Obsessive-compulsive disorder (OCD) is one of the most frequently diagnosed psychiatric disorders in people with eating disorders. It is known to make eating disorders more severe and harder to treat, leading to a longer time until remission is achieved. Recently, more and more researchers are beginning to recognize the significance of the overlap between EDs and OCD, and are trying to develop specific treatments targeted at this population.

A 2004 study by Walter Kaye and colleagues in the American Journal of Psychiatry measured how frequently anxiety disorders (OCD is a type of anxiety disorder) occurred in people with anorexia and bulimia. They found that two-thirds of the ED sufferers had been diagnosed with an anxiety disorder at some point in their life. In general, the onset of the anxiety disorder pre-dated the ED by several years. Of the people with an anxiety disorder, 41% had OCD and 20% had social phobia (social anxiety). The problem, then, is very significant.

The gold standard in treating OCD is a form of cognitive-behavioral therapy known as exposure and response prevention (ERP). You can read more about ERP here. The idea is relatively straightforward: You create a hierarchy of the things you're afraid of that would normally provoke a compulsion. For someone who is afraid of germs, something lower on the list would be touching an unused surgical mask. Higher up might be touching a doorknob at a doctor's office or being coughed on by someone with a cold. Together with a therapist, you would begin to expose yourself to these anxiety-provoking situations and then not engage in any compulsions (like hand-washing) to relieve the anxiety. The point of this is to learn to tolerate the anxiety and that you're not going to die if you happen to inhale a few germs.

Some researchers are beginning to use components of ERP to treat food fears in EDs, especially anorexia nervosa. In a 2011 study in the International Journal of Eating Disorders, researchers at Columbia University first outline a behavioral model for AN that is driven by anxiety and obsessionality (see figure below; the caption is copied from the paper).

Figure 1. Model of Anorexia Nervosa. Traits of high baseline anxiety and obsessionality interact with environmental factors such that patients develop maladaptive behaviors, including food avoidance, and rigid eating patterns (or dieting practices), and they experience high levels of anxiety around eating. These behaviors are interrelated in that rigid dieting leads to increased anxiety about food and vice versa. These behaviors result in a diet that is low fat (low energy density) and limited in variety. This, in turn, promotes weight loss. The low weight state feeds back on the baseline traits and leads to increased levels of anxiety and obsessionality.

Anxiety about eating more and gaining weight consistently interferes with weight gain in AN and with interrupting the binge/purge cycle in BN. The idea is that recovery cannot and will not occur unless these fears are addressed. In a 2012 review article in the European Eating Disorders Review, psychologists hypothesize that one of the reasons family-based treatment is successful for many adolescents is that it forces these exposures. Since the patients can't (theoretically) choose what to eat, they can't choose to avoid "scary" foods. Parents are also coached on how to help stop other food-related rituals

A study published earlier this week addressed the issue of treating OCD and EDs, this time in a residential setting. Published in Cognitive Behaviour Therapy, the researchers treated 56 individuals with AN, BN, or EDNOS in an eating disorder program specific for individuals with co-occurring OCD. Of these patients, 41% were diagnosed with AN, 25% with BN, and 34% with EDNOS. Rates and levels of depression and OCD did not appear to vary by diagnosis. After treatment, the researchers found a significant improvement on scores for OCD, depression, and eating disorders, as assessed by a variety of surveys and self-reports. Patients with AN also significantly increased their body weight.

Which is all well and good, but the problem is that this study (nor any others that I'm aware of) compared the treatment group to anything. Other studies have shown that treating an ED generally improves levels of depression and OCD. Was the improvement seen in this study due to regular eating and the prevention of binge eating and purging? What effect did being in a structured environment have? Would these results have been different if the patients weren't treated for OCD? What about if their OCD was treated and not their ED? I realize that actually conducting a research study in that last scenario would be unethical, especially in a group that qualifies for residential treatment, but it's something that should at least be considered in the discussion.

Another question the researchers didn't factor in was the use of psychotropic medication. Eighty-nine percent of patients were on some type of psychiatric medication; the authors said they didn't control for this in their analysis since only 7% started on medication during their treatment. But they didn't mention how many patients' medication was adjusted, increasing or decreasing dose, or changing types and brands of medication. These things can have a significant effect on OCD and depression symptoms (although a recent study indicated that no psychotropic medications appear to be effective for AN)

As well, one of the researchers is the medical director of the treatment center where the research was carried out. This makes me a little skeptical of the results as a matter of course.

The researchers concluded that "Simultaneous treatment of OCD and eating disorders using a multimodal approach that emphasizes ERP techniques for both OCD and eating disorders can be an effective treatment strategy for these complex cases." But how effective? Is it better? How much better? How long did the results last for? There was no follow-up on any of these patients. Improving in a program is great, but the rubber doesn't really hit the road until after discharge.

This study is a start, but it's a small start. Co-occurring EDs and OCD can be very difficult to treat, but many people do go on to develop healthy and productive lives. We desperately need more resarch into the subject, but we need to start making comparisons to help develop the best, most effective treatment possible.

I've gotten emails from several people over the last few weeks about finding a therapist, knowing if s/he is for you, and so on. Others have commented on progress (or lack thereof) with their therapist and whether to leave or stay.

One of the arguments in favor of staying--or for what people are looking for in a therapist--is that the person is "nice."

Believe me, I understand this argument. I've been there. I wanted someone nice, someone I could pour my heart out to. I wanted someone to whom I could confess my deepest thoughts and secret desires. I thought this person should be a therapist. In all honesty? I should have just adopted a puppy.

Here's the thing: talking only gets you so far. As someone said at this year's NEDA conference, "Insight doesn't lead to behavior change. Behavior change leads to behavior change." We want to feel loved and accepted and that's not a bad thing. I'm not dissing nice people or feeling heard and validated. But just having someone listen to you isn't going to treat your eating disorder. "Nice" is often code word for "They don't push me into actually making any significant changes."

Being a complete jackass does not make for a good therapist any more than being nice does. I'm not advocating seeing a meanie. I am advocating thinking long and hard about why you are seeing a therapist in the first place. Presumably, you have a problem. If you're reading this blog, chances are that problem involves an eating disorder. So before you go looking for a nice therapist, it might help to think what you want to get out of therapy.

