Why we wait

The last few days I've been thinking about the question of why we wait to get treatment.  This question surfaced when a client e-mailed telling us she would not be in class this past week.  Her e-mail had said she had a family emergency where her "bad" dog almost tried to kill her "sweet" dog. From other details of the e-mail, this assessment would be about right since the injured dog wound up in a neuro ICU at an emergency vet clinic for four days and now needs constant care.

A., my boss, and I had discussed this client before.  She had not asked about private consultations, but we knew it sounded like she could benefit from them.  She lives with 5 or 6 German Shepherds, at least 1 or 2 of them have to remain separate from the rest, and the most recent GSD, her son's dog, has dog reactivity issues.  The latter had gotten in a dog fight several weeks prior to class, and her husband got bit.  Our assessment was that either something awful and traumatic would happen before immediate action would take place, she was in denial there was a real problem, or possibly her husband did not want to do private training due to time, cost, or only wanting to use a heavy hand so to speak (we run into this frequently)

Now, I'm not just pointing out this specific client, because we run into problem all the time.  In fact, ask any dog trainer, and most will say that a good 75% of their cases are related to fear and aggression.  Many times, people wait until there is a real problem where major damage has been done, instead of looking at all the warning signs that have been shown.  Sometimes, people do not even know what the potential signs are, so it is vital to continue education.

I think this entire thinking is very similar to eating disorders and other illnesses.  We often wait until we have a major break down before getting help.  Whether it is denial, validation purposes, or whatever, we wait.  We wait until it's almost too late, until the problem is acutely, visibly seen, until our bodies and mind begin shutting down from starvation, purging, compulsive exercise, etc.

In other instances, people still have the notion that this is just a phase for the ED sufferer, that the person will just snap out of it, that all they need to do is eat, and all will be better.  Other times, people fear the stigma of having a mental illness or that they don't deserve help.  Meanwhile, no treatment is done at all, therefore, the problem which might have been caught early has now escalated and snowballed into months and years of an eating disorder.  

This is certainly not to say that sometimes efforts are made by both the sufferer and other family members/friends and either treatment is denied/unaffordable or the sufferer refuses, but here, I'm focusing on the whole concept of waiting until things go from just awry to bad to worse to traumatic.

In some ways, it almost seems like human nature. Whether it is a dog's behavior, an ED or another illness, 

having some major trauma, break down episode forces us to see and realize things are not hunky dory.  It's sad that most times this is what it takes to get our attention. Imagine if we all took more of a proactive stance?  With dogs, there would be less dog behavior problems.  With those with EDs, more would get help earlier on and not fall into years and years of misery.

I have to say that with recovery, I've gotten to a point where it is easier for me to be more proactive than I used to be.  Therefore, I have less chance of falling into a deep, dark pit of despair.  It's not easy to change this type of thinking, but in the end, your life may be worth it.

Building a life instead of rehashing the past?

I recently read an interesting blog post on the treatment of borderline personality disorder at mentalhelp.net. Many people with BPD have had childhood trauma, and this is where therapy usually begins. The patient and clinician delve into whatever traumas they may have faced, what happened, how they felt, etc. Sound similar to eating disorders, eh?

In a new book titled Treatment of Borderline Personality Disorder –A Guide to Evidence-Based Practice by Joel Paris, a researcher and professor at McGill University, he offers a different viewpoint. In studying various forms of theories and controlled trials of psychotherapy of BPD, Paris concludes that the most effective BPD treatments all have one commonality. He says:

They focus on the present, and on the current issues a person is dealing with. According to Joel Paris, people with BPD don’t get better by uncovering memories and rehashing the past, but by using the past as a context for understanding the present. This includes validating and acknowledging a person’s life history, and then putting it behind them. What sets successful therapies for BPD apart is that, in one way or another, they teach people how to tolerate painful feelings and to how experience difficult emotions without acting upon them in self-destructive ways.

He goes on to say that how a person with BPD needs to give a commitment to making a life for themselves. The goal is to work on building a life worth living, while putting the past into perspective and learning skills to tolerate intense emotions. Building a life for oneself is by no means an easy task. It includes developing goals for the future, finding work, and building relationships...The trick is to diversify one’s interests, and to try to retrieve satisfaction and pleasure from a range of different activities, relationships, and emotional investments.

Much of what Paris proposes has similar connotations with DBT therapy, but I still think it needs to be heard more. So often in eating disorder treatment, it seems the clinicians want to focus too much on the past and not enough on the present. While I certainly think delving into the past is one integral part of therapy, it doesn't need to be rehashed but more than once or twice unless it is causing a complete detriment to the present. All the past does is offer context and understanding for the who we are and how we came to be. Once we learn that, it really is time to let go, move on, and live in the present. After all, the past cannot be changed, but you do hold the power to change your own future.

Note--*I'm currently working on one past issue which has plagued me for awhile, but I'm hoping after that to not revisit the past. More can be learned at post Revealing secrets

UCAN

The University of North Carolina at Chapel Hill is conducting a trial focusing on UCAN--Uniting Couples in the Treatment of Anorexia Nervosa. More information can be found at the link. I think this could be very beneficial as many times spouses, partners, significant others, etc. do not know how to help their loved one with an eating disorder. I think this could especially be helpful for the older eating disorder individual.

