Night-vision cameras, heavy whipping cream, and “magic plates”: The fascinating world of Family-Based-Therapy (FBT) for anorexia

I think it was back in 2009 that I first stumbled upon the Around the Dinner Table online forum or what my best friend and I cleverly call the “Maudsley Mom Forum.” At the time I was already aware that Family-Based Therapy (FBT; also referred to as the Maudsley Method) existed. However, this was the first time I saw it “live” in action and it was actually quite terrifying.

When your kid asks, “Dad, what’s in this shake?” you’re going to need a story. And the story can’t be “about 75% heavy cream, 20% heavy syrup, and some other stuff for flavor.” The truth won’t fly. So give some thought to your alibi before you are asked to come up with an answer. It goes without saying that the kid can’t be in the kitchen when you are making a shake.

Make vegetarian chili and then dump a bunch of olive oil into it. 100 kcal per Tbsp is the oil. It is a good oil, tastes great, requires no explanation. Dump it into anything. What they eat is not the issue. The total kcals is. We don’t care how the kcals come in but they have to come in. Shakes, oils, Boost, HWC, whatever. It is all the same.

These are just a few selected posts from the “High calorie suggestions” thread that dates back to 2005 and is still going strong today. It’s pretty much what it looks like– a bunch of highly involved concerned parents of children and adolescents with anorexia trading tips on how to trick their little ones into packing on the pounds. Because recovery from anorexia is a simple matter of stuffing a person with food, right? Oh boy.

Here’s a brief description of FBT from the Around the Dinner Table forum:

Family Based Therapy (FBT) is a home-based treatment approach that today remains the only treatment proven effective in controlled trials for anorexia nervosa in adolescents.  FBT takes an agnostic view of cause of the eating disorder but instead places initial focus on re-feeding and full weight restoration to promote recovery. All family members are considered an essential part of treatment. FBT has been successfully adapted and utilized with adults of all ages. FBT does not focus on psychological therapies, though family therapy and individual therapies may be employed after full weight restoration is achieved.

From that description, it doesn’t sound so bad. And it is true that FBT has shown some promising results for children and adolescents with anorexia. However, I can guarantee you that the parents sneaking butter and heaving whipping cream into every ounce of their child’s food are not the ones seeing those promising results.

FBT abides by the principle that anorexia is a biological disease that can be fully cured through proper nutrition and weight restoration. There is no need to go searching for any “underlying cause” because it was nothing any one could have controlled. A person with anorexia is suffering from malnutrition and can’t benefit at all from therapy anyway until fully weight-restored. To treat anorexia, parents needs to stop everything they’re doing and devote their entire life for the next 6-12 months to their sick child. There’s no need to see a dietitian or to worry about meal plans or any of that because the goal should simply be on feeding the child. And what parent doesn’t know how to feed their own child? That’s like, a mother’s instinct, right?  Once the child reaches an appropriate weight, she will be back to her normal old self again. And if she isn’t, you just aren’t feeding enough! More food! Higher weight! Food is medicine!

I’ll admit it’s easy for me to get carried away with my sarcasm here, but there are aspects of FBT that I like. Obviously malnutrition affects the brain and certain symptoms like starvation-induced depression and obsessive thinking are alleviated somewhat with proper nutrition. It’s also true that some people truly aren’t capable of engaging in therapy when they are profoundly malnourished. And yes, having the support of a parent can be crucial for young sufferers.

The problem I have with FBT (that was an even bigger problem in its early days) is when people take it to extremes or overstate its effectiveness. Lying to a kid about what you’re putting in her food is always wrong. You think your kid is afraid of food now? Just wait until she finds out that 200 calorie homemade yogurt you’ve been giving her is actually 1300 calories of heavy cream and lard. Dismissing all potential environmental influences of your kid’s eating disorder is also wrong. Accepting that the way she was brought up may have contributed to her distorted beliefs about food and her body is not the same as admitting to being a bad parent. If you’ve been feeding her 5,000 cals/day for the past year and she still hasn’t “gotten rid of the evil ED” despite now being in the overweight BMI range, feeding her even more is not the answer.

I know FBT does “work” for some kids, usually kids who are diagnosed very early into their disorder who have parents who are truly equipped to deliver FBT in a reasonable way. This leaves a lot of people still suffering despite the hardcore FBTers making it seem like they’ve made some kind of miraculous headway in ED treatment. Not every family has the luxury of having one or both parents devote the majority of their waking hours to feeding and monitoring their child. Both parents may work long hours, if there are two parents. Even parents who do have the time, many are not be cut out for that kind of intensive work with their child. Not to mention, many children themselves are not cut out for that kind of treatment. Many end up resenting their parents and plummeting deeper into their ED as a result. And I’m sorry, I don’t care what anyone says, FBT does not work for adults. I mean, I know there have been a few rare cases where an adult with anorexia happens to have this really special (weird?) relationship with her parents and is totally okay putting her life on hold and being somewhat force-fed by mommy and daddy, but this is clearly not the norm.

