Body Transformation or Body Dysmorphia?

It’s easy to get caught up in the perfectionism psyche when things are changing so quickly after bariatric surgery. You imagined yourself thin, fit and svelte, but really, you did not comprehend what it would be like to have hanging flesh on your body after you worked so hard for that body. Have you caught yourself thinking, “I just don’t like the way I look in the mirror,” while naked.  Today’s blog is about how to have a healthy mentality about your body after weight loss surgery, considerations for a reasonable time frame to pursue plastic surgery, recognizing unreasonable body image issues, understanding self harm, and working through those issues with a therapist, and stopping unproductive negative self talk.

In the case of the bariatric surgery patient, self acceptance has its limitations, but we must live with the understanding that a model perfect body isn’t going to happen. Where does the line get drawn in the sand between trying to achieve a figure that you can be happy with and living with an obsession with the knife?  It’s certainly possible for anyone to become addicted to ANYTHING. However, in the bariatric transformation from obese to healthy, thin, or slim, if money is no object: is there a such thing as an addiction to plastic surgery?  Better yet, is there room for concern about those members of the community who begin the journey of going under the knife?  Should professional psychologist and mental health professionals look at case history in order to determine if that person will be stable enough to withstand the psychological impacts of plastic surgery, or will it become obsessive?

There’s no way to screen for risk in this regard.  However, the question has been posed that maybe those with personality disorders with a history of cutting might take this journey to extremes.  Like I said, anything is possible with anyone, at any point in time.  Having unlimited resources to indulge in plastics, self harm in pursuit of perfection is certainly obvious with many mega-stars.  Michael Jackson certainly too it to an extreme if you think in terms of his numerous plastic surgeries and history of mental and psychological abuse, albeit extraordinarily talents, he brought it to the max.

Influenced by media, society’s expectations of a perfect body are skewed. We have to love ourselves, and under no uncertain terms should be not love our body, imperfections and all. An otherwise successful, yet dissatisfied bariatric patient’s excess skin removal, coupled with destructive behavior patterns are indicative of a more severe diagnosis of body dysmorphic disorder diagnosis, or even, pronounces issues of self harm included, going under the knife that could be indicative of a borderline personality disorder. How do can we tell the difference?

To identify behaviors as unhealthy and unproductive as a chronic mental illness, one must look at the client’s ability to control the obsessive negative thoughts, (i.e. you can't stop thinking about a flaw in your appearance — a flaw that is either minor or imagined) when your appearance seems so shameful that you don't want to be seen by anyone.  Body dysmorphic disorder is intensely obsessive, image and appearance are often thought about for many hours a day. The perception of your flaws causes you significant distress and has an impact on your ability to function in your daily life. If one seeks out numerous cosmetic procedures or excessively exercise to try to "fix" the perceived flaw but is never satisfied.

The three essential factors I would use to determine an unhealthy obsession with appearance (occupies more than 90 minutes a day, of persistent negative thoughts about self) body image issues, overanalyzes the perception of others on the individual (implied or stated), personality disorder, and GAF (Global Assessment of Functioning) Score.  Any client with a score below 65 on the scale would be of concern to me, as a clinician.

So, how do we define an unhealthy obsession with your body, perfectionism and surgical methods to alter one’s appearance?  Where do self harm/self injury, perfectionism, and personality disorder come into play here?  There’s a certain level of desperation that is a driving motivator to change, but when does it become a disorder?  That’s subjective.  However, there are some issues to consider when moving forward to the transformative body reconstructive surgeries.  A healthy cognition about when that should be done is essential. 

In my former journey with the Lapband, my mother pestered about my bat wings. I always said, “Let me get to my maintenance weight for two years, and then we’ll talk plastics.” Good thing I never got to that point, else when the band came out I and the slow path of my body fighting back with regain set in, I would have been a helluva messy rubber-banded skin.  If nothing, I am logical, methodical and grounded in my decision making—after 6 months, I knew that the Lapband had been a HUGE mistake. (That’s another post, I have been meaning to write out my Lapband trauma during hurricane Isaac for 10 months now, I owe the public that story. I want to tell it.  It’s just tough to tell it through the therapeutic lens while I’m still working out the details on revision, and I still don’t know when that can or will happen.)

