Observations

The Fat Trap

2011-12-31T15:44:00.004-05:00

Just in time for New Year’s and New Year’s resolutions, Tara Parker-Pope has written a sobering article about weight and weight loss. In "The Fat Trap," published in the January 1 issue of The New York Times Magazine, she describes research on the difficulty of maintaining weight loss. Some key points: the body can go into “defense” mode to defend a higher weight, which is why lost weight can be so hard to maintain. In addition, weight loss is much more than simply a matter of willpower -- people lose and gain weight differently, based on body type, genetics and biology.

From the viewpoint of an individual wanting to lose weight, the article is discouraging, because it details how much work it takes to maintain significant weight loss (including daily exercise and careful monitoring of diet). The article, however, also strongly makes the case that being overweight or failing to lose weight is not a personal failing, but a result of a complex interplay of factors, some of which are beyond a person’s control. As Parker-Pope writes:

It is true that people who are overweight, including myself, get that way because they eat too many calories relative to what their bodies need. But a number of biological and genetic factors can play a role in determining exactly how much food is too much for any given individual. Clearly, weight loss is an intense struggle, one in which we are not fighting simply hunger or cravings for sweets, but our own bodies.

In my practice, I have found that many of my clients with weight-related issues.have harshly judged themselves for their inability to lose weight, or have been harshly judged by others. We are far too comfortable criticizing others’ weight or making value judgments about it. I hope this article contributes to more acceptance of different weights and sizes.

Can you be too fat to be President?

2011-10-03T21:49:00.011-04:00

There’s a new wrinkle in the 2012 presidential race: The idea that you can be too fat to be president.

The issue has gotten a lot of attention in recent weeks alongside discussion that New Jersey governor Chris Christie could be a viable candidate for the Republican presidential nomination. As speculation grows that he could enter the race, pundits are writing about his weight, and asserting that Christie is too fat to be president.

New York Times columnist Frank Bruni did his best Sunday to challenge the weight prejudice directed against Christie (who doesn’t talk about how much he weighs, but has referred to his long-running “struggle” with his weight).

We treat weight as if it is simply a matter of willpower, and equate thinness with virtue and weight with gluttony and slothfulness. Despite all the evidence that weight is much more complex than simple willpower, and is affected by many factors, including genetics, we continue to denigrate the overweight and to value thinness above all else. We act as if being thin is a sign of self-control, and being fat is a sign of no self-discipline. Bruni -- a former food critic for the Times and the author of Born Round, an excellent memoir revolving around eating -- writes that his thinness in college didn’t reflect self-control: “It reflected bulimia and laxatives,” he says.

Ironically, this focus on Christie’s weight occurred during the first Weight Stigma Awareness Week, an effort by the Binge Eating Disorder Association to make people aware of the stigma and discrimination that the overweight face. It’s a reminder of the importance of not making judgments about behavior based on weight.

Therapists in Therapy?

2011-09-17T13:58:00.005-04:00

Is being in therapy a mark of personal defect? Or is it an indicator of strength? Dr. Steven Reidbord, a California psychiatrist, explores this question in a recent blog post on Psychologytoday.com. Reidbord describes a patient who asked him whether he had been in therapy himself. Behind that question was the patient’s feeling that if his doctor had been in therapy it would mark him as deficient, since the patient himself felt deficient because he was in therapy with Reidbord.

Many people share this feeling. They believe that they must be defective if they are in treatment and can’t just deal with their problems on their own. If they are coming to therapy twice a week, instead of once, well then they must be twice as defective. I think about it the opposite way. Why struggle alone with something when you can get help with it and possibly master it? Dr. Reidbord writes that chefs go to restaurants where meals are cooked by other chefs. Lawyers often have their own lawyers. What is the problem with shrinks having their own shrinks?

I myself often compare the person who believes it’s better to solve a problem on his or her own to an injured runner who feels a sharp pain in his ankle but believes that no sports medicine specialist can help him. He continues to run or devises his own cure for the injury, figuring out a way to work around the problem. Often, though, he’ll end up re-injuring himself. And when he finally does go to the doctor, the problem is worse. I feel the same way about psychological pain that I do about a sports injury: Rather than suffer alone, I think it’s better to seek help in reducing pain and suffering. And it makes sense to me that a psychotherapist who feels that therapy helps his patients would recognize its value in his own life.

I found Dr. Reidbord’s words refreshing as he tries to destigmatize therapy and mental illness. Does acknowledging that there is a behavior or emotion that is troubling you and that you need help managing mean you’re defective? Hardly. It means you’re human.

Roots of Depression

2011-08-22T22:22:00.007-04:00

If you’re looking for the roots of depression, you may have to look further back in the past than you might think.

That’s an interesting takeaway from a recent study of 100 people who experienced depressive episodes as adults. As reported in The Atlantic, researchers found among those adults, people who had undergone trauma early in their lives were less resilient than people who had not. The people who had suffered early trauma (such as the loss of a parent) were more vulnerable to depression following later events involving interpersonal loss. And when they fell into depression as an adults, those episodes tended to be triggered by events that were less severe than those inducing depression in adults who hadn’t been hit by trauma in their youth.

The Atlantic reported these results as if one should be surprised that people’s lives as adults are affected by their early experiences. But in fact, researchers and practicing psychologists have long known about the importance of a person’s early experience in understanding their adult emotional life. Putting it bluntly, you don’t have to be Sigmund Freud to figure out that our childhood leaves an imprint on how we behave when we’re grown up. When people experience loss as children, the experience is often overwhelming; they commonly haven’t yet developed the emotional strength to overcome it. When another crisis comes along years later, it can be like having a new wound before the old one has entirely healed; people are more vulnerable to the next injury. Moreover, they may rely on whatever imperfect or faulty coping mechanisms they used as children -- behaviors that are no more effective than they were the first time around.

