home come coming home homing come home

This week has been a coming-home of sorts, in ways both literal and figurative.

As I write this, I am at my laptop in my parents' home in suburban Minnesota, back visiting for the Thanksgiving week. As always, coming back home (is this my home still? or in my home in New York, with my husband? ah such questions) is a strange combination of familiar and foreign. My bedroom, while not quite a shrine to my adolescence, is filled with shelves upon shelves of the books that I read in college: Borges, Neruda, Fuentes, Mistral, Arenas -- books that I read when I thought that I would become a professor of Latin American literature, and planned my career accordingly. What got in the way was an eating disorder that made me reflect on what I really wanted out of life. Would I live my life surrounded by books that no one else had ever read, attending literary conferences to debate over obscure topics, and spend my weekends memorizing poetry? Or would I -- as I considered later -- dedicate my life to understanding, to the best of my abilities, the origins of distress, of disease?

I know that I am not alone in saying that my eating disorder changed my life. The obvious ways: I chose psychology instead of literature, empirical study instead of postmodern critical theory. My Ph.D. is a means to an end: I want to do research that matters. I want to bring all that I have witnessed and experienced to bear on my work as a therapist. I want to have an impact that goes beyond my tiny circle. These are the goals that changed after having an eating disorder. And I know that I am not alone in rearranging my priorities, because on Friday night I met up with three other women who have struggled with eating disorders, and all of us are caught up in larger plans that have to do with healing. Twisted Barbie is studying to be a social worker; Stephanie produces films and plays about eating disorders; and the third woman in our group is studying to be a physician's assistant. Wounded healers, all of us.

That encounter was another sort of home-coming, because I haven't spent so much time, in person, with ED folks since leaving college. My ED changed my life, and even though I am not ashamed of it, there are few new people in my life with whom I would feel comfortable talking about what I went through. There are always "easier" explanations to give for why I study clinical psychology, and along the way I certainly have found other reasons to continue in the field. ED was my entry point to so much more, and most of the time I am content to talk about that so much more and take pleasure in the fact that there is so much more to my life right now than the fact that I had an eating disorder. Still, I had it. It marked me. I changed because of it. My eating disorder set off a transformation in me, or metamorphosis if you will, that has yet to end. There is no end to healing and learning from this thing, no limits to what we can do with our experiences. And this week I am coming back to that, reminding myself of where I have been and where I am going.

Subjectivity and science

I am becoming a scientist. I am trained in research methods, statistics, and in the critical analysis of empirical data. As a researcher, I want to study mental health and physical health; mental illness in developing countries; immigrant communities in the United States; and religion and well-being. It would seem like I would think twice before taking on another research topic. Yet that is exactly what I did this week, as I prepared a brief paper on eating disorder classification and the revision of the Diagnostic and Statistical Manual of Mental Disorders. For once, I wanted to study eating disorders face to face, peruse the most recent literature, and put all of my scientific training on a topic that is perilously close to home.

What have I learned from this experiment/experience? I am a bit disappointed at the outcome. My scientific training has prepared me for reading correlation tables and understanding casual relationships, but it has not taught me what to do when the topic that I am reading about pertains to my own life.

The issue of "bias" crept up on me as I read about eating disorders, but not in the way that I expected. I have strong views about eating disorders based upon my own experience, but I am willing to put those aside in the face of strong empirical to the contrary. It was not this kind of bias that I struggled with as I put together my paper, but rather the kind of bias that directed my attention towards those topics that had the most personal relevance.

Usually, when I read scientific articles, I pay attention to things like the methods used, the sample size, the statistical analysis, the significance of the results. With eating disorder research, my initial reaction was different: I read much more selectively. For example: I often struggle with anxiety, so when I came across a few articles that linked eating disorders and anxiety through family studies, I was eager to understand everything that I could. There are similar studies that show connections between eating disorders and obsessive compulsive disorder, and eating disorders and mood disorders -- but because I have been trying to get my own anxiety under control, those were the articles that most caught my attention. This kind of selective reading is most decidedly not the objective approach I have been taught in school, and yet I wonder if it isn't helpful, in its own way.

