Dr. Norman Doidge
A young woman with an Eating Disorder said:
“One day I woke up and realized I couldn’t find myself. No matter what I wore, or how I looked, or who my friends were, myself was nowhere to be seen. I was lost to me, and that’s as lonely as it gets.”
Avalon Hills has benefitted from ongoing consultation with Dr. Norman Doidge in Canada in the areas of program development, innovation, implementation and continuous refinement. Dr. Doidge is recognized as a pioneer in the field of neuroplasticity, the new area of neuroscience focused on brain change (and its relationship to undoing blocks to mental and emotional flexibility). He is the author of the New York Times best-selling books, The Brain that Changes Itself and The Brain's Way of Healing. The Brain That Changes Itself was chosen by the Dana Brain Foundation’s journal, Cerebrum, from among 30,000 books on the brain, as the best general book on the brain. He is also an expert in psychological trauma, treatment and how to put psychological development back on track.
In 2014 Avalon Hills approached Dr. Doidge, to see if he could help us integrate the understanding of neuroplasticity into the treatment of eating disorders, and help us design the world’s first eating disorders program that systematically used these new findings, alongside some of our existing treatments. Eating disorders are thought to give rise to very rigid symptoms, behaviors and attitudes. Benita Quakenbush, Ph.D., our founder and CEO realized, on first being exposed to Dr. Doidge’s work, that an understanding of brain plasticity might help our residents change some of their more rigid attitudes and behaviors. She was initially struck by his understanding of how negative body images develop in the brain, and also how they can be changed if neuroplasticity is understood.
But what emerged from these many visits to Canada to consult was far more than that. Dr. Doidge is also an internationally recognized leader in intensive, in-depth psychotherapy, and suggested an approach that took not only the best of the latest brain science and plasticity, but integrated it with the best of existing intensive psychotherapies. This kind of integration had never been done, and these in-depth psychotherapies are often not used today in residential treatment for the simple reason that insurance no longer covers this intensity of treatment,. As well, these treatments are complicated for staff to learn, and it takes a lot of time to train staff so the new brand of for-profit residential centers don’t consider them.
What emerged was a new model of eating disorders as not just as a collection of symptoms, but rather as a developmental disorder, affecting mind and brain. The symptoms are attempts by the patient to deal with, among other things, the problems in the development of a self, identity, body image, inability to read many of their own feeling states, and discomfort with their own femininity, that underlie eating disorder behaviors. It is often hard for people who don’t have these problems, to fathom these disturbances, because normally, psychological capacities, such as having a self, or identity, or having a body image that matches one’s actual body, operate automatically. Psychological processes, after all, are not easy to see, and have an intangible aspect to them.
But when these psychological capacities or processes are not yet fully developed, they give rise to problems that are very tangible. The well-known perfectionism of patients with eating disorders, the focus on numbers, calories, inches and weight, the tendency to compete with others about weight, or outdo them with their other accomplishments are attempts to find tangible ways to “measure” and document their worth. Some of our patients do have a more solid sense of self and who they are, but in these people we often find that they can never feel that who they are is “good enough.” They are plagued with self-doubt for reasons they cannot comprehend. Sometimes, a patient may fear that if she does find, or expose her true self, she won’t like it, or others won’t, or that she just won’t be “special enough” but instead be “just another boring normal person.” Some girls or women who have trouble finding “the core of who I am or want to be” deal with it by emulating others, but that never feels completely right either. And sometimes, a chronic sense of “not liking myself,” which looks like depression, really covers over an identity problem. At Avalon Hills, we help these residents undo the blocks that get in the way of them developing their own identity, and get back on track to form a healthy sense of self.
This new approach is a tailor-made therapy for eating disorders. It includes a psychotherapeutic approach that addresses not only the symptoms, but the underlying developmental problems and inhibitions of the self that give rise to them. It fosters psychological development, and turbo-charges it, with our added neuroplastic brain-training. But this new program is delivered in the context of our overall program that has many other elements including direct intervention to help patients nutritionally rehabilitate, that we have refined over the years at Avalon Hills (see our treatment components section of the website). And everything we do is organized around our unique “treat-to-outcome” attitude, which aims to give our residents what they need to be able to recover and return to, and begin to function in, the community.
Dr. Doidge has guided us from Canada, in how to train in these in-depth approaches, and develop these aspects of the program. He’s taught us to integrate the five stages of neuroplastic healing that he has described in his work. What follows is an in-depth description of our understanding of eating disorders that has emerged from this work with him, and the treatment that has been developed.
