Steve Bryson

I have in the past blogged a bit about eating disorders. Now I would like to climb on a soap box because I have had yet another mishandled client with an eating disorder. I don’t know if others would refer to me as an expert in the field of eating disorder treatment, but I do feel pretty conversant on the subject, and try to keep up with research (lets hear it for Pubmed). I am also aware that there sems to be some disagreement about the correct ways to treat these conditions. Few of us would disagree that the all too common E.R. intervention is unhelpful: “What is your problem? Are you so vain, so in love with your reflection that you would purposely do this to your family?” (actual quote from an E.R. physician).

There are some people doing great research and publishing very helpful articles and books on outcome-based comparative studies. Craig Johnson, Chris Fairburn, Jim Mitchell etc are making valuable contributions in the areas of cognitive behavioral and dialectical behavioral therapy with eating disorders. Similarly, scientific refeeding regimens are now statndardized and most treatment centers apply this knowledge. But there are two notable omissions that I think show the very provincial stick in the mud culture of too many in academia as well as on the ground. First, there is ample proof that the genesis of eating disorders is from distinct genetic markers, or as Craig Johnson says: genetics is the gun, society is the trigger. And yet I still see centers advertising as an “addiction and eating disorders treatment center” (Fairburn has debunked that). When questioned they say to me they all have individualized treatment plans, but how would one surmise the treatment would proceed if it was advertised as a such, or as a childhood trauma and eating disorders treatment center? Second, other centers advertise in such ways as to imply that their focus is anxiety, personality disorders, ODD, spirituality etc. Now, co-morbidity statistics with depression and anxiety spectum disorders are well published, but the percentages vary so wildly as to leave uncertainty.

As I said in that previous blog, the professional community is notoriously slow in accepting new knowledge, as shown in the infamous “limeys”: British sailors who knew that eating limes prevented scurvy 60 years before the medical establishment accepted that. So preconcieved notions, prejudice and demagoguery seem to be hurting the advance of treatment.

Now for the two pieces of credible research that are being ignored. First, the eating disorders treatment program at the prestigious Karolinska Institute in Stockholm, Sweden has for two decades produced a 96% recovery rate with eating disorders following the premise that these disorders are neuroendocrine in nature. Their treatment is a 6 month regimen of supported refeeding with little else but housing and socio-educational classes. The vast majority of comorbid symptoms disappear as the regular eating patterns and renourishment progresses. They use a unique technological tool they coin a Mandometer which is essentially a Blackberry that works as a neurofeedback device to advise and support healthy eating (see their web site). They have published some compelling research, have a huge ‘n’, and the best success rate anywhere. Yet I only get disdain when I talk to experts in the U.S. Their complaints are that the Mandometer is patented and must be purchased to be utilized. While some would condemn being so prorietary, it seems little different from the pharmaceutical companies, and these same detractors seldom refuse to use newer, proven psychotropic medications just because the drug company is making a mint off of it.

The second oversight involves the now well accepted data that eating disorders are genetic in nature. From an evolutionary psychology perspective, it is questioned why such disorders would be existant, seeing the high morbidity and mortality rates. One researcher/theorist who has tackled this with a rigorous eye for validity has postulated that this is an artifact from primitive days when periods of feast and famine were common occurrances. In those cultures, starvation was a common cause of mortality. When most people are starving, they have little energy, and just give up and die. But studies of aboriginal cultures have shown a curious thing: a subset, of mostly young women, get more energetic, more driven and in oral traditions led the tribe to food. This has been termed “adapted to flee famine”. This is not the place to review all the detatils of how this was derived, but I can tell you that when this theory is told to a new patient with an eating disorder, their shame and denial diminish and compliance soars. So this narrative could offer an important window of opportunity to help those in need who are essentially hormonally impaired. And yet it is little known though relatively well published. Those of you interested can Google Dr. Shan Guisinger or “Adapted To Flee Famine Hypothesis”.

