satisfying meals regularly.

Perhaps most importantly, treating these two groups together allows for some really powerful work to be done and connections to be made. Having patients to come face to face with their hopes and fears allows them to discover that their is a real person on the other end of those stereotypes and assumptions. They discover that their expectations about what it means to be fat or thin are hardly the case, and they can begin to challenge their own beliefs. Sharing treatment allows us to combat weight stigma in a powerful way, and that’s an issue that we all face, regardless of size.

If you’ve been in group treatment, did you have mixed groups? Did you find it helpful or not? If you haven’t, what do you imagine the pros and cons or combining treatment might be?

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