Maybe it's "I want to feel better." Not a bad goal. Now try and think about how, in reality, that might happen. Recovery from an eating disorder usually involves feeling worse before you start feeling better. Feeling better involves doing things like normalizing eating, learning how to socialize and make friends, working on perfectionism. This, not infrequently, sucks. I've had therapists be too nice and not push me to do this because they knew, on some level, how hard it was going to be.

Take my cat. When I first adopted her and she finally stopped hiding under the couch, she liked to jump up on the top of the fridge. Although Her Royal Fuzziness could get up, she didn't quite master getting down. The first few times she got stuck, I hauled out the step stool, climbed up, and rescued her. After a while, however, it got to be really annoying. She kept getting stuck on the damn fridge. Finally, I left her up there for about 10-15 minutes. She was not happy. But I also didn't want her getting stuck up there when I wasn't home, and I also didn't want to be getting her down every day. So I let her stew on the fridge for a bit, tried to drive home the point that, you're welcome to climb on things, but you also have to get yourself down. After her time was up, I got the stool and grabbed her down.

I never had to do it again. I'm not sure whether she stopped going up there or (more likely) she finally figured out how to get herself down. Letting her up there was not a nice thing to do, but it worked.

It's sort of like that with a nice therapist. We tell them about our problems. We talk about how awful the ED is making our lives, is making us feel. And they listen and nod and hand out tissues and seem to get it. Then we leave their offices and go back to the awfulness and nothing changes. It seems to be a good deal because we get to feel like we're "working on recovery" because we dutifully see a therapist for our 50-minute hour, and our therapist gets to be nice and caring and build a relationship with his/her client.

Recovery, though, remains stagnant.

It reminds me of one of the human behavior truisms I've discovered over the years. People don't change when they see the light, they change when they feel the heat. Feeling the heat is uncomfortable. It can seem cruel to insist that a person gain weight when they say that gaining a pound will make them feel suicidal, or that they would rather die than eat that ice cream.

That isn't to say that being an asshole makes you a good therapist, because it's not true. A good therapist listens well, helps you problem solve, is non-judgmental, knows what they are talking about, provides you with an outline of what therapy is going to look like, what the goals are, etc. Nice isn't a bad thing, but it doesn't mean you're a good therapist.

I didn't start getting better until I started seeing a therapist who wouldn't put up with my bullshit. She made it very clear what the ground rules were, and she pushed my forward almost ruthlessly. She did it out of ultimate kindness, but, believe me, she wasn't always nice about it. At the same time, I really respected that. I respected someone who didn't play into the "sick identity" of being anorexic and treat me like I couldn't handle life because I was ill. No, it was "You need to eat, you need to gain weight, and I will help you. You won't like it, you probably won't like me at times, and I'm okay with that."

I had to stop looking for nice therapists and start looking for those who would help get me well. Many of these therapists were nice, but that wasn't how they got me well.

It seems odd, doesn't it.  Medication has side effects--lots of them, in fact.  You can hear them rattled off in the same droning-yet-chipper voice in every pharmaceutical commercial on the air.  But therapy?  How can therapy have side effects?

Time Magazine had a follow-up to a story about a family in Michigan who used a controversial therapy to help treat their autistic children.  And that's when everything unraveled.  The story itself is sad and even frightening, but that's not the point of the blog.  What struck me was a paragraph at the very end:

We don't often consider the "side effects" of nondrug therapies. But the Free Press series shows just how harmful it can be to buy into a technique or therapy that offers nothing but hope. Many things that help can also harm, which is why we need sound science before any new technique is widely adopted — let alone used as evidence in custody or criminal cases.

It struck me that some ED therapies are the same way: they offer hope, perhaps, but no solid results to back up their efficacy.  And that any treatment can have side effects, even if it's not in pill form. 

Eating can be extremely anxiety-provoking for those with EDs, and that anxiety can be expressed in panic attacks, defiance, self-harm, temper tantrums, and more.  But eating can also be thought of as "therapy" for eating disorders, as a type of exposure and response prevention.  The anxiety is a side effect, and sufferers and families should be warned and prepared for this.

The autism story is also a case study in the fact that therapy can, in fact, actually be harmful to patients and families.  Recently, Becky Henry wrote about how parent-blaming in traditional eating disorder treatment tore her family apart. I know lots of examples of lives stunted or lost, of families wrecked because of ineffective and inappropriate treatment.  Going to therapy isn't something we can think, "Well, it can't hurt, can it?"

Actually, yes. It can. 

Therapists and families need to do their homework before just signing up for weekly psychotherapy to make sure that the therapy's benefits outweigh any potential side effects, and that there's good evidence to show that it will help rather than harm.

I was reading one of Grey Thinking's posts from around Memorial Day (you don't want to see the number of unread items that are in my Google Reader right now), and she said this:

I think this is a huge roadblock for many people in recovery — having a lot of insight and knowing what they need to do, but not being able to do it and make changes (or not really wanting to).

It was certainly a massive roadblock for me.  Insight into the "whys" of an eating disorder was seen as my ticket out of my disorder.  Maybe if I uncovered the family dysfunction.  Or the ways in which I felt out of control.  Or could understand why I felt the need to be thin. My insight into insight is this: it's a little a lot overrated.

I knew I was a perfectionist and a control freak--in fact, I frequently thought I wasn't good enough to be considered a legitimate example of either of them.  And there was family stuff, sure.  Who doesn't have family stuff?  I'd always had body dysmorphia.  I didn't know it was body dysmorphia, of course, but there was that, too. Insight really wasn't my problem.  Many of the young adults I met in treatment had some amount of insight--and yet there they were, back in treatment.  Just like me. 

I'm not convinced that having insight into what caused your eating disorder will get you well. But insight is still important to recovery.

So what in the hell do I mean by that?

An eating disorder is hard to understand while you're actually in it.  It seems obvious and sensible at the time, but when you look back, you sort of scratch your head.  So having insight into why you're acting so weird only works if you know you're acting weird. As well, the strength of the insight that promotes change has to be greater than the anxiety (or whatever awful feeling you happen to experience) that will happen as a result of that change.  Let me tell you--insight is very vague and ephemeral. Anxiety provokes action. Anxiety wins every time.

For me, insight into my illness's origins hasn't been the most useful thing to get me on the road to recovery.  As for keeping me on the road to recovery, that's a different story.