Are we being lazy; are we being provincial? Or am I missing something?

Steve Bryson is a counselor in private practice in Whitefish, Montana and a registered nurse. He works with adolescents and adults, couples and families and has a special interest in eating disorders.

Steve Bryson

Well, the holidays are here and as counselors we have a unique perspective on them. We all hear about neither allowing the holidays to become too rushed, nor too commercialized. But the general public only occasionally sees a movie or reads a story in the paper about the part of the holidays that we counselors regularly see: the reality of many of our clients is that the holidays are a horrible time. I myself am seeing people who are enduring the time, as they have bad memories from childhood, some who are grieving as they lost a loved one near the holidays, some who are having a difficult time pretending that their marriage is not ending, not wanting to announce it to the kids until after the holidays, so as not to dampen the festive spirit. I am seeing another whose seasonal affective disorder is in full bloom, but is feeling the need to cover with a happy face as “we are supposed to be happy this time of year”. And some are dealing with the friend or relative who uses the holidays as an excuse to abuse substances at an even higher level than they usually do. Then there are the atheists who feel forced to participate so as not to get grief for being a grinch.

And I wonder how many of you become a lender of sorts, as clients plead that their finances are tight and they have to choose between paying us or buying gifts for their children? We may acquiesce and have a ‘belt tightened’ holiday ourselves.

It is enough to make it difficult for the counselor themselves to stay in a holiday mood. I am sure you can all relate to the situation of deciding how to respond to an innocent “How was your day?” It is especially poignant at this time of the year, coming home to holiday music and the smell of cookies. Indeed, I know of one counselor that takes two weeks off before the holidays so she can enjoy them without the sorrow her clients are experiencing. I respect her personal choice, but I can’t do that to my clients. I tell myself that I am providing some “comfort and joy”, but I know that joy is attained less than comfort in many cases.

And then the holiday has its own personal dynamics for each of us outside of our practices. For myself, this is the first time in 23 years that our children will not be with my wife and me. We could have a big empty nest pity party, but we are going to renew some old traditions from our young adulthood: we will drive around and look at Christmas lights while sipping hot cocoa. We will exchange gifts and go skiing. And we have found a way to reach across the miles to our adult children and have a continuation of a family holiday tradition: we as a family have always put together a large puzzle that takes several days to complete. This year we found a puzzle that has a booklet with it that presents a mystery to be solved. The clues are in the puzzle. So we sent duplicate puzzles to our children. We hope we can all work on it together, using the cell phone and computer to stay in touch.

However we do it, we all owe it to ourselves to create some joy for ourselves at this time of renewal. Whether it is through the hope of a beautiful New Year, the joy of Christ’s birth, the miracle of Hanukah, the lengthening of days, or the likely passage of a health care bill (hopefully with provisions for Professional Counselors), there is much to celebrate. I wish you all happy holidays.

Steve Bryson is a counselor in private practice in Whitefish, Montana and a registered nurse. He works with adolescents and adults, couples and families and has a special interest in eating disorders.

Steve Bryson

There has been some controversy developing in our field, and I wonder if any one else has been seeing it. It involves the recent change in the Federal guidelines about the enforcement of marijuana laws that differ from state laws. For those of you who don’t know, the current Administration has directed the Justice Department not to interfere with states’ medical marijuana laws, thus opening up availability of marijuana to patient use through primary provider prescription and the development of legal dispensaries.

Currently 13 states have medical marijuana laws, and 15 others are considering such legislation. Until the recent Federal directive, the growth of this health care intervention has been minimal, as the prescriber, dispensary, and patient all risked Federal interdiction. But since the directive, there has been a virtual explosion of prescribers, despensaries and patients. One might think that a relatively conservative state like my home state of Montana would be far from this, but a medical marijuana law passed with a significant majority (62%). Nonetheless, the recent change from the Feds has caused a divisiveness: there are those who adamantly decry this as a tragic development, while others are quietly supporting it and still others are capitalizing on it.

