To The Bone: A Film Review From A Mental Health Professional

Content warning: This post deals with eating disorders and may be triggering for some readers.


To The Bone is a new Netflix original movie about a 20-year-old woman, Ellen, who suffers from anorexia nervosa and ends up in a group recovery home for individuals with eating disorders. The official  trailer is included at the very end of this post.

Just like with 13 Reasons Why, there is a ton of controversy surrounding the appropriateness of this film. Many individuals, including many mental health professionals believe that this movie is very dangerous because they believe it will glamorize eating disorders. Some are even calling for Netflix to take the movie down.

Once again, just like with 13 Reasons Why, the majority of these individuals have not even seen the movie yet. Their fears however have some legitimacy.

Research suggests that it’s triggering for those who already have an eating disorder or who are  struggling with unhealthy thoughts surrounding eating, body image and weight issues to watch other people displaying eating disorder behaviors, even if it’s a story of hope and recovery.

With that said, I do not think that those individuals should watch this movie.

If you are someone or you are the parent of a child or friend of someone who is suffering from an eating disorder, I do not think this is a movie you should watch with them. Watch it yourself for sure, as I believe the movie gives some great insight into what it’s like to suffer from an eating disorder, but do not watch it with them  in hopes this will be a great conversation starter between the two of you. It could possibly do more harm than good.

There are definitely some images and events in the movie that can be triggering to certain individuals, such as the main character herself who is scary thin, to the calorie counting and food avoiding behaviors displayed throughout the movie.

Banning this movie however I do not agree with because it is just that, a conversation starter. It’s a movie that needed to be made.

My Issue With The Movie

My only issue with the movie is that Ellen, played by British actress Lily Collins is scary thin. This in itself can trigger individuals who already have issues with their body weight or have an eating disorder.

The real issue is that Lily Collins herself struggled with anorexia nervosa and bulimia nervosa at some point in her 27 years of life and writes a chapter about it in her book, “Unfiltered: No Shame, No Regrets, Just Me.”

For the movie she had to lose a lot of weight to look the part of a very unwell young woman. Although she reports that they did it in a healthy way with the help of a dietician, I still found it alarming that anyone would subject someone who already has a history of struggling with eating disorders, to losing so much weight and then this almost skeletal person is the main character that millions of viewers, some of who will be susceptible to triggers, have to watch on-screen for two hours.

As I watched the movie, before I did my research, I couldn’t tell if she was really that thin or if it was some tricks of the camera or make-up, but upon learning that she actually had to lose such a large amount of weight to play her character, it was just a bit unsettling.

I’m not sure if this film could have been done any other way.

Anorexia Nervosa Versus Bulimia Nervosa

Unless I missed it, the one thing I don’t think the movie did a good job on was differentiating between anorexia nervosa and bulimia nervosa. People tend to think that the only difference is that those with anorexia nervosa severely restrict their calories while those with bulimia nervosa eat and then purge (vomit) in order to control their food intake.

However, there are two types of anorexia nervosa.

One is the restrictive subtype that is more of what people are familiar with. They rarely eat, count calories religiously and may use laxatives, but usually do not purge. The second subtype is the bingeing and purging subtype. These individuals are more like those with bulimia nervosa as they will binge (over eat) and then purge their food.

The main difference between the two is that individuals with anorexia nervosa have a difficult time maintaining the minimal amount of weight considered healthy and individuals with bulimia nervosa are usually at a healthy weight or even overweight.

While anorexia nervosa and bulimia nervosa are the two eating disorders people are most familiar with, other common eating disorders include pica, binge eating disorder, and avoidant/restrictive food intake disorder.

Most eating disorders last 6 to 8 years which is a large part of someones life.

While body image, food and weight loss are generally the focus of an eating disorder, they usually aren’t the underlying causes.

Issues that may trigger eating disorders include a history of abuse or trauma, bullying, parent relational problems, low self-esteem, personality disorders, substance abuse, difficulty dealing with conflict, genetics and feeling as if they have no control over their lives.

Millions of Americans suffer from disordered eating and they’re not all thin, young white girls. People who suffer from eating disorders come in all shapes, sizes and ethnicities from the rail thin to the morbidly obese.

I worked with a 10th grade Haitain-American girl, along with another therapist who specialized in eating disorders as well as a dietician for two years. She struggled with anorexia and it was some of the most difficult work I have ever done.

Eating disorders, just like most mental health disorders, are always hard and uncomfortable topics to discuss and many people would prefer to act like they simply do not exist or are something they never will have to deal with. That is why 13 Reasons Why faced such backlash and why To The Bone is as well. Avoiding these issues will not make them go away.

If people want to be angry with Netflix for making movies such as To The Bone then we also need to be angry with our media in general because it glamorizes weight-loss and thinness. Girls as young as elementary school have started engaging in unhealthy diets and calorie counting due to the images they see on a daily basis through our media.