Neuroplasticity and Its Relationship to Development and Eating Disorders
The discovery of neuroplasticity—that thought and mental experience can change brain structure and function—is the most important change in our understanding of the brain in 400 years. For several hundred years it was believed that the circuits of the brain were formed and finalized in childhood, after which they became “hardwired” and unalterable. This gave rise to a kind of “neurological nihilism” about certain psychiatric and neurological conditions. It was assumed that serious conditions, such as eating disorders, were genetically predetermined, and basically “hardwired” into the brain. So, past childhood, if a person had certain tendencies, there was little that could be done about them, except to manage the symptoms. As these ideas took hold, emphasis on managing symptoms with shorter-term, and more superficial interventions, became the predominant approach to eating disorders treatment (and many other conditions). The mantra of the proponents of this more superficial approach was “who cares what causes the symptoms, just fix them.” And what have we reaped from this approach?
Of course, this appealed to many insurance companies that often only cover families or patients by the year, and are not overly concerned with long-term effectiveness.
However, for patients with serious eating disorders, these less intensive, and less psychologically and neuroplastically sophisticated approaches have led to a series of “revolving-door” admissions which end up being more costly in the long run, and demoralizing and can reinforce the patient’s sense of failure. In the meantime, precious life opportunities are wasted. True, these treatment interventions can sometimes help patients briefly and marginally improve their symptoms (and patients often improve their eating behaviors because they want to leave facilities as soon as possible). But the underlying structure driving the illness is unchanged, and all-too-often relapse follows.
Reopening Blocked Psychological and Brain Development
It has long been known to scientists—and parents—that there are critical periods of psychological development, when certain skills develop very rapidly. (Think of how children are very good at acquiring language, for a period of time, learning many new words a day, effortlessly). In the brain these periods are heightened times of brain plasticity, in which it is easy to alter circuits. So, development is always a time of enhanced brain plasticity. These developmental “windows” tend to close after a while. But by understanding brain plasticity, they can be reopened.
Blocked Development in Eating Disorders; Problems with the Self, and Identity
We don’t just develop language, or the ability to walk. Aspects of our self and our identity, our body image, and our ability to love deeply, and most importantly our ability to read a variety of emotions in ourselves, and read and understand our own minds, and the minds of others, have to be developed as well. So does the ability to regulate our anxiety.
But all these developments can be interrupted by a variety of setbacks in life—including severe hypersensitivities in childhood, a depressed caregiver, an absent or preoccupied caregiver, psychological trauma, sensory processing problems during infancy, serious physical illness and other causes.
A very frequent common denominator in our residents, along with the well-known perfectionism and preoccupation with weight, is something that they often only feel comfortable exploring and talking about once they have established trust with their therapists. These are their problems that center around what we might call, “a sense of having a self.” One of our clients—whom we have quoted at the beginning of this section—spoke about this problem. Her words are worth repeating:
“One day I woke up and realized I couldn’t find myself. No matter what I wore, or how I looked, or who my friends were, myself was nowhere to be seen. I was lost to me, and that’s as lonely as it gets.”
Of course, each person experiences these problems in her own unique way, and there are many different ways in which a person can feel estranged from her self, her body, and her femininity, another common problem. Problems with being uncertain about one’s sense of self, and identity, are often buried under the pursuit of some very “concrete” goals, such as getting to a certain weight, competing and winning in sports, or a achieving a measurable academic, career and social goal. These pursuits all involve ranking oneself in ways that are easier to measure than achieving the more elusive psychological goal of developing “a solid sense of self,” and “knowing who I truly am.”
Some patients may at times express uncertainty about what it means to love, or who they would like to love, or the kinds of friends they want to have, or their sexual or gender identity, or their values. They may be afraid of loving, and commonly fear they are unlovable. They may spend much of their lives being compliant and living solely for others, uncertain of who they are or what they want. They may feel they are being false in a way, by going along. Or, some may fear being engulfed by others, and their needs. We have found that all these seemingly different problems often relate to underlying questions such as “What is my true self?” and “Do I even know what the word, ‘self’ means? Sometimes, just thinking about these problems makes patients very anxious.
A Psychotherapy Focused on What Eating Disorder Patients Need To Develop and Achieve Balance
One key focus of the new approach is appreciating that eating disorder patients are very good at doing certain things, which turn out to be what are called “left hemisphere brain functions.” They are less so at some “right hemisphere functions,” which turn out to be essential to develop a solid sense of self that feels safe, sturdy, and one’s own.
We all have two brain hemispheres, the left and the right, and each are important, and each are good at different things.