I’ll admit I used to spend way too much time perusing the Around the Dinner Table forum out of sheer curiosity and morbid fascination. My friend and I would send each other links to particularly outlandish posts asking, “Can you believe this?
magicplateAre they for real??” Yes, they were for real. One clever dad getting all excited over his new “night-vision” hidden camera to catch his daughter sneaking out to exercise at night. And don’t even get me started on the “Magic Plate…”

I sometimes wonder how things may have been different for me if I was given true reasonable FBT as a newly diagnosed 12 year-old. Maybe all I needed was gobs of hidden oil infused into my food and another 20 lbs? Heh… doubtful. I can’t seriously picture either one of my parents having any luck sneaking crap into my food or convincing me to eat off some headache-inducing “Magic Plate.”

To reiterate, I am not completely anti-FBT. It has its place when delivered in a reasonable way. And actually, it was my discovery of Around the Dinner Table seven years ago that initially got me fired up about some very important issues in the world of eating disorder research. I plan on expanding on this topic in my next blog post, so stay turned!

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To anyone who may be subscribed to my blog through email. . .

Hi readers! I just realized that for anyone who may be subscribed to my blog by email, the posts are actually displayed right in the email message itself, but the formatting is often all messed up. 😦 I don’t want anyone JUDGING ME (lol) for my messy ugly formatting, so please just click on the link in the email which will take you directly to the post on my blog with correct formatting.

Thanks! 🙂

Who’s judging who?

I have a persistent fear of being judged. I fear people judging me for big things like what I choose to do for a living and who I spend my time with, but also for things like what I choose to eat and how I raise my cat. We all know people who claim they don’t care at all what people think of them, but I think everyone cares to some degree. I used to care far too much, and I probably still care too much, but I’m working on that.

I tend to look younger than my actual age, which is a positive in most ways (who doesn’t want to look young? I sure hope it continues) but it can also be an awkward thing, at least for someone as sensitive as I am. Usually when someone finds out my real age (32) they have to tell me how shocked they are, and how they assumed I was in my early to mid 20s. A sensible person would be able to take this and think, “Cool! I look young!” but I kick into over-analysis mode. I tell myself that the reason people think I’m so young likely has nothing to do with how I look. People think I’m young because of where I am in my life and my career. This has long been a major theme for me and I can’t tell you how many people (therapists and friends alike) have tried to make me feel better by telling me things like “There’s no timeline of life, everybody’s different!” or “you’re right where you should be!” I appreciate this, but let’s face it, had my eating disorder not been such a major force for so long, I would be in a very different place. I had goals that sadly were never achieved.

That said, I am generally satisfied with my life right now, so maybe I shouldn’t complain? I used to really hate phrases like “everything happens for a reason” or “you’re so much stronger for having gone through ______.” I felt like it invalidated my struggle– sure, everyone goes through difficult stuff and can learn from those experiences. However, with certain very traumatic events or extremely dark times in mental illness, I found it almost offensive to suggest that anything positive could be taken from those experiences. I got more than a little upset when an overly cheerful therapist said to me, “Well, you’ve been through a lot, but I bet you wouldn’t change a thing if you had to do it all over again. Those experiences made you who you are today!” Ugh, just… no.

These days I can see more of the gray area. There are absolutely things I would choose not to experience as well as choices I would make differently if I had the chance to “do it all over again.” That said, thinking about those things is kind of futile. I can’t go back and dwelling on past experiences or mistakes only brings me down.

Honestly, one of my reasons for wanting to open up about my past was to let people know that there were legitimate reasons to “explain” why I am where I am today. I didn’t want people to think I was just lazy or unmotivated and that’s why it took me eight years to graduate from college, or why I spent most of my 20s working at places like Bath & Body Works instead of having a “real job.”

I also used to constantly worry about people judging me for my life choices, and I even confused myself into thinking I wanted certain things because that’s what I was “supposed to” want. I’m not one of those people who worries about finding a husband or having kids before I’m too old. I actually don’t think about those things at all. Is this weird? Maybe, but I’m learning to be okay with it. Back when I was really deep in my eating disorder I assumed I just didn’t think about or want those things because I was so consumed by my disorder. However, after years of being in a better place I find that I still don’t really care about those things. I’m not completely opposed to the idea of one day being in a relationship or adopting a child, but this certainly is not a topic on my list of everyday worries (and thank god, because that list is long enough). I’m lucky that in reality I don’t have too many nosy people asking me why I’m not dating or why I’m not worried about my “biological clock,” but I know some people get a lot of this. I wish people would stop. Not everyone wants to date or get married. Not everyone wants to have kids. Some people can’t have kids.

