Recovery When Grieving by Carolyn Hersh, LCSW

Grief and Eating Disorder Recovery On May 8th, 2017 my mother died due to complications from cancer. It was an unexpected death. I still cannot believe she died. My mom was diagnosed in January and passed away in May. She had gone to the hospital for trouble breathing and never left.

I can clearly remember going back to my childhood home and seeing her sneakers in her room waiting for her to return to them. I cried so hard seeing everything she had touched just days before but left, never to feel her embrace again. I was one of those things she left.

It’s been more than a year now since I lost my mom. It was a year that tested me in so many ways: emotionally, physically, and spiritually. One thing I had to face was how my eating disorder and my longstanding recovery would play out through the worst thing that has ever happened to me.

I have my own history of emotional eating and bulimia nervosa. It started at a young age. Whenever I was sad as a child my mom’s solution to cheer me up was a trip to the bakery for a giant cookie. My emotional eating and my hatred of being the larger kid was just one of many factors that led me to a path of destructive behaviors of binging, purging, and restricting.

I’ve been through enough therapy and treatment that I am able to recognize moments when I find myself starting to eat mindlessly. I check in with what emotions or events are going on. I have, for the most part, overcome being an emotional eater. But, then I was hit with an intensity of emotions that I had never felt before. The seven stages of grief are very real and I definitely went through and felt each of them.

My anger, my sadness, my pleading to bring my mom back, to having brief moments of acceptance washed over me on a daily basis. My sadness felt like someone placed a brick on top of my heart. Trying to breathe became difficult at times. I was angry, intensely angry, at cancer, the doctors, the hospital, at God, at my mother, and at myself. We hear so often how eating disorders fester when we feel a loss of control. Losing my mother was the ultimate reminder “you have absolutely no control over this.”

In the early weeks and even months of living in a world where my mother no longer existed, I wanted comfort and distraction. I wanted food. I wanted alcohol. I wanted anything that would take this pain away. And in those moments of pure sadness, I consumed. I knew full well this wasn’t the way to handle my emotions. I decided I need to reach out to my dietitian because yes, even professionals need tune-ups. I remember sitting in my dietitian’s office crying because I gained weight and was feeling out of control with my body and my feelings. I quickly felt hypocritical as an advocate for all bodies are beautiful and guilty because a weight gain should not be something I should be crying about. I lost my mother. Worse things have occurred other than gaining a few pounds. My dietitian reminded me that I know how to eat and that my body will go back to where it should be when I honor my hunger and satiety cues. But, then she shocked me by saying, “Carolyn, maybe you needed to allow yourself to binge in those moments. So it happened. You binged. It’s done. Now, go back to your real coping skills.”

My dietitian gave me permission to accept my binges. She demonstrated compassion for me when I had no self-compassion. She was right. Sometimes we have to be okay with where we are at. My dietitian did not give me the green light to revert back to maladaptive behaviors. She pushed me back on a path of not beating myself up during a time where the last thing I needed was to hurt myself more.

So, how do you manage recovery in a time of grief?

  • Don’t go back to your eating disorder. Just don’t. You know it won’t help and when you are feeling low why make yourself feel lower? But, if you skip a meal or eat a few extra cookies just know that it is not a relapse. I do not consider my binging moments a relapse. They happened. I engaged and then I stepped away. Be gentle toward yourself and give yourself permission to say “It’s okay it happened. Now, what can I do to get back to my recovery?”
  • Go back to your coping skills. Maybe I could have engaged in binging and purging. Maybe I could have thrown my hands in the air and said: “what’s the point?” But I didn’t. In all honesty, I knew this wasn’t something I wanted. So, I made a list of things for me to do to help me through those really tough moments. I took time off from work and went figure skating with friends. The ice was always a very therapeutic place for me, and just being able to feel that cold air whip across my face me feel happy. I spent time journaling, cuddling with my dog, and reaching out to friends and family when I needed to talk. I began nightly walks with one of my girlfriends where we had heart to hearts. I made self-care a priority. You have to. The small lapses that I fell into never once trumped the real self-care that I was doing for myself. If I had beaten myself up for binges and weight gain then it could have sent me on that spiral back to a full relapse. Self-care may mean forgiving yourself for your lapses. Forgiving myself helped me continue to move forward.
  • Death really sucks. Losing someone you love is painful. It can be a torturous pain. There is no way around that. Losing my mother and thinking about her still to this very moment makes my stomach twist, my heart pound, and my eyes water. There will be bad days. I use a lot of radical acceptance in my grief where I acknowledge this is how it is and I have to figure out now how I continue to live in a world where my mom isn’t calling me. It’s hard to do. Believe me, there are days I do not want to accept this, but if I have to pull from my DBT workbook, acting the opposite is what gets me through the rough days. I don’t want to accept my mother is gone, but that is the reality. I do not, however, have to forget her and how she has impacted my life.
  • It’s okay to cry. It’s okay to feel whatever it is you are feeling and it is okay if those feelings come and go in minutes or if they last for days. There is no wrong way to grieve. During my grief I went to Nashville for a vacation, I would go out on weekends with friends and laugh, and I eventually moved to California. I managed to feel happy on some holidays and cried on others. I did not stop living, but I allowed for my grief to take space in my life.

In the end, going back to my eating disorder would just have caused more chaos in an already chaotic time in my life. I know it won’t give me control, it won’t make me happy, and it certainly will not bring my mother back. I have this blue butterfly pendant necklace my mom bought me before I went into an intensive outpatient program. It gave me strength then and I wear it now to continue to remind myself that my mother was every bit a part of my recovery and is every bit still a part of me. Now, why would I want to throw all that away?

