Tuesday, December 06, 2011

Let's Say. . .

Scenario 1:  Let's say that there's this young woman who comes to therapy.  We'll call her Diana.  Diana doesn't have an eating disorder.  What brings her into treatment is panic attacks.  In the course of her anxiety, let's say Diana loses weight.  She's panicky, on edge, and she's not eating enough.  Let's say that Diana was "at a normal weight" (whatever that is) before and that when she loses weight, she looks unhealthy.  Let's also say she has a psychiatrist who's treating her for her anxiety.  Then, let's say that Diana's therapist expresses concerns about her weight loss and discusses with her how she can get adequate nutrition even with low appetite.  Remember, Diana doesn't have an eating disorder, so this isn't the most complicated thing.  Next, let's say that Diana starts to feel less anxious.  Some combination of medication and therapy is helping her, and her panic attacks remit.  Let's say, that in the process of this, she gains back the weight she had lost.  Let's say that Diana is again "at a normal weight" (whatever that is).  Finally, let's say that she visits her psychiatrist after some time, who mentions Diana's weight gain and states that 1) Diana needs to lose weight and 2) She needs to do so by their next visit.

Scenario 2:  Let's say that another woman who has been in therapy for many years for anxiety, depression, and a sub-clinical eating disorder, is seeing a relatively new psychiatrist.  We'll call her Sharon.  Sharon likes her new psychiatrist because she seems compassionate and responsive to her.  Like many psychiatrists she's had in the past, Sharon's current psychiatrist is eager to try out new medications and doses of medications with her, in order to alleviate her symptoms.  During one appointment, Sharon, who is "at a normal weight" (whatever that is), expresses concern about her psychiatrist's recent recommendation that she up the dosage of her medication in order to address her residual anxiety.  "Doesn't that cause weight gain?," she asks.  Sharon is concerned because she has a history of binge eating, and she doesn't want to be on anything that exacerbates this condition.  "It could," her psychiatrist replies, "But that's when you just need to focus on portion control."  To Sharon, who again has a history of binge eating, hearing the phrase "portion control" creates such anxiety in her that she actually wants to binge.  She's had many attempts at trying to restrict what she eats (in fact, that's what led to her binge eating, according to her understanding of it all), and this does not seem to be an adequate solution.  

Do you have any reactions to these scenarios?  They can and do occur, highlighting the importance of consulting with professionals who have specific education and training in the field of eating disorders.  A simple, innocuous comment as processed by someone with an eating disorder can do significant, unintended damage.  Ideally, those struggling with eating disorders can arrive at a place in their recovery where a single comment isn't so threatening (as they may come from various sources), but until and unless this happens, it's important to select a treatment team sensitive to these concerns.


Chantell said...

Thankyou for raising a very important point here ~ That psychiatrists/Dr's need to listen to their patients, but also need to be searching for any underlying issues which the patient may not be so 'open' about...I have struggled with anxiety, depression and an eating disorder for many years now... When I first seeked help though, it was only for anxiety & depression ~ I was too embarassed to mention the eating problems I had...

I had very similar experiences to the scenarios you wrote about...I refused to try new meds due to concerns over weight gain, time and time again, but this was never seen as a 'decent' enough reason in their eyes for me to refuse...

I also had a Dr tell me I had gained too much weight during my last pregnancy (when I had tried so very hard to not restrict and not purge for the sake of my unborn child) Major anxiety/eating relapse! And still battling...

Not laying any blame at all, but I do agree that it is crucial for health professionals to search beyond the obvious when it comes to eating disorders...Denial is a major symptom, for one thing! Thankyou for a post I could truly relate to :)

Regina said...

This is a great post. I am actually a therapist, and one of the things I tell clients at the very beginning is, "I am not perfect. There might be times I say something that offends or upsets you. I really want you to tell me when this happens so that we can talk about it. I will not get upset with you or become defensive if you talk about this with me." No matter how great the psychiatrist, he or she is going to make mistakes.

That being said, both of those scenarios made me feel uneasy. I don't feel that the psychiatrist in scenario 1 should mention the weight gain at all, especially after talking with Diana about her weight loss prior (and how it was a concern). Now that Diana has gained the weight back, the psychiatrist is now concerned about her being too heavy? How small of a weight window would be "just right" for this psychiatrist? I don't think it's appropriate to mention weight unless the person identifies this as something he/she wants to work on. In Diana's case, she didn't want to work on her weight. If she were morbidly obese, I might be able to understand if the psychiatrist brought it up, but even then, he or she should have done so in a therapeutic manner. ("Do you ever find that you eat when you're not physically hungry?" "Are you satisfied with your size?") And it was definitely inappropriate to set a time limit on the weight loss! It's not The Biggest Loser!

The psychiatrist in scenario 2 had good intentions, but she was obviously not educated in eating disorders. I had a therapist who said she had "experience treating eating disorders," and when I began talking with her about some of my struggles, she suggested that I switch from ice cream to frozen yogurt. Her intentions were good, and I can tell she genuinely wanted to help me. But her oversimplifying my struggles made me feel invalidated and misunderstood, and I ended up leaving her care.

Thanks for your blog...I love reading it!

Anonymous said...

Both of these scenarios make me angry, and both are things I can relate to and seen in my own journey as a user of the mental health system.
I do not think that psychiatrists or therapists are Gods and they cannot second-guess what is going to trigger a reaction - but in these two examples you gave you only need to be the smallest bit intune with the emotions of the 'patients' to realize that weight could be a trigger.
I think it helps a lot if, especially when dispensing medications, doctors listen to patients much more - and that it becomes protocol that a care plan is drawn up to mange disorders that often, statistically raises rear themselves as co-morbid disorders bourne out of a lack of approapite coping mechinisms. It is no great leap to see why someone with an anxious predisposition may also have a higher chance of getting an eating disorder.
Most patients now who present with self harm wounds or severe depression have a plan drawn up 'just in case' suicide becomes and real risk - and a plan for entering psychosis is often also penciled in. If this can happen then why not make more steps to alert dr's to the budding of an eating issue?
Therapists can't think before they speak every single time, but given their professional work role I think they should en-devour to think through any possible triggering conversations or 'slips'.
I think this is a very difficult thing to solve and monitor but it all comes down to Therapists listening more to patients and taking concerns on board..any fluctuation in weight, while in therapy, combined with a similar personality type than those seen in patients with clinical eating disorders should be flagged up, highlighted, underlined and feature in a care plan.
Interesting post