The left hemisphere, for instance, is good at paying attention if one needs a narrow focus, or to use certain kinds of abstraction, categories, or to focus on things we already know. It also sees things “out of context” because its focus is so narrow.
The right hemisphere has a more broad-minded focus, is interested in novelty, and is curious about the unknown. It’s not focused on categories, but on understanding individuals, and relationships between people and things. Because it has a broad-minded focus, and is interested in relationships, it sees things “in context.” And, most important for our purposes, it processes much of our emotion, and allows us to understand what others, and we ourselves are feeling, including what we are feeling in our bodies. A number of things can interfere with its development.
In trauma, or chronic severe stress (be it mental or physical) the right hemisphere’s ability to process feelings may be partially blocked, and the person is numbed or dissociated, or can feel cut off from her body. But there are other things that can inhibit its proper development.
Our first two years of life are primarily about right hemisphere development; the left starts later after that. During these two years, and later, the right hemisphere needs exposure to people to develop properly. (The brain is plastic, and it is through experience that its circuits develop) Thus, we learn to read emotions by being with others, who help us understand, in real time, what we are feeling. If anything interferes with that development, our right hemisphere will be less able to fulfill its potential. Dr. Doidge pointed Avalon Hills to a scientific literature that shows that eating disorder patients can have interesting imbalances in how these two hemispheres function. In eating disorders, the left hemisphere is, in certain ways, more active than the right, which under-performs on certain tasks. As well, on brain scans, patients with eating disorders tend to have a more distorted body image in their very active left hemispheres, for instance, than in their right hemispheres.
The over-reliance on left hemisphere functions contributes to the illness. For instance, a blood supply problem in the right hemisphere (causing it to under-function, compared to the left) can lead to the spontaneous development of an eating disorder. When it is treated, the eating disorder goes away.
Of course you don’t have to have a blood supply problem to the brain for this imbalance to occur. All you have to do is overuse one hemisphere’s functions, and underuse the other’s, and the balance goes off, because the brain is neuroplastic, and it is a use-it-or-lose-it brain.
There are many clinical examples of how people with eating disorders show high left hemisphere function, and lowered right. Eating disorder patients often show left brain tendencies, by being narrowly focused on abstract goals such as getting to a certain weight. One thing that baffles those around them, is that this focus can often lose the larger context: if they achieve that goal they might just die. And they have trouble using right hemisphere functions, such as monitoring their bodies and subtle emotional reactions, or seeing the big picture.
The individual psychotherapy that we use is an insight and emotion-based, neuroplastically-informed, hemisphere-balancing psychotherapy. It really stimulates the right hemisphere functions. It takes some of the best of what is called psychodynamic psychotherapy, and attachment, and teaches the client to activate her right hemisphere skills, in the sessions, in the context of a caring relationship with our individual therapists, who have been trained in this approach.
Our individual therapists are empathic, and trained to undo developmental inhibitions and conflicts, treat trauma, self-fragmentation, and defenses in the therapy of eating disorder patients. They are trained to deal with some of the common personality organizations that eating disorder patients can often have, including, among others, what is called the borderline personality organization.
One of the things that happens at Avalon Hills is that our residents have “aha” moments, where they start to get in touch with the sense of self, read their own minds much better, and develop more empathy for themselves and others.
At the Same Time…Depth-Neurofeedback and All Our Other Modalities
At the same time our residents are working to lower their anxiety and raise calm focus with neurofeedback, stimulate brains areas that allow them to read their emotions and mental states, develop better body awareness, and self-development.
Everyone who comes to Avalon Hills gets a highly specific kind of non-invasive brain map, called a Quantitative EEG, which can show them how their brain is firing, and what areas are hyperactive, what areas are less active, and how the different areas of the brain talk to each other. Then we design a tailor-made Neurofeedback program to address these problems. Patients can see their progress over time, by looking at pictures of their brains as they change. And they can take heart, that they are, through their training, driving that change in a direction that they want.
For instance, we have found that many of our patients, when they come to Avalon Hills, have difficulty entering a calm, open state of mind, where they can make new connections and be creative, and with the training they can improve that. Or, they can also learn to be more aware of their bodies, lower hypersensitivity, and lower impulsivity.