Marti Noxon, the writer and director of To the Bone says that the movie is based on her experience of struggling with an eating disorder and that the film is intended as “a conversation starter about an issue that is too often clouded by secrecy and misconception”.

So with some warning I recommend this film to anyone interested in learning more about what it is like to struggle with an eating disorder, but not to anyone who is already struggling with body image issues or unhealthy issues about food and weight.

The hope is that this film increases the conversation without increasing the risk of triggering others, but honestly I don’t know if it’s possible to have these type of conversations without anyone ever being triggered. It’s the nature of the beast.

If you or anyone you know are struggling with an eating disorder, please contact The National Eating Disorder Association (NEDA)at http://www.nationaleatingdisorders.org

 

 

Why I Became A Certified E-Therapist

Young Man Using Laptop At Home
embracingyourinnerpower.org

When I first started this blog, I had no idea the number of people I would be reaching from not only across the country, but across the world! It wasn’t long before I started getting comments and emails asking for help with a multitude of issues.

As I started to answer questions and provide guidance and referrals, I realized that many people wanted more than a onetime interaction.

Many of them had situational problems and wanted help to solve that problem over the course of a few email exchanges. Others had more in-depth concerns and wanted ongoing contact with me to help move them to a better place.

It literally became overwhelming trying to keep up with all of the inquires, but at the same time, it was some of the most rewarding work I had done.

For instance, I found myself helping a man and his wife in England who didn’t live near any licensed psychotherapists. I found myself helping people who were too ashamed to go to face-to-face counseling or who just wanted the convenience of talking to a professional therapist from their living room.

Just the yesterday I helped a mother and grandmother get their daughter/grand daughter involuntarily hospitalized due to frequent suicide attempts when they were frustrated and thought they had ran out of options. It felt good to be able to do the research, make the contacts and guide them to a resolution even though it was all through telephone contact and they didn’t live anywhere near me.

I realized through helping so many people that I needed to do something that gave these readers turned clients more. That’s why I started Embracing Your Inner Power, LLC (www.embracingyourinnerpower.org) and became a Certified E-Therapist.

E-therapy (electronic therapy/online therapy) is a growing form of delivering therapy that is just as effective as traditional in-office therapy in most cases, while being more convenient.

I had heard about e-therapy several years ago and over the years it has become more and more accepted and I can easily see why.

The family I helped just yesterday lived in a rural area, didn’t know where to turn or even really what they were asking for. I was able to not only help them identify what they needed, but I was also able to help walk them through the steps as they were driving to a graduation.

I’ve found and research suggests that online counseling can be even MORE effective than face-to-face counseling because clients are more relaxed and feel less intimidated than they would in traditional settings.

Don’t get me wrong, I still prefer face-to-face counseling when possible, but I have also embraced technology and the way people are interacting more and more today through social media, chat, email and text messages. People are also becoming more comfortable with technology assisted care.

I’ve helped people with anxiety disorders, social phobias, people who were too busy to drive to a counseling session or just not motivated enough to go to face-to-face therapy, but were willing to turn on their computer and communicate with me. Because of this, the missed appointment rates for online counseling is less than that of traditional counseling.

My main goal as a therapist and my main goal with Embracing Your Inner Power, LLC is to reduce a person’s distress, depression, anxiety or concerns by helping them build on the strengths they already possess.

I’ve found that I am just as effective doing that through online therapy as I am face-to-face. I’ve also found that the people I have helped probably wouldn’t have reached out for help otherwise if it meant physically going somewhere or even inviting a therapist into their home.

Simply put, online counseling works, especially when you’re paired with a therapist who, like myself, works with a limited amount of clients and therefore is able to deliver very professional and personal counseling and not canned or rushed responses and sessions.

Some of the benefits of online counseling include:

  • Convenience– you can receive counseling from your living room, while on vacation… virtually anytime that is convenient for you.
  • Affordable– Online therapy is a lot less expensive than face-to-face therapy which averages over $100 per hour easily. Even when paying out of pocket, online therapy is usually cheaper than the deductible would be for traditional counseling.
  • Licensed– As a Licensed Mental Health Counselor and Certified E-Therapist, I deliver the same professional and high quality service online as I do face-to-face.
  • Secure– All information is kept secure and confidential.
  • Sigma Free– You can remain as anonymous as you want through message based, email and telephonic counseling.
  • Multi-modal– You can choose from video counseling, chat, email or telephone counseling depending on your needs.
  • Effective– as I stated earlier, online counseling in general is just as effective as face-to-face counseling in most situations.

As a Certified E-Therapist, I am constantly working on making Embracing Your Inner Power, LLC, the best it can be and it is a work in progress. I am dedicated as always to helping individuals discover their true potential and am appreciative that this blog and my readers have allowed me to grow and share so much with them.

I’ve been able to help individuals and families from 6 continents and it’s been an amazing learning experience.