Here's the thing: insight comes in many different flavors.  Thus far, I've talked about the "why" flavor--why did I get sick, what caused this, etc.  The insight that has been useful to me is of the "now what" flavor--what I need to do in order to stay well, what my triggers and weaknesses are, what to do if/when I start to struggle.  It's still insight, but it's a different variety, and I use it totally differently.

For one thing, this type of insight is being used by a brain that is at least on its way back to normal functioning.  For another, there's not quite the uphill battle.  It's more of a let's-keep-this-rock-from-rolling-back-downhill kind of effort.  Okay, yes, you're still fighting gravity, but at least you don't have to get the boulder moving.

To take a line from Forest Gump, insight is as insight does.  To take Grey Thinking's tagline, "Becoming aware of your crap and actually overcoming your crap are two different things."

I had another session with Dr. H this afternoon (and another chance to play with her Keurig!) and we were discussing any number of things.  She asked me how my week went in the most wonderful way.

Think of your week like a rose, she said. There are thorns, there are buds, and there are blossoms.

Roses have thorns.  So does recovery. There's no way around it.  Thorns are the difficulties, the things that don't go as planned, the slips and the slides.  The horrible, awful, no good, very bad days.  You don't have to like the thorns, but you do have to learn how to avoid them--or at least live with them. 

Like I'm guessing some of my readers do, I have conflicts about struggles.  I don't like struggling.  But I also don't like admitting when I'm struggling.  I also also know that talking about my struggles is the path to getting them to stop.

File under: hard place and rock, between a.

I told Dr. H that I feel either I "have to" be a perfect anorexic or a perfect recovering person.  I can get the awful, unproductive mentality of "I already screwed up, so why bother?"  {{Why, hello, black and white thinking.  Nice to see you.}} Or I'm so embarrassed and ashamed of what happened that I cover it up.  Screwing up somehow means that I'm a disappointment. Neither of which is conducive towards recovery.

Which is when Dr. H told me about the rose metaphor.  If roses have thorns, so does recovery.  You're the only one who expects you to be perfect, she told me.  Which is true.  But then, I've always been the main force pressuring myself, so that's not news.  Nor does it tell me how to stop pressuring myself. 

Nonetheless, thinking of recovery as a complete package--screw ups, missteps, and all--helps relieve some of that pressure.  Part of learning how to do anything involves making mistakes and then learning from them.  Recovery is no different.

Sunday was my last group therapy session with TNT.  As much as I disliked the idea at first--I would be the fattest one there, I was either not sick enough or too sick to be helped--I really came to enjoy the group.  One of the requirements was that you had to be in active recovery.  That meant you couldn't be actively involved in ED symptoms.  A slip up didn't mean you would be asked to leave, but you had to have significant abstinence from the eating disorder.

That last little bit was some of what made the group really helpful.  I'd done support groups before that ended in what can only be described as a hot mess.  I quit going because it was so hard to continue my recovery in that environment.  All people would talk about is how much weight they had lost, how many times they threw up, and so on.  File under: Pointless, Definition of.

I had groups when I was in treatment, and many of those were, in fact, helpful.  Learning DBT skills in a group setting, doing relapse prevention with others, learning from each other was remarkably helpful.  I was lucky, too, in that most of these groups were led by good clinicians who could keep things on track.  Other groups I went to outside of treatment were at best a waste of time and at worst directly harmful.

So yes, I was wary, both from ED-related reasons and from experience.  I tried to remember that the ED blog community is kind of like group therapy (well, there is a group of us and blogging is therapeutic), and I've never regretted getting involved in that.  TNT asked me to commit to one month, which I did.  I figured if things really went to hell in a handbasket, I could discuss it with her and leave sooner if I really had to.

The women in the group ranged in age from mid-twenties to mid-fifties.  And the wonderful thing was that we all related to each other so well.  I didn't know anyone's diagnosis, although after the first few weeks I had a guess.  In the end, though, it didn't really matter.  Not age, not diagnosis.  Many of us had similar problems in figuring out life after the eating disorder.  How do you manage urges?  How do you decide who to tell?  How do you handle the holidays? 

I'm going to miss my group.  I actually began looking forward to Monday nights.  TNT tried to find someone else to take over the group after she left, but she couldn't find anyone.  There's no group closer to home--at least, no other similar group.

I'm really grateful I got this chance, though, and maybe one day I'll get another chance.

I had my second appointment with Dr. H this afternoon.  Don't get me wrong--I like Dr. H.  She has a Keurig coffeemaker in her waiting room, so there's no way I couldn't like her. And I like how she approaches therapy and she seems to "get" me.  That's no small order.

But she's not TNT.

I don't miss the hour-long drive each way to go see TNT, but I really did like the work we did together.  She's helped me feel a lot more secure about my recovery.  TNT talked me down from a number of psychological ledges.  We did some work on body dysmorphia, although it's still majorly present.  Nonetheless, although the dysmorphia itself isn't any better, I'm able to overlook it a bit more.

I do like Dr. H, though.  When I asked her what her philosophy was, she said that she mainly did CBT.  She followed this up with the comment that she doesn't see herself as just a therapist, but she also sees herself as part coach and part cheerleader.  Thankfully, she doesn't wear short, polyester skirts or insist that I wear them, either.  Keurig be damned, that would be a deal breaker.

It's hard to adjust to the change.  It's hard for me to adjust to any change, let alone something major like this.  I think I've been lucky overall with finding good therapists, especially recently.  I had a few doozies in my time (like the one therapist who told me, in all seriousness, that "I just needed to get laid." Well all righty, then), but I've mostly found good clinical support.

I think Dr. H will work out just fine, but making the transition is tough.  I see TNT next weekend for one last group therapy session, and then we're done.  I'm trying to remind myself that this is a chance to learn from someone new, to get a new perspective on my recovery.

Also, the Keurig.  Let's not forget the Keurig.

A week or two ago, I mentioned that TNT is leaving clinical practice at the end of the year.  She gave me three therapists in my small town who had at least some familiarity with eating disorders.  One of the therapists wasn't taking new clients at this time, although she said if the other two didn't work out, she would see me.  I called the other two; I left a message with the receptionist of the first therapist and didn't hear back.

I had a "getting to know you" appointment with the third therapist (I'll call her Dr. H) this afternoon, and I really liked her.  Her primary focus is eating disorders, and she's loosely affiliated with the local college.  Ironically, we both graduated from the same college in Michigan, although she's a number of years older than me.