And yet, many people who experienced major emotional setbacks as children berate themselves, if, as adults, they are tipped into a depressive episode by a minor problem. They blame themselves for their emotional weakness. Their difficulties can be exacerbated by psychotherapists who minimize the significance of their past; while some psychologists (myself included) consider the past to be an important element (but by no means the only factor) in understanding people’s present behavior, others see little value in exploring the past. Perhaps more research like this will increase awareness about the past’s importance, enabling people to use it to address present-day issues more effectively.

Craving Fatty Foods

2011-07-16T17:52:00.004-04:00

A recent study at the University of California, Irvine may shed light on how deeply humans are attached to fatty foods.

In the study, reports The New York Times, rats that were given diets high in fat had an immediate reaction in their gut: They began producing chemicals similar to those produced by marijuana use, creating for the rats a further craving for additional fatty foods. When the rats were injected with a drug that blocked absorption of the marijuana-related chemicals, however, the animals lost their interest in fatty foods.

The experiment — which also found that rats didn’t have such a chemically triggered craving for sugar or protein — suggests that people, too, have a strong biological attraction to fatty foods. A similar chemical reaction in humans may affect how easily we can moderate our desire for, and consumption of, fatty foods.

We don’t know whether humans have exactly the same reaction to fat, but the experiment does encourage thinking about how people may be susceptible to eating certain kinds of food and why they might feel deprived by giving it up. The experiment also makes one wonder about the degree to which people might have different biologically based cravings for fatty foods. It’s very easy to judge other people on the basis of willpower, telling yourself that you can restrain your eating, so why can’t they? It’s equally easy to beat yourself up for finding it hard to change eating habits. Perhaps further research along the lines of this experiment will encourage a little less judgment of people’s character based on their weight and their eating habits.

Learning about Suicide Prevention

2011-05-19T23:03:00.006-04:00

When a person commits suicide, it’s common for loved ones to be left feeling a mixture of bewilderment and guilt. Why had she lost all hope? they ask. How come I wasn't able to stop her? What did I do wrong?

These are the questions that Jill Bialosky asks in her new memoir, History of a Suicide. The suicide at the heart of the book is that of her younger sister Kim, who took her life two decades ago at the age of 21. Bialosky, a poet and writer, embarks on a quest to investigate what led her sister to kill herself, and to understand how Kim, as she puts it “had arrived at the moment of resignation.” Jill also wants to alleviate some of her own guilt about not having been able to prevent it. It’s a very moving story.

The sisters, who grew up in the prosperous Cleveland suburb of Shaker Heights, had a painful childhood. Jill’s father died when she was three years old, leaving her mother, who herself suffered chronic depression, to raise her three daughters alone. Remarrying some years later, Jill’s mother gave birth to Kim when Jill was 10. But Kim’s father soon abandoned the family, leaving his wife for another woman.

Over the following years, the girls’ mother struggled to support the family through a series of low-paying jobs. Kim’s father reappeared only sporadically in his daughter’s life. And when he did, he could be cruel to Kim, telling her that she would never amount to anything in life.

In hindsight, Jill sees several points where it was clear that Kim was suffering deeply. One was when Kim, desperately unhappy and homesick at sleepaway camp one summer, ran away from camp and found a house where she called her mother and begged her to pick her up. Another pivotal moment when Kim, during her senior year in high school, had an abortion and soon afterward left school to get a GED. It’s hard not to read about these events without wondering about missed opportunities to help her.

Through her research about her sister’s life, through participating in a group for suicide survivors, and with the help of Edwin Schneidman, a psychologist who specializes in the study of suicide, Jill comes to accept that there was little she could have done to save Kim, who the family knew was depressed, but had no indication was suicidal. Her father’s abandonment, Schneidman says, left a wound and fragility in Kim that neither Jill nor others could heal.

That conclusion shouldn’t be interpreted as saying there is nothing one can do if, unlike the case with Kim, one is aware that a person is suicidal. As Bialosky points out in her book, people who feel like killing themselves may feel that way for only a short period of time. In her book, she questions Dr. Schneidman:

“Do you think she could have gotten through it had she gotten past that moment when she wanted to die and had felt hopeless? If she had maybe found a passion, finished school? If she had gone into therapy?” Those were the questions that had been eating away at me. “A lot of things had to happen,” he said. “But I wouldn’t be doing the work I do if I didn’t think it were possible.”“What should you do if you fear someone is suicidal?” I said.
“Dare to ask,”he said.

That, perhaps, is the book’s most important lesson.

Recovery from an Eating Disorder

2011-04-28T07:43:00.009-04:00

How do you know when you’ve recovered from an eating disorder? The answer is not so simple. The challenge of determining whether someone no longer has an illness such as anorexia or bulimia was explored in a recent New York Times article, “In Fighting Anorexia, Recovery is Elusive” by Abby Ellin. Often — and certainly by insurance companies — recovery is measured simply in terms of a physical condition: restoration of normal-range body weight and, in the case of women, menstruation. But eating disorders are more than just physical symptoms; they’re also a complex mix of sufferers’ thoughts and behaviors. People with anorexia or bulimia can reach a normal body weight yet still have the traits of someone with the disorder: They remain preoccupied with what they eat, restrict certain foods, and have severe body image problems.

