In the spring of 1976, two years into my psychiatric practice, I began having pain in both knees, which soon severely limited my running. I was advised by an orthopedist to stop trying to run through the pain. After many failed attempts to treat the condition with orthotic surgery and physical therapy, I resigned myself to giving up running. As soon as I made that decision, the fear of gaining weight and getting fat consumed me. I started weighing myself every day, and even though I was not gaining weight, I started feeling fatter. I became increasingly obsessed about my energy balance and whether I was burning off the calories I consumed. I refined my knowledge of nutrition and memorized the calories and grams of fat, protein, and carbohydrates of every food I would possibly eat.

Despite what my intellect told me, my goal became to rid my body of all fat. I resumed exercising. I found I could walk good distances, despite some discomfort, if I iced my knees afterward. I started walking several times a day. I built a small pool in my basement and swam in place, tethered to the wall. I biked as much as I could tolerate. The denial of what I only much later came to recognize as anorexia involved overuse injuries as I sought medical help for tendonitis, muscle and joint pain, and entrapment neuropathies. I was never told that I was exercising too much, but I am sure that had I been told, I would not have listened.

Worst Nightmare

Despite my efforts, my worst nightmare was happening. I felt and saw myself as fatter than ever before, even though I had started to lose weight. Whatever I had learned about nutrition in medical school or read in books, I perverted to my purpose. I obsessed about protein and fat. I increased the number of egg whites that I ate a day to 12. If any yolk leaked into my concoction of egg whites, Carnation Instant Breakfast, and skim milk, I threw the entire thing out.

"It Seemed I could never walk far enough or eat little enough."

As I became more restrictive, caffeine became more and more important and functional for me. It staved off my appetite, although I didn't let myself think about it that way. Coffee and soda perked me up emotionally and focused my thinking. I really do not believe that I could have continued to function at work without caffeine.

I relied equally on my walking (up to six hours a day) and restrictive eating to fight fat, but it seemed I could never walk far enough or eat little enough. The scale was now the final analysis of everything about me. I weighed myself before and after every meal and walk. An increase in weight meant I had not tried hard enough and needed to walk farther or on steeper hills, and eat less. If I lost weight, I was encouraged and all the more determined to eat less and exercise more. However, my goal was not to be thinner, just not fat. I still wanted to be "big and strong" -- just not fat.

Besides the scale, I measured myself constantly by assessing how my clothes fit and felt on my body. I compared myself to other people, using this information to "keep me on track." As I had when I compared myself to others in terms of intelligence, talent, humor, and personality, I fell short in all categories. All of those feelings were channeled into the final "fat equation."

During the last few years of my illness, my eating became more extreme. My meals were extremely ritualistic, and by the time I was ready for dinner, I had not eaten all day and had exercised five or six hours. My suppers became a relative binge. I still thought of them as "salads," which satisfied my anorexia nervosa mind. They evolved from just a few different types of lettuce and some raw vegetables and lemon juice for dressing to rather elaborate concoctions. I must have been at least partly aware that my muscles were wasting away because I made a point of adding protein, usually in the form of tuna fish. I added other foods from time to time in a calculated and compulsive way. Whatever I added, I had to continue with, and usually in increasing amounts. A typical binge might consist of a head of iceberg lettuce, a full head of raw cabbage, a defrosted package of frozen spinach, a can of tuna, garbanzo beans, croutons, sunflower seeds, artificial bacon bits, a can of pineapple, lemon juice, and vinegar, all in a foot-and-a-half-wide bowl. In my phase of eating carrots, I would eat about a pound of raw carrots while I was preparing the salad. The raw cabbage was my laxative. I counted on that control over my bowels for added reassurance that the food was not staying in my body long enough to make me fat.

"I awoke at 2:30 or 3:00 a.m. and started my walks."

The final part of my ritual was a glass of cream sherry. Although I obsessed all day about my binge eating, I came to depend on the relaxing effect of the sherry. My long-standing insomnia worsened as my eating became more disordered, and I became dependent on the soporific effect of alcohol. When I was not in too much physical discomfort from the binge, the food and alcohol would put me to sleep, but only for about four hours or so. I awoke at 2:30 or 3:00 a.m. and started my walks. It was always in the back of my mind that I would not be accruing fat if I wasn't sleeping. And, of course, moving was always better than not. Fatigue also helped me modify the constant anxiety I felt. Over-the-counter cold medications, muscle relaxants, and also gave me relief from my anxiety. The combined effect of medication with low blood sugar was relative euphoria.

---

Oblivious to Illness

While I was living this crazy life, I was carrying on my psychiatric practice, much of which consisted of treating eating-disorder patients -- anorexic, bulimic, and obese. It is incredible to me now that I could be working with anorexic patients who were not any sicker than I was, even healthier in some ways, and yet remain completely oblivious to my own illness. There were only extremely brief flashes of insight. If I happened to see myself in a mirrored window reflection, I would be horrified at how emaciated I appeared. Turning away, the insight was gone. I was well aware of my usual self-doubts and insecurities, but that was normal for me. Unfortunately, the increasing spaciness that I was experiencing with weight loss and minimal nutrition was also becoming "normal" for me. In fact, when I was at my spaciest, I felt the best, because it meant that I was not getting fat.