From a clinical standpoint, there is ample evidence that medical marijuana can be of great help to a variety of serious maladies. There is also ample evidence that marijuana is not the demon it was once considered, yet is not the innocuous substance pro-recreational use advocates make it out to be.

I would like to present several potential situations regarding patients who might have been prescribed medical marijuana since the Federal change. It would seem that at times it is a very legitimate and helpful prescription, allowing (for example) cancer patients to eat and gain weight while undergoing chemotherapy. I believe most of us would not see this type of usage as controversial. Next, there is the patient with a neurological disorder whose medical marijuana use can help a great deal by relieving muscle spasms, again probably not too controversial. But then there is the young person with Irritable Bowel Syndrome (IBS) who uses medical marijuana. In this case I have to wondered if his/her “beneficial use” is actually that s/he has become dependent on marijuana and has fewer “IBS symptoms” after using marijuana because s/he has developed a dependence on the substance to alleviate emotionally-sourced physical symptoms of a primary chemical dependence. Is this a “beneficial use”? I am uncertain.

Perhaps, the most troubling is a young teen with short duration anorexia who was prescribed medical marijuana a few weeks before counseling. One cannot deny that her preprandial usage, carefully monitored by her mother, could allow her to have an appetite at mealtime. She does not use recreationally and recovers well. Her refeeding period was remarkably uncomplicated, her weight gain is without the anxiety usually experienced during recovery, and this young cowgirl from a conservative Christian family no longer uses medical marijuana, nor recreational drugs of any kind. And while I see the promise in this intervention, I sruggle with the notion of recommending marijuana to young people with developing minds and bodies. Nonetheless, anorexia is a potentially fatal, or at least potentially chronic disorder, destructive to both the patient and her family. One might say: let’s get some research to tell us of the potential risks and benefits of medical marijuana in the treatment of anorexia. Most university settings would be hesitant to expose young people to this, and the Human Subjects review committee would be even more liability shy.

In my last blog, I noted the glacial pace with the which the treatment community changes: it took 60 years for physicians to accept what British sailors long knew-that eating limes prevented scurvy. Am I being a traditionalist, stuck in dogma? Or am I being cautious, gauging each case individually?

I know that numerous studies have found that most providers view pain in a way that reflects their own experiences with pain: stoic providers tend to expect stoicism in their patients while other providers are just the opposite. Further, those of us with addiction treatment backgrounds are acutely aware of the ravages of addictions, and are loath to open the door to a new substance with abuse potential. But we also are knowledgeable enough to realize that a person who uses large doses of narcotics for chronic pain relief are benefitting when monitored therapeutic use of marijuana reduces or eliminates narcotic use.
I have no firm answers. But it is inevitable that this issue will confront us as more states pass such laws and more people are prescibed medical marijuana. I do know that I must check my prejudices at the door to my office. I am just beginning to realize how far my preconcieved notions carry me, and I see this as an opportunity to grow both personally and professionally.

What do you think?

Steve Bryson is a counselor in private practice in Whitefish, Montana and a registered nurse. He works with adolescents and adults, couples and families and has a special interest in eating disorders.

Steve Bryson

It seems timely, as we head into the holiday season, to reflect on one of the hallmarks of holiday gatherings: eating. Through much of the year, eating has a less ritualistic function (aside from birthday cakes and summer barbeques) than the gatherings at the end of the calendar year. Most people who celebrate this season include eating related functions in which disordered eating is the norm. I don’t intend for this blog to be a how-to guide for surviving the holiday food excesses. If you wish to explore this there are many great ideas on the web. Rather, I want to point out the opportunity for those of us who work with eating disorders (not disordered eating) to encourage the rest of the world to understand better the unique and tragic challenges people with eating disorders face.