Can someone whose weight is stable but who retains these other thoughts and behaviors really be considered fully recovered? I don’t think so. In the wake of the article’s publication, some eating-disorder professionals have commented that they felt the story’s tone was overly negative, leading to the impression that recovery from eating disorders is not possible. Some described patients as reacting to the article with a feeling of hopelessness. Others found it reasonable to anticipate the possibility of a return of eating disorder symptoms during a time of high stress. They agree with the comments of a doctor quoted in the article, Daniel Le Grange, who says he tells patients, “This is your Achilles’ heel.”

I myself did not find the article especially discouraging. When people leave a treatment for any kind of disorder, they often want to believe that they are done with the problem. They feel that any kind of recurrence or a return to therapy is a mark of failure. I disagree. It’s realistic to understand that in times of stress, people tend to fall back on old habits and coping strategies. The depressed person may be vulnerable to a recurrence of depression; the anxious person to a recurrence of anxiety symptoms. Similarly, people with a history of an eating disorder may find themselves returning to their old practice of restricting their calorie intake. But this does nothing to discount the value of all the intervening time in which they lived without their eating disorder. Anticipating a return to old habits, and using it as a signal for intervention, can be helpful and protective.

Mistakes: What We Can Learn from Them

2011-03-28T16:36:00.003-04:00

I generally regard mistakes as something I want to avoid. But a new book, Alina Tugend’s Better by Mistake: the Unexpected Benefits of Being Wrong, persuasively argues that making mistakes can have big psychological payoffs.

In her book, Tugend (she's also a columnist in The New York Times), takes an in-depth look at mistakes -- why we make them, and why we should try to learn from them rather than feel ashamed of them. One of the more interesting parts of Better by Mistake looks at the research of Carol Dweck, a psychologist at Stanford who studies how children react to mistakes, errors and imperfection. Dweck’s work was partially inspired by her sixth grade teacher, who seated kids in descending order, according to their IQ; kids who scored higher on IQ tests got greater privileges.

In her research, Dweck has found that when children are praised for their intelligence rather than for their effort, they are more fearful of making mistakes and less willing to take chances. But when they are praised for effort, or when they think being smart is a skill that they can work at, they try harder and aren’t as discouraged by their mistakes. In other words, it’s better to tell a child, “You worked really hard on that,” than it is to say, “You’re really smart.”

Jugglers are among the most inspirational people in their treatment of errors. If you watch jugglers performing, you will almost always see them goof up: They’ll drop a ball, a club or even a flaming stick. What’s great is how they incorporate the mistake into their performance and keep going. They’ll retrieve an errant ball and then start again; it’s no big deal, and it just seems like part of the act.

Many of us, on the other hand, come to a dead stop when we make mistakes. We berate ourselves, we get discouraged, or we’re filled with regret. We struggle with hindsight bias, in which we look back at a decision that we have made as if we had at the time all the relevant information that we learned only after we made our choice. An example Tugend uses is her father’s family’s decision to leave Germany in 1939. Looking back, knowing the result, it’s easy to say that they should have left the country sooner. But it wasn’t so obvious at the time.

This book got me to think a little more about mistakes, to try to take them less seriously, and to remember that there is not always one right answer out there that is the clearly best choice.

Thinking about the "Tiger Mother"

2011-02-05T17:54:00.014-05:00

Thanks to her new book Battle Hymn of the Tiger Mother,Yale professor Amy Chua has almost overnight become one of the most famous -- and infamous -- mothers in America. First excerpted, to wide attention, in The Wall Street Journal, her book argues that the Chinese approach toward childrearing is superior to that practiced in most American households. Chua contends that “Chinese” mothers (they don’t necessarily have to be Chinese, in her opinion, or even Asian) are unconflicted about pushing their children to achieve and feel no qualms about taking scorched-earth measures in the process -- insulting their children, for example, or meting out harsh punishment for underperformance. Western mothers, on the other hand, are more wishy-washy about achievement, are reluctant to push their children hard, and care too much about mushy concepts such as self-esteem and happiness.

It’s Chua’s belief that the Chinese way results in children who not only grow up to be high achievers, but are ultimately happier, because of their skills and achievements, than coddled Western-raised kids. Battle Hymn of the Tiger Mother is the story of Chua’s efforts to raise her two daughters, now 18 and 15, and mold them into academic and musical standouts.

Since almost everyone who has heard even a fragment of Chua’s argument has a strong opinion about it, I thought it couldn’t hurt to read the actual book itself. What struck me, after finishing Tiger Mother, was how incredibly lucky Chua is. Her daughters are clearly amazingly smart and musically talented. Every time she prods them into going for some big audition, they end up getting it or at least being told they have the potential to be superstars. I try to imagine the effect of this kind of parenting on a child who has learning issues, is tone deaf, or does not end up at the top of her class no matter how hard she tries. Kids need to feel accepted and valued for things other than their achievements.Yes, it is true that having high expectations for a child can empower her. But having insanely high expectations can be destructive and debilitating. I think that Chua overestimates how much of her daughters’ happy outcomes should be attributed to parental prodding and underestimates how much is due to their natural gifts. Because first she pushed and nagged her daughters and later they achieved things, she can believe that she was what made it happen. But there’s not necessarily a cause-and-effect relationship there.

I also found myself wondering about Amy Chua’s attitude towards food. She writes, “Chinese mothers can say to their daughters, ‘Hey fatty--lose some weight.’” I’m not sure why anyone would want to speak to their child like that. For one thing, if hearing derisive comments about obesity were all it took to motivate people to become thin, overweight people would disappear from America. And while some children might be toughened by parental insults, others are beaten down. But my further problem with her attitude is that I wonder whether this is another way that Chua -- a thin person, judging from recent photos -- is luckier than she realizes. She gets to attribute her frame to her self-discipline and self-control when in fact she may be naturally thin. Yes, there are things we can do to control our weight, but there are limits to that, just as there are limits to our intellectual, musical, and athletic capabilities. Part of the job of being a parent is to help a child grow and develop as well as she can, but also to be satisfied if she’s not the smartest, fastest or thinnest child in her class.