Carolyn Hersh is available to see patients with eating disorders and has Saturday hours. Contact us for more information. 323-743-1122 or lmuhlheim@eatingdisordertherapyla.com 

August 2018 LACPA Eating Disorder SIG Event

Jaye Azoff, Psy.D., Los AngelesDate: Wednesday, August 22nd at 7:30 pm

Presenter: Jaye Azoff, Psy.D.

Title: The Anatomy of a Recovery

Description: Recovery from anorexia nervosa (AN) follows an unpredictable, windy path. Rarely does it come quick; there is no single trajectory, no infallible indicators of how a treatment will play out. Opinions about the recovery process vary, depending on whose perspective is being sought. The patient—the former patient—sees it one way—but there is no guarantee that the opinions of others, therapists, partners, loved ones, will concur.

This talk addresses the question in a unique fashion. A patient: a former patient, (a doctoral level psychologist) will share her account of a treatment that unfolded over roughly twenty years.

Several points will be discussed. Importantly, the former patient will consider 1) briefly, the etiology of her illness (and we will assume a basic understanding of eating disorders here); 2) briefly, how (some) of the various treatments were directed and integrated across the multi-disciplinary teams (and throughout the years) 3) how her protests and resistances—and there were many— were met, and with what explanations 4) most importantly, looking back, what aspects of this treatment are now recalled as influential, elements seen in a positive light, elements perceived as detrimental.

Perhaps most important for the purposes of this discussion is the concept of the “power struggle” – that all too familiar war our patients learn over years of treatment with us to get into with themselves which then becomes acted out with their caregivers. How can we as treaters do better at not engaging, and shift the power and responsibility back into their hands?

Namely, how can we teach them that if they are to get well, it will be because they choose to get well? How do we teach them that they “win” nothing by restricting their snack for an evening or vomiting their dinner because they feel hurt over something we as clinicians might have said or done to them? These are complicated constructs, but not impossible ones, and by using Dr. Azoff’s past as a case vignette, we might be able to chisel away at some of the answers.

Bio: Jaye Azoff, Psy.D., has been practicing in the fields of clinical psychology and neuropsychology since 2008, when she graduated from the California School of Professional Psychology in Los Angeles, where she trained under the Health Emphasis Track. Dr. Azoff did most of her field training at Children’s Hospital Los Angeles’ Keck School of Medicine, where she practiced in the hematology/oncology neural tumors unit and trained in many roles over nearly eight years, eventually advancing to become the team’s neuropsychology fellow. It was Dr. Azoff’s own recovery from an eating disorder that propelled her forward and launched her into the eating disorders field. Currently, she is an eating disorders consultant, and she is the owner and operator of Basik Concierge, the world’s only boutique concierge firm offering wraparound services for individuals with eating disorders and their families. She is also the In-House Clinical Consultant for the Kantor and Kantor law firm, which fervently works to attain treatment for individuals with eating disorders struggling to gain access to care. Dr. Azoff is a past board member of the Eating Disorders Coalition. She is a sought-after speaker, having formally addressed the United States Congress in the Spring of 2013, and travels nationally to speak to patients and families affected by eating disorders, as well as delivers in-services to clinicians and other individuals eager to learn about various topics related to eating disorders. 

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

RSVP to:  drmuhlheim@gmail.com

SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

On Buying Bigger Clothes: The Tale of Nana and Her New Shoes

buying bigger clothesbuying bigger clothesRecently, I went to visit my grandmother, who is almost 103 years old.  She was complaining of leg pain. She asked me to help her put on her shoes.  I tried really hard.  But in her sweltering apartment (she can’t stand any temperature below 80), I was sweating and the shoes were not going on.  I had visions of Cinderella’s stepsister needing to cut off her heels to get her feet into her shoes.

Nana has edema—swelling in the lower part of her legs—because she has been sitting in a wheelchair a lot lately.  She is quite fashionable and still loves to get dressed up every day.  But no shoes were fitting.

I had to nearly drag her, but I convinced her to go shoe shopping with me. When we went to the shoe warehouse, we pushed her in her wheelchair but brought along her walker as well.  Nana has always worn a size 7, but we could not fit her into any shoes smaller than an 8.5 or 9!  We tried on one pair of gold shoes —Size 9.  Finally, we were finding some shoes that fit.

Nana loved them.  And she found them comfortable. The woman who had insisted on wheelchairing everywhere, refusing to walk, suddenly started walking with her walker and refused to stop!  She was not taking off those shoes and she was not going to ride in the wheelchair again.  Suddenly, Nana was transformed.  Not only was she comfortable, but she felt stylish.

Why am I telling this story? Often when I am working with patients of any size who have eating disorders, they may have gained weight from a previous lower weight that the eating disorder was an attempt to maintain.  People often experience a sense of failure and surprise when their clothing size goes up a level, just like Nana did. This is no surprise:  our culture overvalues thinness.  But continuing to wear too small clothing is uncomfortable physically and mentally.

People often have a lot of reasons for not shopping for larger clothing —they worry they will be unable to handle the anxiety and sense of failure, and they also don’t want to spend the money on a larger size.  I had to help Nana face this.  She didn’t totally understand why her shoes didn’t fit, she felt disappointed, and she definitely didn’t want to spend any money. But boy, after she got those shoes on, she felt so much better!