She described herself as mostly therapist, but also part coach and cheerleader.  As needed.  I liked that.  I like the hands-on approach.  Talking about feelings isn't something I find universally helpful.  I like CBT stuff, and that's her major orientation.

{{Dr. H also had a Keurig coffeemaker in the waiting room, which was a very nice bonus. If I ever come into a boatload of cash, I will make large charitable donations but I will also buy a Keurig.}}

So I think I'm going to start seeing her in January, after I wrap things up with TNT and we get through the holiday festivities/insanity.

I am smack-dab in the middle of trying to find a new therapist.  As I mentioned last week, TNT is leaving clinical practice, and I am left trying to find someone new. 

I hate finding therapists.  It's painful, time-consuming, and really, really tough.  So with me once again playing therapist picker-outer, I thought this week's Tip Day would be a great time to discuss what I've learned about picking out a therapist (this is the 13th time I've done this--I think I qualify as an expert!).

{{I realize some people don't have the fortune of being able to pick out a therapist.  The system where you are is that you get what you get.  If that's the case, I apologize.  However, I hope that what you read is useful for helping you figure out if you can apply for a new treatment provider or help them help you better.  I have choice, but with choice comes really steep medical bills for insurance and co-pays.  Win some, lose some, I guess.}}

1. Get referrals from people you know and trust. It might be a medical doctor.  It might be a friend or someone from the community who has also had an eating disorder or other mental health issue.  Or a guidance counselor at school.  Also check with your insurance company to see who might be covered and in-network. This way, you already know some things about the therapist--the basics of how they practice, that they're reputable, how much you might have to pay, and so on.

2. Don't rely too much on referrals.  Opinions are opinions, and not everyone sees the same thing in every therapist.  What I might find reassuring may drive you bonkers.  It's important when gathering data to separate fact from opinion.  That a particular therapist practices CBT is a fact.  That your friend finds them a total flake-azoid is an opinion.

3. Nice isn't the most important factor.  Of course we want our therapists to be nice.  Most of them are--misanthropes typically don't go into clinical psychology.  There are times when nice and kind and gentle is probably the right response.  But there are lots of times, especially when dealing with eating disorders, that firm and direct needs to take precedence over hand-holding.  The work of recovery is hard and miserable, and I've had therapists that were too nice and didn't push me into recovery.

4. Find out what treatment modalities they use.  I'm not especially keen on overly emotion-focused, insight-oriented psychotherapy.  I know many people find it helpful and useful, which is great.  For me, I like the acronym therapies: CBT, DBT, and ACT.  I like that they have evidence to show they are effective, and I like that they are much more concrete and practical.  So do your homework.  Find out which types of therapies you think would be most effective to help you move into recovery.

5. Ask them what causes eating disorders.  For me, this is the #1 screening question I use.  Because if I hear things like "unresolved childhood issues" or "boundary violations" as what causes eating disorders, I will run for the hills.  It means that, fundamentally, this therapist and I will not get along, will not see eye to eye on what I need to work on, and also that I know more about EDs than my therapist.  It's an easy way to gather information, and I often ask it right off the bat so that they don't have a chance to try and tell me the answer they think I would like to hear (this isn't that I think a therapist would really be blatantly dishonest, but it is human nature--heck, I've done similar things).

6. Find out their professional affiliations.  If you are trying to find a therapist for your eating disorder, then ask them if they're members of NEDA, of AED, of IAEDP.  Not all areas have an ED specialist, so you can also ask things like how many eating disorder patients do they treat, have they had any special training in eating disorders, do they know of a colleague who knows more about eating disorders, that sort of thing.  Good therapists will be impressed that you're asking this, so don't hesitate.

7. Ask hypothetical questions.  No, not the "if a tree fell in the middle of the forest..." types of questions.  But things like "If my parents called with questions, how would you respond?" Or "If I needed a higher level of care, what would you do?"  Or "If my symptoms increased, how would you handle it?"  It's good to know these things before a crisis hits, and it can also give you an idea of how the therapist generally handles issues, and how knowledgeable they are about EDs.

8. Don't let one bad apple ruin everything.  Bad therapists exist.  They might be a bad fit for you, or irresponsible, or whatever.  That's one therapist out of many.  Just because you found one bad apple doesn't mean that therapy doesn't work or that you're never going to get better.  It means you just found a bad therapist.  That's all.

What have you found helpful when searching for a therapist?  Share in the comments!

I'm like Laura- I've always had 13 as my lucky number after I won a cakewalk with that number.  (Ironically, my OCD "safe" number is 5.  Thirteen has no OCD attachments, though.)

What does 13 have to do with anything?

TNT announced on Monday that she was leaving clinical practice in January due to difficulties in finding childcare (she has several young children).  Which means I have to find another new therapist.  The end of TNT means I will be on lucky number therapist 13.

Yes, I counted. I'm a dork like that.

I love TNT and I don't want to find a new therapist.  On top of that, finding a new therapist is really hard for me.  For one, I'm not the world's easiest client, and not every therapist can put up with my issues.  For another, I know a lot about eating disorders.  More than most therapists, even some of those who specialize in eating disorders.  I don't mind doing some education, but I'm not forking over my hard-earned cash to teach someone about eating disorders.

I also really hate interviewing therapists.  Asking probing questions with my journalist's hat on is different from asking a therapist "So what do you think causes eating disorders?"  It's a hassle.  I don't mind it professionally because it's part of the job, but for finding a therapist, I kind of resent it.

The other really hard part is the fact that I'm not exactly around a large, urban area, which means I probably won't find an ED specialist.  I'm driving an hour each way to see TNT, and I'd ideally like to find someone closer.

I hate change to begin with, and this is not exactly something I want to deal with right now.

Last week, I was freaking out about the start of group therapy led by TNT.  Tonight was the second episode of Group Therapy, TNT-style, and it was much less intimidating than last week.  I wasn't quite looking forward to going--therapy is a positive experience, but it's not fun--but I wasn't freaking out, either.

Facing your fears sucks, and usually facing them results in this gradual ebbing of fear.  It usually happens so slowly, or over such long periods of time that you don't get to notice.

I noticed this week.

I still struggle with getting out of my head each week and really participating in the group.  I usually have comparison-itis, much of which is related to my own body image issues, and the rest of which has to do with how others are dressed, how they talk (ie, thinking I sound dumb when I open my mouth), if they work harder than me or have a cleaner house.  Things like that.  And it's all an excuse for me to find a big metaphorical stick with which to hit myself.