Only occasionally would a patient comment on my appearance. I would blush, feel hot, and sweat with shame but not recognize cognitively what he or she was saying. More surprising to me, in retrospect, was never having been confronted about my eating or weight loss by the professionals with whom I worked all during this time.I remember a physician administrator of the hospital kidding me occasionally about eating so little, but I was never seriously questioned about my eating, weight loss, or exercise. They all must have seen me out walking for an hour or two every day regardless of the weather. I even had a down-filled body suit that I would put over my work clothes, allowing me to walk no matter how low the temperature. My work must have suffered during these years, but I did not notice or hear about it.

"During those years, I was virtually friendless."

People outside of work seemed relatively oblivious as well. Family registered concern about my overall health and the various physical problems I was having but were apparently completely unaware of the connection with my eating and weight loss, poor nutrition, and excessive exercise. I was never exactly gregarious, but my social isolation became extreme in my illness. I declined social invitations as much as I could. This included family gatherings. If I accepted an invitation that would include a meal, I would either not eat or bring my own food. During those years, I was virtually friendless.

I still find it hard to believe that I was so blind to the illness, especially as a physician aware of the symptoms of anorexia nervosa. I could see my weight dropping but could only believe it was good, despite conflicting thoughts about it. Even when I started feeling weak and tired, I did not understand. As I experienced the progressive physical sequelae of my weight loss, the picture only grew murkier. My bowels stopped functioning normally, and I developed severe abdominal cramping and diarrhea. In addition to the cabbage, I was sucking on packs of sugarless candies, sweetened with Sorbitol to diminish hunger and for its laxative effect. At my worst, I was spending up to a couple of hours a day in the bathroom. In the winter I had severe Raynaud's Phenomenon, during which all the digits on my hands and feet would become white and excruciatingly painful. I was dizzy and lightheaded. Severe back spasms occurred occasionally, resulting in a number of ER visits by ambulance. I was asked no questions and no diagnosis was made despite my physical appearance and low vital signs.

"More trips to the ER still resulted in no diagnosis. Was it because I was a man?"

Around this time I was recording my pulse down into the 30s. I remember thinking that this was good because it meant that I was "in shape." My skin was paper thin. I became increasingly tired during the day and would find myself almost dozing off while in sessions with patients. I was short of breath at times and would feel my heart pound. One night I was shocked to discover that I had pitting edema of both legs up to my knees. Also around that time, I fell while ice skating and bruised my knee. The swelling was enough to tip the cardiac balance, and I passed out. More trips to the ER and several admissions to the hospital for assessment and stabilization still resulted in no diagnosis. Was it because I was a man?

I was finally referred to the Mayo Clinic with the hope of identifying some explanation for my myriad of symptoms. During the week at Mayo, I saw almost every kind of specialist and was tested exhaustively. However, I was never questioned about my eating or exercise habits. They only remarked that I had an extremely high carotene level and that my skin was certainly orangish (this was during one of my phases of high carrot consumption). I was told that my problems were "functional," or, in other words, "in my head," and that they probably stemmed from my father's suicide 12 years earlier.

Physician, Heal Thyself

An anorexic woman with whom I had been working for a couple of years finally reached me when she questioned whether she could trust me. At the end of a session on a Thursday, she asked for reassurance that I would be back on Monday and continue to work with her. I replied that, of course, I would be back, "I don't abandon my patients."

She said, "My head says yes, but my heart says no." After attempting to reassure her, I did not give it a second thought until Saturday morning, when I heard her words again.

" I could not imagine how I could possibly be okay without my eating disorder."

I was staring out my kitchen window, and I started experiencing deep feelings of shame and sadness. For the first time I recognized that I was anorexic, and I was able to make sense of what had happened to me over the last 10 years. I could identify all the symptoms of anorexia that I knew so well in my patients. While this was a relief, it was also very frightening. I felt alone and terrified of what I knew I had to do -- let other people know that I was anorexic. I had to eat and stop exercising compulsively. I had no idea if I could really do it -- I had been this way for so long. I could not imagine what recovery would be like or how I could possibly be okay without my eating disorder.

---

I was afraid of the responses that I would get. I was doing eating disorder individual and group therapy with mostly eating-disordered patients in two inpatient eating disorder treatment programs, one for young adults (ages 12 to 22) and the other for older adults. For some reason, I was more anxious about the younger group. My fears proved unfounded. When I told them that I was anorexic, they were as accepting and supportive of me and my illness as they were of one another. There was more of a mixed response from hospital staff. One of my colleagues heard about it and suggested that my restrictive eating was merely a "bad habit" and that I could not really be anorexic. Some of my coworkers were immediately supportive; others seemed to prefer not to talk about it.