My patients tell me the same thing —once they have clothes that fit well and are stylish, they feel more able to face the world, and getting dressed each morning is no longer an occasion for self-deprecation.

Bodies age and change in ways that we can’t control.  We need to accept that.  My advice is always to buy a few things that fit you well and help you to feel great and put the other clothes out of sight for now.

And when I spoke to Nana last week, she let me know how much she was loving her gold shoes and walking more again!

Sleep: Monitoring and treatment of insomnia without drugs

insomnia treatment without drugsBy Elisha Carcieri, Ph.D.

“A ruffled mind makes a restless pillow.” Charlotte Bronte

In our self-obsessed culture, monitoring and tracking heartbeat, steps, exercise, food intake, and sleep is commonplace. My sister has recently been tracking her sleep using an app on her smartphone, and she encouraged me to do it too. My first response was, “Why? I know I’m sleep deprived. I don’t need an app to tell me that.” I was still nursing my baby once a night at the time and I was pretty positive this was negatively impacting my sleep and my ability to function in general. Skeptical, I downloaded the app and started it each night before bed for about a week. The application’s primary measure of sleep quality is called ‘sleep efficiency,’ which is the amount of time you are asleep divided by the amount of time you are in bed, and is represented as a percentage. This is the same measure of progress I use with clients in cognitive-behavioral therapy for insomnia (CBT-I). Typically, sleep efficiency of 85% or higher is considered “normal,” “healthy,” “good” sleep. For example, if you are in bed for 8 hours, asleep for 7.5 of those hours, with 20 minutes to fall asleep and two episodes of waking for 5 minutes each, your sleep efficiency is 94%.

The app uses the microphone on your smart phone to measure whether you are awake or asleep based on movement. Years ago, when I worked as a student clinician at a sleep and pulmonary disorder clinic, we used actigraphy watches which then had to be downloaded, interpreted by hand, and then compared with self-report data. Amazing what smart phones can do!

I was somewhat surprised at what the app told me. Many of the nights I was sure my sleep was poor, “I didn’t sleep a wink last night,” the app indicated that, while I was awake for some of the time (feeding my baby), I was out like a light during the time I was in bed. A user-friendly graph depicted the movement associated with my sleep, and decent average sleep efficiency. I learned from a week of monitoring that I should prioritize getting to bed earlier, because when I am in bed, I’m sleeping. While I am not suffering from insomnia, the little experiment reminded me of the benefits of brief self-monitoring, and inspired me to share some information about insomnia and its treatment.

What is insomnia, anyway?

Most people have bouts of insomnia at some point in their lives, usually in response to a stressful event. These short episodes of sleeplessness usually resolve and don’t require treatment. Chronic insomnia last for months or years and can be characterized by:

  • Difficulty falling asleep
  • Difficulty staying asleep
  • Waking up too early
  • Poor quality sleep

Consequences of insomnia include fatigue, sleepiness, difficulty with thinking (attention, concentration, memory), irritability, headaches, poor work performance, and persistent worry about sleep.

It is thought that insomnia develops as a result of three factors: predisposing factors, precipitating factors, and perpetuating factors. Predisposing factors are risk factors for developing insomnia, such as a highly sensitive biological sleep system or a tendency toward high arousal. Precipitating events are usually stressful events that result in an initial loss of sleep; for example, loss of a loved one, a stressful move, a new job, etc. Most people recover from this initial sleep loss once the stressor resolves. But the perpetuating factors play one of the biggest roles in the development and maintenance of insomnia. Some people become highly focused on their sleep difficulty, which results in heightened anxiety, maladaptive behavioral responses (going to bed early, staying in bed late, avoiding evening activities for fear that it may interfere with sleep, developing sleep rituals, or “crutches”), and unhelpful thoughts, attitudes, and beliefs about the sleep problem. Some examples of these common dysfunctional beliefs are:

“I need 8 hours of sleep to feel refreshed and function well during the day.” 

“When I sleep poorly on one night, I know that it will disturb my sleep schedule for the whole week.”

“When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.” 

“Medication is probably the only solution to sleeplessness.”

These beliefs tend to perpetuate insomnia by further increasing worry and arousal, focusing attention on negative consequences of lost sleep, and decreasing belief in your ability to control your sleep problem. These patterns of thinking, in addition to the well-intentioned but detrimental behavioral responses to sleep loss are the critical targets of CBT for insomnia.

How is insomnia treated with CBT?

Many people believe that medication is the only answer to chronic insomnia. However, CBT for insomnia (CBT-I) is safe, brief (usually 4-5 sessions), has lasting effects, and is well researched. CBT-I is composed of education about sleep, stimulus control strategies, sleep restriction, relaxation training, and “sleep hygiene.”

Stimulus control strategies address the issue of the bed and sleeping environment becoming associated with wakefulness, rather than sleep. In a nutshell, the recommendations go something like this:

  • Go to bed only when sleepy (not just fatigued or tired)
  • Use the bed and bedroom only for sleep (and sex)
  • If unable to sleep, get out of bed and return to bed only when sleepy
  • Wake up at the same time every day regardless of how much you slept
  • Do not nap

Simply put, implementing stimulus control strategies is not fun. Getting out of bed when not sleeping is annoying and takes work. Also, many people with insomnia have the unfounded belief that if they just stay in bed and “rest,” they will increase their likelihood of falling asleep and will at least get some R&R. In reality, more time spent in bed awake will only perpetuate the insomnia, and rest is not equal to sleep.

