When Food is the Enemy

I see women in my practice every week who suffer from eating disorders (ED).   I never used to see men but that has changed. Still much less than women and much less severe in nature. I used to see it more in gay men but now I see it far more in heterosexual men.  I also think it is more on the disordered eating spectrum with most men regardless of sexual orientation,  rather than a full blown ED.  In medical school I recall how many of the women would food restrict. I only knew of one male who would food restrict.   I actually got very thin myself, but quickly realized I needed food to stay awake most nights on call.

What’s on the menu?

It feels like we don’t know how to eat anymore. There is Keto this, low carb that, low fat vs clean eating. In the end we are at war with our bodies and food has become the enemy. When and why did food become a moral issue? I hear my patients say they were “so bad” because they had an extra piece of pie at a holiday dinner. It’s hard to imagine a world where we would accept the bodies we have rather than the bodies we wish we had. What will this imagined body bring us? Will it provide the elusive happiness we have been searching for?

Exercise is Healthy, right?

One of the latest eating disorders that has fallen on the more acceptable realm is ” Exercise Induced Bulemia.” Make no mistake it is still a compensatory way to maintain a lower body weight, but somehow it became socially acceptable to run, cycle or attend workouts at gyms that burn many calories. I frequently see women trying to keep up with their male partners. Sometimes it is the only way to spend significant time with them especially if they too have body image issues. Granted we are a more sedentary culture, but this is beyond going for the evening walk to move those stiff muscles at the end of the day.

Novel concept: eat when hungry

I am unsure of how to win this war on our bodies and the war on food. If my patient hates her body, I will ask her what about it she hates. She will usually say her double chin or her belly that hangs too low. What ever the “perceived defect” is, it likely originates from a place of self hatred. I listen and reflect back the negative and harsh feeling she feels at liberty to use against herself. Sometimes patients leave quickly if I won’t join them in this ritual of self hatred. Hopefully they stay and we can keep going deeper to understand this vicious attack on the self.

Earl Grey Tea

I find myself wanting things that are predictable. Earl Grey tea is something I can count on. It tastes the same every time. It’s easily recognizable. I don’t have to guess as to what flavor the tea is. As a new psychotherapist I found it very hard sometimes to figure out what my patients were trying to tell me. Sometimes I felt completely lost. However, after I graduated from my Psychiatry residency over 22 years ago, I was fortunate enough to meet a Jungian psychoanalyst along they way.   I began my  work with him individually about ten years ago and still work with him today.  He taught me there was a way to recognize things.  To listen more deeply.  He gave me a knowledge that nobody else had offered me in the past. I drank it down like a good cup of tea.   Once I realized what I hadn’t been doing,  it made my work so much easier. I began to listen for things I have never listened for before. I guess it’s similar to also recognizing a flavor of tea.

Relying on science isn’t useful in psychotherapy

Psychotherapy is not like working in a hard science. It’s about emotions, feelings and experiences. Sometimes we feel the emotions in our bodies. Psychotherapy can be very painful. It is not my job to cheerlead my patients. I can’t come up with solutions to make them want to feel better. That would be me being uncomfortable with watching their pain.  It is my job to listen and try to understand how they feel. I don’t have fancy scans or blood tests to figure out what’s going on.  Instead, I have my listening skills. I rely on past feelings. If my patient tells me he feels like a failure again, I pay attention to when we have talked about this before and  ask him what it feels like to feel like a failure. We learn from his feelings. We learn from his experiences.

Psychotherapy is not like a friendship

I don’t pretend to be an expert in psychotherapy, but have enhanced my skillset over the years.   Sometimes people believe psychotherapy is like talking to “a friend.” Unfortunately, that is a way to devalue the experience of psychotherapy.  Hopefully,  by the end of therapy, we have learned what we need to learn. We might learn that we  really don’t want to change. Or we might come to know that “we are the enemy.” Whatever it is, my job is to walk alongside my patients and to accept whatever it is they feel they want and  need.

 

Psychedelic Assisted Psychotherapy?

