Internally Free: How to Develop an Inner Calm in an Externally Chaotic World

 I've been working on a book titled "Internally Free" for several years. Since this new book is about 75% done, I thought I'd share posts with you on the general theme. As an exercise for myself, I set aside an hour each Thursday to churn out a post and publish it without editing. The idea is not only to sharpen my skills, but to practice non-attachment to an outcome (e.g., it being perfect, people loving it, etc.) as well as to practice getting used to other people reading my work in this new area. It's tough to branch out! Of course, I'd absolutely love your input. Thank you for any feedback at all you are willing to share. If you're interested in reading the output of these little exercises, here is this week's post: https://internallyfree.substack.com/p/the-battle-between-love-and-fear.

What is Purging Disorder and How is it Treated?

by Tara Deliberto

Purging disorder is characterized by the presence of purging behaviors (e.g. vomiting, laxative use, etc.) aimed at influencing body size/shape/weight in the absence of binge eating and purging cycles. In other words, the purging exists separate from binge eating. Technically, purging disorder falls under the "Other Specified Feeding and Eating Disorder” - or OSFED - category in the DSM-5.

Relatedly, no treatments currently exist specifically for the treatment of purging disorder in adolescents, to our knowledge. After we received inquiries about whether or not Integrative Modalities Therapy (IMT) can specifically address this disorder, we were inspired to write about it!

Yes, IMT can absolutely be used to treat purging disorder. In fact, IMT was designed to treat all eating disorders. Further, it is intended to be used flexibly. As such, not every handout is going to be useful to administer to every patient. Patients with purging disorder are no exception!

Although every IMT handout may not be useful in treating purging disorder, many will be. This is up to the therapist to determine. That said, the IMT handouts listed below would be particularly helpful in treating the majority of those with purging disorder.

If you are interested in learning more, please feel free to contact us directly or join one of the online IMT communities such as our private Learning IMT Facebook Group!

IMT Handouts for Use with People who have Purging Disorder 1. Individual Therapy a) Regular and Appetitive Eating (RAE) Handouts 1, 3, 4, 8, 14 b) Body Acceptance and Exposure (BAE) Handouts 6, 7, 15, 16, 18, 19, 21 2. Group Therapy  a) Mindfulness and Acceptance (MAC) Group Handouts 1, 2, 3, 6, 19 (the NO PURGE Skills)  b) Cognitive Behavioral Therapy (CBT) CBT Group Handout 12 3. Family Therapy a) Stage 1 Family Handouts 1.4, 1.5, 1.6, 1.7, 1.9, 1.12, 1.15, 1.17, 1.18, 1.29 b) Stage 2 Family Handouts 2.2, 2.6

Integrative Modalities Therapy (IMT) for Eating Disorders

by Tara Deliberto, Ph.D.

Back in March of this year, the approach that Dina Hirsch, PhD, and I created for the treatment of eating disorders was renamed Integrative Modalities Therapy (IMT)!  Here I'll explain the reason for the change as well as the meaning of the new name.

When we started out, our aim was to create a comprehensive collection of evidence-based interventions for patients and families with eating disorders.  For the original plan, we knew that we needed to have an approachable patient-and-family-facing name.  We decided to call the first version of our book "BITE," or Behavioral Interventions, Tips, and Evaluations.  At the time, this name was fitting since the acronym represented the smallest behavioral step a person can take towards recovery (i.e. taking a bite of food) and the fully spelled-out name descriptively explained what was included in the book. It was a go!

Over the years, however, our singular book that brought together interventions, tips, and assessments grew into something much larger: an evidence-based practice treatment approach.  We soon needed to write a treatment manual for clinicians to use alongside the original book for patients and families. Our unpublished manuscript became a resource for clinicians in the trenches who needed a summary of all of the varied evidence-based interventions in one easy place.  Some have called our approach "evidence-based practice in a box."  Recognizing the potential of this type of resource, our goal became to provide clinicians with a comprehensive, practical, flexible, and scalable resource to help navigate the treatment of eating disorders. 

Considering these advancements, prior to both books being published by New Harbinger, it was time for a new clinician-facing name!  We chose to rename our approach Integrative Modalities Therapy (IMT) because it integrates a wide array of evidence-based interventions from gold-standard treatments into the three modalities of individual, group, and family therapy.  In short, the approach is both integrative and can be administered modularly across the three treatment modalities.  As a clinician-facing evidence-based practice approach, we now have the big, hairy, audacious goal of contributing to the efforts of our colleagues by helping to close the eating disorder treatment gap together.

Anorexia Nervosa & Borderline Personality Disorder

Gold-Standard Treatments at Odds: 

Complications in Treating Combined Anorexia Nervosa & Borderline Personality Disorder

Any clinician can tell you that treating a life-threatening psychological condition such anorexia nervosa or borderline personality disorder is seriously challenging.  Treating a person with both anorexia nervosa and borderline personality disorder, however, is exponentially more difficult than the treatment of either condition alone.  This is largely because the gold-standard treatments for these disorders are at odds with one another: treating one life-threatening disorder exacerbates the other.  This post discusses how this happens and what to do.

To being to understand this problem, let's start with a discussion of why these disorders are life-threatening.  Eating disorders are life-threatening because the bodily impact of eating disordered behaviors such as severe caloric restriction and purging can respectively result in conditions like severe malnutrition and esophageal tears.  Borderline personality disorder is also life-threatening because people are at risk of engaging in impulsive behaviors, self-injury, and suicidal behavior when because they lack skills to regulate intense emotions.  Clearly, both disorders are life-threatening and must be addressed.  But what do you do if someone has both an eating disorder and borderline personality disorder?  Just treating both conditions at the same time seems like the obvious answer. Quickly after the implementation of this approach, however, one quickly discovers that the gold-standard treatments of the two life-threatening conditions are at odds.  

