Psychotherapy in the Age of Biological Psychiatry:
“Psychiatrists know about the latest drug trials, but they don’t always know about the latest clinical trials of psychotherapy"
How important it is that we not operate on the extremes, or in little niches. The progress in science and society should result in better outcomes and collaboration, not pendulum shifts that serve no one.
Only the geekiest among us will love this: The Cellular and Molecular Substrates of Anorexia Nervosa, Part 1 - as it isn't written for the average reader and took me two straight readings (hence my delay in posting it as I lately don't get four straight minutes to concentrate) to really absorb.
But I loved it. We need more of this thoughtful and intelligent higher level explanation of the disparate threads of knowledge out there. We need to get out of the ED world and get others to take up the ED information.
I can't wait for Part 2.
, from her father and brother.)If I could, I would slip this under the door of every family the day their dear child is diagnosed with an eating disorder:
D's memory of first refeeding meal
If parents knew from the start that the disease LIES and the patient needs us to take the long view and not take anything personally... imagine.
I've come home for a break between shifts volunteering at the Lion's Club vision and hearing screenings at my son's middle school.
Am I the only one who finds it perverse that the two things I've volunteered to do this year are for Donut Day sales and this health screening?
The Donut Day stuff cracks me up, because we've got this simultaneous dual message going on in the schools: Don't be fat! Buy a box of donuts! Don't eat junk food! School spirit equals eating donuts! Fun equals donuts! Don't eat! Eat! I am the only mom who isn't making comments about guilt and my backside and eating the whole box and skipping dinner. With every donut I say "Enjoy!"
The vision and hearing screening interests me, too. I hate to think that I'm volunteering in search of blog posts, but it is impossible to sit at the screening table and watch these young kids getting their eyes and ears checked and not compare it to the weight screening that also goes on in some schools. (Not ours. Over my dead BMI.) These kids are nervous as they approach the table, it's crowded in the trailer and the kids are self-conscious. They don't want to get it "wrong" and you can tell they think others are judging. They whisper their answers. They don't know which way to go, they confuse right and left. Poor dears.
One girl an hour ago looked close to tears as the Lion's Club guy came and did a re-check, asking me at full volume (he wears a hearing aid) "did she get those all wrong?" Then taking her sheet and telling her she can go now - without explaining what was wrong or how anyone would follow up.
I remember once my daughter heard the dentist say her molar development was "immature." She was crushed. We should be careful.
One girl didn't get all the numbers right and gushed "I just don't want to get GLASSES." I looked at her - through my glasses - and assured her they were fun.
One boy sat down ready to rumble: "I only missed two last time." "It's not a competition" I said.
Kids want to do well, and they don't want to look different or weird to their peers. Even a vision/hearing screening can be worrying and chaotic. The screeners are not necessarily reassuring and polite or thoughtful (I am, I hope, but some people are insensitive or dismissive. Others are sitting there worried about being judged by the other adults in the room - the testing procedure is tough to get a hang of. We got five minutes of training before the kids started filing in, and 'mistakes were made.'
I was, quite consciously, thinking of body mass/weight/fitness testing in schools as I was doing this - thinking about how I do help with one and would never with the other. The biggest difference, of course, is that the stigma of having poor vision or hearing is nothing compared to that of weight. The second is that vision and hearing screening can actually lead to health interventions that are real and helpful (there are no weight interventions for children, nor do we really know whether weight tells us much about health).
The greatest difference is this: telling a child she needs glasses won't lead her to do dangerous things to her eyes, or cause her to blame herself. That boy who beats the hearing test isn't going to be told he should be proud of himself for giving himself superior ears.
I'm going back now for another session. I feel especially gentle and careful to these little souls with their health sheets - for reasons they don't even know.
I like donut day better, even with its mixed messages.
** I'm back. Yes, there were some kids who come through there and clearly no one knew they could barely see with one eye or that they lacked peripheral vision. Yet on reflection I've decided these screenings aren't a good idea. Health measures shouldn't be done in a public assembly line, and amateurs shouldn't be doing the screening.
We're planning for a website overhaul at F.E.A.S.T., but before packing up and moving we want to do some housekeeping. F.E.A.S.T. members are invited to review the website http://www.feast-ed.org/ and fill out a survey online with suggestions and feedback.
http://www.surveymonkey.com/s.aspx?sm=PWPhEdSILISa6WobmmaClQ_3d_3d
If you prefer, you can email your comments and ideas to Laura@FEAST-ED.org.
Oh, what an insightful blog post:
"The Power of Expectations" by Dr. Ravin
And a heartbreaking reality:
"The therapist tells the patient that she must unravel the roots of her problems, and that it will take many years for her to recover. It does. "
The ending is profound:
"Bad therapy is not just ineffective – it has the potential to be every bit as harmful as a surgical error."