One of the most common and revealing statements of non-afflicted people (especially men, as 90% of those with eating disorders are women) is often “I don’t get it, why doesn’t the person with the eating disorder just eat?” This lack of knowledge and resulting lack of compassion is the result of several things: people often react to things they don’t understand with bias based on their own experience, as they try to define and adjust to uncomfortable emotions.

Further, eating disorders have, for most of the history of professional diagnosis and treatment of eating disorders, been misdiagnosed, misinterpreted and maligned. As a nurse working in a major trauma center many years ago, I remember there was only one patient more capable of bringing out the GOMER (Get Out Of My Emergency Room) mentality in ER staff than a seriously medically ill eating disorder patient, and that was a drunk seriously medically ill eating disorder patient. Indeed, I myself have observed and partaken in these mistakes over the years: I read about and incorporated the proposals that eating disorders had been linked to the Electra dynamic, sexual abuse, addiction, personality disorders and willful adolescent oppositionalism.

And I remember studying closely the proposed dysfunctional family dynamics. Some of you may remember the ‘Influence of the Family’ article in an old ACA newsletter describing very eloquently the three stereotypical dysfunctional family dynamics to look for when treating eating disorders: The Chaotic Family, the Abusive Family and the Perfect Family. But as I studied them I realized that the writer had effectively described the vast majority of families in Western culture! Taking into account that the prevalence of the various eating disorders is somewhere around 8-15% of the general population, this analysis was overreaching, to say the least.

What are we to make of these errors, coming as they have from otherwise learned and experienced clinicians? Some of the answers might include the ‘publish or perish’ dynamic, but that is likely not the major culprit. Some might be attributed to a need to find explanations for a problem which is downright scary for those of us who see clients whose medical status is seriously compromised. And quite likely, some of the errors were sexist; as one of my professors once informed us, Freud was reported to say that he never intended psychoanalysis to bring about permanent change, he considered it as entertainment for bored housewives….I think sexism in our field has been a problem that is thankfully improving. And the traditional treatment community has been notorious for taking its time to change paradigms. It took 60 years for medical science to accept what “Limey” sailors knew: that fresh limes prevented scurvy. Doctors continued to use bloodletting as a primary treatment.

But in the past two decades, and especially the last decade, careful, replicated research has shown that eating disorders are a hereditary construct of a neuroendocrine dysfunction that is compelling, ne demanding. We even know which parts of which genes are implicated in anorexia and bulimia. We also know that the emergence of an eating disorder is now describable from a neuroscience perpspective, to the point that it may one day be described as a neuroendocrine disorder with psychiatric/behavioral symptoms.

Of course we all know that behavioral disorders are not diagnosable until the behavior is exhibited, and therein lies another part of the explanation for the misdeeds of our colleagues.

For many of those who currently suffer from E.D.’s, the trigger (not the gun) was the drive for thinness, usually predicated on fashion. One doesn’t need to be Freud to understand why a provider might look askance at an otherwise (often) bright and capable person who is in mortal danger because of their eating behaviors. As one ER physician said to a client of mine who was in electrolyte crisis: “What, are you so vain that you would do this? Look at how you are making your parents suffer.” (She attempted suicide that night.)

So what are we to do about this? First and foremost, we must stay abreast of recent research about etiology. We must follow the evidence based interventions and hear what these interventions imply about causation. (More about this in another blog.) And we must admit that just because we are intrigued by complex, intricate and elegant theories, that doesn’t mean they are accurate.

One is reminded of former First Lady Barbara Bush. The media reported her increasingly irascible and pugnacious behaviors. During a medical exam she was diagnosed with Graves disease, was given appropriate medical interventions and her untoward behaviors stopped. But, to my knowledge, no one later said to her: “Now that we have fixed this endocrine problem, I would like to explore how your mother treated you during your formative years.”