To further understanding as to why these treatments are at odds, let's first discuss the singular treatment of anorexia nervosa, one type of deadly eating disorder.  In anorexia nervosa, a person becomes underweight following a prolonged period of severe caloric restriction.  This severe caloric restriction is a behavioral strategy used to temporarily decrease the experience of fearing  fatness in a given moment.  In the treatment of this condition, the goal must be weight gain to ensure both physical and psychological recovery.  Further, from a psychological perspective, a person recovering from anorexia nervosa must endure the following exposures: 1) eating a large quantity of food many times per day (upwards of 4,000 calories), 2) eating a variety of high-fear foods every day such as pizza and burgers, 3) enduring a physical feeling of fullness that the eating disordered mind equates with immediate "fatness," 4) actual weight gain slowly occurring all day, every day for what is more often months, rather than weeks, and 5) not engaging in any "safety" behaviors that result in a respite from fear of fatness such as exercising, purging, and taking laxatives.  As such, the treatment of anorexia nervosa involves what can be viewed as a series of multiple, intense, all-day in vivo exposures, that carry on for months.  And because the person is in medical crisis, the intensity of this extended exposure cannot be lessened. There is no luxury of spacing out exposures based on psychological readiness in the treatment of anorexia nervosa.  A person with anorexia nervosa must be thrown into the metaphorical deep end.  As such, I imagine that the series of exposures involved in the treatment of anorexia nervosa are more intense than the treatment of any other disorder.

Now, let's discuss the singular treatment of borderline personality disorder.  In the treatment of borderline personality disorder, we are taught early on in graduate school that it is a bad idea to star therapy by addressing underlying trauma, which of course is normally treated with "prolonged exposure."  The idea is that if someone does not have skills to cope with intense negative emotions that arise when addressing trauma in exposure, they may be at increased risk for impulsive, self-injurious, and suicidal behaviors.  So, rather than implementing exposure in the treatment of borderline personality disorder, we are taught the focus in the treatment must be on skill building.*  Returning to a deep-end metaphor, learning coping skills is the equivalent of learning how to swim.  The skills, of course, are very helpful to know before being thrown into the deep end.  

As such, in the treatment of BPD, teaching skills decreases impulsive behaviors, the life-threatening component of the disorder.  A person with anorexia nervosa, however, is not immediately saved in the same way with skills.  Because the treatment of anorexia nervosa first requires medical & nutritional interventions that are psychologically experienced as exposures, there isn't enough time to teach skills before the interventions begin.  Further, even intelligent people with malnourished brains are much more likely to think inflexibly, and therefore, skills such as flexible & dialectical thinking may not be absorbed even if taught well to smart folks.

Now with a greater understanding of the individual disorders, let's return to the problem: focusing on treatment of an eating disorder in which intense exposure is needed can exacerbate the emotion dysregualtion inherent in borderline personality disorder, increasing the odds for impulsive behavior, self-injurious behavior, and suicide; alternatively, focusing primarily on skill building to treat the borderline personality disorder would does not allow for the rapid weight gain needed to ensure medical stability in the treatment of anorexia nervosa. 

To increase understanding of this problem even further, let's combine the above concepts with understanding a bit about how the brain is impacted by both disorders. A patient with anorexia nervosa has a malnourished brain that will result in inflexible thinking, further obsessionally, increased irritability, and other cognitive deficits.  If this person also has borderline personality disorder, not only is the brain malnourished, but the system in the brain in charge of emotion regulation is malfunctioning.  As such, the brain is malnourished - and needs nourishment to function properly - but the process by which re-nourishment occurs involves intense, all-day, multiple exposures that predictably result in rather severe emotion dysregulation, which is efficiently calmed by the immediate escape of negative emotion through the sabotage of the re-nourishment process (e.g. purging).  Big problem.

The problem is so big, in fact, that I do not think that simply treating someone with both outpatient gold standards of treatment - Family Based Therapy for anorexia nervosa and Dialectical Behavior Therapy for borderline personality disorder - will be helpful.  I do, however, have some strategies for fighting the two-headed monster that is comorbid anorexia nervosa and borderline personality disorder.

When clinicians finally see a patient with anorexia nervosa and borderline personality disorder in treatment, the complex interplay of psychological and physical pathology has already seriously compromised the patient's overall health.  Without any time for fostering full understanding of our rationale, the only thing to do in the moment is push the person into the deep end of the pool.  As clinicians we must also, however, dive in after them.  In the pool, we can hold them up until they learn how to swim.

I don't believe there is much hope of recovering from comorbid anorexia nervosa and borderline personality disorder without massive amounts of support.  Inherent in the disorder of anorexia nervosa, the person with this diagnosis cannot reach the conclusion that consuming large volumes of food and gaining weight will result in recovery.  We have to show them this.  As such, an outpatient level of care is very rarely enough.  It makes sense to me that most people who are severely underweight with anorexia nervosa and borderline personality disorder must be hospitalized on a psychiatric unit with staff and structure that can limit dangerous behaviors.  Because re-nourishment will inevitably be an awfully triggering experience, we must be as emotionally supportive as possible  We must also must be practically supportive and help the person learn as many coping skills as possible.  When someone is very underweight, we don't have the medical luxury of spending time focusing on skills, nor is it likely that most people can effectively learn the skills with a malnourished brain and body.  I think we must focus on re-nourishment while mitigating as many destructive behaviors as possible and teaching skills.  Once the person is stabilized, going to a structured program, likely makes the most sense.  

Unfortunately, in 2017 America, people with anorexia nervosa do not stay on inpatient units until they are 100% weight restored, even without the added complications that borderline personality disorder brings.  On a larger scale, I intend to advocate for a return to a time when patients stay until they have truly weight restored, especially if there is co-morbid borderline personality disorder.  In short, a presentation of both anorexia nervosa and borderline personality disorder really seems to call for the highest levels of care that you can get for the longest amount of time that you can get.  Whether you are a provider, patient, or loved one: I urge you to convey the information in this post to foster an understanding of the serious problem the comorbidity that anorexia nervosa & borderline personality disorder presents to advocate for more time in higher levels of care.

