100% Accurate Trauma & PTSD Symptom Assessment by Expert Scott Giacomucci, MSS, LSW, CTTS, CET III

Scott Giacomucci, MSS, LSW, CTTS, CET III

A colleague and friend of mine, Scott Giacomucci, MSS, LSW, CTTS, CET III has been up to some pretty amazing things in the world of trauma, psychodrama and PTSD healing.  He was kind enough to share some information he put together for his clients with us.  The following is a handout on Trauma and PTSD.  Let us know what you think and if you have any questions in the comment section below:

 

Trauma and PTSD

                                by Scott Giacomucci, MSS, LSW, CTTS, CET III

Client: "What's wrong with me?"

Therapist: "Well, given your symptoms, I think you have Post Traumatic Stress Disorder."

Client: "Post Traumatic Stress Disorder?  What are you talking about?  Trauma?  It doesn't make  sense.  What trauma did I have?  I wasn't in a war or survive a holocaust or anything.  I didn't even really get hurt."

This is a typical response following an assessment and diagnosis of this poorly understood disorder.  It seems appropriate that this diagnosis - like many other serious medical diagnoses - would be initially met with denial to temporarily protect the person from the reality of his/her own vulnerability.  However, in order to effectively treat the condition, the diagnosis eventually needs to be accepted, and in order to accept the diagnosis, one needs to understand it. To this end, I offer the following answers to the two most frequently asked questions: What is trauma? and How bad does it have to be to be traumatic? 

What Is Trauma?

According to one of the foremost experts in healing trauma, Dr. Peter Levine,

“Trauma is a basic rupture - loss of connection to ourselves, our families, and the world.  The loss, although enormous, is difficult to appreciate because it happens gradually. We adjust to these slight changes, sometimes without taking notice of them at all…although the source of tremendous distress and dysfunction, it (trauma) is not an ailment or a disease, but the by-product of an instinctively instigated, altered state of consciousness. We enter this altered state let us call it "survival mode” when we perceive that our lives are being threatened. If we are overwhelmed by the threat and are unable to successfully defend ourselves, we can become stuck in survival mode. This highly aroused state is designed solely to enable short-term defensive actions; but left untreated over time, it begins to form the symptoms of trauma. These symptoms can invade every aspect of our lives.”

One of the most effective ways to evaluate if you have been traumatized is to answer these simple questions about a significant incident: when you remember the incident, is the memory exactly the same every time? Is the memory unusually fragmented or difficult to recall?

If an answer is yes, then the memory is likely a traumatic one.  By no means does one traumatic memory constitute a diagnosis of PTSD; however it does indicate that the traumatic event has been dysfunctionally stored; remains inadequately processed; and continues to cause you distress.

What is a PTSD Diagnosis?

A diagnosis of PTSD is different from most mental-health diagnoses in that it is the only diagnosis that explore and places emphasis on “what happened to you”. The Diagnostic and Statistical Manual of Mental Disorders (5th edition) offers 4 criteria for a PTSD diagnosis.

1.     The first criterion relates to the actual trauma:

•  Directly experiencing the traumatic event(s)

• Witnessing, in person, the event(s) as it occurred to others

• Learning that the traumatic event(s) occurred to a close family member or friend

• Experiencing repeated or extreme exposure to aversive details of the traumatic event(s); this does not apply to exposure through media such as television, movies, or pictures

2.     The second criterion involves the persistent re-experiencing of the event in 1 of several ways:

• Thoughts or perception
• Images
• Dreams
• Illusions or hallucinations
• Dissociative flashback episodes
• Psychological distress or reactivity to cues that symbolize some aspect of the event

3.     The third criterion involves avoidance of stimuli that are associated with the trauma and numbing of general responsiveness, as determined by the presence of 1 or both of the following:

• Avoidance of thoughts, feelings, or conversations associated with the event
• Avoidance of people, places, or activities that may trigger recollections of the event

4.     The fourth criterion is 2 or more of the following symptoms of negative alterations in cognitions and mood associated with the traumatic event(s):

• Inability to remember an important aspect of the event(s)
• Persistent and exaggerated negative beliefs about oneself, others, or the world
• Persistent, distorted cognitions about the cause or consequences of the event(s)
• Persistent negative emotional state
• Markedly diminished interest or participation in significant activities
• Feelings of detachment or estrangement from others
• Persistent inability to experience positive emotions

5.     The fifth criterion is marked alterations in arousal and reactivity, as evidenced by 2 or more of the following:

• Irritable behavior and angry outbursts
• Reckless or self-destructive behavior
• Hypervigilance
• Exaggerated startle response
• Concentration problems
• Sleep disturbance

6.     The duration of symptoms is more than 1 month

7.     The disturbance causes clinically significant distress or impairment in functioning

8.     The disturbance is not attributable to physiological effects of a substance or medical condition

According to Levine,

“The symptoms of trauma may be continually present or they may come and go. They may even surface after being hidden for decades. Usually, symptoms do not occur individually, but in clusters grow increasingly complex over time. Unfortunately, they become less and less connected with the original traumatic experience, making it increasingly difficult to trace the symptoms to their cause, and easier to deny the importance of the traumatic event in one's life. However, if we pay attention to these symptoms, for what they are -internal wake up calls - we can address and begin to heal our trauma.”

