jrust August 23rd, 2010

FEARLESS WOMEN DAY

At Mirasol we are looking forward celebrating Fearless Women Day on August 26!

This is the 90th anniversary of the passage of the19th amendment that
gaved women the right to vote. We celebrate this day in remembrance
of the women who never had the right to vote, to own property, to
equal wages, and among other things, the right to be heard

We celebrate the women who, over the course of the last two centuries,
struggled tirelessly so that we, as women, could enjoy those basic rights.
They set an example of courage and resilience that, even 90 years
later, still inspire women all over the world.

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jrust August 9th, 2010

At Mirasol we have been seeing much more serious trauma in clients who are currently admitting for treatment. In fact we’re seeing so much trauma that we’re in the process of having all clinicians trained in EMDR, one of the most effective trauma interventions used at this time. Our clinicians are experienced when it comes to working with PTSD and childhood trauma but we want to make sure that each one of them has the best tools available. Because so many people with trauma are admitting, Diane Ryan, the clinical director, and myself have been doing vast amounts of research on any new information available in regards to trauma and its treatment.

We have found that the subject of complex trauma or DESNOS, a diagnosis of extreme stress not otherwise specified is in fact much more common than a diagnosis of straight PTSD.

PTSD was originally developed as a diagnosis in the 1970s to explain the symptomology of Vietnam veterans returning home after the war. Research has shown that men are traumatized most frequently by accidents, war, assaults, and natural disasters, single event occurrences.

Women are most frequently traumatized by childhood sexual abuse. B.A. van der Kolk (2005) reported that between 17 and 33% of women in the general population had histories of sexual-physical abuse while women who were in psychiatric treatment reported 35 to 50%.

PTSD has captured only a partial snapshot of posttraumatic psychopathology. The PTSD diagnosis does not capture the facets of long-term, repeated trauma. People with a history of physical and sexual abuse over long periods of time report many psychological problems such as substance abuse, borderline and antisocial personality disorders, eating disorders, impulsivity, self-mutilation and suicidality. They will be chronically depressed with dissociative episodes of varying lengths of time. Extreme aggression and impulse control difficulties are also present.

PTSD clinically has referred to these other problems as co-morbid conditions, as if they have occurred apart from the PTSD symptoms. As a result the authors of the DSM-IV began to separate these other symptoms under a category of extreme stress not otherwise specified (DESNOS). They found that the earlier the trauma the more severe the symptoms of DESNOS. Studies also have shown that it is possible to experience DESNOS without having PTSD, certainly above and beyond PTSD.

DESNOS represents a psychological injury from long-term social and/or interpersonal trauma that is characterized by lack or loss of control, disempowerment, and the victim is unable to escape.

In many situations such as caring for a mentally ill person at home, a care- giver may develop symptoms themselves of traumatic stress from prolonged exposure to traumatic stress.

When a patient admits to treatment, we do pre-treatment testing, such as the Beck Depression Inventory, the Eating Disorder Inventory III, the SCL-90 including testing for trauma and dissociation. If the client has a history of trauma, our clinicians will immediately focus on stabilization techniques.

The therapist must have the attitude that nothing is more important than safety and stability. The therapist must assume the role of teacher or guide for the client. Trauma survivors cannot teach themselves how to be safe and stable because
they have no baseline, no meaningful experience of what the words “safe ” or “stable”
mean. This is where a strong, centered, grounded therapist is necessary to be the teacher. They help the client learn to ground herself and to find a safe place where she can go and be protected under any circumstances.

The therapist teaches the client that no recovery from trauma is possible without paying attention to issues of safety, learning to care for herself, making connections to other human beings, and a finding a renewed faith in the universe. The therapist’s job is not just to be a witness to this process but to teach the patient how.

Tags: eating disorder, eating disorder treatment, eating disorders, trauma and eating disorders

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jrust July 30th, 2010

At Mirasol we have been admitting many more patients recently who are considered to be dual-diagnosis patients, meaning that they have more than one serious diagnosis. Can these patients really be called dual-diagnosis when they have more than two co-occurring conditions? Should we refer to them as having multi-diagnoses? It is not uncommon for a patients to admit with not only substance abuse, an eating disorder, but also post-traumatic stress disorder, depression, and accompanying anxiety.

Previously the conventional way of thinking was to treat the substance abuse first, then address the eating disorder. At Mirasol we have long believed that all co-occurring conditions need to be treated at the same time. If all the conditions are not treated at the same time, treatment outcomes are usually poor, and what would ordinarily be considered a small slip can turn into a cascading event, almost like a house of cards, with one slip triggering another one rapidly.

