written by Clementine Miami Pinecrest Clinical Director Bertha Tavarez, PsyD. Bertha discusses treating an adolescent who is resistant to care. She offers some strategies to help strengthen the therapeutic alliance and build the groundwork necessary for full recovery.
“The sun and the wind were having a dispute as to who was more powerful. They saw a man walking along and they had a bet as to which of them would get him to remove his coat. The wind started first and blew up a huge gale, the coat flapped but the man only fastened the buttons and tightened up his belt. The sun tried next and shone brightly making the man sweat. He took off his coat.” – Anonymous
The metaphor of the sun and the wind is an accurate depiction of the challenges that many clinicians face while working with adolescent patients. Although we may have access to the gravity of our patient’s clinical needs, simply communicating our concerns and providing much needed skills can be met with resistance. Our patients remain “locked in” to their emotional experience while simultaneously feeling “locked out” of the insight and motivation needed to increase their receptivity to much needed skills development. The adolescent, preoccupied with exerting and maintaining control and autonomy, may hold tightly to their coat, rendering our intentions to provide care futile.
So how do we, like the sun, create shifts in awareness and influence change?
The power of reflection
It may be tempting to adopt the roll of cheerleader (“You can do this!”) or problem solver (“Why don’t you try this?”). When an adolescent patient presents with resistant talk (“I don’t want to be here”) or talk that inhibits change (“I got straight A’s with ED, what’s the problem?”). Often the simplest and most effective way of building rapport and loosening the grasp of resistance is to simply reflect the patient’s message in your own words. Often, patients are primed for persuasion and direction. Reflection statements can contribute to feelings of validation and interpersonal trust.
Resistance as an interpersonal process / Resistance as developmentally appropriate
It is important to keep in mind that resistance is both developmentally appropriate for adolescent patients and an interpersonal process that occurs within the therapeutic alliance. Although, we may expect a certain degree of resistance on a developmental level, we can provide corrective experiences around resistance that still promote autonomy. A clinician may benefit from awareness about the resistance that is brewing in a session, abstain from engaging in a power struggle, and promote an alliance with the patients’s desire for autonomy.
Highlight intrinsic control
An effective technique that facilitates a shift from resistance talk to change talk is the clinician’s emphasis on the patient’s access to her personal control. A clinician may reflect the pros and cons experienced by the patient:
Patient: “I got straight A’s with ED, what’s the problem? Gosh! That was so hard!”
Therapist: “It sounds like you did well in school this year, but ED made it more difficult.”
A clinician may also reflect a patient’s choice within the constraints of the treatment environment while having the knowledge of the consequences. For example, the patient may be informed of her choice to select what day an exposure is initiated or asked to reflect on her choice to not participate in a group while being aware of consequence of losing a daily privilege as a result.
If resistant talk persists, the clinician can shift the focus to another closely relevant therapeutic topic that may tie into the overall theme beneath the resistance. For example, if the patient states, “I don’t want to take medications and that’s final!” the clinician can say, “Ok, how about you tell me how you’re feeling about your overall health today?”
Working with patients experiencing resistance and treatment ambivalence can be challenging. However, there are great opportunities at this treatment phase that can strengthen the therapeutic alliance and build the groundwork necessary for lasting change. Motivational interviewing and person-centered techniques are an integral component of the clinical work at Clementine adolescent treatment program.
For more information about Clementine adolescent treatment programs, please call 855.900.2221, visit our website, subscribe to our blog, and connect with us on Facebook, Twitter, and Instagram.
Clementine’s newest location, Clementine Briarcliff Manor, will open on April 24th. To visit or tour a Clementine locations with one of our clinical leaders, please reach out to a Clementine Admissions Specialist at 855.900.2221.
Originally published on April 4, 2017 on http://clementineprograms.com/blog/
Written By Shiri Macri, MA, LCMHC, Clinical Director at Green Mountain at Fox Run’s Women’s Center for Binge & Emotional Eating
When treating Binge Eating Disorder, it’s quite common to identify trauma as one of the root causes of emotional overeating and binge eating. Food does more than simply satiate hunger, among those who suffer from binge and emotional eating. Food and eating become:
How Our Brains Respond to Trauma
When people experience traumatic events, the fight-flight-freeze response is activated at such an intense level that our systems become hyper-aroused and hypervigilant in an effort to protect ourselves from future traumas.