*Please note: there is evidence that PTSD & BPD can be treated simultaneously (Harned and colleagues; for more info: http://bit.ly/2cCrbiy).   But let's think about the treatment of borderline personality disorder and co-morbid PTSD v.s. anorexia nervosa a bit more. In the treatment of PTSD, "prolonged exposure" typically refers to about an hour of exposure once per week, the intensity of which is selected based on the psychological readiness of the patient.  From the perspective of someone who has undergone treatment for anorexia nervosa, the term "prolonged" is likely to seem sarcastically adorable.  I can imagine my patients saying "Wait, that is considered prolonged?  Ha!"  Although PTSD might be able to be treated in the context of BPD with careful consideration, the challenge of treatment anorexia nervosa is much greater.

A Holiday Facebook Surprise

I just discovered the "Message Requests" section of Facebook: it holds all of the messages from people you're not Facebook friends with. It was so surprisingly wonderful to find a bunch of lovely messages of gratitude from people who have read the posts on this blog over the last several years. What a totally unexpected and wonderful holiday gift.  Thank you so much for reading, sharing, and engaging.   

Happy holidays,
Tara

Scattergood Foundation Award Nomination for BITE

Dina Hirsch, Ph.D. & I are extremely excited to announce BITE's nomination for the behavioral health Innovation Award from The Thomas Scattergood Foundation! Please check it out here. The more comments the better so please feel free to post on the Scattergood site with any questions or feedback!

Thanks so much,
Tara Deliberto, Ph.D. & Dina Hirsch, Ph.D.

Behavioral Integrative Treatment & Evaluation (BITE) for Eating Disorders - Our Mission

I've spent the last year, together with Dr. Dina Hirsch, Ph.D., developing a comprehensive approach to the treatment of eating disorders called Behavioral Integrative Treatment & Evaluation (BITE).   Now, in only 4 short weeks, we're going to be releasing BITE.  In preparation for our launch, we'd like to share something very dear to us: our mission.  We hope you like it: http://www.bite-ed.com/our-mission/.

Further Musings on Potential Predictors of Suicidal Behaivor

In the last post I discussed thoughts on why certain groupings of physiological measurements may turn out to be a better predictor of suicidal behavior than genes (check out that post here).  On top of that, I have some general ideas as to how this may play out.

I would imagine that each psychological disorder may end up having its own constellation of physiological factors with predictive power.  For instance, people with major depression without psychotic features would have a different constellation of physiological factors associated with suicidal behavior than people with schizophrenia.   The people in the major depression group may have lots of indicators of very low mood but a certain amount of anxiety / excitement too.  Currently, it is a commonly held belief among clinicians, researchers, and even the general public that a certain amount of energy is required to make a suicide attempt.  Rather than a 1 to 1 correlation between low mood and suicide - i.e. the people w/ the lowest mood are at the highest risk of making an attempt - low mood plus a certain amount of motivation/excitation to attempt is believed to be in the mix.  It's worth noting that the excitation wouldn't necessarily improve one's mood.  Low mood and excitation are not only likely to be separate and valid psychological constructs, but they would represent themselves differently physiological tests.   Speaking in terms of totally made up units of measurement to illustrate a point, a person with major depression may need lower than -100 endorphins (representing low mood) and somewhere between +15 and +30 cortisol (representing excitation) in order to qualify as being at imminent risk for suicide.  On the other hand, a person with schizophrenia may need lower than only -25 endorphins (representing low mood) and higher than +200 cortisol (representing excitation) to be at imminent risk for suicide attempt.  Continuing down the path of this totally fabricated example, high levels of excitation may be more indicative of imminent suicide risk in schizophrenia than in major depression for a couple of reasons.  If someone with schizophrenia attempts suicide, it has a decent likelihood of being because they heard a voice in their head commanding them to do so.  As such, the experience of hearing a scary voice telling them to kill themselves would hypothetically induce a physiologically state of excitation. On the other hand, a relatively low but existent amount of excitation would hypothetically be required for a person with major depressive disorder to attempt suicide.  Concurrently, their mood would presently need to be extremely low to be at risk for such destructive behavior.

Pulling back out of the examples and towards the larger picture, in short, I would imagine that each disorder would have it's own set of physiological risk factors.  Major depression, schizophrenia, bipolar, borderline personality disorder, etc. would all have different high-risk constellations.  Some more thoughts on the specifics to come.

Musings on Potential Predictors of Suicidal Behavior

I was recently asked for my thoughts about blood tests as a genetic predictor of suicide on Twitter.  I tweeted them out, but I thought I'd quickly organize them here as well.  It admittedly may be very flawed, but here's my logic:

1. Completing suicide is one isolated behavior that results from a complex myriad of genetic, biological, environmental, and situational factors.   As such, simply looking to genetics - the building blocks of life - to predict one isolated behavior seems far fetched.

2.  There's also a lot of noise introduced when your outcome is the one isolated behavior of a suicide attempt resulting in death.  Someone who may be prone to suicide, for instance, may die in an accident before they ever have the change to attempt suicide.   Further, people who may be prone to suicide otherwise may lead a charmed life & the thought may never cross their minds.  Alternatively, someone not genetically prone to suicide may have a terrible life, develop a substance abuse habit, and impulsively kill themselves one night while under the influence.  Because the environment and circumstance play such a large role in whether or not someone actually dies by suicide, looking to genetics intuitively doesn't feel right to me.  Studying epigenetic factors, however, may yield something very interesting, but my money isn't on it.  I don't think it will be the silver bullet we want it - or hype it - to be.  Think back to the human genome project. (P.S.  Psychologists will recognize this argument as part of the "low base rate behavior" issue.)

3.  It is true that suicidal behavior is linked with psychological disorders, but is perhaps more important to focus on this: the behavior of completing suicide is intimately tied to the circumstances in the immediate environment.  These immediate circumstances will have an immediate effect not a a person's genetics per se, but on their physiology.