That Saturday I knew what I was facing. I had a fairly good idea of what I would have to change. I had no idea how slow the process would be or how long it would take. With the dropping of my denial, eating disorder recovery became a possibility and gave me some direction and purpose outside of the structure of my eating disorder.

The eating was slow to normalize. It helped to start thinking of eating three meals a day. My body needed more than I could eat in three meals, but it took me a long time to be comfortable eating snacks. Grain, protein, and fruit were the easiest food groups to eat consistently. Fat and dairy groups took much longer to include. Supper continued to be my easiest meal and breakfast came easier than lunch. It helped to eat meals out. I was never really safe just cooking for myself. I started eating breakfast and lunch at the hospital where I worked and eating suppers out.

"After ten years in recover, my eating now seems second nature to me."

During my marital separation and for a few years after the divorce from my first wife, my children spent weekdays with their mother and weekends with me. Eating was easier when I was taking care of them because I simply had to have food around for them. I met and courted my second wife during this time, and by the time we were married, my son Ben was in college and my daughter Sarah was applying to go. My second wife enjoyed cooking and would cook supper for us. This was the first time since high school that I had had suppers prepared for me.

After ten years in recovery, my eating now seems second nature to me. Although I still have occasional days of feeling fat and still have a tendency to choose foods lower in fat and calories, eating is relatively easy because I go ahead and eat what I need. During more difficult times I still think of it in terms of what I need to eat, and I will even carry on a brief inner dialogue about it.

My second wife and I divorced awhile back, but it is still hard to shop for food and cook by myself. Eating out is safe for me now, however. I will sometimes order the special, or the same selection that someone else is ordering as a way of staying safe and letting go of my control over the food.

Toning Down

While I worked on my eating, I struggled to stop exercising compulsively. This proved much harder to normalize than the eating. Because I was eating more, I had a stronger drive to exercise to cancel calories. But the drive to exercise seemed also to have deeper roots. It was relatively easy to see how including several fats at a meal was something I needed to do to recover from this illness. But it was harder to reason in the same way for exercise. Experts talk about separating it from the illness and somehow preserving it for the obvious benefits of health and employment. Even this is tricky. I enjoy exercise even when I am obviously doing it excessively.

"Just like so many of my patients, I had the feeling that I was never good enough."

Over the years I have sought the counsel of a physical therapist to help me set limits to my exercise. I can now go a day without exercising. I no longer measure myself by how far or how fast I bike or swim. Exercise is no longer connected with food. I do not have to swim an extra lap because I ate a cheeseburger. I have an awareness now of fatigue, and respect for it, but I do still have to work on setting limits.

Disengaged from my eating disorder, my insecurities seemed magnified. Before I had felt as though I was in control of my life through the structure I had imposed on it. Now I became acutely aware of my low opinion of myself. Without the eating-disorder behaviors to mask the feelings, I felt all my feelings of inadequacy and incompetence more intensely. I felt everything more intensely. I felt exposed. What frightened me the most was the anticipation of having everybody I knew discover my deepest secret -- that there was not anything of value inside.

Although I knew I wanted recovery, I was at the same time intensely ambivalent about it. I had no confidence that I would be able to pull it off. For a long time I doubted everything -- even that I had an eating disorder. I feared that recovery would mean that I would have to act normally. I did not know what normal was, experientially. I feared others' expectations of me in recovery. If I got healthy and normal, would this mean I would have to appear and act like a "real" psychiatrist? Would I have to get social and acquire a large group of friends and whoop it up at barbecues on Packer Sundays?

Being Oneself

One of the most significant insights I've gained in my recovery has been that I have spent my whole life trying to be somebody I'm not. Just like so many of my patients, I had the feeling that I was never good enough. In my own estimation, I was a failure. Any compliments or recognition of achievement did not fit. On the contrary, I always expected to be "found out" -- that others would discover that I was stupid, and it would be all over. Always starting with the premise that who I am is not good enough, I have gone to such extremes to improve what I assumed needed improvement. My eating disorder was one of those extremes. It blunted my anxieties and gave me a false sense of security through the control over food, body shape, and weight. My recovery has allowed me to experience these same anxieties and insecurities without the necessity of escape through control over food.

"I no longer have to change who I am."

Now these old fears are only some of the emotions that I have, and they have a different meaning attached to them. The feelings of inadequacy and the fear of failure are still there, but I understand that they are old and more reflective of environmental influences as I was growing up than an accurate measure of my abilities. This understanding has lifted an enormous pressure off of me. I no longer have to change who I am. In the past it would not have been acceptable to be content with who I am; only the best would be good enough. Now, there is room for error. Nothing needs to be perfect. I have a feeling of ease with people, and that is new to me. I am more confident that I can truly help people professionally. There is a comfort socially, and an experience of friendships that was not possible when I thought that others could only see the "bad" in me.