When I would bring these things up in therapy my therapist would ask, “Who is judging you for these things? What are they saying?” and I could never give her a quick answer. The truth is, very rarely does anyone ever explicitly question me about these things. I’ve always just been worried that people were silently judging me for all of it.

Sure, if it wasn’t for my eating disorder and other things, I could have finished college in the standard four years and gone straight to grad school. I could have had my PhD by the time I was 26 or 27. I could still be living back East, working a completely different job, making a lot more money. Would I be happy? Maybe but maybe not; there are no guarantees in life. These days I try to appreciate where I am. Some people who have been through what I’ve been through never make it nearly this far. Some spend the rest of their lives on disability, unable to function well enough to fulfill any of their dreams. Some also die. I eventually did graduate from college and even went on to get my master’s degree. I’m working for an amazing agency alongside people I love. I hope to continue to grow here and see where it leads me.

Diagnostic Disarray: Implications of the DSM-5 changes to the anorexia diagnosis

As anyone involved in the field of mental health knows, the most recent DSM (the DSM-5) was released in May 2013. Although that was three years ago, people are still adjusting and reacting to the changes. In this blog I will explore this newest edition’s changes for eating disorders, particularly the changes for the anorexia diagnosis. At first this topic may seem a little dull– who the hell cares about the detailed criteria for an eating disorder? Isn’t that stuff only relevant to the doctors and therapists doing the diagnosing? Well, you might think, but I can tell you that for many people with eating disorders, this stuff matters a lot. Too much, probably. . .

But first, a little context for my friends reading this who are in a completely different field and have no idea what this DSM business is– The Diagnostic and Statistical Manual of Mental Disorders is a large book published by the American Psychiatric Association that is used by various professionals (e.g., therapists, psychiatrists, researchers, insurance companies) to guide them in diagnosing and understanding mental disorders. This is the standard manual used for mental disorders in the United States, but other parts of the world tend to use another manual called the ICD-10, which covers not only mental health conditions but physical conditions as well.

The previous DSM-IV-TR listed three main eating disorder diagnoses– Anorexia Nervosa, Bulimia Nervosa, and Eating Disorder- Not Otherwise Specified (ED-NOS). When an individual’s symptoms did not fit into the criteria of the anorexia or bulimia diagnoses, that individual was given the ED-NOS label. The new DSM-5 added five diagnoses to the eating disorder chapter (now called “Feeding and Eating Disorders” abbreviated “FED”– how clever). Now, in addition to anorexia and bulimia there is Pica, Rumination Disorder, Avoidant/Restrictive Food Intake Disorder (AFRID), Binge Eating Disorder (BED), and two “umbrella” diagnoses– Other Specified Feeding or Eating Disorder (OSFED) and Unspecified Feeding or Eating Disorder (UFED).

Another major revision to the eating disorders chapter was relaxing the criteria for both the anorexia and bulimia diagnoses. An individual can now be diagnosed with bulimia while having fewer binge/purge episodes per week and having these symptoms for a shorter length of time. Similarly, an individual can be diagnosed with anorexia without meeting any kind of specific weight criteria. One of the biggest implications of these changes is that more people can now be diagnosed with either anorexia or bulimia, which a lot of people consider to be the two “major” eating disorders. Before, about half of all individuals diagnosed with eating disorders were given the ED-NOS label, which insurance companies did not always take as seriously (and therefore were less likely to cover treatment for). For this reason, many people were quite thrilled about these changes. The thought was, the more people diagnosed with the “serious” eating disorders, the more people would be able to access treatment. Yay! Life is fair again! Everyone’s going to get better now!

Except… not so much. I saw problems with some of these changes before the DSM-5 was even released, and I know I’m not the only one. First of all, if the problem is that people were being denied treatment because they weren’t being diagnosed with the “serious” eating disorders, the solution should not be relaxing the criteria of those disorders. The solution should be to fix society’s messed up notion that only certain disorders are worthy of treatment. I have no brilliant ideas on how to do this, but it seems completely counter-productive to start rearranging things so that people can now be classified as having anorexia or bulimia so that doctors (or insurance companies, or who/whatever) take them seriously. Isn’t that letting them win?

Eating disorders are perhaps a unique category of mental disorders in that the sufferers themselves are often very emotionally invested in their given diagnoses. I don’t believe there is any other family of disorders where people are so personally tied up in their specific diagnosis. Of course this is not always the case, and it has certainly become more common as information has become readily available on the internet (i.e., before you could easily google “diagnostic criteria for anorexia” most people probably had no idea what the actual criteria were, or that criteria even existed).

