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2. Once more with feeling

13/8/2013

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For those who have been to my office in Wahroonga they may recognise my slight obsession with Buffy and this is one of my favourite episodes.  It also is a tentative link to my previous post.  

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This post is about what to do with the feelings that come along in the journey of recovery.  To return to the picture that I have put up before..
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In this post we are going to focus on this part of the picture.  It is a small but crucial part of the picture.
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At any giving time we are "stuck with" the thoughts our mind gives us.  When our mind gives us thoughts that bad things will happen ("I can't cope"; "If I eat that I'll get fat") then this is going to come with feelings.  You don't really get to choose the feelings that arise.  If you mind predicts that bad things will happen then you will experience fear and anxiety; if it tells you how bad the world is or things you have lost, you will experience sadness; if it tells you how bad you are you will experience shame.  Often the more stuck on your thoughts the stronger the feelings are, but even when you are taking a helicopter stance to your thinking the feelings may be really strong.
If you have an eating disorder you may not be very good at having emotions, they are hard to recognise and name which can make them seem even more overwhelming.  
If you are human (and I am going to make that assumption about you) then you probably don't like having really strong uncomfortable emotions.  You might have lots of ways to "get rid of" these emotions - this might be one of the reasons that the eating disorder keeps going. It may be a way of trying to avoid these feelings.  This comes at a cost - which is usually a "smaller life".
I think a really important part of recovery is accepting that these thoughts and feelings are coming along with you for the journey of having a more meaningful life.
I have never met a patient who wanted to feel terror and panic, sadness and shame.  I have however had the privilege to work with countless people who have been "willing" to have these emotions on the journey.  
Willingness is about accepting that these difficult emotions are coming along for the ride.  It is not about wanting to have them, but deciding to not try to get rid of them by engaging back in old behaviours.
These feelings need to be acknowledged, named (which can be hard at first- but a hint might be don't call them fat), and a space found for them.  I often say to patients that it is not about "sitting with" your feelings as this always conjours up images of being in a straight jacket and rocking under a table while you sit with these feelings being dominated by them.  Just know they are there and make a conscious and deliberate choice to move in a direction that moves you in the direction of a bigger life no matter what the intensity of the emotion or what your head is telling you to do.
We can talk about some ideas I have about ways to do this in a later post.
Take care of yourselves.
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"Denial" in Anorexia: Wilful or Choiceless (or in between)

25/5/2012

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The “denial”  (note those “”) of the illness in anorexia is well described. It is one of the most frustrating aspects of the illness for carers and clinicians alike.  It contributes greatly to the expressed emotion (frustration, anger, criticism and patient blaming) that comes from clinicians and acts as a therapist driven therapy interfering behaviour.  Therapist will describe their feelings that somehow the patient is willfully lying to them, because the patient “must” be aware of their illness.  They are being that naughty anorexic patient who seems to seek out to disrupt therapy.

What if clinicians ask that question that we ask patients so often “Is there a different, more workable, way of thinking about this?”  As always, the answer is yes.

Until I began reading the blogs of Laura Collins, I had never heard of anosognisia.  This is apparently a common problem in several brain diseases which where the sufferer no insight or is unaware of the illness.  It occurs in neurological diseases such as Alzheimer’s disease, Huntington’s disease and after strokes.  It can also be a feature of schizophrenia and bipolar disorder.

Some FMRI pictures and more information can be found here.

Im not sure if it has ever been studied in anorexia nervosa.  Im not sure if it would be preexisting and exacerbated by starvation, or caused by starvation.  

It important though for us to hold information in a way that may help us see that anorexia nervosa is not a willful choice. Holding this stance is incredibly helpful for therapist (and hence their patients).


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Relapse of Depression and a role for Mindfulness.

28/5/2011

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A recent post on the PsychCentral Blog reports on a study by Norman Farb, a PhD psychology student from the University of Toronto published in Biological Psychiatry.  

"When previously depressed individuals enter mild states of sadness, their brain’s response can predict if they will sink into depression again, say researchers at the University of Toronto.

“Part of what makes depression such a devastating disease is the high rate of relapse,” says Norman Farb, a PhD psychology student and lead author of the study.

“However, the fact that some patients are able to fully maintain their recovery suggests the possibility that different responses to the type of emotional challenges encountered in everyday life could reduce the chance of relapse.”

For the study, researchers used functional magnetic resonance imaging (fMRI) to track the brain activity of 16 formerly depressed patients as they watched sad movie clips. Sixteen months later, after nine of the 16 patients had relapsed into depression, th
e team compared the brain activity of the relapsed patients against those who remained healthy as well as a control group who had never been depressed". .....


Click here to read the full PsychCentral post 

This has some interesting implications for psychological treatment of depression.  

The article suggests that the neurological difference is related to rumination about sadness. This is where we get sad or worried about our own sadness, which of course keeps the cycle of depression going.  Mindfulness Cognitive Behavioural Therapy (MBCT) teaches patients to develop what might be called an "observer self".  This is where we develop the skill of "meta cognition" where we look at, rather than respond to our thoughts.  We notice that they are thoughts which may or may not be helpful, rather than facts that must be followed as truth.  Patients with depression are specifically taught in MBCT to be aware of their thoughts about sadness and to let them pass, rather than act on them.  


For example, "It's awful that I'm sad, I think I am getting depressed again.  Why is this happening to me. This is awful" could be noticed, rather than ruminated on.  Rumination is likely to focus your mind on all things negative, which begin to create a self fulfilling prophecy about becoming depressed.

The UK National Institute of Clinical Excellence (NICE) has recently endorsed MBCT as an effective treatment for prevention of relapse in Depre. Research has shown that people who have been clinically depressed 3 or more times (sometimes for twenty years or more) find that taking the program and learning these skills helps to reduce considerably their chances that depression will return. The evidence from two randomized clinical trials of MBCT indicates that it reduces rates of relapse by 50% among patients who suffer from recurrent depression.

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    Author

    Chris Thornton is a Clinical Psychologist and the Clinical Director of The Redleaf Practice, a specialist outpatient clinic for the treatment of eating disorders.  He is interested in bringing elements of positive psychology, Cognitive Behavioural Therapy and Acceptance and Mindfulness approaches to the treatment of eating disorders.   

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