Not a quick fix. Abstract LSD capsule pills with bottle. Drugs narcotic concept. Capsule pharmacy bottle pill drug concept.

This year the field of psychiatry has seen psychedelic  assisted psychotherapy research explode. I am  personally  a bit concerned about it. My greatest concern is that patients will be once again looking for a quick fix. This will also do nothing more but excite the insurance companies. They would like us to quickly fix our patients. Will this give them one more reason? This also begs the question as to whether or not we actually “fix our patients?”

Trauma, not the Reader’s Digest version

Trauma happens mostly over a long period of time. It’s not usually the one time awful thing that happens to someone. It’s usually cumulative in nature. That is why it is so hard to rid oneself of trauma.  Dealing with trauma takes a long time.  It is not something we can rush through.  Rushing through trauma can have deleterious effects and cause issues such as regression and increased depression and anxiety.   It is my job to be patient. As I have said before, treatment takes as long as it takes.

Will this become the New SSRI?

Recently on a listserv I frequent, with other Psychiatrists, there was a lively discussion about psychedelic assisted psychotherapy. The actual drug being discussed was Ketamine. There were Psychiatrists with strong opinions on both sides of the issue. One Psychiatrist who has been a round a long time mentioned this was tried before with LSD.    He was right, and it caused “psychosis”  and other undesirable outcomes.  A concern is this will become the new norm.  Similarly ,  when the SSRI’s hit the market. , they quickly became one of the most prescribed drug classes.  Another  concern is the cost to patients.  The therapy is not currently covered by insurance and  even if some of it is, the reimbursement is  a fraction of what the actual cost will be.

Staying the course

I am not sure if this will ultimately get FDA approval, but I know it is not something I will be doing in my practice.   Currently a very low prescriber of medication in general.,   I still believe in psychotherapy. Medication is certainly of value in some instances, but I will stay the course for what I believe works best over time.  

Stayin’Alive

We all remember the Bee Gees’ song from the 1970’s movie Saturday Night Fever. Who knew the phrase would have so much meaning almost 40 years later? I certainly didn’t. Fever was now something to be feared. As I have aged another year and have more gray hair to prove it, I find my body feeling older each day. 57 wasn’t that hard of a pill to swallow. However, the stress of the pandemic certainly added more than one year for most people emotionally. We learned new ways to shop, to mask and to love. Hugs were no longer allowed unless someone was in your “bubble.”

To vax or not to vax, that is the question

Then came the question of vaccine or no vaccine. I became a doctor long before I became a psychotherapist. I am not afraid of needles at all, but this was a new vaccine unlike any other. BUT COVID-19 was also a virus unlike any other before it. I was lucky in that being on the medical staff of a local hospital gave me the opportunity for vaccination back in February .There is no doubt in my mind getting vaccinated was the right decision for me. I will always support my patients decisions on what they feel is right for them. Sometimes that can be hard because I have to leave my own bias’s and opinions out of the therapy room. I can’t say I haven’t made that mistake in the past. I am far more conscious of how important it is to let my patient decide what is right for her.

I hope you Dance

I hope you all have remained healthy and safe. I  am personally feeling very hopeful  now that the numbers have dropped again.  If you have a fever may it be caused by dancing to some good old music!

Time to Face the Change

I have decided to make some changes to my practice. I am no longer accepting new medication management patients. This means seeing myself as a psychotherapist. I worked hard to become a doctor and letting go of that identity isn’t easy for me. Of course I am still a doctor, but I will  be practicing  very little Psychiatry now. I used to think primary care wasn’t the place for psychotropic medication prescribing, but I now see it as the right place. Many primary practices are moving toward a model of Integrated Behavioral Healthcare. This model is supposed to help de-stigmatize patients seeking mental health services. I think it may help with that. I think where it makes the most sense is for someone who strictly wants medication management. I know there is a place for Psychiatry and when I went into this field 27 years ago I had planned to do psychotherapy and medication management.