 

Five Ways To Combat Worrying

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“Worry is the direct descendant of the need to be in control. We cannot see everything. We do not know everything. It’s impossible for us to control everything…” –Iyanla Vanzant

Worrying is a natural part of life. Occasional worrying is actually a good coping skill that helps us plan ahead. However, worrying too much can become counterproductive, distracting and damaging to our mental and physical state.

Most of the things we worry about aren’t likely to happen in the first place, yet we waste vast amounts of emotional energy on them.

1 out of 10 people worry excessively. Extreme worrying can be a symptom of a mental health issue such as depression or generalized anxiety disorder. Some people who worry constantly and their worrying derails their lives may have a chemical imbalance and need medication, therapy or both.

For many of us, we worry because we want to control a situation, person or outcome that we usually don’t have that much control over. Worrying a lot usually means that you are trying really hard to control something, yet worrying usually doesn’t do anything to help or change the situation, it just causes us more emotional anguish.

Here are five tips to help combat worrying:

  1. Allow yourself to worry in small increments: I’ve told clients who worry a lot to designate one part of their day as their worry time, that way their worrying doesn’t build up nor do they worry throughout the entire day.
  2. Try to problem solve: Worrying is a poor attempt to solve a problem. It simply doesn’t work. Instead of wasting the energy on worrying, try to think of solutions to the problem you are worrying about.
  3. Learn to deal with uncertainty: Uncertainty is just a part of life, sometimes random things just happen, but many of us are unwilling to except that. We have to know and/or be in control of things that we simply can’t be. The faster we learn to deal with uncertainty, the easier it will be to stop worrying and the easier it will be to actually deal with the unexpected.
  4. Stay in the present: When we worry, we aren’t actually enjoying what’s going on around us now. We are so far into the “what ifs” of the future, that we are missing out on the great possibilities of right now. You can acknowledge your worries, but that doesn’t mean you have to allow them to pull you in. Meditation and mindfulness activities can help ease some of the stress from worrying and bring you back to the present.
  5. Get out of your head: You may find that putting what you’re worrying about down on paper helps release some of its power over you. Some people keep a worry journal next to their bed so that if their worries keep them up at night they can just jot them down on paper and “release” them. Guatemalan worry dolls, for example, are dolls based on a legend where children in Guatemala make dolls to tell their worries to and the doll “takes” their worry away.

“I have spent most of my life worrying about things that have never happened.” -Mark Twain

Who And Where You Are Today Is Right Where You Are Supposed To Be

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Many of us spend a whole lot of time not being happy with ourselves and our current situations. We we always think there is somewhere else we should be at this point in our lives and would have a lot less stress if we learned to embrace who we are and where we are right now. We would have a lot less stress also if we learned to let go instead of trying to control situations and other people.

How much of our energy is spent beating up on ourselves or trying to make an outcome turnout in our favor or stop someone from doing something that really isn’t in our control?

I have to admit that during certain parts of my life I wasted a lot of energy trying to control the future, trying to control other people’s behaviors and even emotions. I went to great lengths to keep people from getting mad, to keep people from leaving or to get people to be who I wanted them to be. It was exhausting and robbing me of my sanity, but during those times, I thought it was keeping me sane. I thought it was keeping my world balanced, but in reality it was destroying certain parts of myself and my life.

A lot of the desire to control outcomes and people come from us not trusting that things will eventually workout in our favor. Some people will call it not having faith in God or the Universe, therefore we try to take control over things that are really out of control. I’m not talking about sitting back and not taking action in your life and just hoping things will happen by happenstance, but I am talking about not worrying excessively over whether you’re going to get the job you interviewed for when you’ve already interviewed and given it your all. I am talking about not worrying whether or not your friend will be mad when you let her know you can’t lend her $20 because you barely have $20 yourself.

We all have our own way of trying to keep our world in balance, especially when we don’t trust that things will be okay no matter what and that the Universe, for the most part, is working for our good. What we have to learn, what I am still learning, is that life is good right now. That everything that is happening right now is just the way it is supposed to be. That where I am right now is where I am supposed to be. I am not behind, I am not trying to play catch up to this other me that is living a better life, and I have not missed out on some magical opportunity that will never come back. I am exactly where I am supposed to be right now.

Realizing that and letting go of trying to control every little thing frees us from our past. Who we were back then and what we did back then was just fine for back then. Who we are at this moment is also just fine for right now. Once we stop trying to control circumstances and people, once we stop beating up on ourselves for not being better, we will realize how much control we actually have over ourselves, our thoughts, our emotions and our present moment. We all want to be better, to be happy, to grow, but sometimes we have to enjoy life as it is today and just be and realize that where we are and who we are right now is good enough for today.

We All Need To Practice Emotional First Aid

istock0000179371As a mental health professional, I have found myself spending a lot of time trying to convince people that they need to take care of themselves mentally and emotionally. Meaning, I run into people who are working two jobs, taking care of their family and everyone else around them, but are letting themselves go mentally and are getting sicker and sicker over time.