Healthy Eating

2011-01-09T21:39:00.002-05:00

For the last week, I’ve been following the blog Clean Plate by Ellen Tarlin, hosted on Slate. In her blog, Tarlin, a Slate writer, is documenting a 6-week effort to figure out how she can eat more sanely. Happily, the blog is not about losing weight or counting calories, but about eating healthfully without dieting. Each week has a theme; this past week, the blog's first, was devoted to figuring out how to sort through the immense amount of nutrition information available about our food. For the upcoming week, the theme is money and how much it costs to eat well.

It’s interesting to read about someone trying to figure out how to eat so that they feel better and feel healthier. One takeaway from the first week is how much more energetic she feels when eating regular meals, rather than going from coffee to chocolate to snack. At the same time, she’s noting some of the challenges: planning meals, shopping for food, lugging food around. But mainly it’s refreshing to see someone writing so much about everyday eating without also writing about calories, dieting, and weight loss.

Overcoming Procrastination

2010-10-14T22:05:00.004-04:00

Why do we put off unpleasant tasks, especially when we know that we’re going to have to do them anyway? Procrastination is a universal human behavior, and it’s one that makes no logical sense. If you delay an unavoidable action, you’re still going to have to do it anyway; all you gain is a mounting sense of frustration or worry as the undone responsibility haunts you. When you finally get around to completing whatever it is you’ve been dodging, the experience is either worse because you put it off or not as bad as you feared, making you wonder why you procrastinated in the first place.

In the October 11, 2010 issue of The New Yorker, James Surowiecki reviews The Thief of Time, a book of essays about procrastination written by economists, philosophers, and psychologists. He summarizes procrastination as a “complex mixture of weakness, ambition, and inner conflict.”

The weakness lies in the mismatch between our immediate desires and long-term goals. While we may have very laudable plans for the future (be fit, eat right, and live in a clean, uncluttered house, for example), these goals are often overriden by our short-term impulses. As we shift our attention to pleasures today, we mislead ourselves and pretend that we won’t feel just as avoidant tomorrow.

Ambition and perfection also lead us to procrastinate. Surowiecki writes about the Civil War general George McClellan, who delayed engaging in battle, convinced his army wasn’t perfectly positioned. The combination of lacking confidence in what we can do, coupled with high expectations can be paralyzing. Rather than taking action and risking failure, it can feel safer to embrace the fantasy that if we wait, whatever we do will be great. Meanwhile, nothing gets done. A painful portrait of this is the recent movie Greenberg, in which Ben Stiller plays a man in his 40s who turned down a record deal in his 20s because it wasn’t exactly what he wanted, torpedoing his career.

So how to combat procrastination? I think first we have to recognize that we have what Surowiecki describes as “competing selves” with conflicting goals, and which need to be tamed and managed (a familiar notion to anyone who has read a little Freud). We can acknowledge that our short- and long-term goals can conflict, and we can learn strategies for focusing on the long-term goals we’re tempted to avoid. These strategies include things like breaking things down into more manageable tasks, setting deadlines, and rewarding ourselves with pleasurable experiences for completing less-than-pleasurable jobs.

It’s also important to gain some better understanding of one’s feelings about the task being avoided. What makes it procrastination is that you are acting against what you rationally know to be your own self-interest. Understanding your motivations behind self-defeating behavior can help you overcome it.

Trauma and Memory

2010-08-01T20:46:00.004-04:00

People who are in therapy -- and a lot of people who aren’t -- often question the value of discussing traumatic events in their past. It happened, goes the argument. You can’t change it,so why talk about it? What’s the point? Well, a new book by a woman who spent years blocking out memories of her own trauma, then threw herself into an in-depth investigation of it, makes a convincing case for how helpful it can be to examine troubling events from one’s past.

Denial: a Memoir of Terror, by Jessica Stern, is the author’s account of her and her sister’s rape at gunpoint in 1973 and the aftermath of that crime. For years Stern -- who was 15 when she and her sister were attacked by a stranger -- didn’t talk about the event, nor did members of her family. And, judging from her achievements, she did not appear to suffer lasting psychological harm; she earned a doctorate in public policy from Harvard, wrote noteworthy books on the subject of international terrorism, and became a respected academic in her field.

But in fact, Stern was suffering from post-traumatic stress disorder, a condition most people associate with wartime experiences and battlefield violence. At times, she was nervous -- frightened by crowds or upset by the sound of a ticking clock. At other times, when as an adult she faced real danger (such as when she was the victim of an armed robbery) her reaction was to go into a trancelike state. She had difficulty maintaining relationships with the loved ones in her life.

At some point in her life, however, Stern decided to address her past head-on. She started by requesting the police file on her rape, for which no one had ever been arrested. She ended up researching the rape and its circumstances as thoroughly and as professionally as any of her books or articles. When a police officer subsequently re-investigated the rape and identified the likely perpetrator -- he was a serial rapist who had since committed suicide -- Stern researched the rapist’s life, speaking to his friends and interviewing another of his victims. She interviewed her father, too, whose emotionless response to the rape colored her experience of it; traveling at the time of his daughters’ assault, he didn’t cut his trip short to come home but waited three days until his previously scheduled return date.