That hypervigilance usually gets translated into distorted beliefs about our worlds, again, as a protective measure. Much like a war veteran might have a startle response to a loud sound, so too do those who experience trauma develop distorted beliefs. Beliefs such as “loud sound = enemy fire” (in the case of the war veteran) or “staying home to binge keeps me from having to go out on dates” (in the case of binge eating) can, at times, only be explained by traumatic experiences.
A Perfect Storm
Often eating becomes the way out of such intense fears and belief systems, especially if eating and food have been made an issue in earlier life. Sometimes families put great importance on eating the “right” vs. “wrong” foods or on having the “ideal” body type. When this is the case, there is already stress and importance placed on eating and food.
It’s in these “perfect storm” scenarios that we most often see people turning to food to escape the dissonance created by trauma, among other things. For example, turning to food as a form of self-medicating difficult, trauma-based emotions; or as a protection, perhaps by attempting to add layers to the body to keep from being exposed; or perhaps eating to avoid situations that may trigger the trauma, like socially related situations.
We know this as an ego-dystonic behavior, in which an individual engages in behavior that is incompatible with his / her beliefs. The result of this behavior only feeds the struggle, in that binge eating to cope with trauma leads to increased dissonance, shame and guilt. These further distressing emotions, in turn, lead a person to return to their coping mechanism; in this scenario, it’s another episode of binge eating. The cycle continues.
Mindfulness as a Path Towards True Healing
We see this painful cycle time and again at our Women’s Center for Binge & Emotional Eating. But we also see true healing among our clients, which happens from the inside out.
When body size becomes a target of healing and people turn to dieting, weight loss programs and surgery, only the external concern is addressed…and, incidentally, is rarely successful. Instead, true healing for those who turn to food after trauma means moving towards the body in a different and more tolerable way. It means plunging into mindfulness, and often therapy.
Traumatic stress, especially when coupled with emotional and binge eating behaviors, requires gentle, compassionate support to heal. And we know that the body can very much be an ally in healing the often frozen state people find themselves in with this struggle. By engaging in a mindfulness practice, whether through meditation or mindful movement such as yoga, tai-chi, qi-gong, etc., people can gently and tolerably begin the healing process.
Trauma-Informed Strategies for Focused, Effective Treatment
Most of the women we treat at the Women’s Center for Binge & Emotional Eating have experienced loss or trauma…whether during childhood or simply from living in a plus-sized body in today’s appearance-obsessed culture.
We have learned through neuroscience that empowering our clients to self-regulate their own arousal systems can put them in charge of their physical and emotional states. Rhythmic activities such as dance, tai chi and drumming integrates the senses to help heal the frozen sense of isolation and separation.
Furthermore, physical empowerment is encouraged through movement activities such as kickboxing.
Lastly, mindful meditation is taught and practiced daily.
Safe spaces for client narratives and emotional expression are essential…as is evidence-based therapy AND relationships. Teaching the language of the inner experience while transforming the inner critic into a self-compassionate advocate supports the path to healing.
written by a New Haven Residential Treatment Center Student
I have been at New Haven for over 5 months now. My journey here has taught me so much about myself and my family. A lot of my family’s progress has happened through Experiential Therapy. My family and I began our treatment with challenging family dynamics that were getting in the way of our relationships with each other. A few months ago, we found out that there was an extreme lack of trust in many aspects of our relationships. So, during one of our family weekends, we completed two Experiential Therapy tasks that were based on trust.
The first task we completed was rock climbing together, blindfolded. I climbed first, with my dad belaying me, and my mom directing me on where to go. It tested me to trust that my mom would lead me “safely “to the top and that my dad would catch me if I fell or needed to rest. We successfully completed the task, twice, once more with my mom belaying me and my dad directing me where to go. The hardest part for me was letting go of the wall at the top and having my mom or dad lower me to the ground. I didn’t trust that they were capable of holding me or that they wouldn’t drop me. After we completed the task twice, I felt safer with my parents and confident that they would be there for me. I then belayed both my parents to ensure them that I would always be there to do the same for them.