There is an unspoken belief system around the “hierarchy of eating disorders” that is probably going to come off as very strange to anyone who has never dealt with an eating disorder. I don’t want anyone to get the wrong impression here. All eating disorders can and do lead to miserable existences, and what I’m about to say should not be taken to mean that people actually want any eating disorder. Yes, “pro-anorexia” is a thing, but the majority of those people either do not have real eating disorders (and never will) or are in the very early stages when the allure of such a “lifestyle” is still novel and enticing. Once they fall a little deeper into the disorder I can guarantee you they will no longer find it cool or desirable. That said, people often remain very attached to their given diagnosis, believing it to reveal more about them as a person than it was ever meant to reveal.

Anorexia has long been seen as the most “desirable” eating disorder. If you’re going to have an eating disorder, it damn well better be anorexia because at least that means you are (a) thin, (b) in control, and (c) taken seriously. Bulimia is often considered the disorder for the “failed anorexics” who could not keep up with the pace of behaviors needed to lose weight or remain underweight. ED-NOS is the disorder you were given if you weren’t thin enough to be anorexic or did things like (gasp!) binge without purging.

Maybe an anecdote will help here:

I once really took it to heart when a doctor recorded my diagnosis as bulimia when my diagnosis was actually anorexia- binge/purge type. I know, the horror! At the time I was well below the 85%/17.5 BMI “cutoff” for anorexia and assumed this mistake in diagnosis meant I really did have an unfortunately proportioned body that makes me appear way larger than my weight would suggest, which has always been my “disordered” (according to the professionals) belief. I spent an entire therapy session crying about this until I finally accepted her alternative explanation. It wasn’t that this doctor thought I looked overweight, or could not recognize that I was quite underweight, but that she was a primary care physician who had no experience diagnosing eating disorders or anything out of the DSM. She probably just heard “eating disorder” and “binge/purge” and immediately thought “bulimia.” I saw her for all of five minutes. It’s likely she had no idea that individuals who binge/purge but are underweight get diagnosed with anorexia- b/p type or even that different sub-types of anorexia exist. Hell, I’ve even come across eating disorder “specialists” who are unclear on this.

Does this all sound crazy? It should because it is, although I’m not sure who is really to blame here. How did we become so obsessed with diagnoses? Why are some seen as superior to others? Are there other families of disorders that have this same kind of “hierarchy?” (I’m truly curious to hear people’s thoughts on this. . .)

But back to the point of this blog– I want to look specifically at the changes to the anorexia diagnosis that came with the DSM-5. The previous DSM listed four major criteria, plus divided the disorder into two sub-types. To summarize, a person had to show the following:

(A) Refusal to maintain a “normal” body weight (defined as less than 85% of the “expected” weight for age/height, or below a BMI of 17.5)
(B) An intense fear of gaining weight or becoming fat, even when underweight
(C) A disturbance in how one sees her/his own body, and “undue influence” placed on the importance of body size
(D) For postmenarcheal females, amenorrhea (an absence of at least three periods)
(E) And finally, one was classified as having either “restricting type” or “binge/purging type” (because yes, contrary to popular belief, many people with anorexia who are underweight do binge/purge)

The DSM-5 made several notable changes to these criteria. First, the focus was turned to behavior rather than attitudes, by changing the wording in criterion B to “persistent behavior that interferes with weight gain” and removing the word “refusal” from criterion A. I like both of these changes. I always thought the word “refusal” was a little strong, and falsely made the disorder out to be one of choice. Also, for some, anorexia really isn’t about a fear of being “fat,” but rather an unexplainable compulsion to eat in a way that prevents them from maintaining a normal weight. The DSM-5 also removed the amenorrhea criteria, which I also support, as there have been documented cases of females continuing to menstruate even at emaciated BMIs.

The change I have a problem with is the removal of the weight criteria for a diagnosis of anorexia. The DSM-5 removed the 85% marker and replaced it with the very vague “significantly low body weight.” At first, this seemed like a welcome change. I mean, who’s to say someone at 86% of their expected body weight is any less sick or anorexic than someone at 84 or 85%? And who determines what “expected body weight” really is anyway? Certainly there are people who naturally settle at higher or lower weights than others. And certainly, a person who drops 40 lbs in a few months by restricting to 600 calories a day while excessively exercising and purging has a problem, even if their weight is still in a “normal” range. Medical and psychological consequences of these disordered behaviors can occur at any weight, and should not be overlooked just because a person is not yet in an “anorexic” weight range. My problem with the removal of the weight criteria does not mean I think people need to be a certain weight to be considered sick or deserving of help. My problem is that I don’t think lumping these people into the anorexia diagnostic category is the answer because (a) it perpetuates the idea that anorexia is the only eating disorder worth taking seriously, so the only way to get anyone help is to label them as anorexic and (b) it creates a very ambiguous (and therefore in many cases, useless) diagnosis in terms of understanding the unique characteristics of anorexia that are indeed attributable to low weight.