Although there are pervasive misconceptions about trauma, PTSD is neither rare nor unusual. But unlike seeking treatment for symptoms related to diabetes or glaucoma, seeking treatment for the symptoms of PTSD is somehow interpreted as a weakness. Although this couldn’t be further from the truth, you may believe it. Maybe even said something like it; Real men don’t ask for help; Trauma couldn't possibly affect a well balanced person, there must be something wrong with me; or the all time favorite, It wasn’t really that bad; I should just get over it.

Don’t you think that if that were an option, you would have done just that?

(reference: DSM5 & Linda Curran)

Scott Giacomucci, MSS, LSW, CTTS, CET III is a certified trauma treatment specialist and licensed social worker in Pennsylvania. He is a graduate of Bryn Mawr College where he received his Masters in Social Service (MSS) with a concentration in clinical social work. He facilitates trauma treatment services at Mirmont Treatment Center serving a variety of populations including young adults and emergency responders (veterans, police, fire, etc..) in both individual therapy and group sessions. Scott has a gentle, non-judgmental treatment approach that honors the inherent worth of each individual. He utilizes a blend of treatment modalities including both traditional talk therapy and experiential therapy which have been research-proven as the treatment of choice for treating trauma. 

To learn more about Scott Giacomucci and the work he does, you can visit his website at: http://sgiacomucci.com/

The 5 Secrets to Quit Binging

At times, all of us have eaten a bit, or a lot more than is comfortable in our bodies.  Holidays, celebrations or sometimes mindless eating in front of the TV can leave us feeling overly full.  For some, this way of eating is more common and happens more frequently than we’d like.  The new DSM-V, the Psychiatric Association’s manual on diagnosis, has created a diagnosis under the eating disorder umbrella called Binge Eating Disorder or BED.  Whether you meet the criteria for this disorder, for bulimia, anorexia, or you just find yourself overly stuffed at times, these tools can be helpful:

1.     Notice what types of foods you’re binging on and write them down. 

It helps to look at your behavioral patterns.  Some people find themselves eating excessive sweets, some are more geared towards fats or starches.  Some people with emotional eating tendencies excessively eat any kind of meal including vegetables.  See if you can find a pattern in your binge choices. 

2.     Notice what you DON’T binge on. 

Are there any types of foods that you’d never consider in a binge or never feel the need to over-eat?  In a recent session, a client was relaying the guilt and shame he felt after a binge.  He reported that he doesn’t usually allow pastries in the house, but was feeling strong recently and thought it’d be okay.  He found himself finishing off the pastries he had in one sitting.  Upon further investigation into what foods he was allowing himself to eat regularly, the client determined that he felt very satisfied when he ate waffles and allowed himself to eat waffles multiple times per week.  I asked him if he ever binges on waffles.  He was shocked when he thought about it and said that – no – he never binges on waffles.  Ok, great, so there’s no waffle binging going on, but how does that help?  Follow me here.

3.     Take a look at what you ‘allow’ yourself to eat regularly. 

What foods do you consider safe?  In an attempt to be healthy, lose weight, or just get control over your food choices, you may be very rigid or restrictive about what you allow yourself to eat on a regular basis.  Perhaps your choices look benign enough like chicken and veggies multiple times per week.  Write down what you’ve eaten over the past 3 days to 1 week or track your food for a week.  What do you notice?

4.     What is missing from your regular eating habits? 

Take those same meal journals and notice what you don’t have there.  If we consider all the food groups: protein, fat, starch, veggies, fruits and dairy – are there any food groups missing?  Are there lots of repeated meals without much variety?

Now I know this might seem completely insane and a bit scary, but HERE’S THE KEY to quit binging.  Ready?

5.     Allow yourself to eat the foods you binge on.

Try adding a portion or 2 of the foods you don’t allow yourself to eat and some of the most common foods you binge on to your regular meal schedule.  I know this might seem counter-intuitive.  Our society tells us to resist, have discipline, diet harder, avoid sugars and carbs and fats and this may be the only voice you’ve ever heard that encourages these things, but just give it a try for a month or even a week and see what happens.  If you are on the anti-carb kick, but then you find yourself binging on carbs, try adding a normal amount of carbs to each meal and see what your body craves after a while.

Here’s the rub – We are creatures of desire. 

Food is part of life!  It’s nourishing and delicious and sensual.  When we restrict ourselves from eating foods we love, we may lose weight in the short run, but this does not happen without consequence.  Our animalistic nature, our Id, it craves pleasure and passion and vigor.  If we force ourselves to live inside a rigid box of rules around food and body, we will always desire to break free and stepping outside of that box causes immense shame and fear.  I am not telling you to overeat or teaching you how to binge differently, but what I am suggesting is that you try to take the power out of the foods that haunt you. 