Or, I meet someone who is obviously not dealing with various issues in their lives, probably hoping that ignoring them will make them go away, but all the while they are growing emotionally unhealthy.

It reminds me of when a parent would bring a child in to see me for therapy and it would become apparent pretty quickly that it’s the parent that needs therapy, not the the child. Many times the parent would like at me as if I was crazy. They couldn’t see that their own neurotic behavior, substance abuse or even past childhood issues are creating the “problem” they are prescribing to their child.

It’s easy to tell when someone is physically not doing well, but it’s not always easy to tell when someone isn’t mentally doing well, especially when it comes to everyday things like anxiety, depression and self-esteem. Things we all deal with from time to time.

I have a sister who at one point was working a very demanding job, raising a challenging teenager on her own,  volunteering her sparse free time to multiple organizations and if that wasn’t enough, she was trying to help every friend that called and needed something from her.

On the outside she looked ambitious, energetic, like a true type A-personality. On the inside she was feeling overwhelmed, flustered and fragile.

One night, while having dinner with our family which should have been relaxing, seemingly out of the blue she had what some would call a nervous breakdown. She started crying, hyperventilating and felt as though she was going to lose control of her mind. I could look at her and tell she was having a classic panic attack, but she was too far gone to hear me and was convinced she needed medical attention.

Soon afterwards she was diagnosed with an anxiety disorder and was told to cut back on the million and one things she did in her day to day life to take care of other people and to start taking care of her own mental health, something many of us don’t do enough of.

Sometimes I even catch myself too caught up in work, life and everything else and before I realize it I am dealing with some type of anxiety, insecurity or dysthmia. I have to slow down, stop myself and figure out a) where is it coming from and b) how do I take care of it. Often times for me the solution is simple awareness and acknowledgement that something is bothering me. Other times it takes journaling, reading something inspirational or processing my feelings with someone I trust. I’m usually that person for everyone, but sometimes I need someone to be that person for me.

It doesn’t always have to be something major and it doesn’t always take a therapist, but sometimes it does. Sometimes it’s simple mindfulness, meditation, or getting out and having some fun, but many of us have no real idea of what it means to administer emotional first aid to ourselves which is why I included this Ted Talk by Guy Winch: Why We All Need To Practice Emotional First Aid

Family Shares UPenn Student’s Suicide Note

Suicide affects thousands of families each year. Last year, many people were shocked to hear about Madison Holleran’s suicide. She was a beautiful, intelligent college freshman, but like many college students, she was having difficulty adjusting. Her suicide took her family by surprise and if you read her suicide note, it appeared to have taken her somewhat by surprise as well.

I’ve read a number of books on suicide and have unfortunately read a number of suicide notes during my career as a psychotherapist.

Reading suicide notes, especially from people who have completed suicides, can help us understand what that person was going through at that time and may be able to help us prevent other suicides.

Many times families and friends have no real ideal of the internal struggles and emotional pain that suicidal people are dealing with.

Madisons’ family recently released her suicide note to the public. If you’d like to read it, it gives a brief but heart wrenching account inside of Madisons’ mental and emotional state.

Family Shares UPenn Student’s Suicide Note – FOX 29 News Philadelphia | WTXF-TV.

Anti-Depressants May Increase Suicide Risk In Children, Teenagers and Young Adults

Sucide-depression-pillsIt’s been known for a long time that when people with depression are treated with antidepressants, their risks of committing suicide can actually increase, at least initially.

It’s thought that one of the causes of this is because highly suicidal people are often so depressed that they don’t have the energy to go through with attempting suicide. However, when they start taking antidepressants, sometimes they will start to feel more energy before they actually start to feel less depressed, therefore they now have both the thought to commit suicide and the energy to do it.

Recently, a study published in JAMA Internal Medicine explored the effects of antidepressants on children and young adults and found that they too have an increased risk of suicide when they first start on antidepressants, perhaps even more so than older people, especially when given selective serotonin reuptake inhibitors (SSRIs).

SSRI antidepressants can increase suicidal thinking and behavior in children, teenagers and young adults which is why the Food and Drug Administration issued a warning about the risk in 2004 after various independent studies showed a higher rate of suicides and suicide attempts among children and teenagers taking SSRI antidepressants .

The risk of suicide was most severe for those young people who started taking antidepressants at higher than average doses. They were twice as likely to attempt suicide when compared to those taking an average dose.

Than why are SSRI antidepressants being used? It’s because many think the benefits of them far outweigh the risk since the medication eventually lessens the risk of anxiety, depression and suicidal thoughts and behaviors. In most cases, SSRI antidepressants work really well and can be life savers, but there are risks that every parent should know about including the risk of increased suicidal thoughts.

People under 25 who were started on a higher than recommended dose of SSRI antidepressants were twice as likely to attempt suicide, especially in the first three months of starting them.