I'm guessing this isn't the point of the group.  Especially because I can compare and despair without driving for an hour and paying for group and individual therapy.  I know this has nothing to do with what everyone else has done, and much more to do with my own deep-seated feelings of inadequacy.  I'm starting to realize that I'm wasting much of my life beating myself up for things I have no control over, when there are really much more productive ways to use my time.  Like for the pointless navel-gazing I like to call blogging.

I think group will be good for me.  It's good to spend time with people who relate to what you're going through and can provide instant feedback.  I guess TNT knew what she was doing when she said that group would be good for me.

TNT is starting a therapy group, and she wants me to go.  The group is CBT-based, and it's sort of an "Advanced Recovery Skills" group.  In order to attend, you need to be asymptomatic in your ED and at least decently into recovery.  I fit the bill, and TNT wants me to come.  She says "it will be good for you."

I think all therapists say this when they know you're going to object to their advice.  It's in the Therapist's Handbook that provides scripts like "Tell me about your mother," and "How does that make you feel?"  Okay, I'm being somewhat sarcastic, but still.  I definitely have mixed feelings about group therapy.

I agreed to go, and I had to commit for the first month.  So four Mondays, 1.5 hours each week, 6 hours total.

But still I worry.

I worry I will have nothing to say or contribute.  I worry I will be either too utterly mental or too normal.  I worry the group will turn into a competition-fest.  I worry that no one else will think I should be there.  I worry I will waste everyone's time.

And yes, sad to say, I worry a lot that I will be the fattest one there.  I've already gained over my target weight--significantly over my target weight.  Whether that means the initial target was wrong or that my body wants to hang onto some extra weight because of the years of starvation, I'm not sure.  So yes, I am very uncomfortable with my weight right now.  It's worse because I have no idea of my actual size (I know, I can look at the tags on my jeans, but unless I know everyone else's pant size, I have no real way to compare), and so all I can do is obsess about how large I really am.

I know EDs can come in any shape and size.  I know that.  This comparison is much more of an internal thing.  It's competition combined with body dysmorphia combined with the fact that I have no real idea how big my ass is.  When I see pictures of myself from New York two weeks ago, all I can see is how huge I am.  It blots everything else out.  I get panicky and start to feel ill. I'm HUGE compared to everyone else.  And I'm so disgusted I kind of want to throw up.

This is the part that TNT thinks would be really good for me to deal with in group.  That would be a fantastic group icebreaker: "I feel like the fattest one here. Let's discuss." 

So, yeah, group therapy.  This should be really interesting...

Earlier today, Laura wrote that insight and eating disorders might be overrated. In many senses, she has a point. Often as a patient, therapists and treatment providers would ask me why they thought I was going downhill but made no real move to stop me from going downhill. "What's really bothering you?" they would ask me. "I dunno," I would say. I felt guilty about slacking off on exercise, so I tried to make up for lost time. I felt I ate too much, so I started cutting back. "No, no," they responded. "What's underneath that?" "Um...I dunno." And my task for the next week would be to figure out what was really going on. That, and try to cut back on the exercise.

No kidding.

Often, I had insight--or at least enough insight to start parroting back to my treatment team what they wanted to hear so they would stop asking me such asinine questions. Insight wasn't really my problem. I knew I had issues with depression and anxiety and perfectionism that was a big part of my eating disorder. I could talk to you at length about obsessions and compulsions and neurobiology and all of that. Still, I remained afraid of eating and entrenched in my eating disorder.

No amount of insight would have gotten me better. I wavered between extreme denial and anosognosia (I'm fine, there's nothing wrong) and pretty good insight. But insight is as insight does. I didn't stop being afraid of food until I was forced to eat 5-6 times every day, and do it over and over and over again. I'm still wary around food. But I'm not terrified of it. That wasn't insight. That was eating.

My insight often frustrated me. I knew that starving and overexercising and purging were ruining my health and making me miserable. Yet I also knew that stopping would make me more miserable. I knew that my symptoms were helping me deal with unbearable anxiety and depression. And what of it? I knew all of this, and I had been taught that this knowledge should have been enough. It wasn't. That's where I often got frustrated and gave up.

I'm not anti-insight, though. I think developing insight is a very important part of the recovery process. I haven't found much use in finding insight into why my ED developed--I know that I used my symptoms to self-medicate for anxiety and depression, and that explanation is fine for me. I know others have found such insight very useful, and that's great. What I have found insight very useful for is relapse prevention.

Eventually, I came to realize that very stressful situations--exam time at school, applying for jobs, moving, family issues--were major ED triggers. My brain could only cope with so many stressful things at once. Since recovery was stressful (and, in my eyes, often stupid and therefore optional), it was the first thing to get jettisoned. Enter relapse, stage left. It took me a long time--remember, I have a very thick skull, osteoporosis be damned--to realize that in these times of stress, when I felt that therapy and eating were the last things I had time for, therapy and eating needed to be at the top of my list. (I'm still not very good at this, to be honest.)

Now, with TNT, I'm working on developing insight into the depth of my negative self-talk. I often don't realize that I'm engaging in such self-hatred because it's such a part of my inner monologue that I don't think about it. And then developing insight to see the subtle ways it plays into my ED thinking. If I usually think of myself as a lazy pig, then it's not a hard leap to see how restricting food (negating the "pig" bit) and increasing exercise (negating the "lazy" bit) might make me feel better.

Of course, feeling like a lazy pig doesn't mean I am a lazy pig. I understand how that applies in other people, but I don't have much insight into why that wouldn't apply to me.

So yes, insight. It is useful, and it can be a good goal. But it often isn't enough to get someone over the initial hump of moving towards recovery. For me, it took having no other choice than to eat. Others have found different ways and different motivations. Insight can be a part of that, too. But I have found insight more useful later, after my thinking had cleared a bit, when I can look back at the craziness and be more rational about what the hell I had been thinking.

I struggle with hunger cues. The major struggle is that they exist outside of the prescribed mealtimes of my meal plan. If I could only get hungry when it was convenient, that would be nice. I think I'd prefer not get hungry at all, but alas, that's not going to happen.