If you regularly binge on entire cartons of ice cream, see what happens when you have a cup every night for a week.  What emotions come up when you eat it?  Can you journal about them and bring them into your therapist?  What do you find yourself craving after that week of glorious freedom with ice cream?

If you live near The Main Line of Philadelphia or West Chester and want to learn more about binging and how to quit, or you’re not sure where to find support for your feelings around food, you’re not alone.  Please feel free to contact me at 610.314.8402 – I’d be happy to help you find support.

WHAT IS PTSD AND DO I HAVE IT?

Post-traumatic stress disorder, also known as PTSD, is an indication from your body that it needs support in sorting some things out.  Traumatic memories are stored in a different part of your brain than the rest of your memories.  When therapy is completed successfully, brain scans show that the trauma memory has been moved to a different area of the brain.  This alternate area of the brain doesn’t trigger your mind to get confused, your adrenaline to rush, and your body to be on alert.

Here are some of the symptoms of Post Traumatic Stress Disorder from the Diagnostic and Statistical Manual (DSM-V):

A stressor such as actual or threatened serious injury, threatened death or witnessing of death or actual or threatened sexual violence.

Intrusion symptoms such as

• intrusive memories
• traumatic nightmares
• dissociative reactions such as flashbacks
• prolonged or intense distress after being exposed to a trigger

Avoidance symptoms such as persistent efforts to avoid anything that triggers traumatic memories.

Alterations to thoughts and mood symptoms such as

• not being able to remember important parts of the traumatic event
• believing bad things about yourself and/or the world
• blaming yourself for the traumatic event
• overwhelming emotions such as horror, shame or anger related to the trauma that continue to happen even long after the event
• losing interest in things that you used to enjoy
• not being able to feel positive emotions such as joy

Reactive symptoms such as

• exaggerated startle response
• difficulty concentrating
• sleep difficulties
• hypervigilance
• aggressive or irritable behavior
• reckless or self-destructive behavior

If you are ready to listen your body signals and get some support to untangle the memories and put them in their proper place, I can help.  My name is Tiffany Spilove and I LOVE working with people to heal their past.  I want to make sure that you find peace inside your body and your mind.  I have specialized training and experience helping people who have gone through sexual abuse, physical trauma and emotional pain.    

Call me today for your free 15-minute phone consultation at 610-314-8402 and find out if therapy is a good option for you

How to Find an Expert on PTSD & Trauma for Therapy on The Main Line of Philadelphia

The Main Line of Philadelphia

is a very special place to live.  If you already live here, you know how unique this place is - if you don't live here, you are in for quite a treat.  The suburban area to the west of Philadelphia has been referred to as The Main Line because of the main train line that connects Philadelphia to all the beautiful towns built up along the train tracks: Lower Merion includes Overbrook, Merion, Bala Cynwyd, Wynnewood, Narberth, Ardmore, Bryn Mawr and Rosemont.  Further out we have Radnor, Villanova, Wayne, St. Davids, Berwyn, Paoli, Malvern, Exton and Frazier.  Each town is unique and has it’s own spin on charm.

Finding an expert trauma therapist on the Main Line of Philadelphia

seems harder than it should be.  With Bryn Mawr's Graduate School of Social Work close by, Villanova University, Rosemont College, Saint Joseph's University, Widener, Immaculata, Cabrini, Ursinus and not to mention University of Pennsylvania, Swarthmore and LaSalle, we have so many talented therapists, social workers and counselors.  So, how do you find the therapist who knows just how to help you manage your post-traumatic stress symptoms?  How do you find the counselor you can click with and trust to guide you through an evidence-based method of healing your past traumatic memories?  Choosing a therapist is a very personal decision.  You can have three great therapists, but if you don’t feel safe with them, what’s the point?  If you are looking for a counselor, psychologist, life coach or therapist - I'd like to help you find someone who can help.

Here are some ways to search

Educate Yourself About Methods that Work for PTSD

When you have PTSD, there are only a few ways of treating your symptoms that have been studied and proven to effectively reduce or eliminate symptoms.  Those nightmares you’ve been dealing with, the heightened startle response, hypervigilance, and avoidance of triggering situations – those are the things that get in the way of your life.  These are the issues you’ll want to be sure your therapist knows how to help you manage and heal, not just talk about.  One of the top researched methods for eliminating these symptoms is a method called Eye Movement Desensitization and Reprocessing (EMDR). 

EMDR has been studied and proven as an evidence-based treatment method.  You can learn more about EMDR and how it works here.  Here is a short explanation: when we have traumatic memories, the memories tend to get stuck on one side of the brain and our body tries to heal it by re-playing it over and over, but it stays stuck.  EMDR is a technique that stimulates each side of the body alternately while the patient processes the traumatic material.  This technique helps the brain move the traumatic memory from one side of the body through to be able to process it so it’s not stuck on a loop any longer.  You can find therapists who are trained and certified to utilize EMDR by going on the EMDRIA.org website or asking people who know therapists in the area.  Think about asking friends who have or know therapists, your doctor or someone at your school.  Therapists that come highly recommended and are known to work with PTSD through EMDR methods are a good way to make sure they have a good reputation.  