For instance, on any given day, a woman with moderate depression may be at a certain point in her menstrual cycle, on substances, vulnerable from a myriad of factors (e.g. relationship stress, lack of sleep, health condition, etc.), and feeling particularly impulsive.  Lets just say that we add a life tragedy to this vulnerable mix of factors and she gets admitted to an inpatient unit for suicidal thoughts.  Eventually she reports her suicidal thoughts have remitted, she is discharged, and then our hypothetical woman unfortunately makes a suicide attempt.  Some of the aforementioned factors (e.g. menstrual cycle, etc.) have a specific physiological impact.  If we had measurements taken from the inpatient unit of this woman's estrogen/progesterone levels, oxytocin, waking levels of cortisol, toxicity, etc. it would result in a specific constellation of physiological factors.  Over time, scientists can examine which constellation(s) of physiological indicators most often co-occur with recent (serious) suicide attempts / completions.  Determining & using immediate constellations of physiological factors to predict suicidal behavior in the near future seems to me like it will be much more accurate (i.e. have "incremental predictive validity") than our current tools (e.g. self-report questionnaires).  The general idea is that in the future we may be able to divine what people are actually feeling based on physiological measures rather than self-report.

4.  One last thought about the utility (and sensitivity) of genetic testing for suicide:
Not only do I think that blood tests for genetic factors will not yield reliable predictors of suicide completion, they will likely not be of much practical utility.  Consider this: what course of action must a clinician take with the information that a person is at genetic risk for suicide?  If someone is admitted to a psychiatric inpatient unit because of depression and suicidal thoughts, at some point they report they are not imminently at risk.  At that point, we must then discharge them from the hospital.  We would not be able to detain them longer based on a genetic test.  Correct?  How much longer would we keep someone on an inpatient unit based on a genetic test?  Genetic markers are not what we call sensitive measures - they are not sensitive to change.  They are static.  We would, however, have a more firm basis for detaining someone in the hospital if we had evidence that certain physiological constellations were present in a person & evidence that this type of constellation is associated with imminent risk of suicide.  Over time, we would have an idea about how generally someone would be feeling based on the output of physiological tests. Of course, how accurate or difficult to manipulate these hypothetical physiological constellations may be is unknown.  But if I were a betting woman, I would put my money on the scientists examining circumstantial physiological compositions winning the race of determining the most accurate, useful, & sensitive predictor of suicidal behavior.

In short, a suicide attempt is a behavior, not a disorder.  I'm not so sure that treating suicide attempts like a disorder by examining genetic contributions will produce the best predictors of this behavior.  Exploring physiological factors that represent immediate shifts in a person's internal experience however, intuitively feels more promising to me.

P.S.  This post was in response to this CNN article: link.

BITE for Eating Disorders

Hi there,

This is more of an announcement than an actual post!  Here's the big news: Dr. Dina Hirsch & I are cooking up a new eating disorder treatment manual I think you might like. For updates, follow us at @BITEforEDs.

Details about the BITE manual & website are to come!

Best,
The BITE Therapy Team

Letters to a Young Student of Psychology

Letters to a Young Student of Psychology

Background:

I was recently asked by a young student in psychology to answer questions for a report she was writing.  The report was on working with patients who are experiencing problems that hit close to home.  Below are both her questions and my answers. Because I graduated from my last clinical training year today, I thought it would be a nice day to publish this post.

Response:

Dear Young Psychology Student,

In the text below, I've done my best to fully answer your questions about my experience training as a psychologist.

Question 1:

Have you worked with school-aged children and adolescents? Briefly explain in what capacity you have worked with this population. What were the successes? What were the challenges?

Answer 1:

Yes, I am at the very end of my 6th year in a clinical psychology PhD program and I just completed internship at North Shore LIJ Hospital (I came directly from my graduation ceremony to this blog, in fact).  On internship I carried a caseload of child & adolescent patients; however, my prior training was largely with adults.  

For the first six months at North Shore LIJ, I carried a caseload on the locked adolescent inpatient unit at the hospital.  There I treated patients with first-break psychosis, recent suicide attempts, or physically violent behaviors.  During the second six months of my position, I worked with patients medically at risk secondary to severe eating disorders.  My patients were either hospitalized on a medical inpatient unit or attending the eating disorders day program, which is a 8:30am to 5:30pm fully structured hospital program.  Additionally, for this entire year, I carried an outpatient caseload.

I conduct only evidence based treatments (EBTs; e.g. cognitive behavioral therapy). So, in terms of successes: when Evidence Based Treatment is being conducted, a lot of symptoms tend to improve.  Therefore, I get to see a lot of success.  Specifically, I love seeing patients recover from anorexia nervosa.  It is consistently amazing to literally see a great deal of progress made over a short period of time.  For instance, we typically treat people who start off at risk of dying from being so underweight until they gain upwards of 15-20 pounds.  You can see that progress. At LIJ, we have a very strict refeeding program that promotes both physical and mental health.  

The biggest challenges for me are:

A) Working with parents who do not accept diagnoses.  Many times parents of children with certain disorders (e.g. autism or eating disorders) refuse to accept the diagnosis. This can be particularly frustrating when this prevents the child from receiving services during a critical phase of their development or illness.  If the parent doesn't come to accept a diagnosis in time, that child runs the risk of being severely affected for his / her entire life by the parent's lack of acceptance.

B) Calling child protective services (CPS) under some conditions.  In some extreme circumstances, CPS must be legally called when parents are neither abusing nor neglecting their children.  Parents may simply not be equipped to deal with their child’s emotional needs.  For instance, if your patient premeditatively stabs a sibling and threatens to do it again, a CPS call may be made even if the parents are "good" parents.  In a case like this, the issue is that parents are unable to control risk of one of their children seriously injuring / killing another of their children.  If the parent does not take the appropriate measures to ensure the safety of the victimized child by making (sometimes expensive) accommodations for the violent child, CPS may be called.  It's very difficult to be in situations like these.  Although in my experience only very reasonable accommodations are requested, in order for parents to follow through, they must emotionally accept that one of their children is a serious threat.  A well-intentioned parent may have the "he won't intentionally stab his sister again... it will be ok" type of mindset.  Of course, this is unacceptable when a patient has clearly expressed murderous intent.