Last Friday, it was late and I had already eaten my evening snack. All is well until I start getting hungry again. Like really hungry. And what sounds really good to me at that time were some baked beans. I debated for quite some time about whether to eat those damn beans. I had already eaten "enough" for the day. The beans had lots of salt which means water retention (said in singsong voice). Blah blah blah. Those reasons were my anxiety talking. I was anxious about eating extra, about eating something significantly extra (I've gotten to the point where I can have an extra piece of candy and not freak the hell out), about, mostly, doing something different. Breaking the routine, doing something "risky."

Yes, I define risk as eating something new or different or extra. Anyone still wonder why/if I have an eating disorder? Didn't think so...

I ate the damn beans. I used the CBT skillz (all the work I've done on learning them totally gives them the extra "z") I had been working on with TNT and told myself the following:

• I was hungry. There was no doubt here.
• I had been unusually active on Friday (worked a half shift at the bakery).
• I don't have a history of emotional eating, so the hunger was almost certainly physical.
• The real risk was negligible- I knew that one serving of baked beans wouldn't hurt in the long run, even if my emotions weren't exactly on board.

I was hungry. I ate. Then I wasn't hungry.

Somehow, this shouldn't result in so freaking much drama. But there you go.

Tonight, something similar happened. I had already had my evening snack (the same thing, come to think of it, that I had on Friday) and I was still freakishly hungry. I wanted, more than anything, to not be hungry because I didn't want to eat again, and I didn't want to have to find something to eat again.

So I tweeted about my feelings, and reminded myself that I need not hate myself for needing to eat more. And that as much as I would like my car to get better gas mileage, I don't begrudge it the fuel when it needs it. I ate an apple and peanut butter.

I feel disgusting right now.
I feel disgusting and I know I did the right thing.

Maybe that last bit is the saving grace.

An eating disorder has often been described as a metaphorical "crutch." For me, anorexia helped me self-regulate (or self-medicate) my often crippling depression and anxiety. Some of this was the peculiar biological response to starvation unique to eating disorders--not eating altered my brain chemistry and made me feel better. Some of the response was psychological and more related to the meaning I ascribed to my anorexia: that it made me special and unique, that I could tell myself it didn't matter if I screwed up at X because at least I could be good at losing weight, restricting, and exercising. Looking at it through the lens of OCD, self-starvation was a compulsion I used to alleviate the anxiety of, well, pretty much anything.

Some psychologists posit that you are using a "crutch" because you are "hurt" somehow. Although I won't deny that co-morbid conditions are the rule rather than the exception in eating disorders, I don't know that I buy the blanket statement that EDs are some metaphorical way of trying to heal a past hurt. I may have been a little barmy before AN came around, but that doesn't hold a candle to how whacked out my brain and life are now. Yes, the ED made me feel better in profound ways, but I've known people who were very well-adjusted before they got sick.

I guess the best analogy is this: being predisposed to an eating disorder is like being prone to joint and bone problems. There's a greater likelihood that something is going to throw you "off course," either in terms of stress or mood or whatever, and so you're much more likely to find yourself using a crutch, just as someone prone to joint injuries is probably more likely to wind up using crutches at some point.

But the only way to learn how to walk without your crutches isn't really to sit around and ask what is hurting and why and acknowledge that part of you. The only way to walk without crutches is to...walk without crutches. That's not to say that you won't need a lot of support and training to learn how to do this, but the analogy of a psychological hurt to a broken ankle isn't 100% perfect. You do need to stay off of a broken ankle to let the bone heal. In that case, the crutches are serving a good purpose. They're benefiting you. An eating disorder probably has plenty of adaptive functions, but, on the whole, it's hardly benefiting you.

I've broken my ankle, and I found literally learning how to walk without crutches to be bizarre and painful. And perhaps this is where the analogy is the most true. I didn't really need my crutches as my doctor had cleared me to walk. But I still felt like I needed them as much as I never wanted to see the damn crutches again. Similarly, I often felt like I needed the anorexia when, in fact, that was just another ED lie. Recovery is a lot like rehab, in that it involves the repetition of a lot of seemingly basic tasks until my "recovery muscles" are strengthened.

You can't get there, though, unless you ditch the crutches. Understanding why you're using them isn't much use unless you actually stop depending on your crutches. Using actual crutches to let your ankle heal is a legitimate purpose and helps your body heal. Using an eating disorder as an "emotional crutch" might make you feel better, but it's not helping your mind heal. The eating disorder essentially broke your ankle and than gave you crutches to "help" you out- how kind.

Yes, ask for help. Yes, ask for support and a walking buddy and painkillers and all of that. But let go of the crutches.

As the economy began it's nausea-inducing nosedive at the end of 2008, many US banks and insurance companies were loaned money by the government because they were "too big to fail."

This week, as I have been on my own and trying to bull my way through piles of writing and work, I have been hearing the siren call of AN. I wasn't looking for the call, I wasn't seeing it out. But with my routine shaken up a bit with my parents out of town and then visiting my friend for the weekend, I got off track. And sleeping through breakfast yesterday meant that I felt pulled to skip breakfast this morning. Surely it won't make a difference, will it? And lunch. Who really needs lunch, anyway. Think of all of the writing I could get done.

I did eat breakfast, and lunch, but not nearly enough. I knew this should have been a big red flag--a red light sign in my relapse prevention plan--but I felt strangely not bothered by this. I wasn't particularly hungry, and eating seemed like such a damned inconvenience.

Apparently, I was bothered by this at least somewhat because I mentioned it to TNT at our session today. Not in the on-my-way-out-the-door, at least I can assuage my guilt about lying sort of way (admit it--you've done it, too!), but in a way where I actually sought out feedback about what was happening. We discussed what I needed to do to get back on track (eat a meal plan compliant dinner and evening snack, both of which I did) and then plan out my meals for tomorrow.

We also discussed where I was in recovery, about my blossoming writing career and all that I want to do professionally. About the fact that I really, really want to get my own place and pick out paint colors. About how I want to travel to the Galapagos and Australia. I have a fighting chance at a real life now.

Like the banks that were too big to fail, I have too much to lose now.

Before, all of these wishes and dreams were so nebulous and ephemeral that I could shrug off their loss. I mean, I'm not going to own a Mercedes, either, and I'm not exactly bothered by that. But now, my dreams and my life are so much closer. They're realer (if that's a word). I'm making them happen, right now. I can't continue to make them happen when I am deep into ED. I won't be researching how bacteria can smell, I will be looking up calories in food and determining how much I need to exercise and staring at recipes all day long.