Stern’s dissection of her traumatic experience -- via both this research project and psychotherapy -- ultimately made her life more satisfying, in several ways. She found she had a greater capacity to be in a romantic relationship. She was able to understand her father, a Holocaust survivor, in a way she never had before. And she was more conscious of how her ordeal had shaped her -- how she had developed the skill of functioning coolly under great pressure, such as when, as an adult, she was interviewing terrorists in the field.

In other words, Stern’s self-examination -- this dredging-up of a long-ignored nightmare from her past -- has enabled a richer life in the present. As she writes in her book (in the context of her relationship with her father), “I do not believe in ‘forgive and forget.’ To forgive in the truest sense, we must remember first and then forgive....”

Living up to your Potential--or Not

2010-07-14T21:16:00.003-04:00

What do you do when you don’t quite live up to the dreams you have for yourself? That’s the question that writer Abby Ellin tries to answer for herself in the current issue of Psychology Today. Ellin, the author of the book Teenage Waistland, describes her own feeling of inadequacy in comparison to Tina Fey, the creator and star of the TV show 30 Rock. Ellin is smart and funny, she tells herself, and it nags at her that Tina Fey is winning Emmys and she isn’t. This vague feeling that she isn’t living up to her own potential is what Ellin labels the Contender syndrome, a reference to the scene in On the Waterfront in which Marlon Brando says, “I coulda had class. I coulda been a contender.” That envy of what she thinks she could be doing, Ellin recognizes, gets in the way of her taking pride in what she has actually done, from writing her book to climbing Mt. Kilimanjaro.

How can you prevent yourself from feeling bad about your non-accomplishments? Being “self-referential” for one. This means using yourself as your reference point, rather than just looking at how you stack up next to someone else. If you think about how slowly you’re running compared to the other runners you see at the park, you might feel bad. But if you think about how much faster you can run than you did when you first took up the sport, you’re more likely to feel good about your performance.

Seeing the idea of potential as something you can affect helps, too. When kids feel that being “smart” is a static trait that comes naturally--not something they can work at and improve--they are less likely to try new and difficult tasks. Similarly, if you see yourself as having “potential” but don’t connect that potential with a task or goal you can work on, you likely won’t realize that potential yet will be more envious of people who do live up to their dreams.

It also helps to broaden your idea of success. If your only definition of success as an actor, for example, is to win an Academy Award, then your odds of reaching your goal are slim. If you can focus on what you’re doing, your enjoyment of the process, then you’re likely to feel good along the way--and feel less cheated by others’ success.

Don't Blame your Parents

2010-04-28T22:17:00.003-04:00

The recent death of Alice Miller, an influential European psychoanalyst, revives a question that has nagged people for decades, whether or not they’ve been in therapy: To what extent are our parents responsible for our own psychological problems?

Dr. Miller, in her book The Drama of the Gifted Child, spotlighted the effects of childhood abuse and trauma on people’s emotional development. The headline version of her work is this: Blame your parents for your psychological problems. It’s a pretty simple, powerful idea, and one that has taken root as a stereotype of what happens in psychotherapy: An adult patient and his or her therapist sit around talking about how the patient’s parents are at fault for the psychological problems the patient is facing.

But this isn’t true. The lesson that I and most other psychotherapists have drawn from Dr. Miller and others is that adults’ psychological problems can indeed be rooted in childhood trauma. If a patient comes in wanting to address self-defeating behaviors, one step of the therapy process is to understand where and how these behavior patterns developed. Some of that may be traced to a patient’s parents or to other circumstances of one’s early life. But exploring how something started isn’t the same as blaming. And what gets explored in psychotherapy isn’t just what other people did, but also how the patient reacted to that, understood it at the time, and interprets it now. In other words, other people’s actions are only one part of the puzzle.

Furthermore, re-examining long-ago events isn’t the point of psychotherapy; it’s just a step. The ultimate goal, if you’re in therapy, is to change your life now. Reflecting on how you understand and interpret your past can help you better see why you’re engaging in counterproductive behavior in the present. Do you find yourself fighting with your coworkers or bosses over and over again? Do you keep having the same unsatisfying and destructive relationships with romantic partners? If so, that’s not your parents’ fault. What it may be instead is your treating people today as if you were the same person you were when you were a child. The responsibility is on you to take your awareness of what drives your behavior and use that to change.

Therapy and the Internet

2010-04-03T17:22:00.004-04:00

Here’s one more arena in which Google has changed our lives: the process of psychotherapy.

How the internet can complicate the patient-therapist relationship is the subject of an interesting story by Dana Scarton that ran in The Washington Post this week. Scarton writes about the growing amount of information that patients can find about their therapist online -- and that therapists can find about their patients.

Googling your patient or therapist, or checking out the other’s Facebook page, if he/she has one, raises all sorts of issues relevant to the therapeutic relationship. The most significant, I think, is that the internet enables both the patient and therapist to learn all sorts of things about each other’s lives that they haven’t learned directly from the other.

I think it’s a bad idea for therapists to google their clients, and I don’t do it myself. I think it’s essential that my understanding of my clients be based on what they disclose during a therapy session. What patients tell me -- or don’t tell me -- about their lives, when they tell me, and how they tell me are all, in and of themselves, important things for us to talk about while helping them work out their problems. Researching a patient’s life online would put me in some awkward situations: If I don’t tell the patient what I’ve done, I end up with information about him or her that I know but can’t talk about. And if I do tell the patient what I’ve done, the patient may interpret my outside research as a sign that I don’t believe what he or she is telling me in person. Either way, my research would destroy the trust and honesty that are necessary for a productive therapist-client relationship.