A strong connection between eating disorders and substance abuse has been long evident with a majority of women reporting binge eating and/or bulimia nervosa along with the substance abuse. Some 40-50% of all women who have an eating disorder will have a problem with alcohol and drugs either currently or at some time in their lives. The eating disorder and substance abuse are frequently accompanied with PTSD.

In a recent piece of research by L. R. Cohen, S. F. Greenfield, S. Gordon, T. Killeen, Y. Jiang, and D. Hien, Survey of Eating Disorder Symptoms among Women in Treatment for Substance Abuse, the investigation found that in women with co-occurring substance abuse disorders and PTSD, a little more than one-third of the women were binge eaters as well. The women who were binge eaters had higher eating disorder, PTSD, and depressive symptomology than those women in the non- eating disordered group. Researchers also found that progress in the binge-eating group was much slower. It stands to reason that the relapse rate would also be higher with the binge eaters.

The researchers said that the women with an eating disorder responded differently to group treatment than did the PTSD and substance abuse group. They recommended individual treatment plans. This is exactly what we do at Mirasol. Since we have only ten patients and a staff of over 50, we can highly individualize treatment plans for these complex cases.

I am always reading journal articles that report new research in eating disorders, substance abuse, and PTSD, and I found that the greater the severity of childhood trauma and PTSD or Disorder of Extreme Stress Not Otherwise Specified (DESNOS), the earlier the onset of alcoholism and related problems. When any patient now admits to Mirasol with dual-or multiple diagnoses, we are including testing for PTSD and trauma in the initial battery of tests (Dom, G., De Wilde, B., Hulstijn, W., Sabbe, B. Traumatic experiences and posttraumatic stress disorders: differences between treatment-seeking early- and late-onset alcoholic patients.)

Complex trauma is the type of trauma that is associated with childhood trauma that is usually ongoing. There is another type of trauma that can be traced to a single event, such as a war experience, automobile accident, etc. When a client has PTSD with an eating disorder, the trauma is generally complex trauma. We have developed specific protocols for these patients.

Here is one of the best short overviews that I’ve seen defining complex trauma. It is from Dr. Felicia Mueller in Seattle. She says that:
“Complex trauma or Disorder of Extreme Stress Not Otherwise Specified (DESNOS) refers to a condition resulting from exposure to multiple traumas or from exposure to high levels of chronic stress. Whereas Post Traumatic Stress Disorder (PTSD) is a condition that develops from exposure to a single traumatic event, complex trauma results from multiple exposures to one or more traumas.

When the human organism is repeatedly exposed to traumatic stress, disruptions can occur in brain functions and structures, endocrinological function, immunological function, and central and autonomic nervous system arousal. These biological disruptions interact with psychological, emotional, spiritual, and cognitive processes and a variety of disturbances can result that go beyond the re-experiencing, avoidance/numbing, and arousal symptoms that characterize PTSD.”

Tags: anorexia, bulimia, complex trauma, dual diagnoses, multiple diagnoses, PTSD, trauma

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jrust July 29th, 2010

Most eating disorder patients suffer from an illness that has no name. EDNOS (eating disorder not otherwise specified) has become a catch-all diagnosis for clients who may be desperately ill, but whose symptoms don’t match rigid clinical criteria for anorexia or bulimia. Several recent studies have concluded that at least 40% and possibly up to 90% of clients seeking treatment for an eating disorder have symptoms that don’t fit neatly into established diagnostic criteria.

Many mental health professionals use the DSM (Diagnostic and Statistical Manual) as a basis for determining a diagnosis for a patient after an evaluation. According to the DSM (Diagnostic and Statistical Manual), an anorexia diagnosis is now based on being at less than 85 percent of the expected body weight, loss of menstrual periods for at least three months and fear of weight gain despite being dangerously thin. Bulimia patients repeatedly binge on large quantities of food, then “purge” calories by vomiting or abusing laxatives or diuretics.
However, anyone who treats patients with eating disorders can tell you that this disease encompasses many variations and can be extremely difficult to define. For example, some of Mirasol’s clients overcome their anorexia only to succumb to bouts of binge eating and obesity. Many, many of our clients are compulsive exercisers for whom exercise is simply another method for purging. We’re also seeing increasing numbers of “orthorexics” who suffer from a dangerous obsession with “healthy” foods.
A new version of the DSM scheduled for release in 2013 will likely include revisions to strict criteria for anorexia and bulimia and recognition of binge eating disorder (BED). However, many health professionals worry that a significant percentage of eating disorders will remain undiagnosed and untreated.