One drawback to empirical studies is that they often lack a clear sense of their own meaning. What does it matter if people with anorexia are more likely to have anxiety disorders than your average Susan? To scientists, such connections teach us more about the origins of mental illness, but to individuals who suffer from anorexia, knowing that anxiety may be par for the course may be immensely reassuring, in its own way. Going back to my own example: I have recovered from my eating disorder, but I feel that I still have something to gain from addressing my anxiety. Knowing that anxiety often accompanies (or precedes) eating disorders is reassuring in that it tells me that there is an order to this mess of my mind, that it may behave in predictable ways even as it feels chaotic to me. In fact, knowing that anxiety is linked to eating disorders makes me more inclined to treat my anxiety seriously, not just as a remnant of my eating disordered past, but as something that might be worth understanding better in the here and the now.

I am curious: if you have had an eating disorder, how do you feel about reading research about them? Do you have trouble drawing the line between personal experience and scientific evidence and, if so, how do you reconcile the two? I suspect that my attitude towards ED research will change as I learn more about it -- in the brief span of writing this paper I became noticeably more focused on the data, and less on my own experience -- but I would like to know how others deal with this problem, too.

The right to privacy

Tonight my husband asked me if I had told anyone in my graduate cohort about having had an eating disorder, and how that experience brought me into clinical psychology. I have not told anyone yet, and may not do so for a very long time, if ever. Even within the field of mental health, there is still some stigma surrounding the admission of mental illness by its practitioners. When I was applying for Ph.D. programs in clinical psychology, for example, I studiously avoided any mention of eating disorders or my own experiences in therapy. It wasn't hard to do -- I had a story ready for anyone who asked me how I became interested in psychology, and though it is only part of the truth, it was enough to keep me feeling authentic.

The other night, however, I heard what was perhaps the best explanation yet for why psychologists and psychologists-in-training might want to think twice about letting other people in their profession know about their own histories with mental illness. I was at a meeting about externships in neuropsychology, and a member of a panel discussion strongly advised the students in the audience to avoid putting too much personal information in their application essays. "In this profession [clinical psychology], it is necessary for us to know how to maintain personal boundaries, and part of what you show us in writing an application essay is how well you will be able to maintain those boundaries in your practice."

Hearing her words, I felt a sense of relief. So I wasn't the only one hiding my past! And nor was there anything to be ashamed of in doing so -- in fact, it is de rigeur in the profession! In a sense, this speaker gave me the permission to do what I have instinctively done: protect my most fragile self, maintaining my own space in the midst of so much talk, and study, of mental illness. This is my experience, one that I am willing to write about here, but one that will remain unknown to my professional colleagues, at least until I know better.

For the meanwhile, I am grateful to have this space to write about eating disorders, food, and my own experiences. In this way, I have an outlet for all of the opinions that I am forming about eating disorders and a way to work out the experiences that still trouble and inspire me. I have a community here of fellow travelers, people who speak with the raw honesty of having lived through an eating disorder: they know, as I do, distress from the inside.

I am committed, for the next five years, to understanding distress from the outside, from the scientific, clinical viewpoint. But I am also committed to you, my reader, and to this, this process of writing out and writing through my past pain, in order to come to grips with all that I bring to my profession and to my present.

Gray matter, no matter

These hours between school or work and bedtime are the most precious to me. They are when I see my husband; when we prepare and eat dinner together; and when I get a few scant hours of course reading in before I have to head off to bed. So I'll be brief here.

I have spent more hours than not lately studying my neuroscience textbook and pushing all other responsibilities out of the way. I have memorized the parts of the brain, figured out action potentials and neurotransmitters, and charted the effects of drugs on the body. The last two Saturdays I have spent cooped up in our apartment, a mug of tea in hand and Bach on the stereo, examining neuroanatomy slides and repeating, to myself, the names of ventricles and nuclei and tracts over and over again. Even though I feel tied to my chair, forced unnaturally to be studying on a weekend, I love the material. I love the sense of awe that I feel at understanding the origin of our thoughts and feelings, and the amazement at thinking that, some day, I could understand this field as well as I understand Spanish literature or cooking.

