Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

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June, 2011

Thursday, June 30th, 2011

When Books are Wrong

A new book on eating disorder treatment entitled When Food is Family will be published later this year. The book is written by a therapist with over 25 years of experience treating eating disorders who is also the founder and director of an eating disorder clinic.

The premise of When Food is Family is that early childhood relationships play a significant role in the development of an eating disorder. The book is based on attachment theory, which posits that “emotional support, understanding, empathy, and acceptance during a child’s development are the foundation of self-esteem and self-worth throughout life.” The author asserts that children develop eating disorders in part because they do not receive the emotional support and nurturing they need from their families, so they develop a “relationship with food” as a substitute for the intimate familial relationships they crave.

According to the online synopsis, When Food is Family “provides family members a step-by-step approach to understanding what attachment means, why connection to each other is important, how relationship breakdowns can lead to an eating disorder, how food becomes the relationship of choice, and how to go about repairing these relationships so that food (and the eating disorder) is replaced by healthy relationships within the family.”

My primary concern with this book is that it seems to set our field back about 20 years. There is no reliable scientific evidence to support the theory that disrupted attachments or dysfunctional family relationships lead to eating disorders. Nor is there any reliable evidence that treatment approaches predicated on these attachment theories help patients achieve recovery.

I absolutely agree that “emotional support, understanding, empathy, and acceptance during a child’s development are the foundation of self-esteem and self-worth throughout life.” Of course childhood environment is important in the development of self-esteem and emotional well-being. Of course “relationship breakdowns” within a family cause emotional suffering for everyone. Disrupted attachments are bad. Healthy attachments are good. But I am not aware of any evidence that disrupted attachments can lead to eating disorders.

The fact that some eating disorder patients come from dysfunctional families does not indicate that said family dysfunction caused their eating disorder. Correlation does not equal causation. Despite decades of research and millions of dollars spent on cross-sectional and longitudinal studies, researchers have not been able to identify anything that parents do, or don’t do, to cause eating disorders in their children.

The theories espoused by this book are not only unfounded and incongruent with our modern scientific understanding of eating disorders, but also potentially harmful to young patients and their families who are seeking treatment for these life-threatening illnesses.

When parents have a child with a poorly-understood, stigmatized, confusing, life-threatening illness such as anorexia nervosa or bulimia nervosa, they do not need to be told by an expert that family dysfunction is at the root of her illness. The family unit is not well-served when parents are told by an expert that they have failed to bond properly with their children, and this failure to bond has resulted in their child developing a serious illness. Parents with an anorexic or bulimic child do not need to be taught skills to develop healthy attachments with their children. They need well-informed professional support which empowers them to take aggressive action to help restore their child to health.

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Saturday, June 18th, 2011

Insights on Insight

Patient “insight” is a much-discussed topic in psychotherapy. Most clinicians believe that developing insight is a crucial aspect of recovery from a mental illness. Many clinicians believe that insight is a necessary prerequisite for change. There are some types of treatment, such as psychoanalysis and psychodynamic psychotherapy, which are based entirely on the development of insight. These types of treatment are predicated on the assumption that increased insight naturally leads to positive behavior change and recovery from mental illness.

These assumptions originated with Sigmund Freud, who believed that mental illness was the result of unconscious psychic conflict. He believed by bringing this conflict into the patient’s conscious awareness, it would no longer have power over the patient and the neurotic or psychotic symptoms would disappear.

The notion that exploration into one’s innermost psyche leads to healing is alluring and romantic. It makes for great novels, memoirs, and movies. The problem is, it rarely works this way in real life. While most people suffering from mental illnesses do indeed experience tremendous inner psychological conflict, there is no evidence that this inner conflict is the cause of any mental illness or that gaining insight into the conflict will promote recovery. Insight, as discussed in psychoanalytic theory or pop psychology, refers to something along the lines of “why I am the way I am” or “why I developed this mental illness.”

There are several reasons why this type of insight alone rarely leads to recovery:

1.) Contrary to popular belief, we do not know what causes most mental illnesses. We may know what factors may trigger, perpetuate, or exacerbate the illness. For example, a loss of some sort often triggers or exacerbates depression, and dieting often triggers or exacerbates an eating disorder. We may know what types of treatment are effective for certain illnesses. For example, we know that DBT is effective in treating borderline personality disorder. But any notion about causality is, at this point in time, largely speculative. So if we don’t really know what causes mental illness, insight into the supposed cause will not promote recovery.