You may be asking, why then do doctors prescribe a higher dose than necessary?

In the study, almost 20 percent of the people had been given an initial prescription for higher than recommended doses. Part of the reason why is often times doctors including psychiatrist, play a guessing game when prescribing medication. They often don’t know what doses will be effective for a person and often don’t follow guidelines. They start people off with a dose that may be too much or too little and count on them to come back and let them know if it’s working or if they are having too many side effects. Then they will decide if they should increase the dose, decrease it or change the medication all together.

I’ve worked in the mental health field long enough to know that psychiatry is often a guessing game and anyone who has been on psych medications before can attest to this. Many patients often tell me they feel like the psychiatrist is using them as a Guinea pig because they keep trying different medications and doses of medications out on them. In all fairness, usually psychiatrist do this to see what works best for the patient, but often time the patient is left feeling an experiment and may even stop seeking help.

I’ve included a great Ted Talk video on psychiatry that talks about the importance of looking at individual brains instead of playing guessing games when it comes to treating people. Not everyone who has depression or anxiety or any other mental illness should be treated in the same way with the same drugs or with the same therapy, but in psychiatry and the mental health field in general, that is often the case.

If you or your child is depressed and thinking about getting on an anti-depressant, make sure you talk to your doctor, read the black box warnings and ask the important questions so that you will be informed and also know what warning signs to look for. antidepressants have worked wonders for many, but for some they have also been tragically bad.

 

Six Things Therapists Don’t Want You to Know

Woman-with-finger-over-li-007As therapists, we want you to open up to us. To trust us enough to tell us things you may have never told anyone else. We want you to explore your deepest, darkest places and deal with things you may not even be aware that you were dealing with or avoiding. However, as therapist, there are some things that we keep from you and here is what I consider to be the top five.

1. “Sometimes You Bore Me.”

As therapists, we get paid to listen to other peoples problems and that may seem like an easy task, but it’s not. Sitting and listening to someone talk for 50 minutes can be mentally and emotionally draining, especially when the person talking is going on and on about something that is irrelevant to why they are actually in therapy. Sometimes it is hard to shut out our own internal chatter and (I feel guilty to admit this) it’s easy to start daydreaming or letting your mind wander instead of being attentive and present.

When I find this happening, it’s usually a clear sign to me that I need to redirect the client, or that whatever I am doing isn’t working and I need to try a different approach. Some clients however simply aren’t that interesting.

I remember running into a fellow therapist at the coffee machine saying she needed some extra caffeine because her next client was “a snoozer”. Fortunately, this is a rarity and not the norm, but if your therapist looks bored, it’s a good chance he or she is and it could be a clue to both of you that you aren’t really working on the real problem at hand, but dancing around it.

2. “You’re All Better, But I Want You To Keep Coming Back Because I Need Your Money.”

Therapist in private practice depend on their clients to make a living so, sometimes, even when therapy should come to an end, after the problems have been resolved, a therapist will keep rescheduling you to come back, even if you run out of things to talk about. They don’t want to let you go or to discharge you because that is taking money out of their pocket, so they will continue rescheduling you to come back as long as you or your insurance company continues to pay them.

Speaking of which, most insurance companies will only pay for a certain number of sessions so a therapist may want you to keep coming back until you’ve used up all your sessions and then, rather you are better or not, they may stop seeing you. That is unless of course you have the money to pay out of pocket, which can be costly. Most therapist charge anywhere from $75 to $200 an hour.

If you feel like your work is done with the therapist, but they continue rescheduling you to come back, it’s okay to bring this up to the therapist, to stop going to see the therapist or to get another one if you feel like your therapist is using you. A good therapist doesn’t want their client in therapy longer than necessary, even if discharging that client is going to take some money out of their pocket.

3. “Your Secrets Are Safe With Me… Sort Of.”

As therapist, we want you to feel safe talking to us and tell you that everything is confidential and we like to think that it is, but there are somethings that may not be confidential such as when someone talks about killing themselves, someone else, abuse, neglect, etc. Also, courts can demand to see our records in the event of a court case such as an employment dispute or divorce proceedings. As therapists, we generally fight to keep our records private and only release what we absolute must, but while we promise confidentiality, there are exceptions.

Also, therapist often consult with other therapists, but usually we keep names and irrelevant details out of the discussion. It’s not uncommon for therapists to discuss patients with friends and family even, but in those cases names and details are always kept out because violating confidentiality is against the law and a therapist can be sued if it’s proven that he or she violated their clients confidentiality.

4.  ” I May Need More Help Than You Do.”

Therapists are human. Sometimes therapists have problems consciously and unconsciously that they may not be able to deal with on their own, yet they still show up to the office everyday to help others. This isn’t necessarily a bad thing, but it can be. If your therapist is not in the right frame of mind and doesn’t know how to let his or her own problems go once face to face with a client, a litany of problems can occur.