A recent study by Stanford University School of Medicine and Lucile Packard Children’s Hospital concluded that diagnostic criteria for anorexia nervosa and bulimia nervosa may be too strict and may delay treatment for patients who are critically ill.” According to Rebecka Peebles, MD, the study’s primary author, the EDNOS diagnosis lumps dissimilar patients into a single category that gets poor recognition from clinicians and health insurers.

Peebles’ team examined records from more than 1300 female patients treated for eating disorders from 1997 through 2008 to determine whether patients with EDNOS were less ill than those who met the full diagnostic criteria for anorexia or bulimia. Patients’ conditions were assessed by noting signs of malnutrition — such as low heart rate, low blood pressure, low body temperature, low blood levels of potassium and phosphorus — and long QT interval (an electrocardiogram measurement linked to risk of sudden cardiac death). The study found that 60 percent of EDNOS patients met medical criteria for hospitalization and this group was, on average, sicker than patients diagnosed with full-blown bulimia.

While patients diagnosed with EDNOS may be sicker than those who meet strict criteria for anorexia or bulimia, they may find it much harder to obtain treatment. Many health insurers offer little or no coverage for eating disorders other than anorexia or bulimia.

We frequently find that patients are denied insurance coverage particularly if they’ve gained a couple of pounds. The rational from the insurance companies is that patients can continue to recover at home because they now eat and they’ve gained a little weight. I mean a little weight – many times their weight is still far below 85%.

All eating disorders are alike in that they involve the use of food to satisfy emotional rather than physical needs. A recurrent theme in Mirasol’s process groups is that all our clients – regardless of their clinical diagnosis — struggle with the same issues of self-esteem, obsessive behavior and body image. As clinicians, we must satisfy the demands of insurance companies for precise diagnosis while remaining focused on identifying and treating the underlying cause of the disease.

By learning new ways of communicating and coping, and practicing those skills in a safe and supportive environment, our clients can restore balance in their lives and achieve lasting physical and emotional and well-being. And while the eating disorder may be undefined, this is surely the definition of “recovery”.

Tags: anorexia, bulimia, eating disorder not otherwise specified, EDNOS, insurance denials, Rebecca Peebles, treatment

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jrust July 28th, 2010

Enthusiastic CARF surveyors said on July 23, 2010 that Mirasol is light years ahead of any other program in the country. Continuing they said, that in all of their years working in the mental health field, they had never seen a program as excellent as what we do at Mirasol.

CARF, a national accrediting agency that examines and awards accreditation to more behavioral health facilities than any other agency, examines Mirasol every three years. A CARF endorsement means that a program’s policies and standards meet the highest possible criteria of excellence. An accreditation by CARF is proof of excellence in all areas of a facility.

Last Thursday and Friday two CARF surveyors arrived. Both of them were long-time inspectors. One member of the team was an RN with 30 years of experience in the mental health arena. The other was a man with behavioral health experience as a social worker but also an experienced surveyor having done surveys for CARF for over 25 years.

When the survey was over, our management team and the surveyors gather round for “The” report. The entire staff had worked for months making sure that we had everything ready. After the CARF people gave their report , my mouth was hanging open. I knew that we had an excellent program. I knew we were really good, but I didn’t imagine in my wildest dreams how good we are!

Basing their comments on our outcome data and after viewing our treatment at the units they said our treatment was like magic.

I have never wanted to play the game of outcomes. “Mine is better than yours. “ “No, mine is much better…….. “ Statistics can be manipulated and when I hear someone claiming a success rate of 92% at a year, I know it’s not true.

The team made me promise that I would share some of our numbers with our stakeholders which are all of you!

When someone enters treatment, we do quite a lot of psychological testing. Two of the most important psychological instruments we administer are the Eating Disorder Inventory-III and the Beck Depression Inventory.

I’m going to give you all of this information just as we gave it to the surveyors. It’s rather complicated but you can read the numbers – I’ll help.

The Eating Disorder Inventory 3 (EDI-III) is the third edition of a test that reports in multiple scales.

The test consists of 91 questions answered in terms of frequency of behaviors from always to never.

Reports consist of 21 separate scales; three are validity scales, four are eating disorder risk and composite scales, nine are psychological scales, and five are psychological composite scales. Results are presented as percentiles for all, anorexia, bulimia, and EDNOS diagnoses.

For simplicity of reporting percentiles of two risk scales/composite scores are used, each chosen for broad-based relevancy to Mirasol’s program, the Eating Disorder Risk Composite (ERDC) and the Global Psychological Maladjustment Composite (GPMC). In addition, the 9 psychological scales, including Low Self-Esteem (LSE), Personal Alienation (PA), Interpersonal Insecurity (II), Interpersonal Alienation (IA), Interoceptive Deficits (ID), Emotional Dysregulation (ED), Perfectionism (P), Ascetism (A), and Maturity Fears (MF).
These will all be compared for pre and post scores for the total, anorexic, bulimic, and EDNOS populations.