The one thing that boggles me about this is why this hasn't really been implemented sooner, or maybe it has just through family therapy? In any case, I hope it will just be another tool in the process of recovery.

The study is still open, so go to the link if you're interested.

Life coaching for eating disorders

I've always wonder how life coaching would be for eating disorders. Several well known eating disorder recoverers have ventured into this field. Caroline Miller comes to mind. In this snippet from The Democrat and Chronicle out of Rochester, NY, a transition program will begin in mid January for those who've finished eating disorder treatment but are still having trouble reconstructing a normal life. The program runs for eight weeks, is free, and will be led by Cindy Bitter, an anorexia survivor, certified life coach, author, and educator on eating disorders.

If anyone is in the east Rochester, NY area and participates in the program, I'd be interested in hearing your comments.

CBT-E and eating disorders

The hot article of the day is about about a "new" form of Cognitive Behavioral Therapy (CBT) called Cognitive Behavioral Therapy-Enhanced (CBT-E). It's interesting to see how the media decides to title the article. Words range from "potential" to "curing" eating disorders.

CBT-E, developed by Christopher Fairburn, professor and researcher at Oxford University, is an extension of the standard CBT treatment used for bulimia. Fairburn developed two forms of CBT-E--one focuses only on the eating disorder, while the other also delves into low self-esteem and extreme perfectionism issues.

In a study of 154 patients with bulimia and "atypical" eating disorders, results found the majority showed improvement and had sustained effects over a period of a year with both forms of CBT-E. Two-thirds of those finishing the study had complete and lasting responses.

Fairburn says, "Now for the first time, we have a single treatment which can be effective at treating the majority of cases without the need for patients to be admitted into hospital." He is now currently studying a large-scale trial using CBT-E with anorexic individuals.

I guess I'm not quite seeing what the big hoopla is and how this CBT-E is "different" from standard CBT. I'm certainly not a fan of some media outlets saying how this therapy could "cure" eating disorders. Perhaps, that's just the skeptic in me.

I guess my other qualm with all this is, well, shouldn't issues of perfectionism, low self-esteem, depression, etc. already be addressed in whatever therapy is considered?

Obviously, more information on this new psychotherapy needs to be given. Maybe those of you in the UK might know more about this since it is apparently increasingly being used there.

Here's an interesting article The Independent which asks similar questions and looks at both sides of the coin in how CBT is effective and also its problems.

Text messenging as a therapuetic intervention in eating disorders

A raise of hands how many people use text messaging with their therapists? I haven't come across many that have. Do you think it would be helpful?

In this article out of Nursing Times, Amanda Hazelwood, a consultant nurse, uses text messaging as an adjunct therapeutic tool along with therapy for treating eating disorder patients. The idea of text messaging is to help clients express their feelings and emotions without enduring the face-to-face contact, especially for those who may have social anixety issues or feel guilt and shame. Text messaging can also help build trust in the therapeutic relationship as well as allow the therapist and individual to see the mind frame she or he may be exhibiting. There is also the aspect of being able to "save" a message or help in immediate crisis.

Overall, I think this is another tool, showing how our technology is evolving into treatment. I think my only gripe is the possible overdependence issue with some individuals. I'm sure the policies would be outlined beforehand, but the possibility is there.

I've actually always wondered how many therapists implement these types of tools or whether they feel it goes beyond boundaries. Though I'd consider myself more of an e-mail type, many of my therapists have not been. Or rather, they'd let me e-mail but just never respond or they had a disclaimer about how the internet wasn't private and e-mails could be lost. This is of course all valid reasoning. Most times, if I was e-mailing it was about things I thought about after the session or things I didn't say, and sometimes it would be brought up at the next appointment, other times not.

These days, I stick to my face to face appointments as I think my body language says a lot about how I'm really feeling. Therapy is probably the only place where I try to let go and forget about living behind the mask. It's not always easy as my natural reaction is to hide, but C. seems to pick up on this and ask about it. I'm still not sure whether I'd ever go the text route. It feels funny to me. I rarley text anyway, so maybe that is why. But I think for this new generation where texting seems all the rage, text messaging might be helpful as a part of therapy as long as the policies were told beforehand..

Web based CBT versus face-to-face CBT

In a recent article from Psych Central, there is a new study underway assessing web based CBT )Cognitive Behavioral Therapy) versus face-to-face CBT for the treatment of bulimia. The principal investigators of this study are Cynthia Bulik, a well known researcher and head of the eating disorder program at UNC Chapel Hill and Marsha Marcus, professor and chief of the Center for Overcoming Problem Eating at Western Psychiatric Institute and Clinic, part of the University of Pittsburgh. Half the study participants will be at UNC, while the other half in Pittsburgh. Through randomization, half will receive 20 face-to-face group therapy sessions, while the other half will receive web based CBT. The web based CBT (CBT4BN) will have traditional, manual based CBT online as well as weekly online chat sessions, moderated by experienced therapists.