Therapists aren’t supposed to give advice, but often we do and if your therapist is going through their own life situations, they may give you some very bad advice, not be present or make some very unhealthy decisions.

I’ve heard stories of therapists crying and confiding in their patients as if their patients were there own personal therapists, leaving the patient confused. I’ve also heard of therapist who were so cold and bitter while going through a divorce that they couldn’t be objective and empathetic when listening to their patients talk about their own relationships.

I’ve also known enough therapists who went into counseling and psychology (probably unconsciously) to help themselves and ended up being therapists who were just as neurotic, unstable and mentally unhealthy as many of the patients they were supposed to be helping.

This is where issues come into play like the therapist who slept with his or her patient, or had some other unhealthy, inappropriate dual relationship with a patient like having a patient temporarily live with them or being overly and unprofessionally involved with a client.

It is often advised that therapists have their own supervisors or therapists to talk to so that they can keep their personal and professional lives separate. Fortunately, most of the people I knew would make bad therapist ended up going into other fields.

5. “You Will Get A Diagnosis Rather You Deserve One Or Not”

Unfortunately, in this day and age of managed healthcare, everyone that has insurance has to get a diagnosis in order for the therapist to get paid. Sometimes this is easy because the patient obviously fits a certain diagnosis like depression or anxiety, but sometimes it’s not so obvious.

For example, when a patient is just dealing with typical life stressors that don’t meet criteria for a mental health diagnosis, the therapist will have to make a diagnosis fit if he or she wants to get paid.

Sometimes therapist will go for a “soft” diagnosis, like adjustment disorders, but some insurance companies won’t even pay for a “soft” diagnosis, so an adjustment disorder with depressed mood may be unnecessarily upgraded to major depressive disorder, single episode.  Your therapist may never tell you that you have been diagnosed, but you have been and at some point, if you care, you should ask what your diagnosis is.

A major part of my job is to diagnosis clients and everyone that enters my door leaves with a diagnosis if they didn’t have one already. I am always surprised at the number of patients who are referred to me with a current diagnosis, but when I ask them if they’ve been diagnosed with anything they either say “no” or “I don’t know”. These people are walking around with a diagnosis and don’t even know it.

6. “This May Hurt”

Most therapists won’t tell you up front that therapy can be emotionally and mentally painful. Most of the time we go to therapy because we are dealing with or avoiding some type of mental pain and we as therapist want to help you find it, confront it and deal with it. It can be pain that you know, like a recent divorce, or pain that you didn’t even realize was there, like how much you miss your dad that abandoned you when you were 3 and you haven’t thought of in over 10 years.

You may also come to some conclusions while you are in therapy, conclusions that may be difficult like ending a relationship, telling your mother how you really feel about the way she raised you or learning to say no to people you’ve always said yes to. A good therapist will be there with you and walk you through that pain, but most won’t tell you upfront how much this may hurt, otherwise, you might not go through with it.

Most therapists are good people who are in this field for the right reasons, not for the money (which isn’t great in the first place, but can be made), the power (some therapist like having a “God Complex”) or any other selfish reasons. Still, like in every profession there are good therapist and bad therapist and knowing how to identify a bad therapist can not only save you time and money, it may keep you from coming out of therapy worst off than you started.

Mental Health Awareness Week: Borderline Personality Disorder

istock_000008463493xsmall-243x300Perhaps out of all of the different types of personality disorders, borderline personality disorder is the most studied and most known as it seems like more and more people today are being diagnosed with borderline personality disorder (BPD) and it was definitely one of the most common personality disorders I run into when working with teenage girls.

People with borderline personality disorder are said to stand on the threshold between neurosis and psychosis. They are characterized by their incredibly unstable affect, behavior, mood, self-image and object relations (how they relate to others).

Borderline personality disorder is thought to represent about 1 to 2 percent of the population and is twice as common in women compared to men.

People who have borderline personality disorder seem to be in a constant state of crisis. They experience almost every emotion to the extreme and typically have mood swings. They can go from being very angry and confrontational one moment, to crying the next moment to feeling nothing at all the very next. They may even have very brief periods of psychosis known as micropsychotic episodes that are generally not as bizarre as those who have full-blown psychotic breaks and may even go largely unnoticed or written off as “strange”.

The behavior of people with BPD is highly unpredictable and they generally do not achieve everything they can to their full potential. Their lives are usually marred by repetitive, self-destructive actions.

These individuals are very often associated with cutting and other self-injurious behaviors as they may harm themselves as a way of crying out for help, to express anger or to feel pain or numb themselves from intense and overwhelming emotions and affect. As a matter of fact, most of the young women I ended up counseling who had BPD were referred to me for their self-injurious behaviors and/or their intense mood swings.