I’ve already addressed the first point so I’ll move onto the second point– the fact that the revised criteria in the DSM-5 lead to a poorly defined and sometimes even useful diagnosis in terms of understanding anorexia. Eating disorders are mental disorders, yes, but there has been plenty of research looking into the unique medical and psychological features of anorexia that are present specifically due to an individual being significantly underweight. I highly recommend reading Klein and Walsh’s “Eating disorders: clinical features and pathophysiology” for more on this (I’m a total nerd and have a copy of the full article so you don’t have to pay for it– just ask and I’ll send you a copy 😉 ).

You would think the fact that the DSM-5 still specifies that a person must be at a “significantly low body weight” would eliminate this problem. I truly think this change was well-intentioned, and made to give clinicians freedom to use their own clinical judgement without having to rely on a concrete weight cutoff. The problem is, the lack of a concrete cutoff has actually led to a huge range of ambiguity on what can be considered “significantly low body weight.” I have come across individuals who admit to being well into the overweight or even obese BMI categories while also claiming to have a diagnosis of anorexia. I hope this doesn’t come off as insensitive, but that does not make sense. I know some will claim that although they are not technically underweight by BMI standards, they are indeed under what is “ideal” for them personally. This may be true; they may have a naturally very high set-point. These people may very well have eating disorders, but they do not have anorexia, at least not how that disorder was originally conceptualized and researched for most of its existence.

Think of it this way– you are a new therapist intern who is just starting a rotation on the ED unit of a hospital. You are assigned two of your first clients. One is a woman who has a BMI of 11 (undeniably “significantly underweight”) and the other has a BMI of 28 (high end of the “overweight” BMI range). Both are said to have diagnoses of anorexia. Are you a little confused? Lost as how to proceed? Probably. Although you don’t have a deep understanding of eating disorders, you have studied them and were always taught that anorexia was a disorder characterized by fears of gaining weight and behaviors that led to an individual being underweight. Treatment usually involves therapy but also nutritional intervention that helps the client return to a normal weight. But here you have an overweight client who is also “anorexic.” Does this person get the same treatment plan as the severely underweight client? Does she also need to gain weight, despite already being overweight? Should you be discussing the same things in therapy with this client?

This example may seem extreme or even absurd, but situations like this are actually occurring due to the changes in the DSM-5. To complicate matters, there is also now an “atypical anorexia” specifier included in the OSFED category. This is reserved for people who exhibit many of the behavioral criteria for anorexia without being underweight. This means that the same client could be diagnosed with regular old “anorexia” under the actual Anorexia Nervosa heading, or with “atypical anorexia” under the OSFED heading. With the concrete weight cutoff, this would not be an issue.

I hesitated to post this blog because I realize it is a sensitive issue for many. I know a lot of people have not been taken seriously because they don’t “look anorexic” or because their symptoms do not match perfectly with what is outlined in the DSM. I’ve experienced this myself. The way therapists/doctors/other professionals have treated me has definitely been influenced by the way I look. I have always been treated as more sick/worthy of attention when at very low weights even when I’ve been suffering just as much mentally at less underweight or even normal weights. And I won’t deny that this has probably contributed to my inability to completely give up my own eating disorder. Hell, the fact that I just wrote an entire tldr blog about this stuff may also say something about me and how important this stuff still is to me (and maybe shouldn’t be? Who knows). So please, don’t take my arguments in this blog to mean I’m one of those diagnostic snobs who wants to keep deserving people from getting the help they need all of the sake of keeping these diagnoses “pure” or some similar bullshit. I do hope this post was at least interesting to some, even if it just opened people up to the complexities and controversies that exist within the mental health system.

On that note, maybe anyone who exhibits any symptoms of an eating disorder should simply be diagnosed with “Eating Disorder.” Short and sweet; no confusing criteria, qualifiers, or subtypes. Just kidding, I’m not actually proposing this. 😉

 

Confronting suicide: Breaking the silence around one of mental health’s biggest taboos

A couple months ago I had the wonderful opportunity to participate in the Applied Suicide Intervention Skills Training (ASIST) through my workplace. This was an intensive two-day training designed for anyone (i.e., not just mental health professionals) who wanted to learn how to deliver “suicide first aid.” In the training we learned very practical intervention skills that were based on a scientifically-proven model. One of the best things about this training was that it also allowed for honest, candid conversation about some of the controversial aspects of suicide. We openly discussed questions like, “Is suicide morally wrong?” and “Is suicide always preventable?” The discussions had me reflecting back on a lot of the attitudes I’ve encountered over the years. People tend to have very strong feelings about suicide, and I’m not here to tell anyone their opinions are wrong. I merely want to add some more context, based on my personal experiences, to some common ideas.