Google

Type into Google your town and the issue you are looking for help with.  For example, "Bryn Mawr and PTSD" or "Rosemont and Trauma" and see what comes up.  In the top listings that come up in your search, you will hopefully see some links to therapists that specialize in your particular need and are trained in EMDR.    

Psychology Today

What you will most likely see is a result that links to a Psychology Today profile for therapists in your area that have indicated these specialties.  Psychology Today is a great site that is most commonly used for therapists to post their profiles and for clients to find a therapist nearby.  It’s very helpful that you can refine your search by specialty.  The unfortunate thing is that therapists can indicate that we specialize in as many topics as we'd like.  Although a therapist might indicate that they specialize in PTSD, if it's really something we know a lot about, we obtain specialized training in evidence-based methods specifically for PTSD and we will often note areas we are trained in on our websites, so don’t stop with Psychology Today, make sure you read through the clinician’s website as well.

Websites

Check out the websites of potential therapists.  If you are looking for help with flashbacks and the website you are visiting talks a bunch about flashbacks, that's a great sign!  If you are looking for help with a heightened startle response and you're on a website that doesn't mention this symptom, you might want to keep looking.  

Phone consultation

Some therapists offer a free 15-minue phone consultation which is a great service and an excellent opportunity for you to interview your potential trauma therapist.  You are going to be spending a good amount of time and finances on effective therapy, it is very important that you find the right fit for you.

Here are some questions to help you navigate your phone consultation:

1.     What methods do you use to treat PTSD?

2.   How do you help your clients manage overwhelming emotions while they work on traumatic memories?

3.   What do you do to treat the symptoms versus the root of the problem?

4.   How long does it usually take before your clients start to see relief from their symptoms?

5.   How effective are the methods you use?

6.   Given my specific set of symptoms and needs, do you think you can help me and have you helped many others’ with my specific symptoms before?

In an ideal world, you would find a therapist who has special training and expertise in the methods that show the best results and someone who has tons of experience working with eating disorders and trauma.  Unfortunately, this is not an ideal world.  So you'll need to search a bit further.  You'll be searching for someone that you connect with, who you feel comfortable talking to, someone who will be honest with you and you'll know you can be honest with them.  

I hope this helps you in your search for the right therapist on the Main Line of Philadelphia.  If you want some tools to help now, sign up for my newsletter to get some tips and tools for managing PTSD and eating disorders.  If you are still feeling stuck, feel free to call me at 610.314.8402 for a free 15 minute phone consultation.  I am available to listen to what's happening and help direct you to the right person.  If you are looking for help with eating disorders or PTSD, you can read more about how I can help here.

Guest Writer: My Journey With Bulimia by Melissa King

A brief update from the author:

I wrote the following post just over 6 years ago. I had been fully recovered from bulimic symptoms for about 4 years at the time. It’s now been 10 years of recovery and I still deeply believe in all of the words I speak in this piece. The only thing that’s changed is that I feel even further away from experiencing desires to binge or purge. There was a time when it was hard to imagine feeling completely comfortable around food, easily stopping when full, and not thinking about the ice cream in the freezer constantly. I hope this article helps some of you! Be brave. Recovery is totally possible! - Melissa

My Journey With Bulimia

December 6, 2010

About ten years ago I developed a condition known as bulimia. I never would have guessed that a smart girl like me would struggle with something like that. I knew better. I had learned about eating disorders when I was younger and could never make sense of why someone would force themselves to vomit after eating or avoid eating all together.

I think very differently about eating disorders today. You can be intelligent, self-aware, and informed about eating disorders and still struggle with the “disease.” I remember the first time I displayed signs that I was at risk for developing bulimia. I was reading a book about how bad refined sugar was, and I was doing an excellent job of eliminating it from my diet—that is until I was tempted by a birthday cake brought into work one day. I decided to treat myself to a slice, and as I was finishing it, I felt deeply concerned about how the sugar might be harming my body. I don’t know what made me think of it because I had never chosen to throw up food before (nor did I know of anyone who had), but I quickly went to the bathroom and vomited in a stall.

I felt much better after getting rid of the sugar and didn’t think of it again until a year later. I had begun a big transformation in my life. I was starting to question my faith, my choice of career, the reasons for my failed romantic relationships, etc. I decided to go to counseling, and after a few sessions the counselor asked, “Where is Melissa?” I didn’t understand what she meant, but after some back and forth, she finally explained, “You tell me everything you think you SHOULD do and SHOULD want, but you don’t tell me how YOU feel and what YOU want.”

No one has said anything that has impacted me more deeply than that statement. I realized that I had become so good at assessing what I thought other people wanted that I had become disconnected from my own desires, feelings, and opinions. It’s like they were crowded out by the noise of all the other expectations and demands I thought I had to meet.

After that session, I started concentrating on my inner world and made a lot of effort to to connect more deeply with myself. As part of that exploration, I went back to dance class. Dance was an innate joy for me. It was my childhood passion, something I knew that I didn’t do to please anyone else. I hoped that dance would remind me of what it was like to feel.