I know that many people seeking therapy start by researching therapists online (I have my own website, after all). I also know that searching online for one’s friends and acquaintances is an inevitable part of modern-day life, and it’s a hard habit to break. If you’re a person googling your therapist while in treatment, I would suggest that you bring this up with your therapist. Searching online in this context is usually a reflection of a patient’s curiosity about the therapist and the therapist’s life. These questions and feelings can be extremely helpful when discussed in the course of therapy. What does a patient want to know about the therapist that he isn’t learning in therapy? Why does he want to know this? How does he think this knowledge will help him? Discussing these questions in therapy, and trying to answer them, can often give patients insight into their own problems and their relationships with people in their lives other than the therapist.

As a psychologist with a private practice, I think it’s important that I have a presence online; the challenge for me is to not be too online. But aside from my website and initial emails with potential clients, I try to keep my professional communications with clients on the phone or in person.

Attacking the Overweight

2010-03-16T06:28:00.008-04:00

Harriet Brown writes so articulately about the stigma and prejudice experienced by people who are overweight, it’s hard to say anything other than link to it. She highlights how well accepted it is to disparage the overweight, despite the increasing evidence that weight loss and regulation is not simply a matter of self-control and discipline. Unfortunately, doctors can be as guilty of this as anyone, routinely attributing health problems to weight without looking further. When people feel that disdain from their doctor, they are less likely to get consistent medical care or comply with their recommendations. For some reason, weight and fat remains one of the few areas where people feel free to disparage others. Surely, there must be ways to address issues of health and weight without also demeaning those who wrestle with it.

How Not to Talk About your Child's Weight

2010-02-07T22:17:00.006-05:00

This week, Michelle Obama, trying to promote efforts to combat obesity, described taking her kids to the pediatrician and being told that they were overweight. She also mentioned that President Obama had referred to one of their daughters as “chubby.” These remarks caused consternation among eating disorders professionals, because of their apparent overemphasis on weight and dieting, rather than on healthy eating and health in general. Too often, when people talk about the obesity epidemic, it sounds like an attack on the overweight.

There are better ways to promote healthful eating than to call a youngster “chubby.” Those who treat eating disorders strive to help their patients move away from dieting and strict rules about good and bad foods. They aim to help their patients be less rigidly focused on a number and a weight and instead aim for healthy behaviors. One of the challenges in treating people with eating disorders is when the culture at large supports exactly the same attitudes that get in the way of fighting an eating disorder. In this link, Laura Collins, the executive director of FEAST (Families Empowered and Supporting Treatment of Eating Disorders), writes about how some of the First Lady’s comments sound in the eating disorders world. In a later post, she also mentions speaking to a member of the First Lady’s staff and explaining these issues. It will be interesting to see if this will have any effect on the way Michelle Obama talks about her daughters’ eating habits in the future.

Making your New Year’s Resolutions Stick

2010-01-03T16:18:00.006-05:00

It’s a new year, which means that people are already making (and possibly breaking) their New Year’s resolutions. A useful article on Time.com takes advice from addiction experts on how to make your resolutions stick. What are the main points?

-Be honest with yourself about what you’re doing. If you’re trying to moderate your drinking and every time you plan to have 2 drinks, you end up having 5, then this should signal to you that your drinking may be more problematic than you’re acknowledging.

-Start out by trying to temporarily go cold turkey. For example, if your ultimate goal is to drink less, it might be easier to stop completely for a designated period of time rather than trying to taper off.

-Think before you act. Expect to get urges or cravings for whatever you’re trying to change. When you feel an urge, try to delay acting on it immediately. Try to reflect on the craving and think about the trigger. This may enable you to resist it better. The more you practice resisting or delaying giving in to cravings, the easier it will become.

-Give yourself a break. Be positive in your approach. Rewarding yourself for making a small change is far more effective than punishing yourself for not being able to do it. In fact, learning to tolerate imperfection in yourself may be the most useful change of all.

-Try to surround yourself with people who are doing what you want to be doing. It’s hard to stop smoking when you are only around smokers or to drink less when you mainly hang out in bars. It can be tough to change friends or to change the way you socialize, but it will make it easier for you to achieve your goals.

A last point (and this part is from me, not Time.com) is that change can be very hard. We all know what is good for us--eating right, exercising regularly, and not smoking, for example. Yet it can be very difficult to give up something that we know is not in our best interests. Be honest with yourself about what payoff you get from this habit you are trying to break. If you can’t acknowledge what you like about it--what it does for you, or the loss you will feel if you do give it up--it will be more challenging to achieve the change you want.

New Research About Handling Stress

2009-11-22T17:35:00.009-05:00

Two recent articles discussing studies of animals in stressful situations shed light on some valuable lessons about the role of stress in people’s lives.

In today’s New York Times Magazine, Gretchen Reynolds writes about an experiment in which two groups of rats ended up reacting differently to the same unpleasant situation. One group of rats exercised regularly for several weeks; the other group didn’t exercise at all. When both types of rats were exposed to stress -- specifically, forced to swim in cold water -- the brains of the exercising rats weren’t affected as negatively as those of the active rats. A related study indicated that, after an injection with chemicals designed to increase their stress level, active rats were less anxious than the idle ones. The studies support the idea that the physical stress of exercise helps the brain better handle emotional stress. But the payoff isn’t immediate. For rats, when it comes to seeing the benefits of exercise, the magic number is apparently between three and six weeks.