And we can do much to help both the sufferers of eating disorders and the general public perception with a comparison that everyone could relate to, especially during the holidays: imagine that you are newly married. This is your first time spending the holidays with your in-laws and you don’t want to blow it. But both of your families live locally and your families’ tradition is to have holiday dinner at 2:00 pm. You attend this festive occasion, eat all the favorite foods that your mother has painstakingly prepared-maybe even an extra piece of grandma’s pie. All fine so far, but now you have to honor your spouse’s family tradition: dinner is at 4:00 at their home. Even though you are not hungry at all, you may feel compelled to force yourself to be cordial and eat another full meal. So how do you suppose that third piece of pie goes down? That is the experience of a person with anorexia: they are not hungry because of a neuroendocrine messenger that says they are uncomfortably full, but others expect you to be naturally hungry and must politely eat.

I think we can all see the narrowness of this analogy, but following it through, how would the average, not psychologically sophisticated person respond? It could be difficult. We can all be agents of change in this paradigmatic shift. So let us share our loving acceptance of differentness. I truly believe that we can do no better than to function out of the attitude once voiced by William James. To paraphrase: the most important thing in the world is to be kind, the second is to be kind, and the third is to be kind. Happy Holidays to all of you-have a piece of pie for me.

Steve Bryson is a counselor in private practice in Whitefish, Montana and a registered nurse. He works with adolescents and adults, couples and families and has a special interest in eating disorders.

Steve Bryson

I just returned from some much appreciated time off. I went into the backcountry of Montana for a week and then went to a conference: “Motivational Interviewing to Competence”. Being refreshed and renewed, I found the conference enlightening, instructive and intriguing. As a “seasoned” counselor, I have observed over the decades many new perspectives on the counseliing process. Many of them have made important contributions to a field that some would say is nebulous and indefinable, more akin to art than science. While I adamantly disagree with the view that what we do is fluff, there have been times when the art of counseling took the limelight while the science sat in the background.

The newer fields of CBT, DBT, ACT et al have done much to dispell the notion that we are just “tell me more about it” charlatans. Indeed, evidence based practice has allowed us to gain ground, not just for our clients, but for our standing in the professional helping communities.

At the conference, I learned that Motivational Interviewing (M.I.) has developed much since first introduced in the 90’s, including outcome based research that shows effectiveness. The difference I appreciate with M.I. is that it focuses on the process of interacting with the client in such a way as to stimulate internal motivation. Of course Carl Rogers focused on this many decades ago, and it was good to hear the M.I. instructors credit him. But M.I. has scientifically evaluated what the counselor says that motivates, breaking down interactions not regarding the subject matter, but rather how the subject matter is discussed.

This seems to be full circle: process to subject to technique and back to process. While I think we all know we need to be knowledgeable and competent about the latest evidence based interventions most helpful with each identified problem, the fundamental truth is that without an effective relationship we cannot be helpful with anyone. And the beauty of M.I. is that it deconstructs interactions so that we can learn what will get the client in a mind frame to change.

Lets just not forget that without respect, genuineness and unconditional warm positive regard the client will not feel safe enough to be with us in our sophisticated techniques. And competent M.I. does just that. I can’t help but think that Carl Rogers would be pleased.

Steve Bryson is a counselor in private practice in Whitefish, Montana and a registered nurse. He works with adolescents and adults, couples and families and has a special interest in eating disorders.

Steve Bryson

In this, my second blog on the ACA website, I want to talk a bit about case consultation. I know we all have heard from legal counsel that consultation is necessary to support yourself should a lawsuit happen. But it is always surprising to me how many counselors do not engage in consultation.

I know we all get busy and tired. I myself often times want the time I am not engaged in counseling to be completely unrelated to counseling. And I know it takes time and energy to prepare case presentations, not to mention the embarrassment when a fellow counselor points out something we should have seen. But that is one of the main reasons to consult. In my experience, seasoned therapists don’t engage in consultation because they feel it is unnecessary, or because they often feel like a supervisor rather than a colleague. Or perhaps our egos are more fragile than we would like to admit.