They may feel both dependent and hostile which creates an environment for stormy interpersonal relationships. They can be dependent on the people they are closest to, yet lash out with intense anger at the smallest perceived slight or frustration. They basically pull and push people away all the time, yet they can not tolerate being alone and will prefer chasing and trying to have relationships with people who are not good for them, even if they themselves are not satisfied in the relationship. They tend to prefer that roller coaster over their own company.

They will complain about being treated like crap in their relationships, discuss leaving their partner, yet if their partner doesn’t respond to their text or phone call they will panic and do whatever it takes to track them down.

When they are forced to be alone, even briefly, they will take a stranger as a friend or become promiscuous to fill the loneliness they feel. They are often trying to fill the void of chronic feelings of emptiness, boredom and lack of a sense of identity. They may even complain about how depressed they feel despite all the other emotions that they usually display.

People with borderline personality disorder tend to distort their relationships by characterizing people to be all good or all bad. They will see people as either nurturing or as evil, hateful figures that threaten their security needs and are always threatening to abandon them whenever they feel dependent. The good person, even if they really are not a good person, then gets idealized while the bad person, even if they really are good, gets devalued. More often than not, the same person can be seen as good one moment and bad the next, meaning that a woman can see her husband as perfect and caring today and tomorrow he is the most evil man in the world and she hates his guts, even if nothing really changed between them over the last twenty-four hours.

This aspect of BPD I found extremely frustrating at times because one moment a client would see me as the only person in the world who could understand and help her and the next session she would treat me like she hated me and like I hadn’t ever helped her. One client in particular for instance was chatting with me like I was her best friend one week, the next week when I was redirecting a negative statement she made about herself she said “F*ck you” out of the blue and walked out of the room, only to come back the next week and apologize, but this cycle repeated itself over and  over again. It wasn’t uncommon for her to tell me in one session that she “couldn’t stand me” and the next session tell me that I was the only one who understood her.

Another reason people with BPD are trying even for therapists is that they are very good at subconsciously projecting a role unto someone and getting that person to unconsciously play that role. It can be very draining and even scary trying to deal with someone who has BPD as their impulsiveness and instability as well as their dependency needs can make them overwhelming for many people.

For the most part, this particular client and all other clients I’ve dealt with who had BPD were overall pleasant people with great personalities whenever they were in a good mood and I generally enjoyed our sessions, but there were times when they made therapy so difficult that although I enjoyed working with them, I was relieved when I was able to discharge them, not that I was happy to get rid of them so to say, but it was draining and by then I felt like I had given them everything they could have learned from me and now needed to practice the skills they built up with others.

 DSM-IV-TR Diagnostic Criteria for Borderline Personality Disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is what we use in the mental health field to diagnose mental disorders and personality disorders and it list the criteria for BPD as:

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1)   Frantic efforts to avoid real or imagined abandonment.

Note:  Do not include suicidal or self-mutilating behavior covered in Criterion 5.

2)   A pattern of unstable and intense interpersonal relationships characterized by alternating between  extremes of idealization and devaluation.

3)  Identity disturbance:  markedly and persistently unstable self-image or sense of self.

4)   Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).

Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

5)   Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6)   Affective [mood] instability.

7)   Chronic feelings of emptiness.

8)   Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

9)   Transient, stress-related paranoid ideation or severe dissociative symptoms.

 Treatment

Psychotherapy has had the best results for treating individuals with borderline personality disorder, especially when combined with pharmacotherapy. Reality-oriented and social skills training are ideal in order to help people with BPD see how their actions affect others. Intense psychotherapy on an individual and group level is often recommended to help clients work on their interpersonal skills and to deal with their self-destructive and self-injurious behaviors.

Dialectical behavior therapy (DBT) is a specific type of psychotherapy that works great with people who have borderline personality disorder, especially those who do self-harm behaviors like cutting. It has perhaps gotten the best recognition for being high effective with people who have BPD.

I mostly used psychotherapy in the form of cognitive behavioral therapy, but later started utilizing much of DBT and it proved to work faster if not better than traditional cognitive behavioral therapy.

More Information

There are some great books on borderline personality disorder, but I recommend the classic, I Hate You- Don’t Leave Me: Understanding Borderline Personality Disorder by Kreisman MD, Jerold J. and Hal Straus as a great place to start.

www.borderlinepersonalitydisorder.com  is another great resource and they even have a list of movies with characters who have BPD and they include:

Fatal Attraction (1987)

In “Fatal Attraction,” the infamous femme fatale character played by Glenn Close displays the emotional instability and fear of abandonment that are symptomatic of someone with Borderline Personality Disorder. Her character also exhibits the BPD symptoms of self-harm, intense anger, and manipulation as she stalks her former lover and his family.

Single White Female (1992)

Jennifer Jason Leigh’s character in “Single White Female” exhibits the Borderline Personality Disorder symptoms of fear of abandonment, impulsivity, and mirroring as she attempts to take over the persona and life of her roommate (Bridget Fonda).

