Author: T. O. Paul Harper, PhD

SUPPORTING NEW BELIEFS, EMOTIONS AND BEHAVIORS

“Cindy (name has been changed) was seventeen but looked more like twelve. She was pretty, smart, athletic and a twin. She was talkative and open in session, but painfully shy around other young people. She was afraid of other people, deeply depressed, and suicidal. She had just been admitted to her fifth inpatient stay. She was behind in school, didn’t have a driver’s license, was jealous of her twin sister who was playing soccer in college. Cindy compulsively compared herself to others and always concluded she was defective. She had recently been sent to a transitional program to help her recover from her eating disorder and after sensing she wasn’t like the other girls her age she became so depressed she considered taking her life and completely reverted to her dependency on her eating disorder.”

An eating disorder comes into an individual’s life because she has powerful and painful emotions that the eating disorder behaviors nullify, mask and cover up. The individual turns to the eating disorder behaviors because they are easy to learn and because they work to numb out or distract her from the painful and powerful feeling they carry. The seemingly innocuous eating disorder behaviors eventually take over its victim’s life, often reaching the status of a separate psychological problem. One of the reasons deep painful feelings are felt by individuals is because they do not know how to adequately deal with events and situations that evoke the painful and powerful emotions in healthy ways. One could say they lacked adequate life skills. And to be fair to an individual suffering with the terrible effects of the eating disorder, perhaps those they associated with and depended on also did not have adequate life skills and could not help the sufferer to learn to deal with these overwhelming problems. Mental health involves the effective utilization of thoughts and behaviors (life-skills) to meet life challenges and accomplish life goals. The purpose of this article is to explore the need and value of life skills as a support to the treatment of eating disorders and to share suggestions on how to utilize life skills training to support and augment eating disorder treatment and recovery.

People eliminate the need for destructive coping mechanisms such as an eating disorder if they have certain coping skills available for their use in their daily life. These skills are many and include the ability to express what is happening in their lives, confidence in going to others in healthy interpersonal interaction, the ability to share what they are feeling with people they trust, the ability to find people who are trusting, the ability to solve basic problems and feel confident in doing so, the ability to make friends and to be a friend, the ability to get their needs for affection and association met, the ability to sense information needs and to be proactive in uncovering information, the ability to be flexible and to set goals but to also be able to amend them as needed, the ability to think critically and to control thoughts, the ability to set healthy boundaries, the ability to have a healthy realistic sense of self, and many others. With such abilities, individuals are able to change distorted beliefs, make appropriate life changes, seek out good advice and help, and to quickly bounce back from fears and failures and avoid the negative build up of overwhelming and over powering doubts and fears.

CASE STUDY

Life Skills are important to healthy living. They help us meet challenges, process difficult issues, put events and information into perspective and effectively deal with difficult emotions. Without life skills it is possible for individuals to feel they are different from others. They can see that others seem to be dealing with difficult life challenges and wonder why they have such a difficult time. They feel out of step and out of touch with their peers. They lose their sense of equilibrium and feel confused, overwhelmed and awkward. They start to shy away from others and want to hide to avoid the pain that comes from feeling like others are staring at them.

Without adequate life skills an individual may come to the conclusion that a patient, Cindy, came to in her life. During one of our first visits she made the statement that “I will just be different than others all my life!” She had obviously resigned herself to the belief that she was different and would always be different than her peers out in the normal world. My patient was beautiful, intelligent, and very talented in sports and art. She was soon to be turning 18, but felt way out of step with her peers and even felt cheated in life. I tried to reassure her that she had not been born with some defective gene that castigated her to being some freak of nature. I tried to help her realize that she didn’t have to be different for the rest of her life. My initial attempts to persuade her didn’t impact her at all as she had been reinforced in her beliefs by the fact that this was her fifth stay in a treatment center. In addition, she was very behind in her academic program in school, despite her intelligence. She didn’t have her driver’s license, she had very little experience and skills interacting with the opposite sex, and she had little experience in living in the “real world” as she would say. “I don’t know how to keep a check book, manage my money or live on my own,” She would respond. In addition, she had little faith in her ability to have a healthy relationship with food. Part of this was due to the fact that whenever she was reminded that she lagged so far behind what her peers already had learned and were doing, she would want to run to what she had used for so long to numb her pain, which was her eating disorder. It became very obvious that in order for this young patient to recover from her eating disorder that her treatment would need to include lots of life skills training. She would need to complete her high school education and either graduate or get her GED, get a driver’s license, be able to express her talents, learn to interact with peers in healthy ways, and especially believe that she didn’t have to be different than others for the rest of her life. In addition, my patient would need to develop personal confidence in these skills. These skill-based competencies would in turn help her turn away from her negative coping skills of the eating disorder.