Now, for a moment, imagine the power of GOOD therapy!
Dieting mothers have anorexic daughters, study suggests...
Okay, I should not take the bait on this, but since I subscribe to a lot of news-feed services this "study" keeps landing in my inbox with a trail of increasingly offensive headlines.
I am painfully aware that families often get their information about healthcare issues from articles like these, and worse still that these types of pieces are what help form public opinion and mother-in-law conversations and the tsk tsk over coffee among one's friends when one is not there.
So, I'll take the bait.
This is not a "study." This is a poll of magazine readers. Polls are not science, they are not representative of the population; they tell you something about the market of that magazine.
Correlation is not causation. Both moms and their daughters are under similar and related pressures to diet.
The culture of dieting runs in families and social groups.
Eating disorders run in families - one's risk is 50-80% determined genetically.
Dieting is not the same as eating disorders.
Why do I expend so much energy trying to refute this kind of thing? Am I just hellbent on defending parents no matter what? Have I no sensitivity to the toxicity of a dieting environment and the influence of mothers on their daughters?
I spend energy on this because I AGREE that no one should be dieting, that some parents are terrible role models, and that an environment of dieting and body hatred is toxic. The question is whether an eating disorder is a sign of those things - and I would argue that an eating disorder is not a sign of anything except a predisposition to respond to dietary restriction/energy imbalance with a self-perpetuating mental illness.
When we admonish moms for dieting - something that our entire society is actively and delightedly and almost religiously ENCOURAGING - because it causes eating disorders we make two mistakes. One is that an ED diagnosis becomes a witch hunt for the bad influences in one's life when there is no evidence whatsoever that this helps prevent or treat an eating disorder: none. The second mistake is in mistaking dieting for an eating disorder.
Dieting is a choice, but the eating disorder that may be activated by a diet is not. None of us should be choosing dieting, in my opinion. Dieting is well-known to be futile, unhealthy, depressing, and sucks the life and fun out of life and our relationship with our body. Using food to change our bodies, our appearance, or our emotions is an inherently unhealthy activity whether or not you have the genes and biology to become horribly mentally ill as a result.
Moms need to be freed from the overwhelming pressure to diet and feel aesthetically inadequate, period. Moms need help learning and learning to model loving their bodies and their appetites and their biology - as do dads. Eating disorders cause horrible suffering for a small percentage of the population, which we then go on to blame on being too influenced by toxic surroundings - a horrible injustice. But dieting and our body-hating food-phobic culture hurts us ALL, and it needs to be stopped for its own sake.
I fear it is futile to rant like this, though. Even my friends and family don't get it. But thank goodness for blogging, it lets me say it anyway.
In parting, I'll leave you with the sidebar articles to the piece above - which tell you more about the reality of the blame-mommy-for-dieting-tell-mommy-to-diet culture we live in:
Related Articles
Hospital admissions for obesity more than triple
Junk food as 'addictive as drugs'
Exercising with a friend 'helps to lose more weight'
Diabetes jab better than obesity drug at cutting weight
Anorexia victim offered place at Cambridge University dies at 18
Blame Mummy, not Madonna, for low self-esteem in girls
More fodder for Halloween thinking: Liking Sweets Makes Sense For Kids
With a picture of scary Laura from a recent Halloween:
And yes, that is green flourescent eyeshadow. You'll have to imagine the black velvet hooded cape. Always wanted one as a child, but now I have an adult-sized credit card.
Ever given birth? Passed a kidney stone? Smashed a finger with a hammer?
Well, there's a reason for bleeping out the words we use on those occasions: cussing is a pain-reliever especially for women.
Two stalwart moms I know mentioned the therapeutic need to yell a blue streak as things "went pear-shaped" yesterday. In their honor I declare today as Curse at ED Day. For all the parents around the world who could use a good yell into a pillow, cry in the shower, speaker-damaging decibels on the car radio, or just a bracing round of 'f*&^%$ you ED' today, a tutorial:
(cover baby's ears)
An approach to Halloween candy that I really like: Ellyn Satter
***A student at Johns Hopkins University is looking for a parent to interview. Here is the description of her project:
"I am interested in interviewing an individual for a class assignment who has either been directly affected by an eating disorder and/or a professional who is working in patient advocacy regarding their experiences surrounding prevention, recovery and the disease itself. The interview can be conducted in person if they are in the Baltimore area or over the phone, whichever works for the interviewee. The interview itself will last about 30 minutes and will be completely confidential. This is only for class purposes and will not be published. Thank you so much for your help!"