Question 2:  Have you worked with a child that has lost a parent?  What have you found challenging? What have you found to be helpful for the client?

Answer 2:

I haven't worked with a child grieving the death of a parent; however, I have worked with patients grieving the loss of a parent. Specifically, patients in foster care grieve the loss of their parent in a primary care giving roll.  Some parents clearly demonstrated neglectful / abusive behavior, while some parents were not able to protect others from the violent behavior of the patient.

Challenging: It pulls at my heart strings when patients grieving the loss of a parent ask questions about the future.  The question when the child is removed from the home is always “what is going to happen to me?” and I can’t really answer those questions.  While some foster homes and residential settings are wonderful, others are not.  When working with patients in the hospital, I have no idea about the quality of the home where they would be next.  That can be tough.

Helpful: It is helpful not to intervene when a patient is actively grieving.  While on internship, I have had to break very difficult news to patients and have been present at the time the very instant the grieving process started.  In that specific moment, my job isn’t to relate to the patients or actively try and make them feel better.  My job is just sit there with the person and be as fully present to them as possible.  In instances like this, only when the person truly wants to be alone, do you leave them alone.  

In terms of advice, I would say this: knowing when grieving ends and a disorder begins is imperative.  Unfortunately, there are no easy rules to follow about this.  You can't say something like "oh, after two months, this child should be over the death of their parent."  You can, however, assess whether or not the person is emotionally avoidant.  Grieving implies that the person is actually experiencing the emotion of sadness that naturally accompanies loss.  If the person is doing things like drugs etc to avoid feelings of grief, we have a problem.  Once you figure out if/how the patient is avoiding, then rule is this: if the person is actually experiencing grief, sit with the emotion; however, if there is dysfunction secondary to avoidance, then intervene.  I think the ability to skillfully assess and intervene will naturally come with experience.  There's a whole book to write about this.

Question 3:

Is there a population that you see yourself in or relate to on an emotional level? What is that like? What has helped you maintain emotional distance? What has helped you to not “take the work home?”

Answer 3:

I have thought about this a lot, but I’ve never actually talked to anyone about it.  So here we go.  I think that if you really undergo a lot of self-examination over many years across many different experiences, you have the ability to remember even very mild emotional reactions, inclinations, and urges.  If you’re aware of the wide breadth of your own experience, it can be very easy to relate to patients, at least on some level.  In short, understanding yourself helps you understand others.  Because of this, I have found that I relate to every patient about something on an emotional level (to varying degrees of course).  

There have been a few times where I really see myself in a patient.  When this happens, it forces me to look at decisions I have made.  In these circumstances, I internally relate as much as I can to the patient and use genuine sympathy and understanding to build the relationship.  And with a strong relationship, we can facilitate adaptive change together.

I didn’t think it is necessary - or even helpful - to maintain emotional distance.  I don't wall myself off from experiencing my own emotions because that usually ends poorly.  It is helpful to use my emotions in session.  That isn't to say though, that a therapist shouldn't maintain an objective lens.  A good CBT therapist will know how and when to think rationally.  In fact, it is wholly possible to think rationally about a scenario while also experiencing real emotion.

In a way, you should take your work home.  Of course it isn't helpful to be overly involved with your patient's lives, but if a patient's experience was emotionally triggering for you, take home your own emotion about your own life.  Process that.

Question 4:  

Do you have any advice for me?

Answer 4:

I know that the reason why you're asking these questions, Young Student in Psychology, is that you lost a parent and you're worried that having a patient with a similar experience will be too much.  So listen, if you’re working with a patient who lost a parent and it triggers sadness about your own loss, sit with that.  Accept it.  Pay attention to it.  Ignoring this opportunity for your own emotional growth would only be hurting you.  You are going to have strong emotions and that is ok.  In this field, we have the privilege of helping other people through difficult emotions, which also happen to provide us with special opportunities for insight into ourselves.

In terms of advice, I would say this: be genuine and don’t avoid.  If something upsets you, obviously don’t make the session about your problems, but allow yourself to feel emotions about the patient’s pain in session and express your own pain when you get home.  Over time, exposing yourself to what you’re afraid of or emotionally sensitive to will make you stronger than you can anticipate.  Although the hole in your life caused by the death of a parent will never close, it will become easier to manage your emotions about this.  The more opportunities you give yourself to experience those emotions, the better therapist you will become and the stronger you will be.  Make mistakes and put yourself in situations you are not sure you can handle.

Life Isn't a Story: The Narrative Fallacy

I noticed something familiar at the very top of an important list.  Author and designer, Frank Chimero, published a post on New Years Day entitled Some Lessons I Learned in 2013.  The number one lesson here is "life isn't a story."  But seeing as this blog isn't life, here's a true story.

The True Story:
One late December evening in 2013, I was shuttling Frank around Brooklyn in my brand new but beat up car.  The winter was pretty rough in NYC and my car was literally weathered.  Unfortunately, it wasn't only a trying winter, but a trying year.  As such, we were discussing how not to handle hardship.  Frank said something along the lines of "I know that creating a story out of life messes people up.  But I don't know why.  Tara, you're a psychologist and you've probably thought much more about this.  Why is it that making life into a narrative isn't helpful?"  Frank was in for an earful, a blog post, and a birthday present.

I immediately conjured up a label for the phenomenon Frank was describing, "the narrative bias."  My next thought was "hm, maybe I'm the first person to think up this term... wouldn't that be cool?"  Five months later, I finally got around to looking into it.  So today, which is Frank's birthday, I did a Google search for "narrative bias."  Then it happened: I learned that someone I've actually met beat me to the punch!  He's not even a psychologist.  His name is Nassim Taleb.  He wrote a book called The Black Swan.  And no, not the one about the ballet dancer, but the one about improbable events (how relevant).  Anyhow, I was introduced to Taleb while dining at Naya, a swanky Lebanese restaurant in midtown, with a friend of mine who is a professor of aerospace engineering (or as we laypeople call it, "rocket science").  But the events of that night are a whole other story!