Occasionally, a strategy called sleep restriction is used in which the amount of time in bed is restricted to the amount of sleep a person typically needs to feel rested. This process can also be unpleasant as it results in an initial loss of additional sleep. However, after a few days, most people begin to see results.

Relaxation training can help to address the increased anxiety and arousal associated with insomnia and the process of sleep. Learning breathing and muscle relation techniques such as progressive muscle relaxation can be important targets for the management of insomnia. If bothersome thoughts and worries are a major component of insomnia (which is often the case for those who have difficulty falling asleep), taking time out of the day to focus on worries and write them down can be helpful.

Sleep hygiene recommendations are a beneficial add-on to the treatment of insomnia (but are not usually sufficient treatment) and are applicable to most “normal” sleepers. The following are some of the guidelines I’ve found to be the most powerful:

  • Wake up at the same time each day regardless of bedtime – This is part of the stimulus control instructions as well. Bedtime can be more difficult to keep consistent.
  • Avoid naps – Especially in the afternoon, naps reduce your sleep drive and may make it more difficult to get to sleep at bedtime.
  • Get regular, daily exercise – …but not right before bedtime (this can delay sleep onset).
  • Don’t watch the clock!!! – Checking the clock during a normal, middle-of the night waking can trigger many of the negative cognitions associated with insomnia and is likely to promote wakefulness.
  • Keep a quiet and comfortable sleeping space
  • Avoid going to bed hungry
  • Avoid coffee, alcohol, and nicotine – especially in the afternoon and evening.

The use of electronic devices around and up to bedtime and in bed is a problem that is becoming more and more ubiquitous and is associated with poor sleep outcomes. Using a cell phone, tablet, computer, etc so close to bedtime can be problematic for a couple of reasons, listed below:

  • Blue light exposure – Smart phones and other devices emit light that has the potential to disrupt the sleep cycle and the brain’s “understanding” that it’s time for sleep.
  • Alertness/stimulation – Engaging with your device in the bedroom environment, especially in bed, serves to associate bed and the bedroom with alertness, rather than sleep.
  • Worry – Checking email right before bedtime or in the middle of the night can initiate worry and anxious thoughts about the following day, tasks that need to be done, etc.

Remember, if you do not have a sleep problem and “problematic” sleep hygiene-related behaviors are not affecting your sleep in a negative way, don’t worry about it! But these behaviors can be important aspects to consider for those who are suffering from a long-term sleep problem.

There are good self-help resources for insomnia both online and in book form. The Centre for Clinical Interventions (CCI) has some solid information sheets, and the book Quiet Your Mind and Get to Sleep is recommended. It can sometimes be difficult to find a CBT-I provider, but there is a directory of member providers on the Society of Behavioral Sleep Foundation website: www.behavioralsleep.org.

References

Carney, C., & Manber, R. (2009). Quiet Your Mind and Get to Sleep. New Harbinger Publications.

Morin CM; Vallières A; Ivers H. Dysfunctional Beliefs and Attitudes about Sleep (DBAS): Validation of a Brief Version (DBAS-16). SLEEP 2007;30(11):1547-1554.

Spielman AJ, Caruso L, Glovinsky P. A behavioral perspective on insomnia. Psych Clin N Am 1987; 10: 541±553.

 

Raising the Bar: Competence in Outpatient Eating Disorder Treatment

Raising the Bar: Competence in Outpatient Eating Disorder Treatment
Lauren and Alli with Charles Portney, MD (who enthusiastically gave us feedback) at ICED 2016.

When my friend and colleague, Alli Spotts-De Lazzer, M.A., MFT, LPCC, CEDS, asked me to join her in writing an article on competence for therapists treating eating disorders, I jumped at the opportunity.

Psychotherapists are ethically bound to treat within their scope of competence. Yet how does a psychotherapist determine if he or she is competent to treat eating disorders, the mental disorders with the highest mortality rates? Alli had searched for a guide or brief resource to help clinicians in training to better understand the basic knowledge recommended for treating eating disorders. To our surprise, few documents existed. Furthermore, we have both often heard that patients and families would like to feel better supported in knowing how to verify the credentials of outpatient eating disorder therapists. Many insurance companies do little vetting in choosing which therapists are listed on their panels as eating disorder treatment providers.

So we decided to create what we hoped would be a helpful document.

Alli and I each have extensive experience treating eating disorders in the outpatient setting. We come from different and complementary backgrounds. I received my original training in the 1990s in an evidence-based research lab under the direction of Terry Wilson, Ph.D, a developer of Cognitive Behavioral Therapy for eating disorders, and I have focused on evidence-based treatments ever since. Alli aligns with an eclectic approach informed by evidence-based concepts, personal experience with eating disorders and eating disorder trainings that range from Continuing Education Units to pre-licensed work at Monte Nido Treatment Center under the leadership of Carolyn Costin.

While we acknowledge that there are many possible paths to becoming a psychotherapist who treats eating disorders, we sought to answer questions including:

  • What set of competencies seem necessary for therapists to know in the outpatient setting?
  • What are many of the unique therapeutic needs of patients with eating disorders including anorexia nervosa, bulimia nervosa, and binge eating disorder?
  • What basic knowledge and training might therapists pursue if they desire to treat eating disorders in the outpatient setting?

In addition to a mental health treatment focus, patients with eating disorders also commonly present with nutritional and medical issues that may need attention. While having well trained, collaborative team members covering medical and nutritional disciplines in a patient’s care is desirable, in a real-world outpatient setting, these team members may not always be available. Psychotherapists working in the outpatient setting who do not have well-established protocols, resources, or collaborators can be particularly vulnerable if/when issues of competence arise.