My last relapse brought me face to face with the stark reality that I couldn't have what I wanted in life and also have my eating disorder. I had to choose.

And I chose life.
I chose life and I didn't look back.
At least, I haven't looked back very often.

TNT told me I had worked my ass off to get where I am in recovery (I turned around, looked down, and said, "No, I didn't. My ass is sadly still there."). There's the reality that I always have another relapse in me, but I don't know if I have another recovery.

So I ate.
And hated myself.
And then forgave myself.

Eating can be an inconvenience, but relapse is a bigger one for me right now. I have stories to write and condos to find and places to go and dreams to fulfill. My ED is not part of this--it never was.

My appointment with TNT yesterday was at an unusual time (1pm, and she's an hour drive away), so I ended up eating my afternoon snack right after my appointment and had my lunch at about 3:30pm instead. I had driven myself, and it was essentially up to me whether I would eat the snack I had brought with me. I knew I could toss it or hide it or lie about it and no one (except for me) would be the wiser.

I wanted to chuck my snack so freaking badly. Not because I really wanted to restrict, but a) because I could and b) to be a little rebellious. Ultimately, I didn't throw out my snack and ate what I had brought because I was aware that this little stunt would prove a big fat load of nothing.

What I wasn't prepared for was how pathetic and weak I felt by eating my snack.

Yes, yes, I know: I should be proud of how I acted. Maybe I should, but that's not really the point here. I was thrown by how strong the AN "kickback" was for eating something when I didn't "have to" or wasn't being watched. The dialogue in my head went something like this:

Why am I eating this? This is so stupid! Snacks are ridiculous! I am eating way too much as it is. I'm such a wuss, eating when I don't have to or even want to. Isn't that what they tell you on TV- don't eat if you're not hungry? Right? This snack used to be way more than I ate in an entire day, and I was exercising about a trillion times more than I am now. I have gotten so weak. All of this eating has made me weak! I'm so pathetic, all of this eating...

I'm frustrated because I am committed to getting better, and have sacrificed so much to getting that way, that I'm still tormented by these thoughts. I know it's AN thinking, but I have been at a healthy weight (and then some!) for almost 9 months now. You'd think my brain would get the message, no?

TNT is primarily a CBT-oriented therapist, and I know she would want me to slow my thinking down and take a good, hard look at the rationality and usefulness of my thoughts. Some obvious places to start:

• just because I feel pathetic doesn't mean I am pathetic
• eating is necessary for recovery, and it doesn't make me weak
• I eat more now and I also do more now and am happier
• following a meal plan is necessary right now for me
• losing weight and restricting will only lead to relapse, which is something I definitely don't want

So my addled brain is very much capable of producing logic, even though its use of logic seems to be a bit limited.

But what other solution is there, other than to ignore the thoughts and keep plugging along?

Such was the title of the talk given at the 2010 International Conference on Eating Disorders by British clinician Glenn Waller. Dr. Waller had a fascinating talk and, even when I didn't agree with him, I always thought he had a really good point.

In his talk, Dr. Waller looked at the difficult issue of patient motivation in eating disorders. It's a thorny and fascinating issue to many in the field because people with eating disorders often struggle with staying motivated for treatment. This is inherent to the nature of eating disorders: the denial of a problem (or the inability to see that there is a problem). It's one of the reasons eating disorders are so damned hard to treat.

When my illness first started picking up speed in college, I seriously had no clue that there was anything wrong. I was exercising more! I was losing weight! I felt great! What could be wrong? How could this be an illness? Easy: when you're not eating because you're scared of food, and you're health is starting to suffer. Ultimately, the downsides of an eating disorder become more apparent, and the idea is for a therapist to use these downsides to help patients make behavioral change.

The problem is that motivation is often, as Dr. Waller calls it, a manifesto statement: it's what we want to do, rather than what we intend to do (or are capable of doing). He compared these motivation-oriented statements to campaign promises--they don't really mean much until they're followed by action. This follow-through is where people with eating disorders really struggle, much like politicians.

Dr. Waller's response to this was rather eye-opening. He told therapists to stop being a part of the problem in maintaining poor motivation for change by buying into the motivation manifesto. By doing this, the therapist is trusting the anorexia, not the patient. "The anorexia can only be trusted to try to survive," Dr. Waller said, and motivation to attend/be in treatment doesn't equal motivation to change.

The main factor for me was anxiety and fear about changing my behaviors. I was often tired of the eating disorder but unable to push through the anxiety that was keeping my ritualistic behaviors in place. Thus the status quo remained in place. My other issue was that this fear was coupled by my minimizing the issues that my AN behaviors created. They weren't that bad, I could handle it, most people were on a diet- how was my life different? So how could I be motivated to work on a problem that I often wasn't even sure I had?

Researchers often talk about issues related to patient drop-out and premature treatment termination in people with eating disorders. What astounds me is not so much how many people drop out but how and why so many people stick with it. Dr. Waller didn't really address the issue of outside support, and I wish he would have. I found that I couldn't conquer my ED without someone temporarily stepping in and helping me start eating and gaining weight. I needed to have no other option but recovery--and then I was able to slowly start stepping up to the (dinner) plate and taking charge of my recovery.

The issue of motivation is still very relevant to me, even though I'm rather far along in recovery. Dr. Waller said that motivation work needs to continue throughout therapy as a person can be motivated to address certain issues and not others. Furthermore, motivation can wane or disappear entirely, so it's not something that can be addressed in the first session and then checked off.

There were lots of other bits of Dr. Waller's talk that I didn't agree with, such as his belief that patients who don't change are choosing to stay ill. It often looks like that, but the situation is more complicated. Many times, it wasn't as much that I was choosing to stay ill as much as it was that I didn't have adequate support to change. Yet I'm glad Dr. Waller addressed the issue of motivation, and how therapists can better help people move towards ongoing recovery.

I hate being weighed. It makes me freaky anxious and I just don't like it. I worry that I might have gained, which will make me hate myself. I worry that I might have lost and then everyone will freak out on me. The ED part of my brain still sees maintenance as some sort of abject failure because I should be losing weight, not maintaining it.

It probably sounds pretty paradoxical that I find the concept of being weighed at my therapist's office to be reassuring and helpful. Not because I take comfort in being weighed--I most certainly don't--but because I find it helpful to know my weight and know that it is staying where it needs to be.