Our second task was the “Triangle of Trust”. It was on a ropes course, high up off of the ground that required equal energy from both people in order for you to stay suspended in the air. This was even harder for me and my parents because we are all afraid of heights. After practicing first on the ground, my dad and I went up on to the ropes course. I’m not exactly sure how high up we were, but it was high enough to make me grip on to anything I could so hard that my knuckles turned white. My dad followed me up until we were facing each other, on two separate wires. We grabbed each other’s hands, and leaned into each other as we began to walk. We were wobbly and unstable because my dad was putting more into it than I was. We got a little less than half way, when the difference in the effort being put in took effect, and we fell. Once we were lowered to the ground, I got to go back up with my mom. I had the advantage of already doing the task once, but it was my mom’s first time and the height scared her. She kept looking down. When we held our hands above our heads and leaned into each other, I told her to just look at me. We started moving slowly, talking to each other and taking deep breaths. We got about half way until we were so stretched out that we fell. My parents and I processed our experiences after, and learned quite a bit.
I realized that my turn with my dad portrayed our relationship in these past few years perfectly. Dad would always be putting so much into our relationship, while I resented him for the past and neglected our relationship. The “Triangle” shows exactly how a relationship works. For it to thrive, both people must be equally invested and put the same amount of energy into it. However, if one person is putting more into it than the other person, the relationship will “fall”. For my mom and I, it showed us that we support each other well and that we should trust in each other more.
I am so grateful for the Experiential Therapy that we experienced, because I have learned so much. I am excited to have more enlightening experiences in therapy like these tasks.
By, A New Haven Student
written by Monte Nido Rivertowns Assistant Clinical Director Gillian Tanz, MSW, LCSW
Gillian is an expert in the mental health field with almost ten years of experience. In her writing, Gillian shares some of the do’s and don’ts she has learned through the years from families and loved ones supporting those in eating disorder recovery.
Supporting a person with an eating disorder can be a very tricky thing to do. How do you know whether what you are doing is supporting your loved one in their recovery process, or enabling their eating disorder to retain its grip? This is a theme that comes up again and again at Monte Nido Rivertowns. Below are some helpful guidelines, as told to me by families, clients and staff engaged in the process of recovery.
Do: Educate yourself about eating disorders. The more you know about what your friend or loved one is going through, the better you can support them. Don’t be afraid to ask them questions also, as every person is unique. Eating disorders are serious illnesses, with the highest mortality rate of any mental illness. If you know or suspect you have a loved one suffering from an eating disorder, it is important to support them to get effective treatment.
The following web sites are a good place to start educating yourself:
Don’t: Talk about or evaluate your body or other people’s bodies, or talk about dieting or weight in front of the person in recovery. Even if you are not commenting on their body or their diet, you send an important message about what you value or judge in a person by how you discuss yourself or others. Of course, many people are unhappy with their weight or appearance and the prevalence of the diet industry in our culture cannot be understated. Just because you may be on a special diet does not mean you yourself are engaging in disordered eating habits. However, a person in eating disorder recovery is especially vulnerable to these messages. What is a casual comment to you, can for them be a verbal sledgehammer. This goes for compliments as well as criticisms! For example, noting that a celebrity looks great because he/she has lost weight can send a message that what you value about that person is their appearance. These messages are subtle but insidious, and it takes practice to become aware of them.
Do: Ask to be involved in your loved one’s treatment. One of the most important components of eating disorder recovery is developing a support network of people who understand what you are working on and how they can help. This is what we often call “putting the eating disorder out of a job.” For many people with eating disorders, the ED is a way to cope with difficult emotions, thoughts or events. Using food or disordered behaviors to exercise control over one’s situation is a strategy that may seem helpful to a client until it becomes a real problem. In order to move away from the disorder, the person must begin to trust and rely on friends and family to gain the emotional support that all people need.
Another reason offering your support and involvement can be so powerful is because of the shame and stigma so often associated with eating disorders. Joining with your loved one and engaging in therapy to the degree they are comfortable sends a message of empathy, acceptance and love that they may not believe possible. The alleviation of shame can be incredibly impactful on the recovery process for a person with an eating disorder. This is something supporters can offer in a way that the person in recovery often values more than if it comes from a treatment professional. The validation you can offer with your kindness and acceptance is incredibly healing and important.