I would challenge those who experience the supervisor dynamic to bring that up as part of the consultation. Pehaps there is a knowledge and/or experience gap, but it can also mean that the seasoned therapist is being directive ” I know so much more than the others”. We don’t want to admit it but, just as we sometimes go to a conference and realize halfway through that we haven’t learned anything, we sometimes can make the conference valuable by asking the right questions. But if instead we ‘check out’ we don’t get the opportunity to learn.

So it has been with my experiences with case consultation. I am often impressed with the fluency fresh therapists, recently educated, show with CBT, DBT or many of the other newer manualized intervention/treatment modalities. And the fresh perspective, often presented with enthusiasm, can not just give us seasoned therapists a new view of an issue, it can rejuvenate our sometimes jaded attitude. I look forward to hearing others perspectives on this.

In fact, this blog, and the others on the web site could serve as a consultation group. So if you agree or disagree with my premise, or if you have more to add, we can make this a sort of virtual consultation group. I am never too old to learn and grow. And even though I may be certain about some issue, your input can help me grow. I would suggest that discussion of specific client’s issues would be inappropriate for so public a forum, but more general client issues, or issues about our own professional lives would be very useful to discuss here. Even though we may enter the counseling office with the client alone, in another way we are all in there together. Lets share our wisdom.

Steve Bryson is a nurse and counselor in private practice in Whitefish, Montana. He works with adolescents and adults, couples and families and has a special interest in eating disorders.

Steve Bryson

I appreciate this opportunity to write about counseling related subjects. I believe I have had valuable experiences over the years which give me a perspective that may be interesting to colleagues across the nation. Some of the issues I look forward to addressing in future blogs include counseling in rural areas, the valuable alternative perspectives of “fresh” versus “seasoned” counselors, trends and fads in counseling over the years, professional collaboration, ethics, and my favorite diagnosis to treat: eating disorders. I will do my best to stay off the soap box, and really look forward to feedback from other professionals.

I have often wondered, for instance, how other counselors in rural areas deal with the “fishbowl effect”. As some of you undoubtedly know, in an area with a small population, the boundaries recommended in graduate school ( I attended an urban based grad school) aren’t just impractical in a rural area, they are impossible. The person you saw yesterday who discussed her/his most shameful behaviors could be the person who fixes your car or cleans your teeth or serves your food or fixes your toilet the next day. It is impossible to be a blank slate, yet I have found that my involvement in my community must be tempered to truly be available to all walks of life. I feel it is important to be invisible enough to have people feel comfortable with the notion of privacy. So I am careful to assess the potential results of my public exposure. As you may surmise, I at times feel a bit isolated. At other times I feel connected in a way impossible in a big city.

I am curious about how many of you in rural settings have had the experience of seeing a client in your counseling office, then later, in another venue, overhearing their conversation or observing them as they behave in a way not at all resembling their presentation in your office. This is quite valuable as a counselor, as the perspective is much richer. But it makes one wonder how much we miss in traditional counseling interactions. And it creates an important caveat regarding brief counseling: things are usually both much simpler and much more complex than at first glance.

Similarly, it is very unnerving to have your daughter or son bring home as a date someone who is known to you through case consultation. You know more about this individual than most concerned and involved parents would be comfortable knowing about the person who is about to go off with your child. Since your child knows nothing of the information you have regarding this person, you can feel pretty stuck. You are prevented by confidentiality rules from asking direct questions that your professional knowledge says your parent self must address. It can make for an uneasy evening…

I think anyone who plans to be a rural counselor needs to start by reading Gerald Corey’s thoughts on the subject in various books and articles. Also a good case consultation group is vital. And of course, being in a rural area, solitude and recreation are literally out your back door.
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Steve Bryson is a nurse and counselor in private practice in Whitefish, Montana. He works with adolescents and adults, couples and families and has a special interest in eating disorders