Eating disorders are psychological disorders that often come with physical, medical, or nutritional consequences and/or complications that call for acute or gradual attention. Psychotherapists, therefore, are recommended to have a basic working knowledge of eating disorder-specific domains extending beyond a psychotherapist’s traditional scope of practice and usual training. Furthermore, each major disorder – anorexia nervosa, bulimia nervosa, and binge eating disorder – can present unique treatment needs and levels of risk.

Our review of the literature incorporating both research and practice guidelines, in conjunction with our own clinical experience in treating eating disorders in the outpatient setting determined that the areas of suggested knowledge generally fell into 5 domains:

  • Assessment and Diagnosis
  • Medical Factors
  • Nutrition and Malnutrition
  • Treatment Strategies
  • Multidisciplinary Collaboration and Levels of Care

Our hope is that the paper will:

  • Help therapists treating eating disorders in the outpatient setting by providing accessible information and resources and assist in potentially improving the experiences of and outcomes for patients;
  • Serve as a useful guide for clinicians desiring to specialize in the treatment of eating disorders;
  • Assist patients and families in feeling more supported by knowledge when seeking treatment providers; and
  • Possibly help to influence insurance companies in the realm of eating disorders.

We are grateful to the following colleagues who gave valuable, substantial feedback on drafts of our paper: Jennifer Thomas, Ph.D.; Charles Portney, M.D.; Stacey Rosenfeld, Ph.D.; Laura Collins; Kristine Vazzano, Ph.D.; Nina Savelle Rocklin, Psy.D; and Elisha Carcieri, Ph.D. We received considerable research assistance from eating disorders informationist, Millie Plotkin. We also thank our additional valued colleagues who provided helpful comments.

After an extensive peer-review process, the paper, “Eating Disorders and Scope of Competence for Outpatient Psychotherapists,” was accepted by and published in the American Psychological Association Journal, Practice Innovations, 2016, Vol. 1, No. 2, 89–104.

therapist competence in eating disorder treatment therapist competence in eating disorder treatment

My work in Shanghai with clients from all over the world

Eight years ago this month, I moved to Shanghai for a 2.5 year assignment.  I have been meaning to share my reflections.  Here they are:

I had been working at Los Angeles County Jail for nearly 10 years when my husband’s business plan for a site-based English Language Learning Children’s business in China got funded by the Walt Disney Company. I was by then more than a little “burned out” and ready for a change.

I know my jail co-workers questioned the legitimacy of my excuse for finally “getting out of jail.” “Really, you’re going to China?” they asked incredulously, as if I were just naming the furthest place I could think of from Los Angeles County Jail. I left my job in November 2007 and became wistful. I wondered if my kids would ever be able to remember having a working mother (they were 10, 8, and almost 6 when we left).

And so, in January 2008, my husband and I packed up our house, 3 kids and a dog, and said goodbye to our family and life in Los Angeles. We arrived in Shanghai during its coldest winter in 20 years.

Within 2 weeks of my arrival, I had coffee with a Dutch psychologist who lived in my compound and supervised the counseling program through the expatriate community center. Knowing of my expertise in eating disorders from my CV, she immediately handed me 2 cases. A friend encouraged me to apply for a job with the Singapore-based Parkway Health, which ran clinics throughout Shanghai staffed by Western-trained doctors, serving a predominantly expatriate clientele. Parkway Health promptly hired me, and within 4 months of my arrival in China I was working two jobs.

My clients were anyone who could speak English. This included clients from every continent with the exception of Antarctica (I never got to treat any penguins!). They ranged in age from children to adults in their 60s. The majority were on expatriate assignments or had children with foreign passports attending international schools. Some were Chinese who had lived abroad and were now living in China while their children attended international school. Others were American-born Chinese who had come to work in China and faced significant cultural issues. Other clients came from the UK, Germany, Brazil, Argentina, Sweden, Canada, Israel, India, South Africa, and Australia.

Map in my office in Shanghai with pins representing hometowns of patients.

Map in my office in Shanghai with pins representing hometowns of patients.

I learned that clients around the world experience very similar problems. Due to my specialty, a significant portion of my clients was seeking treatment for eating disorders. But with a short supply of therapists to treat the large and diverse population of expats in Shanghai, I also saw clients with anxiety, mood disorders, and marital problems.

I found that the stress of being an expat away from one’s family and home, and the clash of living in a foreign culture, added overlays of additional stress to whatever other disorder or issues were already there. I also found that there were a certain number of individuals who had fled their location of origin (sometimes a series of locations) in an attempt to run away from a problem; unfortunately, in these circumstances the problems had merely followed them to China.

A Cognitive Behavior Therapy (CBT) approach provided benefits for clients of diverse ethnic backgrounds. I sought additional training in Emotionally-Focused Therapy for couples and Family-Based Treatment for adolescent eating disorders to enhance my skills.

One of the most exciting aspects of living and working in Shanghai was spearheading the establishment of the Shanghai International Mental Health Association (SIMHA), an organization for therapists serving the international community of Shanghai. Over time, I proactively cultivated relationships with anyone who had been a therapist. This aided me when I needed to consult or refer to another therapist. Unfortunately, although various international schools and organizations serving expatriates retained lists of expatriate therapists, whichever list I consulted of therapists practicing in Shanghai was outdated (and the turnover was relatively rapid). Thus, I reached out to the International Mental Health Practitioners of Japan and sought their advice on forming a similar organization in Shanghai. I then banded together the various and diverse therapists I had identified in Shanghai and together we formed a professional organization of mental health professionals (also from all around the world), adopted an ethics code, and built a website and a community of therapists who could support each other. I am proud that SIMHA still thrives.