Don’t: Make changes in your own life to accommodate the eating disorder. At Monte Nido, we talk about a person’s Healthy Self and their Eating Disordered Self. A person in recovery from an eating disorder may experience a daily battle between these two selves, and it can become quite confusing for them and for their loved ones. For example, a client of mine once told me how supportive her family was—they would stay home and watch tv with her rather than going out to eat at a restaurant. Restaurants made her (Eating Disordered Self) uncomfortable. Rather than making the client choose between what her Healthy Self wanted—time with her family—and what her Eating Disordered Self wanted—to restrict calories—the family’s “supportive” gesture appeased the ED. This enabled her to keep using disordered behaviors with no negative consequences. This client highly valued and loved her family and spending time with them. Before coming to treatment, the client felt her ED was “functional,” despite how miserable she often felt, because she was still able to “have her cake and eat it too.” Creating a choice between staying alone with her ED and engaging socially with her family was exactly what was needed to increase her motivation to recover.
Another reason not to accommodate the eating disorder is because it is awfully tiring! Supporters who go out of their way to appease the disorder can find themselves feeling “burnt out” and even resentful of their loved one. In addition to seeking your own support (see below), it is crucial to know what your limits are and to stick to them. Explain your personal boundaries to your loved one in recovery during a normal conversation (not an argument) and ask for their understanding and cooperation. This is another way to keep yourself healthy and take care of your own needs, so that you can be supportive to them as well.
Do: Get your own support. This can be from many sources, such as a support group, a therapist, friend or clergy. Some treatment facilities offer support groups just for loved ones of their clients for this reason. It is important to recognize that getting your own support can help the person you love who is suffering from an eating disorder. Much like the way that, on an airplane, you’re instructed to put your own air mask on before helping others, you must take care of yourself in order to be supportive to your loved one as they recover.
Don’t: give up hope. Our philosophy at Monte Nido is that real, sustained and permanent recovery from an eating disorder is possible. The road to being fully recovered is not easy, but the presence of loving supporters is essential to progress on that journey. Thank you for taking the time to read this article and for educating yourself so that you can be an effective supporter to your loved one.
Originally published on March 1, 2017 at http://www.montenido.com/2017/03/01/supporting-vs-enabling-dos-and-donts-for-families-and-supporters-of-people-in-eating-disorder-recovery/
By Rachael Clauson, MAAT, Eating Disorder Specialist at Timberline Knolls Residential Treatment Center
The road to eating disorder recovery has many twists and turns. But the important thing to always remember is that it has a destination. This destination does not have an identifiable name like Salem or Miami; instead it is associated with words like joy, happiness, health, abundance and freedom.
Recovery is a process that necessitates intentionality. By remaining committed to certain fundamentals, recovery can be full and complete.
Such fundamentals include:
The word mindful is bandied about a great deal these days. There is even a mindfulness app–and for good reason. The world is so hectic and everyday lives are so busy that we forget the value of the moment…the importance of the here and now. Essentially, today is all we have; and yet we allow days to slip away without much notice.
In recovery, it is not only useless to dwell on the past, it is counterproductive. Yesterday is genuinely gone. No one gets a “do over.” What’s more, if you take ten minutes to think about what you should have done or said yesterday, you just sacrificed ten minutes of today. Similarly, fixating on the future is nonsensical. It hasn’t happened yet, so again, you are squandering time in the present, time you will never get back.
As the old expression goes, Rome wasn’t built in a day—neither was your eating disorder. It took time to become fully invested; therefore, it will take time to fully extricate yourself. Consider this: if you fractured your leg, you would allocate weeks, even months for the bone to repair. An eating disorder is no different. It takes time for true healing to occur. Be patient and gentle with yourself.
Give your mind, heart and body the time required to heal completely, and remember that healing has no exact timeline and this process looks different for everybody.
We live in a world that is full of possibility, limited only by your imagination, self-doubt, and self-judgment. Which leads us to potential. Each human being is a huge packet of potential—you are no different. You may not have what it takes to be a world famous rock star or brain surgeon and that is okay. The beauty of potential is that everyone is different; otherwise the world would be overloaded with singers and surgeons. You may have the potential to grow beautiful roses, write a lovely poem, or simply be a good friend to someone that needs you. The thing about potential is that it is not always immediately evident due to the layers of self-doubt or the internal voice that says “you can’t do that.” But if you look, you will find it.
Passion does reside within every person. But not unlike potential, it must be sought and cultivated. Think hard about what you genuinely care about. Remember, there is no right or wrong. It may be the environment, cats, the elderly, or racial injustice. Now, find your power and use it. And know that using your power can vary in how it looks and functions. You can join a group that cleans up parks on the weekend, volunteer at a rest home or humane shelter, join a political group that is dedicated to change. You can begin by sharing your voice and experience through words, both written and spoken, or through art. Let your power fuel your passion.