My first therapist never weighed me, although it didn't really matter all that much because I was weighing myself 80 bazillion times a day anyway. I ended up in the hospital soon enough because my physical deterioration was making my low weight almost a secondary issue. My second therapist used to weigh me, back to the scale, each week and then she slowly phased that out. Ditto for my dietitian. That left me to my own devices for quite some time, and it wasn't pretty.

Not being weighed felt nice at first, because I really do hate being weighed. It's kind of embarrassing, like someone knows all of your dirty little secrets. The problem was that the ED had a field day. I couldn't self-regulate around food. I would overeat, and then restrict and overexercise. Whether this would have showed up in my weight is unclear, but the lack of weighing added one more way for me to hide the seriousness of my ongoing eating disorder.

With my relapse last year, it was back to the weekly ritual of being weighed. I was weighed with my back to the scale so that the weight gain wouldn't freak me out. This was no doubt a wise move, as I'm reasonably confident that I really couldn't handle knowing the number at that point in time. However, TNT has a very different philosophy about weighing (namely that it's just a number and there's a time when you have to get over it) and so I started actually knowing my weight. After an initial freak-out, the actual number ceased to be such a huge deal. I still detest that number, think I'm a whale, etc, but the number itself doesn't provoke as much anxiety as it once did.

Now that I am in recovery and doing well, I'm still weighed by TNT, although only every other week. It works out well- I get a respite from the grueling scale-induced anxiety attacks but TNT is still monitoring my weight closely enough that the ED can't really get out of hand. My parents and treatment team are (not surprisingly) more worried that I will start losing weight again. Since I have the eating disorder and am therefore not that rational about my weight, I mostly worry that I will once again start gaining. Seeing my weight stay exactly the same week in and week out gives me the reassurance that my body isn't going to flip the hell out at an extra cupcake, and it reassures my parents that I really am taking this whole recovery thing seriously.

There's another interesting variable that my weight gives TNT: an insight to my psychological state. Bouts of the stomach flu aside, usually a drop in my weight means an increase in anxiety and ED symptoms. There's no clear cause and effect (did the drop in weight increase the ED thoughts or did the ED thoughts cause the drop in weight? I think both are true) but the fact that my last therapist pushed for a higher weight and then insisted I stay there (despite me calling her a meanie and much, much worse) has given me much greater psychological stability. The slightly higher weight (5-10 pounds) is the price I have to pay for a hint of peace of mind. But the opposite would have been a Faustian bargain: a weight I "preferred" but an ongoing, never ending, ultimately losing battle against the ED. Seeing my weight every other week is a reminder of that icky number, but it's also a reminder of my renewed peace of mind.

I like the fact that someone is monitoring my weight even though I really do hate getting onto that scale. Waiting for the little slide weights to settle themselves is like waiting to hear a verdict: it's long and agonizing but it probably really takes no more than 10 seconds. I'm getting used to my new weight although I still don't like it. I prefer knowing the number to not knowing it because at least if I know it, I'm not imagining having reached a four-digit weight overnight. Which makes the entire situation one massive paradox: hating getting weighed, liking the security of being weighed; hating what I weigh, liking to know that awful number rather than leave it to the imagination.

Since when did an eating disorder ever make sense?

Lying and keeping secrets are second nature to people with eating disorders. I don't really think of myself as a dishonest person, but when I am into my eating disorder, I feel compelled to lie, cheat, hide, and cover things up. A lot of this covering up has to do with protecting the eating disorder--the real problem isn't that I'm hiding food, the real problem is that everyone is watching me eat--but sometimes I don't come clean even after the fact.

And it's that not coming clean otherwise that really cuts to the core of who I am. The reason I keep some things secret is really rather simple: shame. I am ashamed that I have done XYZ. I am ashamed that I screwed up. I am ashamed I lied. So I lie again, rather than face the facts. It's easier--and I don't have to look or feel "less than."

This works in the short term--the very very short term--but in the long run, I just get more and more mired in the eating disorder. So I keep on lying until even I'm no longer sure what's reality and what's the nice little PR spin I've tried to put on my latest fiasco. This, of course, doesn't do me or anyone else any good at all.

In order to stop doing this, I've had to acknowledge two major things:

1. I'm not perfect


2. It is a big deal

Despite my epic perfectionism, I find it just as hard to deal with the second of these, probably because I have to crack through a pretty thick layer of self-delusion. I know I'm not perfect- in fact, I'm painfully aware of that. My perfectionism is more based on the twin facts of not wanting to hate myself for not being perfect and not wanting others to see just how really flawed I am. But I digress.

I believed for years that one skipped snack, one missed exchange, was really no big deal. I thought I was even dealing with issue #1 because I was being gentle with myself for screwing up. Which, like, ha! I was deliberately interpreting the statement of "Don't be so hard on yourself, Carrie" with "My snack is hard today, therefore I will skip and not be hard on myself." When I started going to the gym several times each day, I didn't really think it was worth mentioning because it wasn't that big of a deal, really. Or when I started skipping breakfast. It was just once, it's no big deal. But the next day breakfast rolled around again, and I was paralyzed by the guilt of needing to eat today what I didn't eat yesterday. So I skipped breakfast again. It still wasn't a big deal, right?

I've had to learn the hard way that one slip really is a big deal because it can so easily become one. I hate having to say "Mom, I, uh, threw away my snack last week," because it's super embarrassing, it lets on just how seriously flawed I am, and I also feel like I'm making a mountain out of a molehill (a skill for which I am legendary). I don't think I will stop hating having to say this, and so there is really only one logical solution: no more secrets.

I can't keep omitting things to TNT or my family because I'm afraid of looking "less than" or because I don't think it's a big deal. I can't keep up the ridiculous hubris that I will be able to handle it on my own, that I'm fine, that no one needs to know when things go pear-shaped. I would like to be able to handle it on my own, but the fact is that when recovering from an eating disorder, I need all the help I can get. Maybe I can handle it on my own, but maybe I can't. The worst that happens if I can is that I have a lot of people on my side; if I can't, well, let's not go there.

It's hard for me to change like this, to admit I need help sometimes, to admit I screwed up, to admit that the eating disorder might once again have gotten the upper hand. That doesn't make it any less necessary, though. So I can only reaffirm this: no more secrets.