Meanwhile, in The Atlantic, David Dobbs writes about the insights of Stephen Suomi, a prominent researcher who has studied the emotional development of rhesus monkeys. Suomi has shown that when monkeys who are genetically handicapped in their ability to process a chemical in their brain known as serotonin -- a risk factor for anxiety and depression -- are raised as babies in poor environments, they grow up to process serotonin less efficiently as adults and are more likely to end up anxious and depressed. But when these genetically-handicapped monkeys are raised in ideal environments, they don’t just grow up to process serotonin efficiently; they do it more efficiently than those monkeys without the initial deficit. Monkeys who thrive despite this genetic weakness may in fact be more likely to prosper than your average monkey.

What does this mean for humans? Suomi’s research with monkeys is relevant to the study of what are sometimes known as “orchid children” -- children who possess gene variants that increase their susceptibility to problems such as depression, anxiety, and attention-deficit hyperactivity disorder. Given a stressful or abusive childhood, these kids are more likely to suffer negative consequences (versus “dandelion kids” who can pretty much thrive anywhere). But the article suggests that if these orchid children are raised in a more favorable environment, then these genetic variants can contribute to enhanced functioning. In short, what has usually been seen only as a liability can, under the right circumstances, be a strength.

As for the stressed-out rat experiments, it adds to a growing body of research indicating that exercise helps not only our physical health, but our mental health as well. As is the case with the rats in these studies, these stress-reducing benefits aren’t immediate. But there’s one important difference between people and the lab rats: Unlike the rats, no scientists are forcing us to exercise. People, unlike rats, need their own motivation. To reap enrichment from an exercise routine, they have to overcome inertia and push themselves to do something they might find unpleasant initially. But if they can stay the course until they start enjoying the returns, it’s worth it.

Positive Psychology Has Its Limits

2009-11-02T21:28:00.009-05:00

Last week, I read the book Bright-Sided: How the Relentless Promotion of Positive Thinking has Undermined America, by Barbara Ehrenreich. What got me interested was hearing a radio interview in which the author, who was diagnosed with breast cancer several years ago, talked about her reaction to the breast cancer culture she encountered during her treatment. Cancer was a gift, people would say. It’s the best thing that ever happened to me.

Ehrenreich wasn’t soothed by the cheeriness that people had in reaction to their cancer, and that they expected from her. Rather, this relentless focus on maintaining a positive attitude felt stifling to her. And when she expressed anger about her diagnosis, about the effects of chemotherapy, and about the frustrations of dealing with her insurance company, people responded by suggesting that she was too angry. Run, don’t walk, someone told her, to some counseling.

Ehrenreich points out that certain assertions that are often accepted as truth -- such that a positive attitude lessens your chances of getting cancer and improves your chances of surviving it -- are actually simplifications of the relevant research. While stress can weaken your immune system, that doesn’t mean that if you’re stressed, you’re more likely to get cancer. Similarly, while therapy and support groups may be good for people's emotional health, therapy, or support groups won't extend their lives. The problem, Ehrenreich points out, is that sometimes this research trickles down in such a way that people end up blaming themselves unnecessarily for their illness or for their inability to prevent its spread.

Another part of the book addresses the spread of positive psychology, a relatively new area of psychology that focuses on the study of positive emotions, happiness, and resilience. In her view, this research, along with some other New Age ideas, is being misused to foster the belief that what happens to us is our fault. For example, rather than focus on systemic issues (such as income inequality or a crumbling economy) as reasons why you lost your job, these disciplines focus on attributing what happens to you on internal, individual characteristics, and essentially blame the victim for what happens to him or her.

It’s an interesting argument that relates to the tension in people's lives between denial of reality on the one hand and debilitating, excessive pessimism on the other. If you have breast cancer, being told that your anger and sadness about the cancer is going to make it worse would most likely fill you with both rage and guilt. At the same time, if all you can think about is what is out of your control, it will be difficult to work to change anything about your situation. Sometimes, it’s important not to minimize the bad, or sad things that happen to us, or that we feel. You can recognize them and acknowledge them in a way that enables you to move forward.

Anxiety Disorders Are Treatable

2009-10-03T22:19:00.008-04:00

Are some people destined to suffer anxiety as adults? That’s one of the questions explored in an interesting article in the October 4 issue of The New York Times Magazine. The story focuses on the work of Jerome Kagan, a developmental psychologist who has studied how children adapt to new situations. In his work, he found that some babies had a particularly negative reaction to unfamiliar stimuli. These babies, it turned out, were more likely to develop into anxious or fearful children. As they reached adolescence and adulthood, their anxiety dropped somewhat and they functioned seemingly well -- making friends, for example, and getting good grades. But more so than other children, they reported a lot of anxiety and nerves.

These subjects are among the people that Kagan and other researchers have identified as responding intensely to new stimuli and stressful situations. They’re known as “high reactives.” Physically, this is reflected in MRI scans of their brains, as well as through a higher heart rate and faster breathing.

But being anxious by temperament does not always correlate how people function in the world. Someone who starts out as a “high reactive” may grow up in a family that helps him or her manage anxiety constructively. Someone else of similar temperament, however, may have experiences that reinforce a predisposition toward anxiety and may end up with an anxiety disorder.

In addition, being anxious by temperament may not always be such a bad thing. Too much anxiety can paralyze you, but having some anxiety can be helpful. It can motivate us to accomplish something that we need to do. It can help us to consider the consequences of a particular course of action that we think of taking.

The message of the Times article is that anxiety is complex, and not necessarily the life sentence that some people think it is. Sometimes people who start therapy will describe themselves as having a “chemical imbalance.” That’s often shorthand for believing that they are born with whatever symptom they are describing and that their temperament has nothing to do with the way they grew up or have learned to cope with their emotions. It’s also shorthand for believing that there is nothing that they can do about their problem other than take medication. But I am more hopeful about the possibility of change. There is a lot we can do to understand ourselves and the way we think, and to modify those ways of thinking so that they are not so debilitating.