2.) The “insights” encouraged by the therapist are often based upon antiquated theories of mental illnesses which have no empirical support (e.g., that depression is “anger turned inward”). These theories may feel good, or make intuitive sense, or seem to validate the patient’s suffering, but that doesn’t make them accurate or useful in terms of recovery.

3.) We learn and mature emotionally through experience. Thoughts and feelings follow from behavior, not the other way around. Simply knowing why you think the way you think, or why you feel the way you feel, does not change your thoughts or feelings. What does help change your thoughts and feelings is by acting opposite to them. So, for example, if you are feeling depressed and lethargic, sitting around the house all day by yourself trying to figure out why you’re depressed doesn’t make you less depressed. However, dragging yourself off the couch to go for a brisk walk outside, and then inviting some friends over to watch a funny movie, may very well lift your spirits, at least a little bit.

4.) Our neural pathways are rewired not through developing insight, but through consistent, repetitive practice of new behaviors. You will not become a good athlete by watching sports or reading about sports. Rather, you develop and hone your athletic skills by consistent practice and physical conditioning. This is why the behavioral therapies such as CBT, DBT, ACT, and FBT are so much more effective than insight-oriented therapies such as psychodynamic therapy.

5.) Some mental illnesses, such as schizophrenia, bipolar disorder, and anorexia nervosa, involve a symptom called anosognosia, which is a brain-based lack of insight. Because of abnormalities in brain function, individuals with anosognosia are unable to recognize that they are ill even when loved ones are extremely worried. For instance, a person with anorexia nervosa may feel great and perceive her body as normal and healthy, even when she is markedly underweight and clearly suffering from the physical and psychological effects of malnourishment. And an individual with bipolar mania may perceive himself as “on top of the world” and vehemently resist intervention as loved ones stand by and watch him make one self-destructive decision after another. Individuals with anosognosia should not be expected to seek treatment on their own, or to “want to recover,” because they will not have the insight to do so until they are well on their way to recovery.

The types of insights described above are relatively useless. However, there is another type of insight which results from successful treatment and is one of many markers of a psychologically healthy individual. Insight, as I conceptualize it, is best described by both the dictionary definition and the wikipedia definition. Thus, in order to successfully manage or overcome a mental illness, one must be able to discern the true nature of their mental illness and must understand cause and effect insofar as it applies to their symptoms. The following insights are extremely important to recovery:

1.) Insight into the fact that one has a mental illness. This element of insight includes acceptance of the fact that the illness is, to some extent, out of the person’s control, and cannot simply be wished away or overcome by willpower.

2.) Insight into the symptoms of one’s mental illness and how they manifest. This insight includes the ability to recognize signs and symptoms in oneself and the skills to eliminate, manage, or cope with the symptoms when they occur.

3.) Insight into the effects of following, or not following, the treatment plan and clinician’s recommendations. This insight involves understanding not only what the clinician is doing or recommending, but why she is doing or recommending it. That is, understanding the mechanism of change.

4.) Understanding how various choices one makes impact the course of one’s illness. For example, a person with a mood disorder needs to learn that by getting 8-9 hours of sleep nightly, exercising regularly, taking medication daily, and monitoring mood changes on a daily basis are essential to stabilizing moods. She will also need to learn that getting drunk on her 21st birthday, traveling across time zones for vacation without making up missed sleep, missing her medication for two days because she forgot to get refills on time, or burning the candle at both ends during final exams, will likely trigger a return of symptoms, even though “normal people” do these things all the time without a second thought. “But that sucks!” They exclaim. “That’s not fair!” They are correct on both counts.

I believe that a patient must develop all four of these insights during treatment. It is the clinician’s responsibility to assist the patient in developing these insights. It is also the clinician’s responsibility to ensure that the patient’s family members develop these insights during treatment, as it is often a parent or a spouse who will first notice the signs of relapse and encourage a return to treatment. This is especially true in disorders characterized by anosognosia.

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Monday, June 6th, 2011

The Price of Assumption

Recently, there have been heated debates between clinicians and parent advocates regarding the role of environmental and family issues in eating disorders. Some people insist that family dynamics and environmental factors play a role in the development of an eating disorder. Others bristle at the possibility. Some people say “families don’t cause eating disorders, BUT…” Others fixate on the “but” and disregard everything else.

My views on this issue are complex. Thankfully, my views became much clearer to me as I was watching an episode of the E! True Hollywood Story entitled Britney Spears: The Price of Fame. Now I am able to articulate my views on this topic in a way that most people can understand.