The Narrative Fallacy:
Much to my dismay, Taleb more astutely coined this concept as "the narrative fallacy."

The narrative fallacy addresses our limited ability to look at sequences of facts without weaving an explanation into them, or, equivalently, forcing a logical link, an arrow of relationship upon them. Explanations bind facts together. They make them all the more easily remembered; they help them make more sense. Where this propensity can go wrong is when it increases our impression of understanding.

—Nassim Nicholas Taleb, The Black Swan

The Story I Told You:
Clearly, humans are verbal animals who are naturally inclined to connect series of events into a narrative.  I've already done it here.  First, I introduced you to Frank.  In case you missed it, I very intentionally called him an "author," not a "writer."  Anyone can be a writer, not everyone can be an author.  Next, I included a link to Frank's Twitter page so that you might happen across the fact that he has quite a following.  All of a sudden, this story is a bit more interesting.  You were already being sold a story before it was told.  Next, I'm officially telling you a story about how Frank and I are palling around BK.  For some artistic flare, I made an uncharacteristic attempt at a harsh-winter-and-personal-hardship metaphor.  We were talking about serious stuff.  But wouldn't ya know it, today is Frank's birthday!  There's levity promised.  But wait, what's his birthday present?  Perhaps you, the reader, will have a voyeuristic opportunity to peek in on a slice of this friendship.  Then, depending on your opinion, another entertaining stunt or cheap trick was pulled.  I told you how a real-life rocket scientist introduced me to Nassim Taleb, the guy who created a better term than the one I was trying to coin with this blog post [It's a letdown.  Maybe you wanted me to be the first because you're reading a story about it.]  Name drop, plop.  But hey... were you interested?  Did it work?  Maybe, maybe not.

The Story I Told Myself:
It doesn't matter if it worked.  Because now you see, the problem is this: in the process of attempting to entertain you with a story, I was telling myself a story.  Reflecting on the company I keep, I'm now starting to liken my life to Midnight in Paris even though it's 8pm in Brooklyn.  Nevertheless, I'm sitting here in the same neighborhood that my friend's mom said "it wasn't worth the risk" to come visit me in, and I'm really starting to consider myself a New York City intellectual.  Spilling coffee on my socks this morning seems like a distant memory.  The fact that I befriended the professor while working a 12 hour shift at a cigar bar cleaning ashtrays is totally lost.  Instead, I start to bet that the reader thinks the professor and I became friends at something like a highly secretive Freemason meeting... that allows women.  Perfect.  The professor and I are practically Freemasons anyhow, right?

Wrap-up:
In short, writing a two paragraph story has made me a delusional egomaniac.  It appears that stringing completely factual events together into a story has a side effect: myopic viewpoint.  A story - whether it be funny or sad -is interesting.  A story is easy to remember.  But when we remember a story, we lose the real richness of our actual experience.  Our balance is lost.  The altered photograph becomes the memory.

Frank, I hope that my attempt at storytelling and delusions have helped illustrate why creating a narrative out of life messes people up.  Anyhow, I need to jet.  Phone call with the Pope!
P.S. Happy birthday.

-Tara

New Autism Theory: "The boy whose brain could unlock autism"

The article "The boy whose brain could unlock autism" from https://medium.com/ is beautiful. It is beautifully written. It is hosted on a beautifully designed site. And most importantly, the non-judgmental theory of autism presented is beautiful.  This theory is also pretty brilliant.

The article presents a theory that reconceptualizes autism as an "intense world syndrome."  This theory suggests that autism is not best thought of as a disorder characterized by a lack of empathy or intelligence, but by the existence of an overload of emotion plus a great capacity to learn.  Further, intense world syndrome suggests that people with autism experience sensations differently.  What an awe-inspiring idea.

There are so many different issues to discuss now!

Let's start with empathy.  Just because it may appear that people with autism lack empathy, doesn't mean this interpretation is correct.  It could be that a person's mind with autism is so overloaded that focusing on someone else is next to impossible.  Over time, this could result in lacking empathy for others.  Further, if people with autism are constantly bombarded with not only intense emotions (e.g. anxiety), but aversive sensory experiences as well (e.g. the act of brushing your teeth produces the internal sensations that nails on a chalkboard would typically evoke), certain consequences can be expected.  We know that spikes in anxiety result in increased calcium release and the encoding of memories.  This process could result in really rigid thinking.  Not to mention, one's focus is really narrowed in those moments.  So if there is constant anxiety, the brain is in a state of rapid-fire learning...on one hand.  On the other hand, it may be difficult to focus on anything but a particular target.  This combination of increased anxiety and rapid fire learning may carve out some pretty "strange" observable behavior patterns over time.  For instance, perhaps a hyper focus on learning calendar dates could result.  Also, the manner of brain processing could leave very little left over for attention on others, hence our current/previous perception of lack of empathy in people on the spectrum.

Speaking of the "spectrum," as a field we are very comfortable examining autism on this spectrum.  But it seems to me that there is still the perception of a dichotomous cutoff whereby some people have autism and others don't.  Right now, once a diagnosis of autism is made, then you are examined on the spectrum as compared to others with this diagnosis.  But what if we viewed every single person as representing a different degree of autism on a full spectrum?  What if the spectrum was thought to encompass all humans?  Well, I think that'd do us a huge service when conceptualizing cases.

Eating disorders, OCD, and self-injury are all jumping into my mind as relevant to this new theory of autism.

Let's take eating disorders for starters.  I'm too invested in writing this blog post right now to look it up, but I remember learning at this year's International Conference on Eating Disorders in Montreal that autism and eating disorders are related.  This was an internal hypothesis of mine for ages.  When I saw the data, I literally scribbled "I knew it!!!" in my notes.  [P.S. Even though I'm not going to look up the exact presentation I saw, here's a Medical News Today article on the relationship between eating disorders and autism from August 2013.]