I have not had to change in the ways that I initially feared. I have let myself respect the interests and feelings that I have always had. I can experience my fears without needing to escape.

next: Impact of Anorexia, Bulimia and Obesity on the Gynecologic Health of Adolescents
~ eating disorders library
~ all articles on eating disorders

Dear Stanton:

I have just learned of the drunk-driving crash involving Audrey Kishline and appreciate the fact that you have not shied away from it here. However, I noticed that you several times use the term "accident," including in your links about the crash.

No, I am not a member of MADD, but I wholeheartedly agree with MADD's position on the use of the term "accident" to describe what happens when people drive drunk and kill or injure themselves or others. As you stated, "even alcoholics can make sure they stay out of cars when they are drunk."

Call it a mistake, call it a crash, call it a wreck. But please don't call it an accident. Accidents are occurrences that can't be prevented. Drunk driving can be prevented by placing responsibility squarely where it belongs—with those who drink. Perhaps if those working in the field of recovery would help drive this point home with suitable terminology when speaking to those who drink, fewer people would be injured and killed at the hands of drunk drivers.

Marion Graham

---

Dear Marion:

I agree with part of your message wholeheartedly. I don't hold people who drink responsible for killing others; I hold people who kill others responsible for their actions. I do not view Audrey as a victim; I do not sympathize with her plight. I sympathize with the people who died — the child and her father — and their loved ones. Audrey has killed people because of her lack of control over her life. Someone who has had drinking problems in the past, who has been in treatment, who organized a support group, who was attending AA, et al. has as much knowledge as an individual can have about her own drinking, about driving drunk, and about behaving responsibly — whether trying to drink moderately or to abstain. I won't prejudge her court case. I won't prejudge her psychological condition (and I suspect she was undergoing severe stress in her personal life). But I agree her actions were volitional and that having a trial for vehicular homicide is obligatory. Incidentally, I have served as an expert witness for the prosecution in a trial quite similar to the one Audrey will likely undergo — where a long-time member of AA got drunk, drove across a medial strip, and killed a woman. This man had been in treatment innumerable times, subscribed to the disease theory of alcoholism, actively attended AA, and engaged in planned binges periodically (while being a sponsor in AA). As I testified about the responsibility of even drunken individuals to make choices, I saw him disagreeing violently (by shaking his head) in the courtroom.

Yours,
Stanton

next: Why Are So Many Indians Alcoholics?
~ all Stanton Peele articles
~ addictions library articles
~ all addictions articles

teenage sex

At one point or another, almost all guys have trouble getting or keeping an erection. There's lots of reasons why it happens. Most of the time, it's just stress or nerves, or maybe you're just not in the mood. But it can also be a sign of other health problems too.

What causes Erectile Difficulties and what can I do?

If you are having some problems getting or keeping an erection, there are a few basic facts you should keep in mind.

• Erectile dysfunction is a common problem that happens to many men.
• As a man grows older, the number of erections he has, how quickly he gets them, how hard they are, and how long they last, gradually decreases.
• Erectile dysfunction is when a man can't get or keep an erection hard enough to have sex and this is a problem that happens often/regularly.
• If you do have erectile dysfunction, in most cases, your doctor can help you.

There are different reasons why a man may have temporary/occasional erectile difficulties or erectile dysfunction. These reasons can be divided into three categories: psychological, lifestyle, and medical.

Psychological Factors

Sometimes a man is able to get an erection when he is asleep, or is masturbating or thinking about sex but he is not able to get an erection when he is having sex with a partner. There are several reasons why this can happen.

• Sometimes a man is nervous about having sex. This is more likely to happen when he is having sex with a new partner. Both partners may be feeling nervous and uncomfortable. The man may be worried that his penis will not be hard enough. Because he is worried and paying so much attention to wanting his penis to be hard he is not able to relax and enjoy himself and this can make it difficult to get an erection.
• Sometimes men and their partners are uncomfortable about talking with each other about sex even if they have known each other for a long time. They do not know what each other likes and the man may not get as sexually aroused ("turned-on") as he used to when the relationship first started.
• Sometimes if a man and his partner are not getting along well in other parts of their relationship, it is not as easy to get aroused and this can also make it difficult for a man to get an erection.

Lifestyle Factors

There are many different lifestyle factors that can affect a man's ability to get an erection. In general, if you do not take care of your health, you are more likely, as you get older, to start to have problems getting an erection. For example, having a healthy diet, getting enough sleep, exercising regularly, not smoking, and not drinking too much alcohol are all things you can do to help you be healthy. The healthier your body is, the more likely it is that you will be able to get and keep an erection.