“Suicide is a selfish (and even, malicious) act.”

Some people really do see suicide as a completely selfish and/or even malicious act. I understand this. I actually used to believe this before I ever experienced serious suicidal ideation myself. A girl I went to school with hung herself in her front yard; her parents found her dead that way as they pulled in the driveway. This event really rattled me, and I found myself really angry at this girl. How could she do that to her family? I knew she didn’t have a great relationship with her parents, but this? It seemed so… evil. 

Fast forward a couple years and my stance really shifted. Things with my eating disorder were not getting better. Actually, they were getting a lot worse, even after countless rounds of “treatment.” I truly felt like I was destined to suffer like that forever. In 2010 I made two serious attempts to take my life and looking back I can honestly say that hurting anyone but myself was the furthest thing from my mind. I actually wasn’t in any sound state of mind; I was at a breaking point with my eating disorder. I used to describe it as “not being able to keep up with my behaviors.” There comes a point when the disease really overtakes you and you feel entirely controlled by it. I was running almost completely on adrenaline, starving and exercising all day and then binge/purging all night until the early morning hours. I slept maybe 2-3 hours a night but only when I finally passed out from exhaustion. I hated every single minute of it, but it had become this compulsive interminable routine that I could not stop. My life as I once knew it was already over, because I had no time or energy to devote to any of the people or things that once meant something to me. I saw absolutely no way out other than to kill myself. I didn’t even feel like a person anymore. I was of no value to anyone anymore (so I thought), so there was no point in sticking around.

I don’t doubt there have been people who have killed themselves with the intent of hurting others, but this certainly isn’t the norm. Many people who attempt or complete suicide are under the influence of any number of things that have significantly impaired their judgement. I’m not only referring to substances like drugs and alcohol; it could also be severe depression, starvation, sleep deprivation, trauma, psychosis, etc. I can tell you that after a few weeks of improved nutrition, sleep, and medication adjustments in the hospital I could no longer identify with the person who had attempted suicide just a few weeks prior. My eating disorder hadn’t gone away, and I wasn’t cured of my depression, but my brain was functioning well enough to be able to see things more realistically. I could see myself as a person again, a real person with real people in my life who cared about me.

“People who are serious about suicide won’t talk about it.”

This may be true for some, but it certainly is not always the case. I know in the worst of my illness I was constantly talking to my therapist about death and wishing to die. I think I probably talked about it so much that she eventually stopped reacting like she had in the beginning. I think my attempts really took her by surprise because she was so used to me just talking about it but never acting. I don’t blame her at all for not “predicting it,” I just think it’s worth pointing out that just because someone has talked about suicide for months or even years without acting, that doesn’t mean they won’t at some point reach their breaking point.

Related to this, I think it’s important not to assume that just because someone has “failed” to complete a suicide once or even several times, this doesn’t mean they weren’t serious in their intent to die, nor does it mean they won’t “succeed” in the future. I’ll never forget the time I saw my psychiatrist for the first time after my string of suicide attempts in early 2010. “Well, you’re not very good at this are you?” He said this with an obnoxious grin on his face. And yes, he had a very odd sense of humor. “Well,” I replied, “I’m clearly not very good at this ‘life’ thing either, which is why I keep trying to end it. Maybe you could help me with that instead of mocking my very real suicide attempts?” Actually, I don’t remember what I said at the time, but probably not that. 😉 This response came to me after the fact, like the best comebacks usually do.

There is no “typical suicidal person;” some people openly talk about their thoughts and plans, whereas other people give no outward signs there’s a problem at all. A person who talks about suicide may not be in immediate danger, but he/she is giving you information that should not be ignored.

“All suicides are preventable.”

I wrote the following in December 2013, after a series of eating disorder-related deaths (mostly by suicide) occurred in one of my communities:

    Over the years I’ve unfortunately witnessed many friends, friends of friends, and acquaintances die from this disease, whether it be directly or by suicide. It is of course always extremely sad. However, I think it is misguided to say things like, “how many more people have to die from this disease until the world gets it?” This implies that if only the world “understood it,” it would go away, or people would stop succumbing to it, or even that the world is somehow AT FAULT for all the suffering. I’m all for (responsibly, in the right way) educating the public simply because it is FAR more pleasant interacting with people who have a clue than with the ignorant, but even everyone in the world “getting it” wouldn’t stop the suffering. Eating disorders are complex multifaceted mental illnesses without simple causes. Can’t we just accept that recovery is really f-ing hard and not easily or at all attainable for some, even after multiple attempts and lots of “knowledge”? I’m not discrediting the importance of having supportive people in your life–people who “get it”– this is incredibly helpful, but even the best friends/family members/therapists/mentors can only do so much. I can also imagine that reading something like “when is the world going to wake up?!?” could come off as insensitive to the people who HAVE been “awake,” supportive, and knowledgable and still unable to stop horrible things from happening to the ones they love.