And it worked. The feelings that dance inspired in me became recognizable in other areas of my life. In an attempt to follow this, I started spending more time alone so that I could learn to hear my own voice. I stopped going to church so that I could figure out what I really believed about God, without pressure from others. I also got a second job and began saving to spend six months in New York studying dance. New York was a place I had always wanted to live and I wanted to gift myself with the opportunity. And lastly, I decided to finally lose the weight I had gained since high school. For the first time, I was choosing to take my dreams seriously and have confidence in my ability to achieve them.

Several months later the pounds were coming off and I felt amazing. I was losing weight in a healthy way and sticking to a diet plan longer than ever before. I felt like I was discovering my real body: lean, healthy, strong, and energetic. I felt beautiful inside and out.

Somewhere close to my goal weight, I gave in and ate something that I knew was higher than the amount of calories I needed. I became afraid. Seeing myself eat food that was not in my plan made me fear that I was stepping back into old behaviors. In the past, I would stick to a diet for a little while but would always end up giving into temptation, promising myself that I would start again the next day. It was a bad cycle that I didn’t want to continue. Not only that, but I was falling in love with the “new” me, the me that was living from her heart, the me that was committing to her goals, and the me who was coming out of her shell and no longer hiding under extra weight. I felt more confident. I was getting attention from boys, and I was interacting more with people. I didn’t want to lose those things. That’s when I remembered my experience with the sugar elimination diet. I realized that I could just get rid of what I ate in the bathroom and my problem would be solved. So I did.

I never imagined that I would do it again. I thought it was a one-time thing. But it did happen again. Not often, at first. But every time I felt unsure about the calories I had consumed in a meal or I knew that I had too many, I ultimately found myself in the bathroom.

At one point, I became concerned that I might have an eating disorder. I remember going online and looking up the symptoms for bulimia. The criteria noted that an individual must have a certain number of symptoms to be diagnosed. Although I thought I might need help, my symptoms didn’t match enough of the criteria. I wasn’t bingeing at all and I wasn’t vomiting enough over the course of a week. As a result, I worried that I would not be taken seriously, so I was too embarrassed to seek help.

Eventually the symptoms did grow. It became harder to vomit if I didn’t eat enough, so I started to binge. My bulimia began to look very “textbook.”

In May of 2001, I moved to NYC. I accomplished some amazing things and had some wonderful experiences. During that time, I had periods when I went for months without symptoms and others when I vomited every day. I eventually went to counseling again, and during those sessions, my counselor offered me one important insight about bulimia. She simply said, “Maybe you’re not ready to give it up.” For the first time I considered the notion that I could give myself permission to continue. What a scary idea, but she was right to suggest it. 

From the time my symptoms began, I was resistant to them. After every purge, I promised myself it would be the last time. My mind was filled with figuring out ways to keep it from happening again. By accepting bulimia’s place in my life, I was able to learn from it and understand why it was there. Since my mind was free from thoughts of guilt, criticism, and resistance, I had space to feel the emotions that bulimia was trying to bring to the surface. I started recognizing the feelings I felt when I would binge and purge and realized how they were connected to other challenges in my life. When I saw the connections, I could start resolving the problems in other ways.

It took awhile, but I eventually let bulimia go. I would stop for several months, have a bout, then stop for many more months, have another bout, then stop for a longer period of time, etc. It’s been over three years now, maybe almost four, since the last period of symptoms.

I believe my bulimia represented a step toward healing. It often felt that people around me viewed bulimia as a problem, as a step backward, as something I was doing wrong. At first, I joined them in this conclusion. But bulimia came into my life when I was beginning a fight to be true to myself and resist the external pressures around me to please others, to follow another’s lead, to do what other people thought was good rather than what I felt was good. I didn’t know how to say “no.” I didn’t know how to negotiate. For years I had been taking in, absorbing and adjusting to what others wanted so that I could gain their approval and respect, ultimately depending on them for assurance and confidence. Simultaneously, I ate all the time. That’s how I gained weight in the first place. I just consumed. I dealt with my problems by eating. I couldn’t say no to food either. 

I was finally coming to a point in my life where I wanted to trust myself, but I was scared. It was a battle. I was taking food in (symbolically, others’ opinions, desires, and expectations) but realized that I didn’t want it. So I would push it back out. I was starting to say no and bulimia represented a violent fight inside me. 

It’s hard to be yourself in this world. There are a lot of demands, many that are indirect, and it was hard for me to resist the impulse to meet all those demands. Food was my vice, so it makes sense that my relationship with food symbolically paralleled my relationship with myself and with the world.

I think my bulimic episodes ended when I started trusting myself more and worrying less about others’ opinions, worrying less about someone being upset if I told them “no.” I knew that I didn’t want to continue bingeing and purging because the health risks weren’t worth it to me. So, eventually I chose to stop, probably when I had the internal strength to make that choice for myself (rather than just to appease others). Much of it was learning how to have boundaries. Just like I had to learn how to have boundaries with people, I had to learn how to have boundaries with food.