Finding Eros

As I have reflected on the direction my professional life should go, it has become clear to me my true passion lies in practicing psychotherapy. Someone might say it is where my eros lies.  It is a  question I frequently ask my patients. What is their eros?  Eros was the Greek God of love  and sexual desire.  I see eros as that intense feeling of desire.  It can be in the form of making music, cooking good food  or writing. It is crucial that we have it.  Finding eros can bring change.   As we all know change can sometime bring on anxiety. It can also be marked with astounding beauty.

  

I Missed Again

Sometimes I can miss things my patient is trying to tell me. I know I can’t be perfect but I do get upset with myself when I felt I may have missed something important in my patient’s session. I generally will feel uneasy after the session ends which is a signal to me that something didn’t feel quite right. I have to watch my own anxiety that wants to make it better quickly. Therapists are not perfect either. We do our bests but contrary to what our patients may think we are not immortal and we make mistakes.

I’m all Ears

I have been trained to listen with a “third” ear. It is my job to connect what my patient is telling me during those precious 50 minutes. Sometimes because I am tired or maybe not wanting to see something in one of my patients I may miss it. I don’t stop thinking about my patient until she comes back for her next weekly session. Sometimes something will gnaw at me. I will do some writing about it to see if something comes. Sometimes I might have a dream. Or something I read triggers me to think about the session again. If I am really struck by something I might bring it to supervision. Supervision is what we therapist use to discuss cases that bring us difficulty. I don’t usually use supervision for cases I am doing well with. It helps to have an objective ear listening with me as well. Part of residency training is weekly supervision. I have found it helpful throughout my career.

The Clue Phone is Ringing

If my patient becomes emotional during a session or their body has a sensation they bring up it can help guide us. But sometimes they have neither experience. I work hard to bring a session’s ideas together but even sometimes I cannot. Luckily if it is left unresolved my patient will bring it up again. Sometimes it takes more than one or two sessions for me to make the connection to what is going on. Maybe a similar dream gets brought up at the next few sessions or more symptoms of anxiety are developing around a certain issue in my patient’s life. Whatever it may be it is my job to listen and be aware something is not yet conscious or resolved. Sometimes patients will avoid going deeper so they might keep the conversations light. I also have to use that as a signal something is being avoided.

Weekly is the right dose

Whatever is going on between my patient and myself will hopefully get resolved. This is why anything other than weekly psychotherapy doesn’t work when the inner emotional work needs to get done.  I continue to pay attention when a session doesn’t feel right to me. I also have to consider it is my own feeling and that it needs addressing, but usually it is what has gone on (or not) in the session that signals me to listen up.

 

My New Blue Door

Yesterday I finally painted my office front door a vibrant blue. It had been the black I painted it a few years ago because I thought that went better with the yellow siding. I think my contractor had suggested it and I went along with it thinking he knew better than me about what I wanted. I have never liked the black but it was “ok.” I discussed colors with my teenage son who has a very good eye for this and we decided on Benjamin Moore’s Pacific Palisades Blue. I didn’t realize it at the time we picked but I needed a change that this door would come to symbolize. Without getting into details I knew that something needed to shift inside of me. That I needed to start seeing myself differently in order to move on from something. In essence I had been stuck in one facet of my life. Yes, even us immortal therapists struggle with being stuck sometimes. I needed a new door to open and I had to have the courage to walk through it. So I did. It was quite liberating and freeing. It feels great!

Stuck feels like a four letter word

Frequently I deal with my patients who are stuck. Sometimes, but rarely it unsticks quickly. Other times it can go on for a very long time. I find it mostly in the stories they have told themselves. It usually involves their self worth. That my patient  believes she deserves far less than than she does. That she must settle for crumbs. I can’t tell her she deserves more and expect she will instantly  believe it. She must do the inner work and determine this for herself. I do of course tell her that she deserves everything she wants. It will require going deep inside to figure out why she doesn’t believe this in the first place. It can be a long and painful process, but the only way through it is through it.

It takes as long as it takes!