Two and a half years later, although slightly less cynical than I was then, I still generally feel the same way. It’s a complicated subject and I’ll admit my views are likely very colored by my own experiences, particularly in the world of eating disorders. I’ve already blogged about my views on conventional treatment and how ineffective it is for many people, especially those with chronic eating disorders. A lot of the people I’ve known who have died by suicide had been through multiple treatments, had access to some of the best doctors and therapists, and had a slew of very loving and supportive people in their lives. It often isn’t a matter of the world not understanding or caring, it’s just the sad but true fact that eating disorders (or depression, substance abuse, etc.) are powerful, unrelenting forces that sometimes can’t be taken down.

This is a tricky subject because I don’t mean to imply that anyone should ever be deemed hopeless or untreatable. What I do want to convey is that we (friends, family members, therapists) are all only human, and we can only do so much. As great as it would be to think that with enough love, effort, and knowledge we can save everyone, that’s not reality. I also think it’s important to acknowledge that it is not always in a person’s best interest to continue to engage with a chronically suicidal person, for the sake of their own mental health. I unfortunately witnessed the dissolution of a very close friendship shortly after my suicide attempts in 2010. This person had to go through the trauma of finding me unconscious one night, not knowing if I would ever wake up. She had to watch me come out of the hospital a few weeks later seemingly “so much better” (my words) only to repeat the same series of events less than a month later. This was on top of having to deal with me as a very sick and unreliable friend for many years. After an awkward attempt to reconnect shortly after these events, our communication gradually dwindled until we were no longer talking. I still miss her, but I don’t blame her for anything. She did what she needed to do to protect herself and I’m glad she did.

The ASIST training focused on the initial interactions with a person at risk, understanding their situation, and keeping them “safe for now.” Sometimes that’s all you can do. As a society, I hope we continue to talk openly about suicide. Even though knowledge alone cannot save everyone, it helps break the stigma and forces people to confront the issue instead of brushing it under the rug.

How to access treatment without breaking the bank: Part II

(For Part I of this series, click here)

Even though I’ve had my eating disorder for nearly two decades, I really just started exploring the world of support groups five years ago, when I first moved to Los Angeles. Before that, I had a pretty negative view of anything that involved interacting with a bunch of people with eating disorders. Up until then, all of my “group” experiences were from structured inpatient, residential, or partial programs. You know, the kind of places I wrote about here. I think spending so much time in close quarters with other eating disordered individuals took it’s toll. Very disordered behavior and ways of thinking became “normal” and I lost out on many adolescent and young adult milestones. In the summer of 2011 I moved to LA and had every intention of not only never attending treatment again, but also never getting involved with anyone in the eating disorder “world” ever again. At the time I really thought it was the best thing for me, and I was excited to finally move on with my life.

Well, surprise! Of course my eating disorder followed me to LA, and “just moving on” was pretty impossible. I found a therapist pretty quickly, but I couldn’t afford to see her as often as was recommended. I was living a “double life” by trying to maintain the image of a high-functioning grad student while also dealing with a very intrusive eating disorder. This is when I started to look into groups. Luckily for me I was now living in one of the most support group-saturated areas of the country. I tried out a lot of groups, and not surprisingly had various degrees of success. Some groups were great, others were “meh,” and a few left me running for the hills.

It’s important to be realistic about what you hope to get out of a group. I’ve never heard of anyone recovering from an eating disorder after attending a once-a-week support group (darn!). Depending on where you are in your ED, a group may not even make a small dent in your symptoms. However, groups can still be of value to almost anyone who shows up, even just allowing you to feel connected and not alone for 60 minutes a week.

I tend to categorize groups into three categories– (1) member-led drop-in support groups, (2) therapist-led drop-in support groups, and (3) therapist-led closed groups or what is more commonly thought of as “group therapy.”

(1) Member-led drop-in groups– These are almost always free groups led by the members themselves. Alcoholics Anonymous is probably the most widely-known group of this kind. For EDs, there are several “Anonymous” 12-step variants, including Overeater’s Anonymous (OA), Anorexics & Bulimics Anonymous (ABA), and Eating Disorders Anonymous (EDA). OA is an interesting group; by the name you would assume it was strictly for overeaters or individuals who deal with what is now classified as binge-eating disorder. However, it has long claimed to welcome all eating disorders. Cool, right? I’ve never been to an OA meeting myself, but from trusted sources who have been I’ve heard this– yes, OA members are very welcoming of those who struggle with all EDs, and you’ll find people of all sizes and disorders in any given meeting. That said, I know many professionals who advise against individuals with anorexia or bulimia attending OA groups, due to the restrictive dietary philosophy of OA. The group was originally created for overeaters, so the focus is truly on “abstaining” not only from overeating, but any food or ingredient that may trigger bingeing, such as sugar or white flour. To a person with anorexia or bulimia who is not overweight, this philosophy can be quite triggering and harmful.