My intentions with blog are to discuss the perfecta of concerns I have for the WLS community.  All of us are crazy, varying degrees of crazy, yes, but some have had more severe mental illness histories than others.  Analysis of previous history of self harm should not preclude patient disqualification, however certain support services should be available to those patients who find themselves forming harmful habits and/or destructive thinking patterns as the transformation of an obese body becomes slimmer.

Signs are inclusive but not limited to negative feelings or thoughts, depression, anxiety, tension, anger, generalized distress, self criticism, self injury, low mood, poor self confidence, preoccupation with dangerous behaviors, purposefully engaging in harmful acts, urges that cannot be distracted from or satisfied, negative/harm act results in pleasure, spending endless time alone in a room avoiding others, and/or 

disruptive influence on interpersonal, academic or other areas of life functioning. 

If you find yourself constantly thinking about these issues, you have options and alternatives.  While I it is important to work with a trained professional, keep in mind that developing hobbies and interesting that help to take the focus off of your dissatisfaction help to low your risk:

• Paint, draw, or scribble on a big piece of paper with red ink or paint
• Express your feelings in a journal
• Compose a poem or song to say what you feel
• Write down any negative feelings and then rip the paper up
• Listen to music that expresses what you’re feeling
• If you cut to calm and soothe yourself
• Take a bath or hot shower
• Pet or cuddle with a dog or cat
• Wrap yourself in a warm blanket
• Massage your neck, hands, and feet
• Listen to calming music
• Call a friend (you don’t have to talk about self-harm)
• Take a cold shower
• Hold an ice cube in the crook of your arm or leg
• Chew something with a very strong taste, like chili peppers, peppermint, or a grapefruit peel.
• Go online to a self-help website, chat room, or message board
• Exercise vigorously—run, dance, jump rope, or hit a punching bag
• Punch a cushion or mattress or scream into your pillow
• Squeeze a stress ball or squish Play-Doh or clay
• Rip something up (sheets of paper, a magazine)
• Make some noise (play an instrument, bang on pots and pans)
• Substitutes for the cutting sensation
• Use a red felt tip pen to mark where you might usually cut
• Rub ice across your skin where you might usually cut
• Put rubber bands on wrists, arms, or legs and snap them instead of cutting or hitting

Source: The Mental Health Foundation, UK

Professional treatment for cutting and self-harm

If your concern is for a loved one because you’ve noticed suspicious injuries or that person has confided to you that he or she is cutting, pulling, scraping or harming themselves in this way, whatever the case maybe, intervention is essential.  Speak respectfully, without blame, and in a calm tone.  Address the matter with an open mind and loving heart.  You are extending a hand to someone who is hurting on the inside.

Deal with your own feelings on the matter prior to the discussion, the shocked, confused, or even disgusted by self-harming behaviors—and guilty for your loved one’s distress can be helped by acknowledging how you feel about this person’s emotional distress. Make the first step by learning about the problem and overcome any discomfort by understanding why your friend or family member is self-injuring. This will help you to see the world from his or her eyes. Avoid judgment and criticisms it is likely the route of the problem, the person is coping with society’s judgment and expectations.  Find your loved one support and make your conversation productive.  Availability to listen and find help is a key to recovery.  Communicate with them as they seek support and intervention.  Above all, be kind to yourself and others when you speak about sensitive subjects. 

Play with your Food!

Try breakfast or snacks differently with this recipe. I left it in the oven overnight, and it was fruit crisps at first, then I brushed the top with water a few times over the course of an hour and let go 2 - 3 hours longer.

FRUIT LEATHER = WINNING

Tasty, slows you down to eat it, let it melt in your mouth. Peach leather for breakfast... I know, it sounds totally weird. But who wants to be normal?

2 c. strawberries, hulled and diced

2 c. peaches, cored and diced

sweetener, varies by fruit sweetness and taste

1 T. lemon

1 T. lime

2 scoops unflavored protein

Blend strawberries, lime, sweetner and 1 scoop of protein. Spread evenly (about 1/2" thick) on a silpat or wax paper.