Sometimes it can take years to get unstuck and walk through the a new door. It can be terrifying.  We can imagine all kinds of bad things happening.  So rather than risk it we stay stuck.  Getting unstuck can be a lengthy process. The insurance companies would have us believing it’s a matter of weeks , maybe a few months to unstick. I don’t agree. I also know   it doesn’t matter how long it takes. In my supervision with a Jungian analyst I used to wonder how long it would take my patient to become unstuck? This particular supervisor always said “it takes as long as it takes”! He was so right. I must be patient with my patient and stick with her through her difficulties imagining a different life for herself. One where she has what she wants instead of struggling to have it. One that lets her walk through the new door and into the life she deserves. My job is to simply walk along side her while she is finding that door.

What new door do you imagine opening for yourself? What in your self proclaimed story needs to change?

Happy Thanksgiving!

‘Til the Cows Come Home

Children need to grow up and become separate from their parents. It is how “normal” development happens, but what happens when children are unable to separate? It can create a very anxious child or an adult who is unable to take care of herself. Separation can be made more difficult if the parent struggles to let the child move away from them. This happens physically and emotionally. The first time it may show up is when it is time to go to school. The child is so anxious they might cry and beg to stay home with “mommy.” The truth is the child senses “mommy” is actually afraid to let the child go. The child feels it unconsciously. They sense somehow the parent won’t be OK without them home. The parent’s anxiety fills the child with anxiety and so the protest to leave begins. Sometimes we see it earlier now that more children go to daycare at a  younger age.

Don’t give yourself a kinehora

It shows up later in life as the adult child who can’t seem to stay at college. Or calls the parent every day while away. The parent will sometimes frantically call the child at college “just to make sure they are ok.” They may have seen something on the news like a fire in a neighboring town that sets the anxiety in motion. The adult child is fine. It is the parent who is terrified of losing them. It can also show up when an adult child struggles to move away emotionally even after they are married. The spouse might feel second to the parent’s demands for constant contact. It also shows up when a parent continues to bail an adult child out financially. It creates an unhealthy dependency. The child may then feel obligated to the parent. Jews have an expression about giving themselves a “kinehora”  which is the equivalent of bad luck. The actual translation is an evil eye. It again is a way to create anxiety in the adult child. After the child says something about an accomplishment the parent will say, “you will give yourself a  kinehora,” which implies bad luck. Ahh, anxiety the gift that keeps on giving.

Stop! You might leave me and I’ll die (of loneliness)

Therapy helps identify the separation problem. It does cause anxiety to move away especially after the patterns have long been established. It can take years to do this. The problem is when the adult child tries to have a life of their own the parent may attempt to undermine it. It can be as small as making the adult child anxious about purchasing their own first car. It is my job to ask my patient what she fears most about saying no to her mother. I am not here to judge or give advice. I am here to explore what drives the fear. The hope is talking about it helps my patient work through her fears. To see if they are grounded in reality which most of the time they are not.

Mother cows are very protective of their calves.  It is what makes them good mothers.  We non-cows  also need to protect our children  but only until the time comes when they can do it for themselves.  It is our job as mothers to release our children. They don’t belong to us. They were just passing through on the way to adulthood.

We Are Really All Alone

Many times I will see a patient who is afraid to be alone. It can become difficult to spend time alone following a divorce or a breakup. It’s not unusual for my patient to stay in a long term marriage or relationship because the fear of being alone becomes too much to bear. So she stays rather than leave and experience the pain of the breakup. As we get older we also see our chances of meeting new partners or friends as less likely and so we may also stay out of fear of being alone. The feeling of “not being alone” is kind of an illusion. For example “being in a relationship” with someone who is drinking too much is actually pretty close to being alone. The drinker is not emotionally available. So in essence we are alone. It goes for any situation in which the other person is addicted to a substance whether it be work, alcohol or exercise to name a few.

Do not enter

Being alone has shown up markedly since the pandemic started. I recently had to have a medical procedure in the hospital. I was not allowed to bring anyone with me. I had my “driver” bring me and pick me up. I sat by myself in the procedure area. After the nurse finished up her part with me I sat for the entire time alone. The whole thing took two hours, but it was very different from years past when I have had other procedures. I had come all prepared with a book and my ear buds but I found myself thinking about how alone we really are in this world.