Similar to what this new theory of autism posits, people with eating disorders are also in a state of anxiety, which results in rigid thoughts (e.g. "fat is bad"), compulsive behaviors (e.g. calorie counting), and a self-centered focus.  There's also usually an increased level of intelligence in people with eating disorders... or perhaps it's better conceptualized as "fast learners."   Sounds a bit like high-functioning autism, huh?  

Unlike autism though, many times people with eating disorders report desperately wanting the approval of others.  So, even if the behavior is seemingly self-centered (e.g. wanting to look good), I maintain that the function of the behavior is not completely egocentric.  But reconciling this seemingly self-centered focus and a desire to please others is usually not easy for family members of people with eating disorders.  The idea is difficult to grasp that intense anxiety about other's approval ironically results in a "self-centered" disorder. In short, I think it could be really useful to use intense world syndrome concepts in fostering understanding about eating disorders. 

Here are a few last notes before I move on with my Sunday: I think eating disorders relate to autism in the same way OCD is related to autism.  In fact, I conceptualize eating disorders as a specific subtype of OCD.  It appears to me that the process is the same in both disorders, but the content of the worry differs.  And as such, slightly different treatments are needed... but not too different.  I'll publish more on what I've written about this in the future.

And lastly, there is the example of how self-injury may relate to autism.  I've blogged here before about my hypothesis on self-injury's relation to sensory integration issues.  To read, click this link.  The idea that intense emotions can create perceptual disturbances (auditory hallucinations such as hearing voices) is not new in psychology.  But the idea that intense emotions can also lead to sensory disturbances remains an area where we need work.  Taking that a step further, exploring exactly how emotions are moderated with sensory acts like self-injury (or even doing things like soothing oneself with lavender hand lotion) is worth researching.

We need to know the following: is there a dose response relationship between intense anxiety/emotion and 1) sensory disturbances, 2) learning, 3) rigid thinking, 4) compulsive/repetitive behaviors, and 5) a self-centered focus?  If not, is there some relationship?  What mediates/moderates that relationship?

This new idea of conceptualizing autism as "intense world syndrome" clicked a few pieces into place of an enormous puzzle that I have been kicking around in my brain for years.  I very much look forward to learning from research on this theory in the coming years. 

The French Paradox

The French Paradox:

Why The French Eat Fatty Food & Are Skinnier Than Us

It is official.  The French enjoy food more than Americans. And they are thinner with less health issues.  Awesome.

As it turns out, this phenomenon is so well documented,  even has a name - The French Paradox.

But what if it wasn't actually a paradox?  Maybe it all makes perfect sense.

Studies have shown that the French stop eating when they're full.  Americans stop eating when their plate is empty (Wansink,  2006).  Interestingly, the larger a person is, the more likely they were to rely on external cues to stop eating (e.g. portion size).

Frankly, this isn't too surprising.   We all understand that the plate sizes in the States are big, some of us have an inclination to eat everything on the plate, and subsequently, we gain weight.  But this begs a more interesting million dollar question:  If relying on external cues like plate size can cause weight gain, what is the answer to weight stablization?

Well, the answer is resoundingly NOT self-control, restraint, effort, pressuring yourself, and/or punishing yourself.  These methods also rely on external cues or rules that you set for yourself.  These types of eating guidelines are largely ineffective in practice too.  Consider how many times you've tried to restrain your eating, only to eat a ton.  You may even binge after trying to restrict.

I would go so far as to say that restricting food intake with any type of diet may actually be just as much a part of long-term weight gain as overeating.  For so many people, restricting food intake is simply just the first step in a sequence that eventually leads to unstoppable eating.

Take a moment to chew on that concept a bit: restricting is the opening act for a grande finale binge.  If this cycle repeats over time, the overall effect could actually be weight gain.  Shortening the message, restricting may = weight gain for some.

[Turns out there is this whole psychological component to dieting practically no one has been considering!  But I digress.]

Now, returning to the million dollar question.  The correct answer is this: the opposite of relying on external cues to stop eating is relying on internal cues of hunger and fullness.  In short, if you go by external cues like your plate size, you could be heavier over time.  Conversely, if you go by internal cues, your weight is likely to be more stable over time (e.g. Augustus-Hovarth & Tylka, 2011)

Interestingly, Rozin et al (1999) found that American's associated "chocolate cake" with guilt, while the French associated it with "celebration."  The French can actually enjoy cake and they're still thinner.

After all of that dieting, could it be that thinking more like a hedonist shrinks your waistline?  Tell me what you think with a comment below.

P.S. As usual, this post is only a sliver of my thoughts on the matter.  More generally, not only does one need to start paying attention to hunger/satiety cues, but also 1) decrease fear about weight gain, 2) try to curb the desperate desire to be thin, 3) stop mentally obsesses over calories, 4) curb efforts to compensate for calories, and 5) very importantly, being "thin" doesn't equal good health in the same way being "overweight" doesn't equal bad health.  But these issues are fodder for another post!  We'll get there.

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References

Augustus-Hovarth, C. & Tylka. T.  (2011). The Acceptance Model of Intuitive Eating: A Comparison of Women in emerging adulthood, early adulthood, and middle adulthood. The Journal of Counseling Psychology, 58, 110-125.

Rozin, P., Fischler, C., Imada, S., Sarubin, A., & Wrzesniewski, A. (1999). Attitudes to Food and the Role of Food in Life in the U.S.A., Japan., Flemish Belgium, and France: Possible Implications for the Diet-Health Debate.  Appetite, 1999, 33, 163-180.

Wansink,  B. (2006).  Mindless Eating: Why We Eat More Than We Think.  New York: Bantam Books.

You can read more about The French Paradox here: http://en.wikipedia.org/wiki/French_paradox

Psychosis in Mania

by Tara Deliberto

Here are some quick late night thoughts on psychosis and mania:

There's some fantastic brand new research showing that beta amyloid, a toxic substance, gets cleared from the brain while its sleeping (article).  Just fyi, beta amyloid is the stuff that is thought to cause dementia and Alzheimer's disease.