If you are interested in helping this student, I'm happy to pass her information on to you. First come first served!
*** Added: Found someone. Thank you to those who volunteered!!
F.E.A.S.T. is a proud member of EDANN, and participating this weekend in a conference to tackle eating disorders - very exciting!
Yay, team!
If you got an email today telling you how to access the new F.E.A.S.T. newsletter, then you are a member of F.E.A.S.T.
If you didn't get that email, it's time for you to become a member.
The newsletter has information on an exclusive audio interview with an author of a new book by a Maudsley family, and announces a new service available at the F.E.A.S.T. site - you don't want to miss it!
I normally frown upon the custom of getting our news and health information from actors, but this one caught my attention: Glenn Close: Mental Illness: The Stigma of Silence
Is Close reading my blog?
(And if so, why can't people add "eating disorders" to the list of serious mental illnesses when they list them off. Too many syllables, I guess. We need a shorter name, people. Work on that.)
Reason 135 we need the public to have a better understanding of mental illness: there shouldn't be any stigma.
A comparison of stigma toward eating disorders versus depression
Sending congratulations to Jeanine at EDC on the birth of her daughter!
Welcome to the world, Nicki!
Want to help other families? Here's a free and simple way: there are so many books out there, it can be daunting to choose. If you've read a book about eating disorders that helped:
Review it or add it to the list on the F.E.A.S.T. site. http://feast-ed.org/bookreviewsbyparents.html
Another important place to write reviews is on the Amazon.com site. These reviews really do matter to buyers, and are widely distributed.
One quirk of Amazon is that you can't write reviews for a book if you didn't buy it AT Amazon. For that reason I can't review my all-time favorite book for parents: "My Kid Is Back" by June Alexander. I highly recommend this book, and ask you as a favor, if you have bought it there and found it useful, go review it: My Kid is Back.
Passing on some good links from the University of Chicago, The National Eating Disorders Collaboration and AED:
A post with more question marks than my editors would ever have allowed:
At first I hesitated to comment on "Early response to family-based treatment", out of fear that it would discourage vulnerable families pursuing Maudsley treatment. One thing I've noticed is that it takes a tremendously optimistic environment for parents to do FBT. But: knowledge is power.
We already know that early response to treatment indicates with some accuracy who will respond to inpatient treatment (goes for AN, BN and BED). In this randomized controlled trial, "Weight gain by Session 4 of FBT predicts remission at post-treatment in adolescents with AN in a clinic
sample."
This is an important clue to the strengths and the weaknesses of a family-based approach - at least as manualized and currently practiced. I can imagine many scenarios: that some patients have illness too intractable to respond; that families who are well-suited to this task will come through early; that families unsuited to this show that early; that the method is simply too inflexible or underpowered to cover the full range of families and illness in need, or that this approach is simply wrong for a percentage of families. We could theorize all day, and I'm sure we all will.
I take from this that families who are not making progress after the first month need another alternative. It is also my sense that many families need a LOT more help than they are getting to be successful at home-based re-feeding. I look forward to data on what happens in terms of long-term prognosis for those patients who do not respond early to FBT. Do they go on to worse outcomes regardless? Do they thrive with some other intervention? What IS the alternative?
I'm left with the continuing question of what the active ingredients in FBT really are, and which of them fail these families. I wonder what parts of FBT will then be discontinued: nutrition, family involvement, separating the patient from the illness, symptom focused treatment. If all the alternatives to FBT are in opposition to the principles of FBT then how will we know what works and why? Is this about FBT being the wrong direction or too lightly applied? What if FBT was done in a whole-family way IN the hospital or more intensively (as is done in 5-day intensive programs)?
Yes, my heart hurts at the parent reading this information who has struggled with a home-based approach and now feels defeated in the hardest and bravest thing he or she has ever done. Yet I do not wish for families to continue to struggle fruitlessly. We can't ignore or wish the data away - these are some of the best researchers in the business - but until we know of viable alternatives we do need to continue to ask: if not Maudsley, then what?
Among the names I've collected in my life, 李 淑 徳 may be my favorite. Chinese was my major in college and I lived in Asia as a young adult, speaking and reading Chinese as I made my living teaching English to other young adults. They were in my class because their moms thought they were enriching their minds. In truth, it was more of a socially acceptable group dating service.
Anyway, I used to speak - and sometimes dream in - a second language. Just enough to grasp the essential differences between Mandarin and English and to ponder the absurdity of my mother tongue. Chinese makes internal sense. English does NOT. The most common grammar question from my Chinese friends? "But, WHY?"
In Do Non-English Speaking Kids Get Dyslexia? we learn that dyslexia doesn't spare different writing systems, it takes a unique form according to the culture one is born into.