Medical Factors

There are a large number of medical conditions and medicines that can affect a man's ability to have an erection. These include:

• diabetes
• high blood pressure
• heart conditions (heart disease)
• thyroid conditions
• poor circulation
• depression
• low testosterone
• spinal cord injury
• multiple sclerosis
• nerve damage (e.g., from prostate surgery)
• Parkinson's disease

Medicines that may interfere with an erection include:

• Antidepressants (e.g., SSRI's)
• Blood pressure medications (e.g., beta-blockers)
• Heart medications (e.g., digoxin)
• Sleeping pills
• Peptic ulcer medications

If you think that a medicine you are taking may have something to do with your erection difficulties, DO NOT stop taking your medicine or take less of it without talking to your doctor first. In many cases, your doctor can change the medicine you are taking or adjust the dose so that your erections are not affected.

Things You Can Do To Deal With, And Avoid Erectile Problems

• Eat a healthy diet
• Reduce or stop smoking
• Avoid using drugs (e.g., cocaine)
• Get enough sleep
• Avoid too much stress (feeling pressure, worrying a lot)
• Limit the amount of alcohol you drink (especially before having sex)
• Take your mind off your penis and pay attention instead to kissing and touching your partner. The less you worry about having an erection, the more likely you are to get one.
• Try to talk openly and honestly with your partner about your sex life together including the pressure you may be feeling about having erections.

Getting Help for Erectile Difficulties

If you continue to have regular difficulties getting and keeping an erection and the problem does not go away, you should go to see a doctor. Don't be embarrassed! More and more, men are going to see their doctors about erection difficulties. Most doctors are used to having their male patients ask about erectile problems. In most cases, the doctor will be able to help and there are effective medicines to treat erectile dysfunction.

When you call the doctor's office to make an appointment, you do not need to give details to the receptionist, about why you want to see the doctor. You could say "I would like to see the Doctor about a personal health issue"When you see the doctor, you could say "I am having a problem with my erections." If you are going to the doctor for a regular check-up, tell the doctor about your erection difficulties at the beginning of the appointment, not near the end. The doctor will probably give you a physical examination and ask you some direct questions, such as how long you have had erection difficulties, if you sometimes wake-up with erections, if there are certain situations when you get hard but others when you don't, if your penis gets a little hard when you are sexually excited or not hard at all, and other questions like this. Try to be as clear and honest as possible in answering these questions. The more clear and honest the information you give, the more likely it is that your doctor will be able to help solve your erectile difficulties.

Suggested Classroom Interventions For Children With ADD & Learning Disabilities

Children with attention deficit disorder and/or learning disabilities can be a challenge for any classroom teacher. This page provides some practical suggestions that can be used in the regular classroom as well as the special education classroom. By looking through a given list of interventions, a teacher will be able to select one or more strategies that are suited to a specific child in a specific environment.

• Ideas for Attention Deficit Children
• Strategies for Cognitively Impulsive Children
• Suggested Classroom Accommodations for Specific Behaviors

Ideas for Attention Deficit Children

Children whose attention seems to wander or who never seem to "be with" the rest of the class might be helped by the following suggestions.

1. Pause and create suspense by looking around before asking questions.
2. Randomly pick reciters so the children cannot time their attention.
3. Signal that someone is going to have to answer a question about what is being said.
4. Use the child's name in a question or in the material being covered.
5. Ask a simple question (not even related to the topic at hand) to a child whose attention is beginning to wander.
6. Develop a private running joke between you and the child that can be invoked to re-involve you with the child.
7. Stand close to an inattentive child and touch him or her on the shoulder as you are teaching.
8. Walk around the classroom as the lesson is progressing and tap the place in the child's book that is currently being read or discussed.
9. Decrease the length of assignments or lessons.
10. Alternate physical and mental activities.
11. Increase the novelty of lessons by using films, tapes, flash cards, or small group work or by having a child call on others.
12. Incorporate the children's interests into a lesson plan.
13. Structure in some guided daydreaming time.
14. Give simple, concrete instructions, once.
15. Investigate the use of simple mechanical devices that indicate attention versus inattention.
16. Teach children self monitoring strategies.
17. Use a soft voice to give direction.
18. Employ peers or older students or volunteer parents as tutors.

Strategies for Cognitively Impulsive Children

Some children have difficulty staying with the task at hand. Their verbalizations seem irrelevant and their performance indicates that they are not thinking reflectively about what they are doing. Some possible ideas to try out in this situation include the following.