The information presented in the following chart is based on residents who completed the program during the years of 2007, 2008, 2009, and through June 2010.

You can readily see the differences between the pre-scores and the post-scores. But look at the post scores for EDRC for 2007, then 2008, 2009, and finally 2010. You’ll see that the scores progressively get lower – meaning that our patients are getting a lot better!
Now do the same for the GPMC.

2007 Results Pre EDRC Post EDRC
ALL (N = 22) 53.27 28.00

2008 Results Pre EDRC Post EDRC
ALL (N = 34) 54.06 21.50

2009 Results Pre EDRC Post EDRC
ALL (N = 20) 49.35 13.60

2010 Results Pre EDRC Post EDRC
ALL (N=11) 46.10 11.82

2007 Results Pre GPMC Post GPMC
ALL (N = 22) 56.55 31.45

2008 Results Pre GPMC Post GPMC
ALL (N = 34) 54.44 25.21

2009 Results Pre GPMC Post GPMC
ALL (N = 20) 49.35 18.15

2010 Results Pre GPMC Post GPMC
ALL (N = 11) 44.00 10.27

On the individual psychiatric scales, I won’t list all of them here. I’ll quote a couple:

Self Esteem – 2007 – Pre-56.5 Post – 30.6
2008 – Pre- 59.2 Post – 26.6
2009 – Pre- 47.8 Post – 17.7
2010 – Pre- 47.4 Post – 15.2

Personal
Alienation – 2007 – Pre- 53.6 Post- 31.0
2008 – Pre- 54.7 Post- 23.6
2009 – Pre- 53.1 Post- 18.9
2010 – Pre- 47.6 Post- 14.4

Interpersonal
Insecurity 2007 – Pre- 51.2 Post- 32.8
2008 – Pre- 54.0 Post- 34.4
2009 – Pre- 46.5 Post- 27.8
2010 – Pre – 40.8 Post- 14.6

I am happy to send anyone the full EDI-III report who is interested. On these scales look at the scores pre-treatment and then the scores post-treatment. Then look at how the scores are improving each year!

I also wanted to share the pre- and post- test scores for the Beck Depression Inventory. The Beck is one of my favorite tests. It’s short and very informative.
2007 Results Pre BDI Post BDI
ALL (N = 23) 34.26 18.13

2008 Results Pre BDI Post BDI
ALL (N = 34) 31.50 13.03

2009 Results Pre BDI Post BDI
ALL (N = 19) 30.42 7.89

2010 Results Pre BDI Post BDI
ALL (N = 12) 29.83 10.5

The decrease in the levels of depression as evidenced by these scores is dramatic. They display a general trend of improvement of feelings of well-being.
I invite anyone to phone me with any comments or suggestions. I’m proud of the work our staff is doing – they are truly incredible as is our treatment model!

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edrecovery June 15th, 2010

Mirasol, an alternative residential eating disorder treatment center in Tucson, Arizona, announced this week that it has obtained additional licensing that will help many more women benefit from its services.

“Our new licensure will allow us to provide level 1 sub-acute care, which is a just a step below the level of care provided by psychiatric hospital,” says Jeanne Rust, PhD, founder and CEO of Mirasol. “This will enable us to serve clients whose insurance policies cover inpatient treatment as well as those who have residential benefits.”

Mirasol pioneered the mind-body-spirit approach to the treatment of eating disorders, combining traditional individual and group psychotherapy with proven alternative therapies including neurofeedback, acupuncture and EMDR. Since its founding in 1999, Mirasol has helped more than 700 women recover from eating disorders. Its residential treatment programs are licensed by the Arizona Department of Health Services Office of Behavioral Health and certified by the Commission on Accreditation of Rehabilitation Facilities (CARF).

Rust hopes that the new license will make Mirasol’s unique integrative treatment program available to a much larger population. “We get calls every day from women all over the country who want to come to Mirasol, but whose insurance doesn’t cover residential care,” says Rust. “By broadening our scope of services, we hope to be able to meet the needs of many more women for effective alternative treatment.”

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edrecovery May 6th, 2010

Polarity therapy is a form of energy healing that seeks to unblock energy fields within the body through gentle touch, rocking and point-specific touch. In a typical session, the practitioner assesses energy flow through palpation, observation and interview techniques.