The neurofeedback helps the psychotherapy, and the psychotherapy helps the neurofeedback. And, we might add, while recently some programs have begun to offer neurofeedback in a non-tailor-made way (one-size-fits-all) we have one of the world leaders, Dr. Ed Hamlin, reading over all our measures, and following our patients, and then we integrate a client’s brain findings with our assessments, psychotherapy and all the other therapeutic interventions that we do. While some Eating Disorder Programs now give clients one-size-fits-all devices to help calm them (as can we) our in-depth neurofeedback training is one-on-one, using programs specifically designed for our patients, and changed as they need it, and they each have their own neurofeedback trainers. Meanwhile, behind the scenes, we have Dr. Hamlin analyzing the data, and then we discuss it with the primary therapists. Because Dr. Hamlin also understands intensive psychotherapy, our insights from our client’s neurofeedback are truly integrated into the psychotherapy. For us, neurofeedback is time-intensive work, and not an “add on” or afterthought, or a marketing scheme.
Or course, all residents are undergoing other intensive forms of therapy at Avalon Hills, such as family therapy, body image exposures, work with the animals, martial arts training, and yoga that allows them to get access to parts of themselves they didn’t know they have.
Summary: What We See With This New Approach
In this program, we understand that while eating disorder behaviors and attitudes may be rigid, this does not mean that the brains of patients with those disorders are rigid or lack plasticity; the illness is in part a product of how they use their plasticity, which is a product of their development.
Working with all our modalities—the best of the most in-depth therapies combined with the best of the new brain science—we help patients access their full psychological and neuroplastic potential, by stimulating dormant psychological and brain capacities, that have been just waiting to develop. They improve emotional self-regulation, so that they are less prone to emotional ups and downs. On follow-up brain mapping scans and psychological testing, we see that their brains are much better at modulating themselves, and more balanced. Above all, in many cases they develop a more integrated, differentiated view of themselves.
When this occurs, patients can develop more life-affirming goals that make eating disorder behaviors less necessary or attractive to them, so that they can grow out of a reliance on them, and mature psychologically at the same time. And their whole relationship to their body begins to change to one that is more wholesome and loving.
Dr. Norman Doidge
Avalon Hills has benefitted from ongoing consultation with Norman Doidge, MD in Canada in the areas of program development, innovation, implementation and continuous refinement. Dr. Doidge is recognized as a pioneer in the field of neuroplasticity, the area of neuroscience focused on brain change (and its relationship to undoing blocks to mental and emotional flexibility). He is the author of the international and New York Times best-selling books The Brain that Changes Itself and The Brain's Way of Healing.
The Brain That Changes Itself, on neuroplasticity, has been described by the London Times as, “Brilliant…Doidge has identified a tidal shift in basic science…The implications are monumental.” The New York Times Science Times has written that The Brain That Changes Itself, has “implications…not only for individual patients with neurologic disease but for all human beings, not to mention human culture, human learning and human history.” Neurologist Oliver Sacks called it, “Fascinating… a remarkable and hopeful portrait of the endless adaptability of the human brain.” It was chosen by the Dana Brain Foundation journal, Cerebrum, from among the 30,000 brain books as the best general book on the brain.
Bessel van der Kolk, MD, author of The Body Keeps The Score, on psychological trauma, has written, “The Brain’s Way of Healing is a stunner…[and] opens up so many novel and startling avenues into our potential to heal. Norman Doidge enthralls us with a rich combination of lucidly explained brain research and pioneering … approaches to recovery. With an eloquence reminiscent of Oliver Sacks, Doidge bolsters the latest advances in brain science with a series of extraordinary case histories of people for whom all hope seemed to be lost, but who healed….”
Dr. Doidge is a psychiatrist and psychoanalyst, on the Research Faculty at the Columbia University Department of Psychiatry, Center for Psychoanalytic Training and Research, in New York, and the University of Toronto’s Department of Psychiatry. He is a Training and Supervising Analyst at the Toronto Institute of Psychoanalysis. He has authored over 170 scientific and popular articles, as well as intensive psychotherapy guidelines. His research is credited with helping preserve these treatments as part of the Canadian and Australian health care systems. He is former head of the Psychotherapy Center, and the Assessment Clinic, at the largest psychiatric hospital system in Canada, CAMH.
He has presented his work on five continents, at neuroscience institutes, at the U.N., the White House, and produced 3 documentaries, showing people undergoing neuroplastic change. He has won scientific and clinical awards, including election to the American College of Psychoanalysts for “many outstanding achievements in psychiatry and psychoanalysis… and national leadership in psychiatry.” He was awarded the Mary S. Sigourney Prize, the highest award in international psychoanalysis, and the U.S. National Association of Mental Illness Ken Book Award, and the Special Recognition Award from Brain Injury Canada for his “heroic contribution to the cause of acquired brain injury in Canada.”