So, when people who are manic don't sleep for days, perhaps some of the psychotic symptoms are triggered from amyloid and other toxins building up in the brain.  In other words, perhaps the bipolar swings result from one mechanism, while the psychosis secondarily results from a lack of brain cleaning.  Further, maybe those who are more susceptible to these psychotic symptoms have a less efficient cleaning mechanisms more generally.

Of course, this isn't my main area of research.  I just felt compelled to encode my responses to this exciting new work on the internet before my beta amyloid levels become too high.

What I Wish I Knew Before Becoming a Doctoral Student in ClinicalPsychology: So Much More Than I Did.

As I am (hopefully) nearing the end of my graduate school training, there are many things I wish I would've know prior to starting. Getting a Ph.D. isn't as easy as it seems - and not for the reasons you may have guessed.

While much of this post is specific to my experience, it still may prove helpful. So without further ado, here's a list of what I wish I knew before going for a doctorate in clinical psychology:

1. The training isn't as hard as having the financial burden. If you're considering going for an academic degree like a Ph.D., chances are you've been pretty good at school. You can go to class, learn, and use the info you've picked up.  That being said, managing to pay the bills can become very difficult. While programs differ, doctoral students generally have to complete three externships, which are 20 hour / week training positions at clinics or hospitals outside of your program. While some externships are paid, I was only accepted to unpaid externships for my first two years. I am extremely grateful to have trained where I did, but I needed to pick up extra work on the side. It was exhausting.

2. Unpaid externships tend to offer better training than paid ones. Because I was running myself into a financial hole, I just figured I would get paid positions. Interestingly, the less competitive positions tend to be paid. Conversely, the most competitive positions tend to be unpaid.  Your supervisors at the unpaid externships are likely to take more time to really educate you rather than just quickly putting you to work. At my unpaid externships, I had about four to five hours a week of supervision, CBT classes, seminars, etc. Conversely, although I really learned a ton at my paid position from my wonderful direct supervisor, I was treated as more of a work horse by the other hospital staff.   While I did my best to have learning experiences at the paid position, much more of my day was spent doing paperwork that (much more) falls under the job description of other members of the hospital staff.  Anyhow, I thought for sure with my publication record I would be able to make a bit more money training. Wrong!  As it turned out, I wasn't offered interviews at paid positions for my first two externship years. The whole process is kind of backwards.

3. Most clinical positions don't care about research experience and publications. Again, I thought for sure that my publication record would help me get clinical jobs. In fact, I was told that I wasn't offered some paid clinical positions because I was "too research-y." People are split into two stereotypes: clinical folks and research folks. Broadly speaking, the clinician is viewed as valuing human connection above science. In turn, the scientist is viewed as valuing data that may be helpful to the masses over helping a smaller number of people via direct human interaction.  Even though I consider myself a good balance between clinical and research, my CV shows a bunch of research conference presentations and papers. It appears I was pigeon-holed.

4. The current APA-accredited internships are not the internships of your professors. Internships are the last year of your training. They are very typically completely clinical in nature (meaning you won't be doing research). It is extremely hard to get an APA-accredited internship nowadays. Something like 67% of people match to accredited sites. Because of financial problems, many internships - especially in the NYC area - were closed. While most of the great unpaid externships are worth it in the long-run, the ones I was accepted to were located in clinics, not hospitals. Getting a hospital externship puts you in a much better place for an APA-accredited internship. They may also pay. Even if you think you "know" you never want to work in hospitals, be prepared to give it a shot as part of your clinical training. Don't try to avoid it.

5. Get experience in a bunch of different type of settings. It doesn't matter if you're afraid of working on an inpatient unit. Use all of your CBT, DBT, and ACT skills. Also, it may not be a bad idea to take a self-defense course. Inpatient units aren't exactly dangerous, but they're not exactly not dangerous. I am lucky enough to have worked at places that require self-defense classes aimed at keeping yourself safe without hurting patients.  Anyhow, work on being willing to have the experience of working on an inpatient unit. And if you can find them, try emergency department experiences too.

6. It is unclear if getting an APA-accredited internship matters long-term.  It's common knowledge in psychology that you will be unable to work at a VA and are unlikely to ever be hired by a state hospital if you don't have an accredited internship.  Beyond that, no one seems to know how not having an accredited internship will impact your career.  I can say though, that if you just want to do research, it likely won't impact you at all since internships are clinical positions.

Also, because universities typically didn't offer stellar insurance policies for students with preexisting medical problems at the time and since I was 26 (the age at which you can no longer be on your parents' plan), I needed private insurance. Because unaccredited internships often don't offer health insurance, I fervently sought out an accredited internship so that I can stop paying through the nose for private insurance.

 By the way, for positions and internships at state-run hospitals, you do not get health benefits until six months after you have been employed. Because internships are one-year, you will not be provided coverage for half of the year.

7. If your program does not teach the Rorschach because it is not considered research-validated, seek outside training. While many consider the Rorschach to be outdated, many APA-accredited internships require it as part of your training. They will not accept you application without it.

8. Read the newest edition of the APA's Publication Manual before you write anything. It will save you loads of time and embarrassment if you read the newest version of the manual before writing your thesis or dissertation. The manual not only tells you how to format things correctly, but offers excellent writing tips you'll want to know.

9. Try to make your master's thesis the precursor / pilot study to your dissertation. This will save you a lot of time in doing a literature review and will make the putting together a plan for your dissertation easily. Before you finish your dissertation, you need to defend a proposal. Knowing the literature well and having piloted your study's method will make the proposal defense go much more smoothly. You'll be able to answer questions based on previous experience.

10. Even after learning all of that, I'm so happy I'm doing what I love. Did the process of going through graduate school leave me unscathed? No. Yet, I would do it all over again. If you're willing to do it, try. Even when I'm doing the paperwork of overburdened hospital staff instead of seeing patients, I'm still part of a solution to a larger problem. Every day has meaning.

And that's all for now! I'll probably continue to add to this over the coming weeks/months/years, as I tend to do with all of these posts.

Comments welcome!

Best,
Tara