Girl, Interrupted (1999)

“Girl, Interrupted” is based on the memoir of Susanna Kaysen, who struggled with mental illness and Borderline Personality Disorder as a teenager and young adult. The film, which stars Winona Ryder and Angelina Jolie, centers around Kaysen’s 18-month stay at a mental hospital.

Hours (2002)

The three main characters in “The Hours,” which include author Virginia Woolf, all struggle with Borderline Personality Disorder, depression, and suicide. The movie, which links women from different generations to Woolf’s book “Mrs. Dalloway,” stars Nicole Kidman, Meryl Streep, and Julianne Moore.

Monster (2003)

Charlize Theron transformed into the role of female serial killer Aileen Wuornos in “Monster.” Wuornos was diagnosed with Borderline Personality Disorder, which may have contributed to the unstable and angry behaviors that led to her killing at least six men.

My Super Ex-Girlfriend (2006)

One of the few comedy movies that features a character with Borderline Personality Disorder is “My Super Ex-Girlfriend.” In this movie, Uma Thurman portrays a woman with superpowers and a secret identity who also displays the BPD symptoms of impulsivity, unstable interpersonal relationships, and poor self-image.

The DSM-V: Coming Soon, Criticisms, Flaws and All

DSM-5_3DThe long awaited and controversial Diagnostic and Statistical Manual of Mental Disorders, version five (DSM-V) is slated to come out toward the end of this month.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered the bible of psychiatry. It is the guide we use in the mental health field to help us diagnose clients and this May, the newest version of the DSM, version five, is slated to be released, but not without much controversy.

The DSM is considered a research standard worldwide, yet, outside of the United States it is rarely used. Still, what is in the DSM is of international concern because trends in diagnosing in the United States (i.e., attention deficit disorder, autism) tend to spread worldwide especially in many European countries, China, Japan and Brazil.

Much of the criticism about the DSM comes from both the way illnesses are categorized and the ever expanding criteria for mental illness that basically makes everyday life issues a diagnosis.

Other  criticisms include weak scientific support and poor reliability in some of the DSM-V field trials, which leave some to believe that it will lose its role as the international standard for research journals.

One of the real dangers if the DSM-V is really that severely flawed is that all of the mental health field will also become tainted, with people not trusting those who are trusted to test, diagnose and help people in need.

With the DSM-V, we also put ourselves at more risk of mis-diagnosing, over-diagnosing and over-medicating individuals.

Some say that the changes to disorders such as Generalized Anxiety Disorder can include almost everyone, as well as a proposed new diagnoses called Somatic Symptom Disorder which will be diagnosed to any patient who has “excessive and disproportionate thoughts, feelings and behaviors” in relationship to an illness, which includes chronic pain and cancer. How much worry constitutes “excessive” worrying. Who wouldn’t be worried when they are dealing with a painful, chronic, potentially debilitating or life threatening illness?

Some believe that much of the flaws in the DSM period are because disorders are placed in discrete categories such as Bipolar Disorder and Schizophrenia, instead of “dimensionality” in which mental illnesses may overlap and people may be placed on one of several spectra such as the proposed Autistic Spectrum Disorders.

Most clients I see have a combination of symptoms, some which do not meet complete criteria for one specific diagnosis, but can meet several others and present differently at different periods, which is why I may see a client who has received three different diagnosis over the same number of years.

However, most in the mental health field prefer for mental disorders to continue to be categories as they already are which is one reason dimensionality won’t likely be introduced into the DSM anytime soon even in the face of growing evidence that disorders are more fluid and less rigid than previously thought.

It would take more research and funding into dimensionality for it to truly be accepted, but much of that research and funding is already put into confirming the categorization of mental disorders the way they already are.

Basically, people don’t really want change. Much of the mental health field, drug and insurance companies, like the rigidity of the DSM even though it is clear that it is failing many people.

Even patient groups and charities prefer the rigidity of the DSM because it highlights their disorder and keeps it visible. They do not want to see schizophrenia or bipolar disorder re-labeled into a spectrum just as Aspergers Disorder is slated to be dissolved into the autistic spectrum disorders.

On top of that health-insurance in the United States pay for treatment based on current DSM diagnosis. As a matter of fact, that is one of the most frustrating things about dealing with insurances.

In order to get paid for my services, they want a diagnosis almost immediately, usually after the first session or two of me meeting a client. Sometimes a DSM diagnosis is obvious, other times it is not and more time with the client is needed, but insurance companies won’t pay for that unless you diagnose them with something first. Insurance companies are probably the last ones who want to see the DSM categories dissolved.

According to Dr. Allen Francis, former chair of the DSM IV task force, the ten worse changes to the DSM-V are:

1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment. This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings.

Even with much of it’s flaws and criticisms, the DSM-V is likely to be the best guide for diagnosing mental disorders that we have had thus far. We can only hope that with further research and funding, the next revision of the DSM will be better and more forward thinking.