1. Provide as much positive attention and recognition as possible.
2. Clarify the social rules and external demands of the classroom.
3. Establish a cue between teacher and child.
4. Spend personal discussion times with these children emphasizing the similarities between the teacher and child.
5. Get in a habit of pausing 10 to 16 seconds before answering.
6. Probe irrelevant responses for possible connections to the question.
7. Have children repeat questions before answering.
8. Choose a student to be the "question keeper."
9. Using a well known story, have the class orally recite it as a chain story.
10. When introducing a new topic in any academic area, have the children generate questions about it before providing them with much information.
11. Distinguish between reality and fantasy by telling stories with a mix of fact and fiction and asking the children to critique them.
12. Assign a written project that is to contain elements that are "true," "could happen but didn't," and "pretend, can't happen."
13. Do not confront lying by making children admit they have been untruthful.
14. Play attention and listening games.
15. Remove un-needed stimulation from the classroom environment.
16. Keep assignments short.
17. Communicate the value of accuracy over speed.
18. Evaluate your own tempo as teacher.
19. Using the wall clock, tell children how long they are to work on an assignment.
20. Require that children keep a file of their completed work.
21. Teach children self talk.
22. Encourage planning by frequently using lists, calendars, charts, pictures, and finished products in the classroom.

Suggested Classroom Accommodations for Specific Behaviors

When You See This Behavior	Try This Accommodation
1. Difficulty following a plan (has high aspirations but lacks follow-through); sets out to "get straight A's, ends up with F's" (sets unrealistic goals)	+Assist student in setting long-range goals: break the goal into realistic parts. +Use a questioning strategy with the student; ask, What do you need to be able to do this? +Keep asking that question until the student has reached an obtainable goal. +Have student set clear timelines of what he needs to do to accomplish each step (monitor student progress frequently).
2. Difficulty sequencing and completing steps to accomplish specific tasks (e.g. writing a book report, term paper, organized paragraphs, division problem, etc.)	+ Break up task into workable and obtainable steps. + Provide examples and specific steps to accomplish task.
3. Shifting from one uncompleted activity to another without closure.	+ Define the requirements of a completed activity (e.g. your math is finished when all six problems are complete and corrected; do not begin on the next task until it is finished).
4. Difficulty following through on instructions from others.	+ Gain student's attention before giving directions. Use alerting cues. Accompany oral directions with written directions. + Give one direction at a time. Quietly repeat directions to the student after they have been given to the rest of the class. Check for understanding by having the student repeat the directions.
5. Difficulty prioritizing from most to least important.	+ Prioritize assignment and activities. + Provide a model to help students. Post the model and refer to it often.
6. Difficulty sustaining effort and accuracy over time.	+ Reduce assignment length and strive for quality (rather that quantity). + Increase the frequency of positive reinforcements (catch the student doing it right and let him know it.
7. Difficulty completing assignments.	+ List and/or post (and say) all steps necessary to complete each assignment. + Reduce the assignment into manageable sections with specific due dates. + Make frequent checks for work/assignment completion. + Arrange for the student to have a "study buddy" with phone number in each subject area.
8. Difficulty with any task that requires memory.	+ Combine seeing, saying, writing and doing; student may need to subvocalize to remember. + Teach memory techniques as a study strategy (e.g. mnemonics, visualization, oral rehearsal, numerous repetitions).
9. Difficulty with test taking.	+ Allow extra time for testing; teach test-taking skills and strategies; and allow student to be tested orally. + Use clear, readable and uncluttered test forms. Use test format that the student is most comfortable with.Allow ample space for student response. Consider having lined answer spaces for essay or short answer tests.
10. Confusion from non-verbal cues (misreads body language, etc.)	+ Directly teach (tell the student) what non-verbal cues mean. Model and have student practice reading cues in a safe setting.
11. Confusion from written material (difficulty finding main idea from a paragraph; attributes greater importance to minor details)	+ Provide student with copy of reading material with main ideas underlined or highlighted. + Provide an outline of important points from reading material. + Teach outlining, main-idea / details concepts. + Provide tape of text / chapter.
12. Confusion from written material (difficulty finding main idea from a paragraph; attributes greater importance to minor details)	+ Provide student with a copy of presentation notes. + Allow peers to share carbon-copy notes from presentation (have student compare own notes with a copy of peer's notes). + Provide framed outlines of presentations (introducing visual and auditory cues to important information). + Encourage use of tape recorder. + Teach and emphasize key words (the following..., the most important point...,etc.).
13. Difficulty sustaining attention to tasks or other activities (easily distracted by extraneous stimuli)	+ Reward attention. Break up activities into small units. Reward for timely accomplishment. + Use physical proximity and touch. Use earphones and/or study carrels, quiet place, or preferential seating.
14. Frequent messiness or sloppiness.	+ Teach organizational skills. Be sure student has daily, weekly and/or monthly assignment sheets; list of materials needed daily; and consistent format for papers. Have a consistent way for students to turn in and receive back papers; reduce distractions. + Give reward points for notebook checks and proper paper format. + Provide clear copies of worksheets and handouts and consistent format for worksheets. + Establish a daily routine, provide models for what you want the student to do. + Arrange for a peer who will help him with organization. + Assist student to keep materials in a specific place (e.g. pencils and pens in pouch). + Be willing to repeat expectations.