Does this mean that I have perfect boundaries with people now, that I never overeat, that I trust myself completely all the time? No. I still struggle with these things, just like everyone does. But the experiences I had while dealing with bulimia transpired into major changes in my life, changes I certainly benefit from now. My boundaries are much stronger and clearer, and I have more awareness of when I am compromising who I am. In fact, if I ever have the urge overeat or vomit, and I do sometimes, it’s a great clue to me that I’m not dealing with something in my life the way that I need to. I know that now, so I can take a step back, look at the problem, and figure out a more productive solution. It’s funny, because that solution often means asking for help or making myself more vulnerable with someone (letting someone in), or saying what I feel and risking possible rejection - again, all connected to boundaries. 

Bulimia is complicated and very layered. I haven’t addressed all of those layers here. Furthermore, I can only speak from my own experience; I don’t mean to represent others’ experiences. Over time, I’ve learned that people’s stories and the reasons behind their personal challenges are varied and don’t all fit into a neat little defined box. But I do believe that for many people, symptoms of bulimia actually symbolize an attempt toward health, the body reacting in order to make something right. I believe the symptoms are symbolic of the internal fight of an individual trying to find their voice, to find confidence, to look for a way to move out of whatever problem they have been dealing with, a problem that existed before symptoms of bulimia showed up. It’s never just about bulimia, it’s always about something much deeper. I think that many individuals with bulimia are trying to figure out how to finally have boundaries—with themselves and with the world. If they can find support to understand and transition through it, support to trust themselves, then the stage after bulimia can be fuller health, greater self-esteem and confidence, and healthier boundaries.

ABOUT MELISSA

Melissa King, LMHC is now a psychotherapist in New York City who works with women, gay/bi men, and couples in the first 10 years of a relationship. Find out more about Melissa here. https://www.myheartdances.com

If you have any questions or need support, please feel free to call me at 610.314.8402 for a free 15 minute phone consultation.

Please comment below and tell us your story !

For Therapists: On How to Conduct a Therapeutic Challenge Meal

Exposure therapy can be very effective when done in a way that gives a sense of empowerment and helps people defeat their fears.  If you have a client who has avoided eating normal meals or meals out at restaurants, challenge meals can be a great intervention for them. 

Assessment

Challenge meals are something that I usually suggest to a client after we’ve been working together for a while.  We’ve sat in the therapy room a number of times and I’ve built a therapeutic alliance with them.  I assess for their fear foods.  I find out what their “red” foods are – their biggest fear foods, their “yellow” foods are foods that are moderately anxiety provoking and their “green” foods – ones they eat regularly and don’t usually feel guilty about.  They’ve relayed their goals, their history and are comfortable in the room with me.  Once this stage has been set, we begin working towards their goals.  Often times, their goals include a desire to normalize their eating habits or to be able to eat in social situations without sinking into extreme guilt afterward.  When I see that the client is motivated and willing to take some risk in order to accomplish their goals, I present the idea of a challenge meal to them.  I let them know that sometimes I go out to eat with my clients in order to help them find normalcy around food and restaurants.  I ask if this is something they might be interested in trying.  If fear, other types of resistance or hesitancy comes up, we process that.  I may use Motivational Interviewing techniques in order to help them find benefit in pushing themselves towards their goal.

Preparation

Once the client has agreed to a challenge meal, I start with the easiest scenario first.  We start with green level foods and see if we can make a “normal” meal out of them.  So for example, if they’re regularly eating tuna fish, but eat it with vinegar instead of mayonnaise, and with vegetables instead of bread, we see if we can create something a bit more normal and a bit more challenging.  So I might suggest tuna with mayo on bread or if bread is too scary, perhaps we’d start with a cracker or tortilla.  During the preparation phase, I negotiate with the client and their eating disorder on what would be challenging yet doable. 

The goal is for the client to feel successful so that they desire to try again.  It’s like learning to lift weights at the gym, we start with lighter, easier weights until our body gets used to it and builds up to the heftier weights.  The first few challenge meals may be done in the office and the client may bring the food or the therapist may bring the food. 

Restaurants

When the client is ready to eat at a restaurant, we prepare by negotiating where they want to eat.  We also decide what we will say if we bump into anyone we know in order to keep their confidentiality.  Sometimes we agree to say we know each other from school or a friend or sometimes a parent’s friend.  I am very careful to speak quietly and refrain from any intervention when others’ could overhear.  I usually ask them if there’s a restaurant they’ve been wanting to try or if there’s a type of food they’d like to get support around.  Once we pick the restaurant, then we look at the menu.  When eating a challenge meal in a restaurant, depending on that particular client, we may decide what they will be ordering before we go to the restaurant or we might negotiate once we get there.  Depending on what would most ease the clients’ anxiety, we may do this right before going to the restaurant or the week before.  I wouldn’t want them to fret all week about what they’ll be eating, but sometimes it helps ease anxiety to get used to the idea and sit on it for a week.  Timing of this is at your and your clients’ discretion.  