I have been to both ABA and EDA meetings. I was first exposed to the principles of ABA in 2007 when a treatment center distributed the ABA manual. To be honest, I was never very sold on the whole 12-step/higher power thing. I am not religious and I see many flaws in trying to apply the 12-step model to eating disorders. However, the groups themselves can sometimes be helpful even if you do not completely buy into the 12-steps. Like AA, ABA and EDA offer a variety of types of meetings ranging from meetings that focus solely on one individual “step” (not for me) to women’s only meetings or speaker meetings (more for me). My most positive experience with one of these was a couple years ago when I attended a weekly EDA meeting in Thousand Oaks. These groups were packed, and I almost got scared off by the crowd at first. I don’t think I ever said a single word during the whole six months I attended, nor was the content of the meetings ever that profound that I walked away with any amazing new insights. What I liked was the feeling of mutual understanding. I liked knowing that as dark and hopeless as things got for me throughout the week, I would at least feel understood and connected for an hour one night a week, even while sitting there saying nothing. Regardless of the meeting type though, be prepared to sit through several minutes of official meeting business as they read the lengthy list of rules, steps, and traditions. And at the end, be prepared to hold hands and say the serenity prayer. For real, just like in the movies. 😉

(2) Therapist-led drop-in groups– These are often free or low-fee “drop-in” groups led by a licensed mental health professional. You’ll often find these groups run by treatment centers. Sometimes they may only be open to alumni, but often they’ll be open to the public. Eating disorder organizations and nonprofits such as ANAD and NEDA may also run these groups. Just like member-led groups, these groups vary in quality and target audience. I attended a group run by a treatment facility in Woodland Hills and was not overly impressed. There were a couple loudmouth “regulars” who dominated the discussion and grated on my nerves. The therapist leading the group was not very good at steering the group back or ensuring everyone got a chance to speak. When I moved to Pasadena I attended the same treatment center’s group at the center’s more local facility. To my surprise, the groups at this location were completely different. There was a better therapist leading who was able to engage the entire group, and the overall atmosphere was much more welcoming and supportive.

(3) Therapist-led closed groups– These are less likely to be free, but are often offered at a “low fee.” Therapists may choose to hold groups with their existing clients who all share a similar issue, and/or they may welcome referrals. Oftentimes there will be a brief “intake” process where the therapist talks to potential group members to determine if they are an appropriate fit for the group.

My very best group experience was one of these groups. My dietitian referred me to a group run by a therapist she knew. I was hesitant at first because this was a very small group. When I joined there were only two other people besides the therapist. There would be no hiding here! Thankfully, It turned out to be a perfect fit. In this group I actually got to process things and interact on a very personal level with the two other group members and the therapist. We “clicked” right away and I always looked forward to Tuesday nights during that time period.

Walking into a group for the first time can be scary, especially if you’re new to the whole group thing. Whenever walking into a new group I tell myself that we’re all there for a common reason. We’re all at least a little insecure. If the group is a dud, you never have to go back. If it’s truly awful, you can just get up and leave. I still regret not just up and leaving after being told by one egotistical therapist “You don’t talk to each other in this group. All feedback comes from me.” um. . .

Some other things to consider when looking into groups:

  • Some groups tend to attract many “regulars” while others are less likely to have a consistent turnout. Very large 12-step groups, for example, can bring in a very different crowd from week to week. If you’re unimpressed one week, you could have a completely different experience the next week based on who shows up. Even for smaller groups that have more “regulars,” the census will still change over time, so it’s worth re-checking out groups you may have dismissed several months or years ago.
  • If you’re looking for a small, intimate group therapy experience and are currently seeing a therapist for individual therapy, you can always ask her/him if she/he would be willing to start a group. The plus here is that the therapist already knows you and should have a good idea of who you would mesh well with.
  • If you’re convinced there are absolutely no groups in your area, you may be surprised. I’ve found a lot of groups are not publicly advertised but can be discovered though talking to local treatment professionals. For eating disorder groups, I have to mention this website. Don’t be fooled by the outdated layout; it’s actually a great resource that is updated on a daily basis. You can search for all types of treatment by state/region.

Finally, if anyone from the Los Angeles area is looking for good groups, please don’t hesitate to contact me. I know of several that are going on in various areas of LA and can help you decide which would be the best fit for you. 🙂