15. Poor handwriting (often mixing cursive with manuscript and capitals with low-case letters)	+ Allow for a scribe and grade for content, not handwriting. Allow for use of computer or typewriter. + Consider alternative methods for student response (e.g. tape recorder, oral reports, etc.). + Don't penalize student for mixing cursive and manuscript (accept any method of production). + Use pencil with rubber grip.
16. Difficulty with fluency in handwriting e.g. good letter/word production but very slow and laborious.	+ Allow for shorter assignments (quality vs. quantity). + Allow alternate method of production (computer, scribe, oral presentation, etc.). + Use pencil with rubber grip.
17. Poorly developed study skills	+ Teach study skills specific to the subject area - organization (e.g. assignment calendar), textbook reading, notetaking (finding main idea / detail, mapping, outlining), skimming, summarizing).
18. Poor self-monitoring (careless errors in spelling, arithmetic, reading)	+ Teach specific methods of self-monitoring (e.g. stop-look-listen). + Have student proof-read finished work when it is cold.
19. Low fluency or production of written material (takes hours on a 10 minute assignment)	+ Allow for alternative method for completing assignment (oral presentation, taped report, visual presentation, graphs, maps, pictures, etc. with reduced written requirements). + Allow for alternative method of writing (e.g. typewriter, computer, cursive or printing, or a scribe.
20. Apparent Inattention (underachievement, daydreaming, not there)	+ Get student's attention before giving directions (tell student how to pay attention, look at me while I talk, watch my eyes while I speak). Ask student to repeat directions. + Attempt to actively involve student in lesson (e.g. cooperative learning).
21. Difficulty participating in class without being interruptive; difficulty working quietly	+ Seat student in close proximity to the teacher. + Reward appropriate behavior (catch student being good). + Use study carrel if appropriate.
22. Inappropriate seeking of attention (clowns around, exhibits loud excessive or exaggerated movement as attention-seeking behavior, interrupts, butts into other children's activities, needles others)	+ Show student (model) how to gain other's attention appropriately. + Catch the student when appropriate and reinforce.
23. Frequent excessive talking	+ Teach student hand signals and use to tell student when and when not to talk. + Make sure student is called when it is appropriate and reinforce listening.
24. Difficulty making transitions (from activity to activity or class to class); takes an excessive amount of time to find pencil, gives up, refuses to leave previous task; appears agitated during change.	+ Program child for transitions. Give advance warning of when a transition is going to take place (now we are completing the worksheet, next we will ...) and the expectation for the transition (and you will need...) + Specifically say and display lists of materials needed until a routine is possible. List steps necessary to complete each assignment. + Have specific locations for all materials (pencil pouches, tabs in notebooks, etc.). + Arrange for an organized helper (peer).
25. Difficulty remaining seated or in a particular position when required to	+ Give student frequent opportunities to get up and move around. Allow space for movement.
26. Frequent fidgeting with hands, feet or objects, squirming in seat.	+ Break tasks down to small increments and give frequent positive reinforcement for accomplishments (this type of behavior is often due to frustration). + Allow alternative movement when possible.
27. Inappropriate responses in class often blurted out; answers given to questions before they have been completed.	+ Seat student in close proximity to teacher so that visual and physical monitoring of student behavior can be done by the teacher. + State behavior that you do want (tell the student how you expect him to behave).
28. Agitation under pressure and competition (athletic or academic)	+ Stress effort and enjoyment for self, rather than competition with others. + Minimize timed activities; structure class for team effort and cooperation.
29. Inappropriate behaviors in a team or large group sport or athletic activity (difficulty waiting turn in games or group situations)	+ Give the student a responsible job (e.g. team captain, care and distribution of the balls, score keeping, etc.); consider leadership role. + Have student in close proximity of teacher.
30. Frequent involvement in physically dangerous activities without considering possible consequences	+ Anticipate dangerous situations and plan for in advance. + Stress Stop-Look-Listen. + Pair with responsible peer (rotate responsible students so that they don't wear out!).
31. Poor adult interactions. Defies authority. Sucks up. Hangs on.	+ Provide positive attention. + Talk with student individually about the inappropriate behavior (what you are doing is..., a better way of getting what you need or want is...).
32. Frequent self-putdowns, poor personal care and posture, negative comments about self and others, low self-esteem	+ Structure for success. + Train student for self-monitoring, reinforce improvements, teach self-questioning strategies (What am I doing? How is that going to affect others?) + Allow opportunities for the student to show his strength. + Give positive recognition.
33. Difficulty using unstructured time - recess, hallways, lunchroom, locker room, library, assembly	+ Provide student with a definite purpose during unstructured activities (The purpose of going to the library is to check out..the purpose of...is...). + Encourage group games and participation (organized school clubs and activities).
34. Losing things necessary for task or activities at school or at home (e.g. pencils, books, assignments before, during and after completion of a given task)	+ Help students organize. Frequently monitor notebook and dividers, pencil pouch, locker, book bag, desks. A place for everything and everything in its place. + Provide positive reinforcement for good organization. Provide student with a list of needed materials and locations.
35. Poor use of time (sitting, starting off into space, doodling, not working on task at hand)	+ Teach reminder cues (a gentle touch on the shoulder, hand signal, etc.). + Tell the student your expectations of what paying attention looks like. (You look like you are paying attention when...) + Give the student a time limit for a small unit of work with positive reinforcement for accurate completion. + Use a contract, timer, etc. for self-monitoring.