Beginning the meal

If the challenge meal is in the office, begin the meal as soon as possible in order to leave the most time afterward to digest and process and reduce the risk and desire for a purge.  The client can use the bathroom before the meal begins so that they won’t need to use it for at least an hour after the meal. 

Ordering from a menu

If the food needs to be ordered in a restaurant, help the client decide what to order, ask if they’d like an appetizer or a side dish and assure them they will only need to eat an appropriate amount.  So if they get an appetizer and a main course, they might only eat half of each, depending on their satiety cues.  Eating a variety of foods is good practice to combat ED.  If they’re getting overwhelmed by the menu, help them to narrow it down by quietly reminding them of the original goal they had in mind.  For example, “well, when you chose this restaurant, you wanted pizza, so let’s stick with that – and you can get a vegetable to go with it and that will provide all the food groups: starch, fat, protein and veg.  So which type of pizza looks or sounds the most appetizing to you right now?”  This way they still have choice, but the overwhelming choices are paired down for them.  Pay attention to what they’re ordering to make sure it’s an appropriate meal.  If they’re ordering an appetizer only, be sure it includes all the food groups and possibly suggest they order 2 appetizers or have a roll with their appetizer to supplement their meal or they may just need an entre.  Salads are usually not an appropriate challenge meal, but a salad with a challenging appetizer may make sense.  Diet foods are not appropriate for challenge meals, so eliminate any diet drinks or egg whites, protein bars, etc.  Make sure the food YOU order is also not triggering to your client.  They are watching you.  If you order the same meal as them, it may make things easier on them.  When they have progressed further along, this may become part of the challenge – to tolerate your food item while they eat theirs. 

Hunger signals

Set the stage for the meal by activating the body signals that have been shut off for so long.  Ask the client on a scale of 0-10 with 0 being supremely starving and 10 being so stuffed they feel sick and unable to move – the most full they’ve ever felt in their life – what number are they at right now?  You can use a hunger cue card like the one shown here.

Identify their hunger signal and yours and if you’re in a group, have each member identify how hungry they are both emotionally and physically. 

Meal guidelines

The actual process of a challenge meal should not be emotionally heavy or food focused.  Try to steer the conversation away from inspecting or commenting on the food or body or fullness.  Instead, talk about lighter appropriate topics like the weather, the atmosphere in the room, how their day was, sports – a movie or TV show.  In a group, playing a game can be very helpful.  Some favorites are “contact” or thinking up famous peoples’ names in alphabetical order. 

Eating the meal should not take more than 30 minutes.  Sometimes clients will try to cut food into tiny pieces or take very small bites or eat very slowly.  This will require an intervening prompt from you.  Something like “please take normal bites” or “that’s cut small enough, let’s start the meal now” or “we’ve got 15 minutes left, please keep up the pace so we can finish the meal on time” are some prompts you might use.  It is our job to help them contain and combat their ED voice.  We state the prompt clearly, yet quietly so others’ don’t over-hear and we say it neutrally and without judgment.  If they’re still playing with their food and interventions aren’t working, I usually just let it be rather than getting into a struggle with them in public and process what happened later. 

If they’re getting an especially challenging meal and they’re anxious about it, I will suggest they can cut their meal in half and just start with the first half.  After the first half, we can check into hunger cues and see how they are with continuing.  I often tell clients that I believe it is more important that they feel successful in eating a challenge meal, but perhaps less of it, than eating too much and feeling overly full and triggered to purge.  This is true in an outpatient therapy setting.  Residential or partial hospitalization has more containment and ability to monitor clients after the meal, so that’s a different story.  But for my purposes, I don’t believe feeling overly full is in the client’s best interest. 

After the meal

Once the meal is complete, be sure to sit at the table for a while and discourage any bathroom use.  You can ask them how their meal was and how they feel emotionally.  Ask what the experience was like and if they’d get the same meal next time or if there’s something else they might like to try next time.  Focus on their success and offer any authentic praise for challenging themselves and their ED.  If they have some regret or guilt, help give them the words to combat the guilt internally.  Something like: “This is one meal, it was enjoyable and my body knows how to process it.” Or “I’m defeating ED one meal at a time.  I need food to nourish my body.  I am proud of myself for standing up to ED.”  Another favorite “this is what normal looks like.  People go out to eat and enjoy food and they’re okay so I can be okay too.”

The more exposure, the more the client will get used to eating food and eating it in challenging settings.  This helps lay the foundation for less social isolation and more ability to tolerate food and restaurants.  Really and truly, one meal at a time really does make a difference.  Supporting a client through a challenge meal shows them that they are capable and gives them a successful experience to remember when they’re ready to try it on their own. 

What have been your experiences with challenge meals?  Comment below.

If you want to learn more about challenge meals, I’d be happy to help.  Contact me at 610.314.8402 or TiffanySpilove@yahoo.com

Please comment below and tell us your story!