The eating disorder, and being sick with the eating disorder, depression and related problems allowed her to not have to be up-to-date with her peers. Without the eating disorder she no longer had an excuse to lag behind her peers in academic and social progress. Thus as long as she felt different than others and could see no way to avoid being different she had a powerful reinforcement to stay sick with the eating disorder and to even escalate the behaviors. Indeed in her past treatment stays, when the time came for her to leave treatment she would often sabotage the treatment and manipulate the situation in a way that would show she was still sick and couldn’t deal with her life. This pattern exasperated her family and especially her insurance providers. The insurance considered her incurable years before coming to Center For Change and it was through her mother’s efforts that the insurance company agreed to continue to pay for her treatment until she turned 18. In addition to clinical therapy we were able to help the patient learn new social skills, examine her past dysfunctional and manipulative behaviors and initiate new strategies, complete her academic and educational program, get her drivers license and even help her to express some of her sport and artistic talents while in treatment. She gained confidence in her ability to interact and deal with others and learned to have a healthy relationship with food in the process. In essence, she left Center for Change no longer believing that she would be different from others for the rest of her life. The patient still has struggles but has lived without an eating disorder for over a year, is working and volunteering in her community, is interacting with friends and peers, is able to deal with the stresses and strains of society without her eating disorder or without the manipulation tactics utilized in the past and is planning to attend college this new school year. In short, she is growing in her successfulness in the world and is competing with her peers in positive and healthy ways.

USING LIFE SKILLS IN TREATMENT

Life skills can be used in a variety of ways to help augment treatment and reinforce the new beliefs, emotions, and behaviors taught in therapy. Effective life skill classes can teach patients how to best take advantage of treatment as well as help them develop skills that reinforce their desire to utilize the new beliefs, emotions and behaviors developed in therapy. The skills that support healthy living also support the skills taught in therapy. Life skills can aid treatment in the following ways.

1) Helping Patients Be Motivated For Treatment.

Some patients are forced into therapy and come with an attitude of not wanting to be helped. Such patients are nearly impossible to engage in therapeutic work and subsequent changes in behavior until they develop a motivation for therapy and the changes it can bring. Life skills education can help to give a stubborn and unmotivated patient a vision of what life can be without an eating disorder. A patient can be introduced to case studies and illustrations of how an eating disorder affected an individual in the past and what life can be like without an eating disorder. A patient can be introduced to testimonials and personal stories about recovery and the positive effects of eliminating an eating disorder to reinforce what can be and evoke a sense of the possible in stubborn patients. Often one’s lack of faith in change comes from an inability to see what can be in the future. Methods of helping an individual learn how to develop a vision of a healthy future and develop a proactive and empowered belief in their ability to enact change in their lives can help an individual increase motivation for change.

2) Educating Patients on How to Take Advantage of Treatment.

Individuals come to treatment with various levels of fears and misunderstanding about the therapy process and what it means. A great deal of stigma exists in our society about treatment. Through the proper use of life skills education at the initial stages of clinical treatment a patient can learn to overcome fears about treatment and be taught how to actually take full advantage of the therapeutic process. Life skills at this initial stage would involve education about what treatment means and what is involved in the therapeutic process. Patients can also be taught about honesty. Some patients have been dishonest for so long, telling others only what they believe others want to hear, that they don’t know how to be honest. Helping patient understand what it means to be honest and how and when to share their feelings and beliefs will greatly benefit the effectiveness of the work done with the therapist and others who are involved with the patient’s care. Education on trust will also benefit the patient. Many patients have difficulty trusting others, especially those requesting sensitive and intimate information. Helping patients understand how they lose the ability to trust and how that impacts their behaviors can help them be more open to building confidence in their treatment team. Giving patients basic information about the treatment process and how and where they can go for assistance will help the patients feel more comfortable with treatment. These examples are a few of the many kinds of therapeutic life skills that can be taught to patients starting intensive treatment.

3) Helping Patients Respond To Therapeutic Interventions.

The new insights, beliefs, emotions and behaviors an individual gains in therapy need to be reinforced in a patient’s life. This process of reinforcement involves utilizing the insights, emotions, and behaviors in increasingly more difficult situations. The confidence a patient has in their ability to deal with and rebound from difficult situations directly affects a patient’s willingness to test out new beliefs, emotions, and behaviors in new situations. Certain basic skills are necessary for effective experiential education of therapeutic insights. Communication skills, interpersonal interaction skills, developing a healthy perspective skills, basic sleep and physical health skills, and a whole host of other skills increase a patient’s belief in their ability to experiment and risk with new ways of being in their social settings and still maintain a stable and adequate sense of self.

4) Helping Patients Learn That They Are Not and Do Not Have To Be Different Than Others.