Only Ticketed Passengers May Enter the Boarding area

The first time I really knew we are alone was after my father’s death as I watched them carry him out from the synagogue in his pine casket. Observant Jews, which my parent’s were emphasize modesty and simplicity. Rabbi Simeon ben Gamliel II started the tradition in the second century C.E. I realized in that moment , as he was being carried to his resting place, that he was leaving by himself. It was then I knew that we are all really alone. We come into this world alone and we leave the same way. 

Leaving on  a jet Plane

I always think of the song by the Peter, Paul and Mary., “Leaving On a Jet Plane.” For some reason the lyrics seem to fit. She sings of having to go.  She knows she must leave. She hasn’t left yet but she already feels alone.  It’s also about letting go.  We have to let go to move forward. There really is no other way.  Sometimes it means being alone for a while.  But the real growth can only happen when we embrace our fears rather than avoid them.

Swimming in the Deep End takes Courage

So how does  my patient get over her fear of being afraid to be alone? We must  look together and be curious about why this particular fear has become so embedded in her psyche. I tell my patient she must go deep inside and she will find her answer. I usually get back, “what do you mean go deep inside?” I mean go as far as you can with writing, visual imagery, paint or whatever else creatively will help her find the answer.

Thin Privilege

In recent times we are learning how certain groups are afforded more rights or privilege than others. As someone who grew up fat most of my life except for about ten years in medical school and residency, I know what it is like to be treated differently from thin people. I was also not a fat child or teen, but I ALWAYS felt like I could be thinner. I don’t think I know any women in or out of my practice that at sometime was not unhappy with her body. I see more women than men in my practice who are dieting or using extreme forms of exercise to maintain thinness. However, lately I see more men trying for that twenty something body well into midlife. Today’s discussion is not about trying to convince you that diets fail in 98% of people.  It is about how badly fat people are treated. It is also about the privilege I see afforded to thin people.

Seatbelt extenders are shameful

On airplanes seats are designed for thin people. At one time a major airline was requiring fat people to purchase two seats. I thought this was odd because up until age two a child can sit in a seat with the parent for free. Yet if you have an extra 20 pounds of fat you will need to purchase the extra room. What’s even more humiliating is having to ask for the seatbelt extender. You might fit in the seat but to safely sit there you will have to ask the flight attendant for the seatbelt extender. Why would anyone design a seat like that? Cars are not designed for seatbelt extenders. If you are a woman shopping for clothing in the plus size category, you will also  know that ten dollars gets added on for those sizes. As someone who sews, I highly doubt an additional ten dollars worth of fabric was used to make the garment and sewing a seam is sewing a seam.

Dieting makes us feel bad

Some of the most accomplished women in my practice “feel like failures” if their bodies have gained back the weight they worked so hard to lose. It is usually a repetitive cycle, they lose, they gain, they lose and gain time and time again. They only see that failure rather than their accomplishments as good friends, mother’s, doctors, lawyers, nurses etc. My job is not to stand in their way if they truly wish to diet to try to be thin. I am there to understand it with them. Why do they hate their bodies so much? What started the war with their bodies? Was it a mother who was always dieting? Was it something they learned?  Did a doctor tell them to lose weight?

It’s time stop hating Fat people

I am learning more about white privilege these days. I will admit I was unaware of how lucky I was to be afforded things others were not. I am now far more conscious of what I need to do to stop it in myself and my community. I know the time is also here to stop thin privilege as well. I am tired of seeing fat people ridiculed, passed over for jobs, labeled as lazy or unfit. It’s time to stop hating fat people.

Fat women hate Fat women too

I know I have had patients leave my practice because of my being overweight. Oddly the women who seemed upset with me were not the thin ones. It was the women who had body’s similar to mine. They wanted to see me as bad because I wouldn’t join them in hating their bodies. Thankfully through my own therapy I found a therapist who helped me stop the war with my own body. Each day I am grateful this body lets me dance, ride a bike, garden or walk. We must stop giving so much privilege to any group. For today I will think about ways I  might still conform to thin privilege, to be “the good fat person.” I would ask you to think about it too.