Dining Out ... With an Eating Disorder

I know, I know, it sounds TERRIFYING!  Yes, I'm serious - you will not die from eating food in a restaurant ... I PROMISE!  It might FEEL like you'll die, it might seem like you'll gain a hundred pounds just from eating the food that is cooked for you back in that kitchen you can't see.  

As my friend and colleague, Natalie says, "there aren't calorie ninja's back in the kitchen adding calories to your food"!  I understand the fear - I get that allowing somebody else to prepare your food is giving up control in a way that might not feel safe for you just yet.  Here's the rub, though - even though it might be hard to admit, I KNOW you want to be able to participate in experiences that involve food.  You WANT to be social.  You want to hang with your friends while they get frozen yogurt or try the food at the new cafe.  You want to live your life again... it's just that ED forbids it.  Here are some helpful tips for you to get more comfortable with dining out:

Practice

When you find yourself feeling fear about eating in a restaurant, it's sort of like a phobia - a very heightened anxiety around something specific.  The way to deal with and cure this type of phobia is through exposure - WITHOUT - re-traumatizing yourself.  So you don't want to push yourself to take it all on without practicing and getting comfortable with various aspects of it first.  

Use affirmations - they are wonderfully helpful ways to rewire your brain!

You might want to enlist the help of your therapist, friend or family member.  Tell them some food options that you consider safe.  Start small.  

It's better to have success with something less challenging than to get overwhelmed with something scarier.  

Your support team member could either get you food from a restaurant or give you food that they made without you present.  Or if you need to start even smaller, you could watch them make your meal so you know it's safe.  Eat with them.  Notice your feelings.  Use anxiety reduction and grounding techniques.  Keep breathing and do your best.  Keep practicing this step until your anxiety stays below a 7 on a 0-10 scale with 10 being the worst anxiety you've felt and 0 being no anxiety at all. 

Increase the challenge slowly

Once you get comfortable with eating meals made by others, up the ante.  If you're still not ready for restaurant dining, try getting take-out or try eating foods you didn't see being prepared.  Use an affirmation like "This food is safe and nourishing; I am safe and I can eat this food".  Make sure you start off each experience with some breathing and relaxing techniques so that you don't associate fear with the experience.

Dining Out

If noise bothers you, choose a restaurant that's quieter or a time of day that's less intense like lunch.  See if you can get a table that's against a wall, in a corner or in a quieter area of the restaurant.  This reduces over-stimulation and feelings of vulnerability.  

Have a plan

In earlier recovery, it's helpful to have a plan.  If you know which restaurant you'll be going to, look up their menu online.  Work with your therapist or dietician to determine which menu item you'll be selecting.  Most restaurants have portions that are significantly larger than the exchanges on your meal plan.  If this is the case, you could anticipate eating half the meal.  One tip is to ask for a to-go box at the beginning of the meal so that you can put half away for later and just focus on what's on your plate.  

Go with someone supportive

This experience is hard enough, don't add to it by going with someone who doesn't "get it" or tries to sabotage your recovery.  Some therapists or dietitians will conduct sessions at the restaurant with you so that you can talk through it as it's happening.  If that's not an option, or you're ready for the next step, choose a member of your support group who understands your recovery.  Let them know the plan beforehand and maybe come up with a code word in case you need to abandon the mission.

Remember to breathe

Keep taking those deep belly breaths and know that this is just one meal.  One meal won't make you fat.  If you notice yourself starting to get overwhelmed or anxious, just come back to your breath.  While you're eating, try to focus the conversation on something else like the weather, the new movie just out or anything fun.  Take a sip of water, feel your feet.  You got this!!

Do's and Don'ts:

Do:

• Keep the conversation light
• Have some topics in mind to talk about while you're eating
• Get the food down
• Chew thoroughly
• Focus on the conversation, the beautiful setting or anything but the food and body
• Wear comfortable clothes
• Stay at the table for the entirety of the meal
• Set your pace to about 30 minutes to complete your meal

Don't:

• Count the calories
• Compare your dish to anyone else's
• Body check while you're at the table
• Talk about food, weight, exercise or anything triggering while you're at the table

Keep your eye on the prize!

This experience is not just about today or next week.  You are engaging in this exercise so that you can enjoy your life - so that you can HAVE a life!  Spending all your time in isolation, feeling lonely, not participating in social events is no way to live.  Remember that you are doing this so that you can be happy and free of your eating disorder.  

One day at a time

One meal at a time

One bite at a time

You CAN recover!!  Recovery from an eating disorder is not a linear process.  It goes all over the place, it's messy at times and sometimes you need to take 5 steps backward so that you can get good 2 steps forwards.  Even one success is worth celebrating, so give yourself credit for EVERYTHING you do right.  

If you're still feeling anxious about dining out and you'd like some support, I'd be happy to schedule a time to help you reach your goals.  Contact me now at 610.314.8402 to learn more about how to dine out with an eating disorder.  Please feel free to share this post with anyone who is looking for help with eating and body issues.

Good luck and enjoy!!

If you have any questions or need support, please feel free to call me at 610.314.8402 for a free 15 minute phone consultation.

Please comment below and tell us your story!