The results of Polarity Therapy can include profound relaxation, relief from hypertension and anxiety attacks and a new appreciation of the importance of energy flow to optimal health and well-being.

Polarity therapy is an integral part of Mirasol’s mind-body-spirit approach to the treatment of eating disorders.

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edrecovery April 29th, 2010

As part of Mirasol’s family program, both clients and their families participate in high ropes challenge courses, including zip lines, high “V” and giant ladders.

“We’ve been doing the challenge course for several years now, and it has become a really important part of our program,” says Mirasol Clinical Director Diane Ryan. “It’s a great metaphor for what the clients are going through in treatment. Recovery from an eating disorder is a huge challenge, but clients learn that they’re stronger than they think they are, that they can access different resources, learn to ask for support, and know that they’re not in this all by themselves.”

Since the challenge course was so powerful in the normal course of treatment, Ryan decided to incorporate it into Mirasol’s three-day family program.

“The exercises help women and their families see how they relate to one another,” says Ryan. “We talk a lot about things like enmeshment and enabling. But it’s one thing to talk about it, and it’s another to get up 40 feet in the air and be leaning on each for support and seeing that one of you is holding back and unwilling to trust. Or seeing how they can push through it by encouraging each other and being clear about communicating what they need.”

In the “High V”, two people clasp hands and traverse a set of cables in a “V” shape, each walking on one of the cables. The farther they traverse, the more they have to lean on one another. The only way for them to succeed is to put their total trust in each other.

“Adding the challenge course has created a whole different dimension. Families often tell us that it was the highlight of the program. It helps them feel connected and learn to communicate in a different way. So it really does what we want family program to do, which is put them in a place where they will have a whole different relationship going forward.”

Tags: challenge course, eating disorder treatment, enabling, enmeshment, family program, high ropes

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DrDawn March 11th, 2010

I was teaching my weekly health group at Mirasol and was feeling really excited about sharing information about herbal medicine with our clients. It was easy to pick-up on their enthusiasm about trying new things as a part of their recovery journey here. I also forget at times how special our program is and how fortunate I am to practice naturopathic medicine in such a unique environment.

One subject of great interest was the topic of nervine herbs. These are herbs that help nourish the nervous system. Many clients discover Kava Kava while in treatment at Mirasol. It’s an herb native to the South Pacific and is very effective in treatment of anxiety. It’s a nice alternative to the highly addictive anxiety medications like Valium and Xanax. You can take it as needed or throughout the day (up three times/day). However, if you’re going to take Kava Kava for more than a few months, it’s a good idea to have your liver enzymes checked.

I’m also a fan of herbal combinations that include passionflower, skullcap and milky oats. These can relieve anxiety and are may help us to better adapt to stress. I also like to include Valerian for clients who have trouble falling asleep or staying asleep.

I have found that there is no “one-size-fits-all” treatment for insomnia. I encourage clients to try different combinations and to practice good sleep hygiene. Cutting back on caffeine intake is a must also for those dealing with insomnia and/or anxiety.

For faster results, I suggest taking the herbs in a tincture form to ensure rapid absorption into the bloodstream. Otherwise, capsules and teas are fine too.

Tags: alternative to Valium, herbal medicine, naturopathic medicine, nervine herbs, treatment of anxiety

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edrecovery March 10th, 2010

There have been big changes in Mirasol’s kitchen, thanks to our new chef, Robert Kuzyk. Kuzyk, who joined Mirasol’s kitchen staff after working in four-star restaurants at country clubs in Kansas and Arizona, believes in maintaining an “open kitchen”, encouraging clients to repair their relationships with food by becoming more involved in the process of creating it.

“What I like to do is help the clients overcome their fears of certain foods by actually cooking those foods with them,” says Kuzyk. “Learning how to cook those foods makes them more comfortable with them when they leave Mirasol and return to the
real world.”

Robert describes his work with Mirasol clients as a ‘building process.’ “The first step is getting them to trust me, and then walking them through the process of preparing the food, so that they realize that what they’re getting is nutritional, healthy food that also fits into their meal plans. I have prepared beef for women who haven’t eaten beef in six years. Even some women who are strict vegetarians have been persuaded to try fish, or shrimp or crabcakes.”

“Robert is very good at encouraging women to come into the kitchen little-by-little and maybe coaxing them to try something they haven’t tried before,” says Mirasol Clinical
Director Diane Ryan. “He’s also really great about teaching them to prepare foods they really like — maybe something they remember from childhood, like a special dessert or even just macaroni and cheese. And they can develop recipes and recreate those foods when they return home, and we find that’s really good for aftercare and for the recovery process in general.”

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Tags: eating disorder recovery, food fears, meal plans

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