Behind my appreciation for neuroscience, I feel a sense of spiritual mooring. The body is our home, after all, and studying the brain makes me feel very close to my origins. I trace its contours and think this is me. Yes, this mass of spongy matter, this curving and branching and spliced, turned, fluid thing. This map to our center, this gray labyrinth of desire, this one mortal coil: you, and I, and all the rest.

How deep our science goes!

News gets around

My thanks to the anonymous reader who sent this link my way -- Tara Parker-Pope, for The New York Times, on "Eating Less or Eating Better." Her article reports on a sea change in the diet wars, as long-time dieters who are tired of the yo-yo effect are turning to simpler, more pleasurable ways to enjoy their food. 

This "new" philosophy is very much the one that I have embraced in my recovery from an eating disorder, though no mention was made of eating disorders per se in the article. Although I don't necessarily use weight as an indicator of health, I was interested to learn that the more time that people spend preparing and cleaning up their food, the more likely they are to be at a middle weight, as opposed to "underweight" or "overweight." In my own experience, preparing my own food has been absolutely central to recovery from my eating disorder -- but I had no evidence for this other than my own experience, until reading this article.

The truth is, I don't read a lot of research regarding nutrition or eating disorders, but this article has me asking myself if maybe it is time for me to pay a little more attention. 

Although I don't write about it much here, in my other life I am a doctoral student in clinical psychology; I spend most of my time reading scientific publications about mental disorders and their treatments. It is certainly within the realm of possibility for me to spend a few hours researching the most current news on eating disorders. But, until now, most of what I have stumbled across in the way of eating disorders -- both in the journal articles and in the persons of the researchers themselves -- has been less than appetizing. 

A few years ago, I worked briefly as an intern in an obesity research clinic whose main project was to enroll participants in a liquid diet and monitor their weight loss while providing "supportive" counseling. Their secondary project was to give group therapy to patients considering bariatric surgery. Fortunately, I did not have to work there long, because I had a lot of misgivings about liquid diets, bariatric surgery, and the attitudes of the researchers towards the patients ("People are obese because they overeat. Period.").

Before that, I had applied for a job as a research assistant at a prestigious center that studied eating disorders. In my application for the job, I was forthright in revealing my past history -- having an eating disorder had made me very interested in eating disorders, after all, and very motivated to work in that field. I ended up in one of the most uncomfortable interviews in my life when a psychiatrist on the team asked me, while looking me up and down, if I had been "a normal-weight bulimic." The nerve! I withdrew my job application immediately and wrote a terse email to the study director, who had gone to my same alma mater, telling her that I had considered her colleague's behavior in an interview absolutely inappropriate.

And that was the end of my great career as an eating disorder researcher.

I got another job, in public health, and haven't looked back. Within psychology, I love studying health psychology -- understanding the connections between mental and physical health -- and I'm not likely to give it up to pursue eating disorder research at this stage of the game. What I write on these pages is personal, not scientific. I form a sample size of 1, hardly a reliable study design. My words are the stuff of clinical anecdote; at best, I am a case study. 

And yet, and yet -- I have the tools at my disposal to find and understand the research that is coming out. I may disagree with much of it, especial with nutrition science, but that's no reason for me not to look it in the eye and evaluate it for what it is, flaws and all. One thing that I love about the scientific method is its willingness to test out its hypotheses, even if they might be wrong. Although I am trained in this method, which is designed to examine external phenomena, my body has always been my first site of investigation -- as it is for all of us. 

These last three or four years have been an exercise in getting to know my body better, in empirically testing what works for me. If you have been reading, you know what I have found: eating whole foods that I cook has been the best form of therapy that I could imagine. Do I have the evidence to back it up? Not now, but I'll look into it.

Until then, will you accept the following? A breakfast of mung-bean and coconut porridge and tangerines, taken around 7:00 am this morning:

 

The proof is in the pudding, as they say.