The goals of the study are to compare the effectiveness of CBT4BN to traditional CBT in reducing bulimia and if the attrition rate (rate of dropout) will decrease. Follow-ups after the study has ended will be at 3, 6, and 12 months. The hope is that if the CBT4BN is effective, it will allow individuals who do not have access or have difficulties with standard CBT to receive treatment.

I believe this study is still recruiting, so if you're interested, it may be worthwhile.
More information here.

Rant about insurance and other thoughts

Since my last post was about eating disorders and insurance, it reminded me of a few things. First off, I get really pissed off at insurance companies. Even for my 4 months of physical therapy I had this year for my hamstring and knee injuries, they covered maybe $400/month. I wound up paying nearly $3,000 out of pocket. For me, that's a lot of money on my budget. However, the interesting thing was that a month prior to physical therapy, I had some labs run (non Ed-related) which was covered without a problem--nearly $1,000. Sometimes I feel like why have this insurance when the coverage just seems like crap. And on individual policies, you can be really limited which further makes it difficult for any type of ongoing treatment mental health wise and beyond.

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Besides not being covered by insurance, there is the whole burden factor. For many, it is quite troubling. Individuals don't want to burden their families with the treatment of costs. This just makes the guilt even worse. At least for me it did.

Here's a vague conversation I had with my father in my mid-teens when the eating disorder had really taken force. He was very frustrated with me for not getting better/recovered. He said things like, "do you want to be emaciated looking, have a tube down your nose?" I replied with that I did not want that. And then he said, (this is jest of what he said, I can't remember it exactly word for word) "because you know, treatment costs a lot of money. I'd have to take money out of my savings. Do you want that?"

Talk about a major guilt trip. Of course, I answered with that I did not want that. The underlying factor of what I heard here is that I really wasn't worth it. Maybe it's one reason why I never got incredibly thin but remained just under the radar all the time. Even with my therapists, they'd ask something like "do you think you need to go inpatient?" I'd say I did not know, but what I really wanted them to say was, "yes, you need to go." At that time, I wanted the choice out of my hands. I thought if I was inpatient, maybe it would convince me that I was truly sick. That maybe if someone really advocated on my behalf, it would show me that I really was ill.

Inpatient never happened, at least not for the eating disorder (inpatient one time when I was 16 for suicidal tendencies which was a horrible experience other than finding coloring to be relaxing), but I'm beginning to realize that I really don't have to be inpatient to be better. Most of the time, the real healing only begins afterwards anyway.

Eating disorder lawsuits

We all know that insurance coverage for eating disorders is virtually non-existent or better put that we are often denied the coverage we really need and deserve. Last week, it was reported that the insurance company Aetna had settled their class action lawsuit among a number of eating disorder families. The Meiskins were the first to file the lawsuit in NJ, and 100 other families were listed thereafter. Aetna agreed to pay seven years worth of denied coverage to these families. Both parties have agreed to the settlement, but a judge still has to approve it. Let's hope he does. If it is approved, it really is quite a big victory for those with eating disorders who have had to battle insurance companies for treatment. Article here

Also to note, the Meiskins were featured back in 2007 on the TLC show ."Shalom in the Home." If you've never seen the show, Rabbi Schmuley uses mostly a family based approach to help his clients. His approach is centered on looking at the family as a whole and helping them rebuild relationships. I'm not sure the show is airing now, but I think there are other available videocasts you can download from the site.

Another class action case, also based in NJ, is with the insurance company, Horizon Blue Cross Blue Shield. The family of Janelle Smith say that the insurance company discharged Janelle when she was not healthy enough to be released. Within days of being discharged, she committed suicide.

Their lawsuit wants eating disorders to be covered like any other biologically based mental illness. The insurance company has supposedly agreed to reimbursing the Smiths The case goes to court this month. Article here

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It'll be interesting to see how this case turns out. So far 13 states have mental health parity laws which allows eating disorders to be covered like any other mental illness. I'm hoping with more cases like this and the convincing literature on genetics and biological components to eating disorders, it will bring bring about even more change. Hopefully, these small victories will turn out to become large ones. After all, sometimes change is slow, but with persistence, it can happen.

Expanding eating disorder treatment centers

I started this post on Wednesday, and then suddenly my computer just shut off. Ugh! It turns out the breaker in the fuse box which the computer is hooked up to switched off. Well, I tried turning it back on and it sparked. Yikes! I contacted my landlord, so hopefully an elecrician will be here soon. I really hate being computerless.

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Just read this online today. The Lucile Packard Children's Hospital, part of Stanford University, is expanding their comprehensive eating disorder program for individuals aged 18-21. I think this is good news as college is often a difficult time for people this age. Plus, actually being in a "hospital" setting, more insurance companies are likely to cover the costs. It's sad but true unfortunately.

Another center in northeastern New York is also opening called the Albany Medical Center. I don't know any other information about it but may be helpful to those in that area.

Also, Remuda Ranch, a well known eating disorders treatment facility, has recently expanded their services in treating anxiety-related problems.