An Unhelpful Attitude About Dieting

2009-06-17T21:48:00.009-04:00

The New York Times this week ran a fascinating story related to food and eating, one that has provoked some strong opinions on the paper’s web site. The subject of the article is MeMe Roth, a Manhattan woman who has clashed with administrators at her children’s public elementary school. Ms. Roth, reports the Times, strongly objects to the sugary snacks and baked goods that her kids and others have been offered at school, such as the cupcakes that parents bring into class for birthday celebrations. “I thought I was sending my kid to P.S. 9, not Chuck E. Cheese,” the Times quotes her as saying.

It is true that it is tough for kids to make healthy choices when they are constantly exposed to sweets. It’s tough for adults, too, to make those healthy choices if their own refrigerator is packed with ice cream and cake. Reducing children’s exposure to junk food makes it easier for kids to avoid eating it.

But in trying to eradicate all traces of snacks and sweets from a child’s (or adult’s life), a person can go too far. By going to extremes in making a diet healthy for oneself or someone else, one can end up perpetuating an eating disorder that can be just as harmful as a steady diet of Tootsie Rolls.

One unhelpful approach is to categorize foods as good or bad. A cupcake by itself, for example, is not intrinsically evil. But if it is demonized and taboo--think of the tree in the Garden of Eden-- it becomes more seductive and desirable. In the likely event that a person eventually does yield to temptation and eat the forbidden fruit (or junk food), he or she ends up feeling terrible and guilt-ridden -- and, feeling defeated, keeps on eating. A key goal in working with people with eating disorders is to help them prevent one slip from turning into a binge. And one way to do that is to stop demonizing certain kinds of food.

Another unhelpful approach is to fast for long periods during the day. Often, people with eating disorders will eat little during the day -- letting themselves get extremely hungry -- and then binge at night. Feeling horrible and guilty, they decide to start dieting the next day -- and begin the cycle anew. So part of treating people with eating disorders is to help them get comfortable with eating regularly, to not let themselves get too hungry and to move away from dieting and deprivation.

For people with food and weight issues, it is not easy to navigate all the external cues and social pressures to eat. At the same time, outlawing fat and food are hardly the way to help.

How Perfectionism Can Help or Hurt Your Life

2009-05-28T12:03:00.001-04:00

When I was growing up, my father would often joke about how when he was a child and brought home a test from school on which he had scored a 98: His father, my father told me, would ask him, half-seriously, “What happened with the other two points?”

I didn’t think much of my father’s story, other than to associate it with my grandfather’s expectations of good grades and high achievement—expectations which he also had for his grandchildren. But in recent years, I have heard similar stories from many different patients—people from a variety of ethnic and socioeconomic backgrounds. When people tell me that they remember parents saying this to them about their schoolwork, it often turns out that these people have high standards and expectations for themselves as adults.

Despite being accomplished and successful, they frequently wish they’d done more in their career or feel disappointed with their achievements.

So I was interested to read a recent New York Times profile of Peter Orszag, the new White House budget director and, at 40, the youngest member of the President’s cabinet. In the article, he talked about his work ethic:

Orszag, who grew up in Lexington, Mass., has always worked himself punishingly hard—a legacy, he says, from a math-professor father who glanced at test scores of 98 and asked about the 2 other points. “It was always, ‘When I was your age, I was a tenured professor,’ ” he said.

For some people, extremely high expectations spur them on to high achievement. For others, it demoralizes them; no matter how well they do, they feel they have fallen short. Not everyone has been as successful in the workplace as Peter Orszag, and for most of us, there will always be someone out there who is doing more or doing better. The challenge is learning how to work hard and strive for goals—but rather than measuring yourself against perfection or superachievers, setting your own goals and learning how to take satisfaction from reaching them.

Obesity Prejudice in the News

2009-05-14T11:16:00.001-04:00

Recently, colleagues on an eating-disorder message board were discussing the value of using weight-loss drugs to help reduce people's weight. (The consensus: There is very little evidence that the drugs lead to meaningful, sustainable weight loss.)

The discussion raised the question of how we see weight. Is being overweight and having a high body-mass index immediately indicative of health problems? Or is a high BMI one of several indicators of poor health? Not everyone who is overweight is unhealthy, and not everyone who is of normal weight is healthy. As one person on the mailing list put it, when we automatically consider someone with a high BMI to be unhealthy, it's as if we are saying that tall people are at a greater risk of medical problems—and then jumping to the conclusion that tallness itself is the disease we need to treat.

Soon after this discussion, I came across the following article on The Daily Beast [http://www.thedailybeast.com/blogs-and-stories/2009-05-04/fat-judges-need-not-apply/] about the candidates for the Supreme Court replacement for David Souter. The article suggests that some Democrats—who want Obama's appointments to be on the court for as long as possible—are using weight and thinness as a proxy for health and longevity. In this case, they prefer thinner candidates, such as Diane Wood and Kim McLane Wardlaw over the heavier ones, Elena Kagan and Sonia Sotomayor. Their belief is that because Kagan and Sotomayor are heavier, they are less healthy and likely to die younger. (Although not slim, neither woman is obese.)

This is a widely held view—that thin equals good and healthy and that fat equals bad, unhealthy and likely to die an early death. Yes, it is true that, on average, obesity is associated with a higher risk of death. But that doesn't mean that any given thin person will outlive someone who is heavier.

What I actually see in this particular Supreme Court debate is a weight prejudice doctored up as a health concern. Underneath the seeming concern about longevity is the dismissal of two women who do not completely fit social expectations for appearance.