Blend peaches, lemon juice, and 1 scoop of protein. Spread evenly on a silpat or wax paper.

I combined both fruits on the same baking tray lined with wax paper.

Place in oven for 12 hours at 170 degrees. Peel paper away from fruit leather, roll up, and enjoy! Makes about 12 servings, 33 calories per serving, appx.

Later... I roughly did the math on this and it was about 35 calories per 2" x 6" slice, but it would certainly depend on what kind of sweetener you want to add. I added 1 T. of agave syrup, but you could use splenda or stevia. Taste and texture will vary by sweetener choice. I may or may not have put vanilla extract in it. When I cook, I cook like Justin Wilson... my genes are to my detriment, sometimes! But God, I miss that man cooking on the PBS on a Saturday morning!!!

Little know fact, I am related to him. It's some strange story about how he's actually related to us on both sides (by married on my mom's side and by cousin to my grandpa on my dad's side), but I never paid enough attention know the whole story. What I know now it that genetics that impacts our metabolism and environment that influences our ability to choose what is essentially good for us. Redefine what "good food" is in your life. It's stuff like this that slows you down when you eat - the fruit leather, beef jerk, enjoy every bite as if it were your last.  It might be, if you pay attention to your gut as you should.

And there's always healthy Gumbo from MamPapaul's Cajun Creole Dinner Mixes (avoid the cake mixes-- even though they are good, just take my word on it.) Double family plug there, entertained you with YouTube and did a little family business marketing.  (Aren't those both things I say I don't do here?  I'll make an exception today!)

Happy Saturday, Everyone!  Go forth, and love people, make them tasty food.

Hearts & Hurts Don't Fade Away

#wlsrealizations You tell yourself it hasn't changed your relationships with people you love... but then you realize otherwise. :-( You lie to yourself and say this person is no longer in my life and that's good because of the hurt and pain we have caused each other, but that not knowing why.... that's more hurtful than anything.

It just dawned on me tonight, WLS may have contributed to the loss of a friend. No, this friend didn't die, this friend just went away. No response to my emails. No explanation as to why she deleted me and never calls anymore. This happened over a year ago. I emailed, no response. I let it go. It wasn't worth worrying about because this friend has "gone away" before.

This friend and I have been through a lot together. Quite literally, we have lost our shit together. We have been down weird, strange, awkward roads and lived bizarre realities, stranger times, once upon a time. We've grown up now. I told myself, lie #1, that we just grew apart and now that she has kids and I don't, she chose to leave my life. It hurt. I won't say I didn't cry, that would be lie #2. But I told myself it was for the best.

http://psychcentral.com/blog/archives/2011/02/18/10-tips-to-mend-a-broken-heart/

You see, this person had surgery 3 months after me. Didn't want me to know about it. I found out about it. I was so happy for her. She chose more wisely, bravely than I did, had a different procedure. She chose something that was still investigational at the time. (I like to think it's because she way smarter than me in the scientific sense, but at the time, I think she just did better research. I look back and realize I was naive, and used poor logic in thinking that not cutting part of my stomach out was a good thing-- rather, squeezing it with silicone would be better--- little did I know the rejection my mind and body would go through.)  She's been more successful than me, since my band is out, I'm slowly regaining weight, and not without trying to keep it off. I'm proud of her success, but I hate that I can't tell her that.

I hate that my best friend is gone. For all the history and love I have for her, all the things that have passed that we did as stupid college kids, I know she's still one of those soul mates in my heart. That we can laugh and cry and goof off like old times if we just looked at each other and said, "I'm sorry."

Actually, whatever it was, "I'm so seriously sorry." If I likely said some asinine thing that made no sense, had no validity, was illogical, offensive or ignorant, whatever it was, I just want to say sorry and have her back in my life. I accepted the loss as likely something that was good. We got in trouble together. A lot. Like, who do you wake up next to you in jail kind of trouble... but that was once upon a time. We've grown out of that kind of behavior. I know I have. I'm pretty sure she has. I wish we could be grown up together.