Living and working in Shanghai gave me an amazing training in cultural awareness and sensitivity. I love learning about clients’ unique backgrounds and experiencing their worldviews. I particularly enjoy working with clients of diverse backgrounds. I am sensitive to the issues of expatriation and acculturation and generational conflicts around culture. I am also comfortable and enthusiastic about engaging with people from different backgrounds, whether cultural, religious, gender orientation, sexual orientation, or lifestyle.  It is this diversity that makes the texture of life so interesting and my work so rewarding.

August and September 2015 LACPA Eating Disorder SIG events

I have two amazing speakers lined up for August and September.  It’s early in the LACPA calendar year, so join now to take advantage of great speakers for the next 13 months!

Monday, August 24 at 7:15 pm

Title:  Shift Happens: Cognitive development, flexibility and remediation in eating disorders

Presenter:  Kathleen Kara Fitzpatrick, Ph.D.  Slide1

Description:  CRT stands for cognitive remediation therapy (sometimes also called cognitive rehabilitation therapy).  This type of treatment has been widely used in other disorders (most notably schizophrenia and traumatic brain injury).  The focus of CRT is on creating different brain connections and learning to change the process of thinking.  In our treatment, we focus on two main areas: set-shifting and central coherence.

Set-shifting refers to the ability to move readily between two (or more) different ideas, concepts or behaviors.  You do this when you multi-task, but you also do this when you create habits.  When you break a habitual behavior it can be a real challenge and the brain uses the same processes to create new connections around simple tasks (like changing the ringer on our cell phones) as we do to more complex behaviors (such as changing our minds about eating feared foods).  Set-shifting is a skill we use every day, so we expect changes in certain areas to be helpful to us in every area.

Central coherence refers to the ability to move between details and the big picture.  Most of us do this constantly, but we all show a preference for one or the other.  People with AN seem to have a greater focus on details at the expense of the big picture and we engage in activities designed to help us learn how to better balance the global and detail perspective.

We hope that CRT helps in several ways.  We know that people who undergo CRT improve in set-shifting and central coherence from other studies we have completed.  And we know that the presence of more obsessive/compulsive symptoms typically mean greater challenges in these domains.  We hope that the addition of CRT to FBT will reduce the amount of time it takes to help participants respond to treatment by focusing specifically on cognitive processes.  We do not focus on content of thoughts – so we do not directly approach eating disorders – which can help facilitate our relationship with participants.  Finally we also know that the adolescent brain is in the process of developing these skills and helping secure skill development provides a great foundation for all-important brain maturation.

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

Bio:  Dr. Kathleen Kara Fitzpatrick is a Psychologist in the Stanford Dept of Psychiatry and Behavioral Sciences and Pediatrics.  She specializes in neuropsychological assessment of eating disorders and evaluation of treatments for children and adolescents. Her current research interests focus on the development of Cognitive Remediation Therapy (CRT), which utilizes neuropsychological components to address cognitive and behavioral difficulties associated with eating disorders. In addition to working as a therapist on research treatment studies, she also provides supervision to therapists on different treatment modalities.  As a therapist on the DSM-5 field trials, she conducted assessments to support changes in diagnostic criteria, with an emphasis on the new diagnosis of Avoidant Restrictive Food Intake Disorder.

RSVP to Dr. Lauren Muhlheim at drmuhlheim@gmail.com

SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

Thursday, September 17 at 7:15 pm  

Title:   Full Metal Apron: Fighting Eating Disorders from the Kitchen Table 

Presenter:  JD Ouellette   

Description:  Just when she thought it was safe to leave the kitchen, after feeding her family a home-cooked dinner nightly for 25 years, the youngest of JD Ouellette’s four children developed anorexia at the age of 17. Thankfully her daughter was diagnosed quickly and excellent treatment at UCSD was readily available. Three plus years after her daughter began treatment she is once again happy, healthy and free (for now) from her eating disorder and thriving in college and life. This talk will cover her family’s journey and the lessons she’s learned in her work as a parent mentor for UCSD as to how clinicians can help parents help their child recover.

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

Bio:  JD is a member of the UCSD Eating Disorders Center’s Parent Advisory Committee, a parent mentor for UCSD, an active member of Eating Disorder Parent Support, a co-ed online support community, and co-administrates International Eating Disorder Action. She is an avid consumer of ED literature and attends ED conferences while holding down her day job as a school administrator. She has a passion for using social media to allow parents’ and other advocates’ voices be heard as advocates and activists in the ED world.

RSVP to Dr. Lauren Muhlheim at drmuhlheim@gmail.com

SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

FBT Insights from the Neonatal Kitten Nursery

Parents feed children in FBT Kitten CollageI recently began volunteering at the Best Friends Neonatal Kitten Nursery. Best Friends Los Angeles opened its neonatal kitten nursery in February 2013.  The nursery is staffed with a dedicated coordinator and supported by volunteers who sign up for two hour feeding shifts 24 hours a day to help the kittens grow and thrive.

If you were an abandoned kitten in the Los Angeles area, or even a kitten with a mother, you’d be lucky to make your way to the Best Friends Neonatal Kitten Nursery.