~Ai Lu

Good governance, bad governance, and health insurance

I have spent the morning puzzling over my health insurance options for the upcoming year, comparing various plans offered by my new university. Choice is good, right?

Choice is good, except when you're trying to simultaneously compare the labyrinthine language of three different health insurance plans. There's no doubt in my mind that such confusion is intentional on the part of the insurance companies; who wouldn't rather just sign on the dotted line and be done with it? That's what the companies hope for: that we'll assume they are taking care of us, and waive our rights away.

Not this time.

I've gone in and out of enough insurance plans over the last four years to be somewhat wary of starting over again with a new plan. In my case, I have been very fortunate: I have never been hospitalized; my health is good, overall; no serious medical conditions to look after, etc. My only real health concern, this time around, has to do with starting psychotherapy again, this time without meeting DSM-IV criteria for an eating disorder, and I'm hoping that I can get at least some coverage from my health insurance to do so.

The reasons that I want to start psychotherapy have little to do with what brought me into treatment seven years ago for an eating disorder, and are more like the everyday things that bring most folks into psychotherapy: life stresses, career changes, family problems, etc. These, and the fact that I'm starting a Ph.D. program in clinical psychology, and would relish the chance to be in therapy again myself before I start to see patients. So in this situation, I ask myself, is it even ethical for me to seek coverage for psychotherapy for the condition of "eating disorder"? Conversely, might I consider these life stresses as possibly related to the eating disorder I once had -- as risk factors for a possible relapse -- and thus justify my treatment?

Regardless of whether it is ethical or not, I am left with a lot of uncertainty about whether I'll even qualify for coverage under the best of these plans. On the one hand, it offers coverage equivalent to other medical illnesses for "biologically-based mental illness," including "anorexia and bulimia". It is wonderful that this plan offers parity for mental health care, especially given the attention that the issue has received in the news recently. But I wonder how far such parity will go: if I am presently asymptomatic, does that mean I can't receive coverage? Or does my one-time diagnosis of an eating disorder last a lifetime, if it were? (Once a bulimic, always a bulimic?) Additionally, as this is a "pre-existing condition," though one not treated in the last six months (as they define pre-existing), will I be excluded from coverage for another 12-months (as the plans threatens)?

I can hardly get my mind around whether or not I'm eligible for treatment, so I can only anticipate the problems that will ensue once I actually sign up for the plan and attempt to get the coverage that I feel is due. It is dishearteningly for me, both as a patient and as a future mental health professional, to see all of the obstacles that are put in patients' way as they try to get treatment. I am reminded of Franz Kafka, of Jorge Luis Borges, of Ambrogio Lorenzetti's frescoes of Good and Bad Governance that we saw in Siena this summer.

One side of Lorenzetti's fresco (the first image of the post) depicts the effects of good governance: the exercise of justice; profitable businesses; happy and healthy citizens. The other side of the fresco (detailed to the right) shows the effects of bad governance: persons unjustly imprisoned; crop failures; violence; poverty; plagues and pestilence. These murals were intended to teach the rulers of Siena the importance of good governance for the health of town and country.

If the state of our health care system in the United States is any indication, I would say that we are erring on the side of bad governance. If not, why do we put the burden on the ill to know their rights and insist on receiving their benefits? Why is it left up to me to try to understand whether or not I should be covered for psychotherapy? Why do we seem to be hurtling ourselves head-first into the scene depicted below, a desolate countryside full of starving and sick individuals? I am concerned for myself, but I also recognize that mine is not a severe case; whether or not I get coverage, whether or not I'll get treatment, I'll basically be all right. But what of the thousands of people who won't be all right? Who have never been "all right"?

I can only hope that these strangers, other Americans with mental or physical illnesses, can find some clause in their insurance allowing them treatment; that they have family members willing to make phone calls when they are too sick to care; that they have considerate doctors who choose appropriate, economical, humane forms of treatment; and that we see some shift towards "good governance" with the elections in the fall.

I'm voting for better healthcare. And you?