This is probably one of the most personal posts you will ever see here. I didn't even cry writing it because I had accepted the unexplained confusion over a year ago. I just let it go... Or so I thought. Until something strange and rather ridiculous brought it back up out of the blue. It brought the blues back....

Putting it out there, saying it, I miss you like hell.

“There is one emotion that is stronger than fear, and that is forgiveness.”

The Tale of Despereaux

New Series on Understand Counseling Theories: Part One - Understanding Theoretical Orientation

We are all unique individuals with certain needs in therapy. I hear very often people say, "I only went to therapy a few times, I didn't like my therapist."  This concerns me because not all therapists are meant for every client. Taking the time to interview your therapist about their approach to counseling is advisable. Any good therapist will give you some time on the phone to discuss their theoretical framework and approach to your specific concerns and issues.

Each therapist is going to have their unique theoretical orientation. This simply means they follow certain schools of thought in the way they interact with clients. What this means is that counselor uses certain techniques to engage clients in meaning for processing of their issues. In this series, I will do my best to explain what a therapist's theoretical orientation is and how you can choose a good fit for your reason for therapy.

There are several central figures in the history of psychology. Sigmund Freud is quite possibly the most renown psychotherapist and the "Father of Psychotherapy." As the field of psychology grew, so did the theories of great thinkers and researchers alike. Freud's psychoanalytical theory provides a set of terms, guidelines, therapy techniques, ways of thinking etc. The picture comes to mind of a person on a couch exploring their experience through talk therapy. Consideration to what you seek therapy for may often dictate which orientations suit your needs. If you like the "talk it out" process and believe that a listening ear and thoughtful insight are good counseling, a psychoanalysis may be the way to go. However, most therapists' are going to use talk therapy and psychoanalysis to an extent, and their actual theoretical orientation is something they call "eclectic," which maybe a combination of many schools of thought.

Often times, our issues maybe central to the relationships in our lives.  Our family structure or relationships may post strains on our ability to cope with difficult problems or emotions. If you are seeking counseling for your marriage and family issues, a marriage and family therapist would engage you in the Family systems theory and process your issues with you through this theoretical framework. A session would look very different than an individual counseling session where the therapist practice existential counseling theories (but more on that later.)  Family systems theories are often performed as an ancillary function of their role as a leader in the community, such a priest or reverend, chief of a tribe or head of a spiritual group.  This approach can be useful with interventions for drug and alcohol abuse if the person holds those in high regard and it fits within that person's belief system. Generally, this spiritual framework will only work if the person accepts the intervention and is willing to do the work to repair broken relationships.

Generally, counselors employ the techniques of more than one theoretical framework.  You will often her them say they are "existential therapists" which means that person employs the use of more than one theoretical approach.  A counselor can practice more than one type of therapeutic intervention and even take into consideration the beliefs of their client in order to meet their needs. An individualistic approach tailored to that client's needs is the best approach by any counselor. However, some therapists choose to work within their framework and don't adapt to client's needs. A counselor who offers you a person centered cognitive behavioral therapy combination may favor may be guided by the behavioralist in their interventions but uses a person centered approach to their session style. You have a right to know, understand, and be educated on the theoretical orientation that your treatment is derived from.

Some types of theoretical orientations simply do not mesh well with Christian beliefs. Aspects of the theory might be used but be weary of a counselor who uses one of these theories for their main practice. Psychoanalysis provides a good example of the foundation of unconsciousness, this is not necessarily
against Christian beliefs but a psychoanalyst explains the unconscious through repressed sexual feelings. The family system, relationships, your overall experience with the world outside of yourself is largely determined by unconscious sexual urges in psychoanalysis. Consideration of this factor determines that Christian morality might not mesh with this framework.

While most of psychology is based on Freudian thought, it possible to counsel a Christian even though psychology is considered an analysis of abnormal behavior. The process of thinking, conceptualizing and formatting your ideas into your moral code and analyzing your cognitive dissonance may allow a person to match the inconsistency of their thoughts, words, beliefs and actions. Recognizing how your beliefs relate to your actions can change a person to live a more morally congruent life.