Numerous magazine and newspaper articles have reported that Britney Spears has been diagnosed with bipolar disorder. According to unnamed “sources close to the pop star,” Spears was suffering from untreated bipolar disorder during her public meltdown and psychiatric hospitalization in 2008. While I have not treated Britney and thus cannot ethically make a diagnosis, I will say that her erratic behavior circa 2006-2008 could be explained by a bipolar diagnosis, and that the rate of bipolar disorder is thought to be quite high amongst people in the creative and performing arts.

Scientists now know that bipolar disorder is a neurobiologically-based, genetically transmitted disease. However, rather than focusing on the neurobiology or genetics of bipolar disorder, The E! True Hollywood Story explored various influences in Britney’s life that fueled her self-destructive behavior. Clearly, this type of commentary is far more interesting to the typical E! viewer than neurobiology, my own preferences notwithstanding. Several mental health professionals were interviewed and gave their opinions as to the influence of early stardom, family problems, a stage mom, excessive fame, and extreme wealth on the pop star’s behavior. Sadly, though, the viewer is led to believe that these environmental and family issues are the cause of Britney’s downfall.

Did Britney’s family or environment cause her bipolar disorder? No. Neither family nor environment can cause a brain disorder.

Did her family or environment fuel her bipolar disorder? Yes. And here’s how: Let’s say Britney had taken a different path in life, married a plumber instead of Kevin Federline and worked as a preschool teacher instead of a pop star. Let’s say she stayed in her small Louisiana hometown, never dabbled in drugs or heavy drinking, went to bed every night at a decent hour, and maintained close, age appropriate relationships with her family and good friends, making a decent living but nothing more. Would she still have developed bipolar disorder? Yes, I absolutely believe she would have (remember, most people with bipolar disorder are not pop stars, but regular people). However, her disease would have been much more easily diagnosed and treated if she had been surrounded and supported by normal, loving people who could influence her in a positive way. As it happened, her disease was certainly protracted and exacerbated by the lifestyle of a pop star, which includes late nights, insufficient sleep, excessive amounts of alcohol and drugs, and endless amounts of power and money.

If Britney’s therapist had held a family session with Lynne and Jamie Spears and Kevin Federline in attempts to “explore the family dynamics which contributed to the disorder,” that would be a complete waste of time. The elder Spears’ and Mr. Federline – the very people who are in the best position to help Britney recover – would have felt subtly blamed and marginalized. There is nothing to be gained, and everything to be lost, by approaching a brain disorder in this fashion.

The most ideal situation for Britney would be for her parents and K-Fed (and any other people close to her) to work together to provide family-based support to help her recover and to help eliminate any environmental or family factors which may be fueling her disease. It would be most helpful for her family members to be educated about bipolar disorder and understand that it is a biologically-based brain disease that she did not choose and that they did not cause. The family would also need to know that certain environmental factors, such as pregnancy and childbirth, stress, insufficient sleep, drugs and alcohol, medication non-compliance, or excessive emotional distress, can trigger episodes and exacerbate symptoms. The family would need to learn pro-active ways to help Britney manage her environment in a way that is most conducive to achieving mental and physical wellness.

In considering this example, it is important to bear in mind that people with bipolar disorder run the gamut from pop stars to professors to businessmen to truck drivers to homeless panhandlers. Families of people with bipolar disorder also run the gamut – some are amazing and supportive, others are average, and some are downright abusive. If treatment for bipolar disorder is to be successful, the clinician must perform a thorough evaluation of the patient and family, and the information gleaned from that assessment should be used to guide treatment decisions. A good clinician would not presume that the family of a person with bipolar disorder is dysfunctional or abusive, or that family dynamics caused or contributed to the development of the disorder. Similarly, a good clinician would not presume that the family is healthy or that there is nothing the family needs to change. Quite simply, a good clinician would not assume anything – she would simply perform an assessment and tailor her approach to the strengths, limitations, and realities of that particular patient and family, in line with the most recent evidence-based research.

Eating disorders are also neurobiologically-based, genetically transmitted diseases which patients don’t choose and parents don’t cause. Family issues and environment certainly can fuel eating disorders by encouraging dieting or glorifying thinness, by making diagnosis more difficult or treatment less accessible, or by making recovery harder than it needs to be.