The most vulnerable animals in the Los Angeles shelters are newborn kittens, often abandoned at birth, or turned into shelters from accidental litters. Because the kittens cannot feed themselves, they will die without someone to bottle feed them.

In the mommy and me section of the nursery, mothers nurse their kittens. In the other sections, kittens are bottle-fed, tube-fed, or syringe-fed until they are able to eat gruel on their own. Kittens are weighed before and after each feeding. If their weights are not steadily going up, the interventions increase. They are very fragile at this age.

The other night, the nursery coordinator, Nicole, was tube-feeding some kittens who were ill. As she explained, they were feeling too sick to eat on their own. Although acknowledging that her tube feeding was making them angry, Nicole was resolute. No kitten would starve to death on her watch. Of course, I connected this back to my families working to re-feed their children with anorexia.

In the neonatal nursery, we don’t spend time thinking about why the kitten is not nursing or eating in the expected fashion. If they are sick, they are treated for that, but in the meantime, every kitten is fed around the clock and those who don’t have mothers are bottle fed, those who won’t nurse from their mothers (often when they are too congested) are tube-fed, and those who won’t eat gruel independently are syringe-fed.

How does this relate to parents doing Family Based Treatment (FBT) for Eating Disorders with children who have Anorexia?

Of course, parents do not literally force food down human children’s throats, but they do set up contingencies to require eating even if the child doesn’t feel well and even if they rail and resist and are angry about it.

This is the heart of FBT Phase 1. When children are not able to eat on their own (due to an eating disorder) parents are instructed to nourish their starving child back to health. Parents need to step in and help their children make steady weight gains until they are able to eat on their own. Parents need to be resolute and not worry about their children being angry at them. They also should not spend time exploring why their child is not eating.

For further information on parental direction over eating in FBT, check out this prior blog post.

 

Psychological assistant providing low cost treatment for eating disorders

I remain committed to the practice of and dissemination of evidence-based treatments. To that end, I am excited to announce that I have added a registered psychological assistant to my practice in Los Angeles:

Liliana Almeida, M.A, Clinical Psychology Ph.D. Student, PSB-94020579 is no longer with the practice, but we do have a new therapist in training who provides low-cost therapy to patients with eating disorders in Spanish, English, and Portuguese. Learn more about Eliane Spagnoletto, ACSW.

Liliana Almeida, M.A.
Liliana Almeida, M.A.

 

Liliana Almeida, M.A., is a fourth year Clinical Psychology Ph.D. student at the California School of Professional Psychology at Alliant International University in Los Angeles. She received her M.A. from The New School and her B.A. from Rutgers University. During the last 7 years she has researched eating disorders and obesity. Her clinical experience includes working with diverse clients in a community mental health center providing cognitive-behavioral and psychodynamic psychotherapy in English and Spanish.

Liliana will be working under my supervision and is available to work with adult and adolescent clients with eating disorders, anxiety, and depression.  She will provide services in English, Spanish, and Portuguese and will be able to provide some low-cost therapy to those in need.

Portuguese

Eu sou uma assistente de psicologia (PBS-94020579) para Lauren Muhlheim, Psy.D., psicóloga clínica especializada no tratamento cognitivo-comportamental de perturbações alimentares. Como assistente de psicologia, eu forneço psicoterapia cognitivo-compartamental em Português sob a licença da Dra. Muhlheim (PSY 15045) para adolescentes e adultos que sofrem com depressão, ansiedade e pertubações de o comportamento alimentar.

Spanish

Soy una asistente de psicología (PBS-94020579) para Lauren Muhlheim, Psy.D., una psicóloga clínica especializada en el tratamiento cognitivo-conductal de los trastornos alimentarios. Como asistente de psicología yo proveo terapia cognitivo-conductal en Español bajo la supervision y licencia de la Dra. Muhlheim (PSY 15045) para adolescentes y adultos que sufren de la depresión, ansiedad y de los trastornos de la conducta alimentaria.

 

Presentation on Social Media for Psychologists

Slide1

 

Reprinted from the Rutgers GSAPP website:  
Dr. Lauren Muhlheim
“Use of Social Media by Professional Psychologists”

 

On Wednesday March 27, 2014, faculty and students at the Graduate School of Applied and Professional Psychology (GSAPP) gathered to hear a colloquium presentation by Lauren Muhlheim, Psy.D, CEDS (Clinical, 1995). Dr. Muhlheim is a prominent GSAPP alumna who has a practice in Los Angeles where she provides psychological treatment specializing in evidence-based cognitive behavioral psychotherapy for adults and adolescents with depression, anxiety, stress, and eating disorders. She presented on the topic of “Use of Social Media by Psychologists in a Safe and Ethical Way.”

After earning a B.A. from Princeton University, Dr. Muhlheim attended the doctoral program in Clinical Psychology at GSAPP. She chose GSAPP because she was “impressed by the quality and depth of the clinical training” and knew that she wanted to work in clinical settings. As a graduate student, Dr. Muhlheim trained in the Rutgers Eating Disorder Clinic. In interview, she shared her favorite memory of GSAPP to be working with Terry Wilson, Ph.D., an internationally renowned eating disorders expert. More recently, Dr. Muhlheim trained in the Maudsley Family-Based Treatment (FBT) for adolescent eating disorders and is certified in FBT by the Training Institute for Child and Adolescent Eating Disorders. She is also certified as an eating disorder specialist (CEDS) by the International Association of Eating Disorders Professionals (IAEDP). Dr. Muhlheim has been providing psychological counseling since 1991. She has also supervised and trained psychology interns and other mental health professionals.