I have long believed that eating disorders are a brain malfunction that presents in different ways depending on the person's history and the culture around them. Notice I don't say I think these things "cause" the illness. I think it changes how it presents. Schizophrenia is similar: still a brain disorder, still real, but whether the person sees little green men or Guan Yin depends on the value system and myths of their environment.
Even the way we think of what "me" means has cultural influences.
Naturally, I bring this back to eating disorders. The fact that our society is in a self-satisfied crusade to criminalize body fat has an impact on those with a predisposition for eating disorders. It makes it harder for us to recognize ED symptoms AS an illness before it is too late. This morality-based campaign clearly confuses and makes recovery that much harder. We won't prevent eating disorders, and it may only reduce the suffering, but I think it is worth challenging the obesity hysteria as one of our time's most damaging myths.
In any language, Fat Talk Free Week is a good thing.
A sad example of how science - interesting science - is digested by the public information stream:
A Few Months of Talk Therapy Treats Bulimia
No wonder people are confused. Headlines like this, that take something useful like "Bulimia-specific CBT 'takes around 4 to 5 months'" and turn it into a meaningless and global prescription.
Every month or so some syndicated headline will declare eating disorders "biological" or "inadvertently caused by parents" or "on the rise" and everyone comments on it and then it is lost until the next headline. None of these headlines are accurate (disease is too complex to boil down to a single Eureka headline), and no one is convinced.These tag lines just get used by those who want to believe them or don't want to believe them as a "so there" against the other one. It matters not whether the headline stems from truth or good science or not: it is all blenderized into a tasteless sludge with every other pronouncement.
Anyway, don't stop at the headline here: go on to the abstract and the paper itself.
Things you wouldn't think were correlated with mental health:
Anxiety and postural sway
Finger length and disordered eating
So many people sent me this link: The Guilt-Trip Casserole - Dinner and the Busy Family because I'm the Family Dinner Queen. What I like best about this article, though, is that it brings up the correlation/causation issue.
Families who are likely to be having family meals are different from other families in a lot of ways: demographically, culturally, religious. While I do believe family meals were both therapeutic and diagnostic in my daughter's case it does not follow for me that family meals are preventive or a moral judgment. We didn't do family meals routinely before our daughter was ill, and I regret that more because it is a lovely and family-building experience than out of guilt. I do now suggest normalizing and prioritizing family meals for many reasons, mostly because I think we've stomped out what would seem to be normal and many of us need permission to adopt it again.
I like the Ellyn Satter idea that kids deserve adults in their lives who are competent and confident and reliable in providing meals. That structure is, like other parenting responsibilities, very individual to the parties involved. I'm still not great at planning and preparing family meals, and probably won't ever be expert at it. I don't iron well, either, and I am just stupid on my son's Boy Scout merit badge requirements. My kids probably don't need me to be perfect, though, just trying - and I am.
A wonderful, thought-provoking, and sorely needed examination of: Confidentiality in Adolescent Psychotherapy
I want to particularly endorse the following:
"I am relatively unconcerned when I meet an adolescent patient who lacks insight or motivation or who resists treatment. I am very concerned when the parents of an adolescent patient are unwilling, unmotivated, or unable to play an active role in their child’s treatment."
Parents need to be included and assisted, but we also need to Step Up.
Well, if you haven't already joined the conversation, you may want to. Lots of people in my bubble of the twitblogadvocatesphere are reading and commenting about Why Psychologists Reject Science. The comments section alone is worth the trip.
Adding to the discussion, Psychotherapy Brown Bag (a great read always) has thrown this in about the role of the therapeutic alliance. **
It gives me happy chills that we even HAVE this conversation. I'm a big fan of therapy: think every baby shower should come with coupons for Play Therapy and we should swap out Algebra for Mindfulness 101 and marriage certificates should include the cost of an on- call Marriage Counselor. I think the world would be a better place if we all would engage in therapy at least as often as we get our hair cut and car washed, and some of my best friends are therapists.
But my good feelings about therapy are matched with my concern about BAD therapy. Therapy based on antiquated and damaging ideas. Therapy provided by people who are themselves unwell. Therapy done according to politics or fashion or good intentions uninformed by current research.
For all the good that can come of a person or family coming together in therapy to address problems - and I have personally experienced so much good in a therapist's office - there are potentially tragic risks as well.
Good for those who are really discussing how evidence and empirical knowledge can inform the art of therapy. Shame on those who find even the conversation unacceptable.
**P.S. Adding this: Shrinking the Shrinks
Following on yesterday's post, I found this interesting: Back to School With Bipolar?
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