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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

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?

01 May

Five Things You Didn’t Know About Your Therapist

Ideas to Consider 10 Comments by Ashley @ Nourishing the Soul

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? 

 

18 Feb

When Eating Disorder Treatment Fails

Guest Post 4 Comments by Ashley @ Nourishing the Soul

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). 

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