Although this has been discussed in the case study, it is important to emphasize this concept. If an individual is self-conscious it is a painful feeling and an individual will usually utilize evasive and withdrawing behaviors to avoid the feeling. Having a general belief that one is different accompanied with a helplessness about changing what is different will result in a patient feeling constantly on stage and self-conscious. These feelings will most likely block healthy therapeutic changes the individual needs to make because of the fear that comes from new, vulnerable or threatening situations. They will want to invest more time in control of their environment than to introduce new choices with unpredictable outcomes. On the other hand, if the patient feels confident in their ability to interact with others and confident in their ability to protect themselves from the unpredictable results in social situations they will be more willing to take risks. Life skills education can enhance a patient’s skill and confidence in their social and self-protective skills. These skills can enhance a patient’s awareness of how all people struggle in social situations, but utilize skills to keep them grounded and protected. Patients will be more able to compete and get needs met in our competitive world and feel more like everyone else. They won’t feel like they have to be different or that they are stuck being different from others.

5) Help Patients Maintain Healthy Behaviors After Treatment.

Perhaps the most crucial time in a patient,s recovery is the six to twelve months after she gets out of a treatment center. This is where the therapeutic rubber hits the road, when the patient must take on their shoulders the responsibility of maintaining their new beliefs, emotions, and behaviors discovered and initially practiced in treatment. Life skills classes can help to prepare a patient for the onslaught of triggers that she will face in the real world. Patients can be prepared for the disparity between the safety of the treatment center and the stark lack of emotional support often encountered in our daily routines. Patients can also be taught how to develop realistic expectations for their ongoing recovery processes and how to define and give meaning to occasional slips and relapses in behavior, i.e. how to guard against the “what the hell effect,” and to guard against setting black and white or perfectionistic behavioral and recovery goals. Educating patients about relapse prevention and how to develop strategies to counter triggers will sharpen their self-monitoring skills and help them to stay on guard. Helping patients recognize the tendency for individuals to get lax and let their guard down from time to time will help the patient plan for effective recovery. Life skills classes can also help to educate a patient to assess when her healthy recovery will require her to change her unhealthy environment and have the assertiveness to do so. One of the most important skills to promote healthy ongoing recovery involves knowing how to find healthy people to associate with and have the confidence in their skills of making new friends of both sexes. The ability to feel one knows how to find a loving significant other and to have the skill to express their opinion and be safe in that relationship, may be the most important skill of all to help one recover from a need for the use of a negative coping mechanism such as an eating disorder. Finally, effective life skills will help recovering patients maintain flexibility as they encounter life’s challenges.

6) Help to Train a Patient’s Support Team.

Life skill education can be utilized to help a patient build an effective support team for themselves after treatment. Patients must be able to select and request the help of a team of individuals that will be effective in helping them stay on track and maintaining healthy behaviors. These individuals will have to be carefully selected by the patient, with the help of her therapist, for her unique situation and needs, and can include parents, siblings, other extended family members, friends, therapists, doctors, dieticians, other treatment team members, religious leaders, counselors and other important people in their lives. Support team members can be taught how to effectively interact, encourage and gently prod a patient along on their recovery journey. Teaching a patient’s support team basic skills in learning to develop a trusting communication environment, how to not be a food police, how to support a patient without overwhelming them, how to know when to offer help and when to back away and when to gently but persistently insist on intervening, and knowing what to do in the case of an emergency and other similar skills will be one of the best investments in the patient’s ongoing recovery. The patient’s therapist can help, but the bulk of the responsibility for training the support team will be on the patient and it will be important to make sure the patient has skills necessary to do this task.

CONFIDENCE TO BE DIFFERENT

The positive experience of confidence in being unique and different as a person while sharing the similarities of all other people around them is a powerful shift toward self acceptance. Improved life skills increases a patient’s sense of self in relation to others but, more importantly, they increase their confidence and trust in themselves. This confidence and trust becomes the foundation for not only the recovery from the use of negative coping mechanisms, but also for the ongoing process of discovery of one’s unique talents and purposes for life. With such positive discoveries will also come an increased desire to share of oneself with others, to live a fulfilled and abundant life and to seek for and experience the satisfaction that comes from such a life. The reality of our lives is that we are unique and different from others. Our life skills play a role in helping us either to discover how to express our differences in healthy and productive ways or to discover ways to hide ourselves from the pain of being different from others.

Cindy has learned to be confident in her differences. Cindy is a beautifully unique human being. She now can be comfortable with this knowledge and can even feel to express her individuality, because of basic life skills that help her recognize how to connect with others in her uniqueness. She is more confident in her ability to compete with others, express her desires, wants, and beliefs, and protect herself from situation that at one time felt out of her control. In essence she has developed a set of life skills that help her to be different in healthy ways and not different in unhealthy ways. Life skills education has been invaluable in her recovery process and should be an important part of the treatment process for individuals recovering from illnesses that made them feel different and insecure in their worlds.