All eating disorder patients have a biological brain disease which most likely would have arisen, at some point in time and to some degree, regardless of family or environment. Some patients have family or environmental issues which are fueling their disorder, and some do not. If such familial or environmental issues exist, they usually become quite obvious if you do a thorough assessment. These family or environmental issues will need to be addressed in treatment, not because they caused the eating disorder, but because they can trigger or exacerbate symptoms and interfere with full recovery.

But if there are no obvious familial or environmental issues fueling the disorder, please don’t waste time searching for them. You aren’t doing the patient or the family any good by “being curious,” or “just exploring.” You are simply satisfying your own voyeuristic drive, as I fulfilled mine by watching the E! True Hollywood Story on Britney Spears.

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Thursday, June 2nd, 2011

Blame it on the Brain

There is much debate amongst mental health professionals as to whether mental illnesses should be called “brain disorders.” A large part of the disagreement, as I see it, comes from a lack of consensus as to the meaning of the term “brain disorder.”

I conceptualize a brain disorder as a disease or disorder that originates in the brain and influences mood, thinking, learning, and/or behavior. By my definition, all disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are brain disorders, including autism, ADHD, major depression, bipolar disorder, OCD, anorexia nervosa, bulimia nervosa, reactive attachment disorder, Alzheimers, and schizophrenia.

To me, “brain disorder” does NOT mean:
• Environment does not play a role in its development
• Environment does not play a role in recovery
• It is 100% biologically based
• It is 100% genetically inherited
• It can only be treated by physician or with a pill
• Psychological interventions won’t help
• The patient can’t do anything to influence the outcome

None of the above is true for ANY brain disorder, whether we’re talking about one that is commonly accepted as “biologically based” or not. In fact, I don’t know of any physical disease or medical condition in which any of the above is true.

Some people in my field are willing to apply the term “brain disorder” to some illnesses which are widely accepted to have a neurobiological basis (e.g., schizophrenia, autism, Alzheimers) but adamantly resist using this term to describe eating disorders, depression, or anxiety disorders, which they perceive to be something else. The underlying assumptions here, which few people would openly admit, are that some mental disorders are legitimate diseases whereas others are choices or responses to the environment; some mental illnesses are serious and deserve to be treated (and funded by insurance) whereas others are the patient’s or the family’s fault, so treatment is optional.

Clinicians who oppose the use of the term “brain disorder” to describe certain mental illnesses typically fall into one or more of the following categories:
• They don’t have a strong science background
• They lack basic knowledge of biology and genetics
• They suffer from (or have suffered from) the mental disorder in question and are personally offended by the term because they believe it invalidates their personal experience
• They feel that their professional identity, the work they have done for many years, is threatened by acknowledgment of the neurobiological basis of mental illness
• They believe that family dynamics or socio-cultural forces are the root cause of mental disorders, and that changing family dynamics or socio-cultural forces will cure or prevent mental disorders.

My clinical work is grounded in the knowledge that all mental illnesses are brain disorders. I believe my patients benefit from knowing that they have a neurobiologically-based, genetically inherited illness which they did not choose and their family did not cause. In order to get well, they must have a profound appreciation of their unique vulnerabilities and how to make healthful choices in order to keep themselves well. It is important for me, as a psychologist, to understand how the brain works – the mind-body-behavior connection – and it is important for me to educate my patients and their families about these issues as well.

It’s a two-way street – brain function affects thoughts, emotions, and behavior; in turn, psychological and behavioral interventions change brain function. The fact that mental illnesses are brain-based does not necessarily mean that medication is required. Research has shown that, for many brain disorders, certain types of psychotherapy are more effective than medication (e.g., mild or moderate depression, panic disorder, social anxiety disorder, anorexia nervosa). For other brain disorders, a combination of psychotherapy and medication produces better outcomes than either treatment alone (e.g., severe major depression, OCD). Less than half of my current patients are taking any psychotropic medication. Many of my patients recover fully without medication, and those who do need medication can often take fewer medications and/or lower doses once they have had good psychological intervention.

One of my college-aged patients who suffers from severe depression and anxiety recently shared the following insight, which beautifully captures the clinical utility of the “brain disorder” concept:

“With my last therapist, we just talked about what went wrong in my family that made me so screwed up. We spent the whole summer trying to figure out why I’m depressed, and it didn’t make me any better. My relationship with my parents just got worse – I got angrier at them and they felt guilty. Now I know I have a brain disorder and I know how to treat it. I come to therapy, I take my meds, and I’m OK. It works.”

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