I know, this has nothing to do with bariatrics, weight loss surgery or weight loss--- yet.  I'll get to that part in the next post.  Next up, your personality and how it relates to your therapist.

Ethics and Professionality in Bariatric Counseling

In the counseling profession, the code of ethics and responsibilities we have to keep confidentiality is a crucial element of our practice.  It's not an option, if we have a client who comes to see us, initially, we must explain to them what our code of ethics and our responsibility to them as a client is in the scope of confidentiality. 

What does all of that mean?

Simply put, if you are my client and I am seeing you in a therapeutic role and thereafter, I will always have an ethical obligation to you to minimize our contact outside of the counseling session, not disclose personal information about you as a client to anyone who you have not given me permission to discuss your case, and to always explain to you my position and role in and outside of the counseling session. Basically, if I see you at the grocery store, gym, church, school, etc, I will purposely avoid you.  If you say hello to me, I will say hello back and go about my business as I would had you not seen me.  I care about you enough to pretend to not know you to protect your privacy and not have any of your private issues potentially be discussed outside of the protected counseling environment.

I will always be upfront with my clients about my personal experience with bariatric surgery.  I cannot ethically, work in this field without telling my clients that I am a bariatric surgery patient.  My experience is not the same as other weight loss surgery patients' experiences.  I recognize and acknowledge that we all have our own reasons as to why we choose weight loss surgery as an assistive tool for us to lose weight. 

Some have major medical issues, others are preemptively electing to have surgery to prevent potential medical issues in the future.  I consider myself as part of the latter group that was anticipating that my health would decline in the long run due to excess weight.  I know that many clients are already suffering from painful, major medical issues and their reasoning behind their choice to undergo surgery maybe different from my own.

I will never use my role as a counselor to seek out my needs as a weight loss surgery patient.  I am in this field because I see a dire need for bariatric counseling in the process of long term after care.  Losing weight will not solve all of life's problems.  More often than not, the new issues are going to be challenging, changing and identifying of underlying problems that may not have been observed by "the cloak."  The cloak is all of the things we've hidden from addressing throughout our lives about what's bothering us on the inside.  What was it that made us turn to food in the first place.  How did we ignore or fail to understand our body's needs and limits?  Our internal ability to find satiation was skewed in some way.  Again, we are all different, each person is an individual and gaining this insight and understanding is crucial for adopting permanent healthy habits. 

Understanding the weight loss surgery community, online communications, and confidentiality, I will never identify in discuss a single person's experience or relay information regarding that person that could impact their life.  First and foremost, I do no harm.  I will never engage in, take sides with or include myself in the conversations that occur regarding a person's situation and/or the choices they make.  Quite frankly, I will acknowledge that talking amongst each other occurs, but as a counselor, I respect the privacy of others.  If someone seeks out help from me, they can be assured that I will take their trust in me seriously and apply my ethical standards to their confidence in me, no matter they be a paying client or an online contact asking for my help.  The only time I would ever breach confidentiality is if the person made me aware of their intention to harm themselves or someone else.  In taking any action, I will make that person aware of my duties prior to doing so and specifically know what that action is I must ethically take.

Also, as a counselor intern in the State of Louisiana, I cannot treat people who reside out of my state.  The practice of counseling must occur in the state, therefore unless I have established a face to face relationship with a client in the State of Louisiana, I will not work with a client through video conferencing mediums.  In email, I am limited in my ability to help and assist clients with their problems.  I will not offer advice but rather ask you how you can change your current situation or what it is you could do to move toward the progress you seek that you are not currently finding.  If I have the resources for professional mental health practitioners in your area, I will refer you to those resources.

This post is meant to be a documentation and clarification for everyone who I have met, become friends with, and come to know in the bariatric community.  It takes a long time to build confidence and rapport in a community. As a counselor intern in the mental health field, I want to establish clear and concise guidelines that show my clients and colleagues that I am aware of my role and responsibility to this community.   I may be seen as a newbie, but counseling is nothing new to me.  We are always learning, and we learn by doing.