Dr. Muhlheim’s work experience has brought her to multiple settings around the globe. For nearly ten years, she was a staff psychologist at Los Angeles County Jail, followed by three years in Shanghai, China, treating clients of varying national, cultural, religious, and ethnic backgrounds. Dr. Muhlheim spearheaded and served as the first president of the Shanghai International Mental Health Association (SIMHA). She has also worked in an Obesity Research Clinic, inpatient hospitals, outpatient clinics, group homes, and private practice.

Dr. Mulheim’s experiences abroad proved to be a portal for her into the world of social media. In her colloquium presentation, she reflected on her years in Shanghai: “That’s where I first became aware of the power of the internet.” She described how she used search engine optimization to attract international patients to their practice website, as well as commented on the challenges she faced when China blocked Facebook.

In 2012, Dr. Muhlheim joined the social media committee of the Academy for Eating Disorders. She served as a co-chair of AED’s Social Media Committee, AED’s Membership Recruitment and Retention Committee, and AED’s FBT Special Interest Group. In her role as a co-chair of the Social Media Committee for the Academy for Eating Disorders, she helped manage the AED’s Facebook, LinkedIn, and Twitter pages, and helped educate professional AED members about social media. More recently, Dr. Muhlheim has stepped up to the position of Director for Outreach with the board of AED.

Over the course of her talk, Dr. Muhlheim educated the audience about social media from a variety of angles. She presented an overview of current technology, reasons why to be on social media, and recommendations for using social media safely and ethically. Loaded with valuable information and insights, her approach was also light and entertaining. She started out her presentation by differentiating among the various social media formats: “Facebook: I like donuts,” “LinkedIn: My skills include donut eating,” and “Twitter: I’m eating a donut.” Although the list of social media sites was lengthy, Dr. Muhlheim chose to highlight Facebook, LinkedIn, and Twitter in particular.

Citing commentary from the APA Monitor, Dr. Muhlheim presented a general outlook on social networking in the world of professional psychology. A rising number of people are turning to the internet for health information, she noted. As the use of social media is growing, psychological professionals are increasingly using media. Graduate students use social media but often lack guidance, because supervising faulty are less experienced with it. She presented the Social Media Ladder as one way to view online participation, showing how people move from being passively involved to being actively involved, actually becoming content creators.

Why is it important to be on social media? According to Dr. Muhlheim, social media helps us stay informed, make connections, meet patients where they are, build a “brand,” learn new information (e.g., “Tweetchats”), disseminate information, advocate for causes, and market products or services. These concepts came alive as Dr. Muhlheim expounded with personal anecdotes and colorful screenshots. “The more online real estate you control, the better,” she explained, “And one way you control your online real estate is through social media.”

Perhaps the crux of her presentation dealt with the safe and ethical use of social media. APA has not yet published guidelines for psychologists’ use of social media, Dr. Muhlheim pointed out. Subsequently, Dr. Muhlheim shared the social media guidelines published in 2010 by American Medical Association, illustrating how these principles apply to her as a professional.

First, she advised, be sure to separate personal and professional content. Keep a personal facebook page for social connections and create a separate practice page for your practice. Create two email address, and do not allow clients to friend you on Facebook. Second, use privacy settings—and don’t rely on even the most restrictive settings as being absolutely secure. Third, routinely monitor your own internet presence, such as by doing a Google search or checking online rating agencies. Fourth, protect patient confidentiality. Per Dr. Muhlheim’s advice, clarify your social media policy for googling, friending, and following; incorporate it into your informed consent for clients. Fifth, maintain appropriate boundaries. Sixth, remember your career and reputation when using social media. In her words, “Think twice, and tweet once.”

Listeners gleaned a variety of handy tips and bits for using social media to advance professional practice. For instance, use LinkedIn as a virtual rolodex to connect with colleagues. Strive for search engine optimization – increase your visibility on other sites and update your site frequently. Utilize twitter as a great way to share articles and stay current, and as an expedient alternative to blogging.

When asked about the challenges of being involved in social media, Dr. Muhlheim stated, “I think the greatest challenge of social media for psychological practitioners today is the fear/resistance many have to using it.” Her advice for current GSAPP students? “Plan to have an online presence” and “be willing to explore and use social media and other new technologies, such as apps.”

Dr. Mulheim’s presentation generated a wave of questions from the audience on the applications of social media to professional practice. In response to concerns over privacy on Facebook, Dr. Mulheim recommended using the most restrictive privacy and security settings, while noting that privacy settings are imperfect. “Assume anything you publish behind a privacy setting will leak.” Further, she recommended that professionals post only that which they can stand behind with integrity. Finally, Dr. Muhlheim responded to questions about the psychological implications of Facebook use on eating disorders. The discussion was thought-provoking and dynamic, as a room of psychology professionals aired concerns over the ramifications of social media use for children and adolescents.

At the end of her presentation, Dr. Muhlheim shared her social media rendition of a bibliography – a link to her Pinterest page. An exuberant round of applause followed, as GSAPP faculty and students acknowledged Dr. Muhlheim’s cutting-edge contributions to the field of professional psychology.

Dr. Muhlheim can be reached by email at drmuhlheim@gmail.com 
or visited at:

Facebook

Twitter

Pinterest

Tumblir

LinkedIN

By: Chana Crystal, GSAPP