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"It is through having the courage and willingness to revisit the emotional "dark night of the soul" that was our childhood, that we can start to understand on a gut level why we have lived our lives as we have.

It is when we start understanding the cause and effect relationship between what happened to the child that we were, and the effect it had on the adult we became, that we can Truly start to forgive ourselves. It is only when we start understanding on an emotional level, on a gut level, that we were powerless to do anything any differently than we did that we can Truly start to Love ourselves.

The hardest thing for any of us to do is to have compassion for ourselves.   As children we felt responsible for the things that happened to us.   We blamed ourselves for the things that were done to us and for the deprivations we suffered. There is nothing more powerful in this transformational process than being able to go back to that child who still exists within us and say, "It wasn't your fault.   You didn't do anything wrong, you were just a little kid."

"As long as we are judging and shaming ourselves we are giving power to the disease. We are feeding the monster that is devouring us.

We need to take responsibility without taking the blame. We need to own and honor the feelings without being a victim of them.

We need to rescue and nurture and Love our inner children - and STOP them from controlling our lives. STOP them from driving the bus!   Children are not supposed to drive, they are not supposed to be in control.

And they are not supposed to be abused and abandoned. We have been doing it backwards. We abandoned and abused our inner children. Locked them in a dark place within us. And at the same time let the children drive the bus - let the children's wounds dictate our lives."

When we were 3 or 4 we couldn't look around us and say, "Well, Dad's a drunk and Mom is real depressed and scared - that is why it feels so awful here.   I think I'll go get my own apartment."

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Our parents were our higher powers.   We were not capable of understanding that they might have problems that had nothing to do with us.   So it felt like it was our fault.

We formed our relationship with ourselves and life in early childhood.   We learned about love from people who were not capable of loving in a healthy way because of their unhealed childhood wounds.   Our core/earliest relationship with our self was formed from the feeling that something is wrong and it must be me.   At the core of our being is a little kid who believes that he/she is unworthy and unlovable.   That was the foundation that we built our concept of "self" on.

Children are master manipulators. That is their job - to survive in whatever way works.   So we adapted defense systems to protect our broken hearts and wounded spirits.   The 4 year old learned to throw tantrums, or be real quiet, or help clean the house, or protect the younger siblings, or be cute and funny, etc.   Then we got to be 7 or 8 and started being able to understand cause and effect and use reason and logic - and we changed our defense systems to fit the circumstances.   Then we reach puberty and didn't have a clue what was happening to us, and no healthy adults to help us understand, so we adapted our defense systems to protect our vulnerability.   And then we were teenagers and our job was to start becoming independent and prepare ourselves to be adults so we changed our defense systems once again.

It is not only dysfunctional, it is ridiculous to maintain that what happened in our childhood did not affect our adult life.   We have layer upon layer of denial, emotional dishonesty, buried trauma, unfulfilled needs, etc., etc.   Our hearts were broken, our spirit's wounded, our minds programmed dysfunctionally.   The choices we have made as adults were made in reaction to our childhood wounds/programming - our lives have been dictated by our wounded inner children.

(History, politics, "success" or lack of "success," in our dysfunctional society/civilizations can always be made clearer by looking at the childhoods of the individuals involved.   History has been, and is being, made by immature, scared, angry, hurt individuals who were/are reacting to their childhood wounds and programming - reacting to the little child inside who feels unworthy and unlovable.)

It is very important to realize that we are not an integrated whole being - to ourselves.   Our self concept is fractured into a multitude of pieces.   In some instances we feel powerful and strong, in others weak and helpless - that is because different parts of us are reacting to different stimuli (different "buttons" are being pushed.)   The parts of us that feel weak, helpless, needy, etc. are not bad or wrong - what is being felt is perfect for the reality that was experienced by the part of ourselves that is reacting (perfect for then - but it has very little to do with what is happening in the now).   It is very important to start having compassion for that wounded part of ourselves.

It is by owning our wounds that we can start taking the power away from the wounded part of us.   When we suppress the feelings, feel ashamed about our reactions, do not own that part of our being, then we give it power.   It is the feelings that we are hiding from that dictate our behavior, that fuel obsession and compulsion.

Codependence is a disease of extremes.

Those of us who were horrified and deeply wounded by a perpetrator in childhood - and were never going to be like that parent - adapted a more passive defense system to avoid confrontation and hurting others.   The more passive type of codependent defense system leads to a dominant pattern of being the victim.

Those of us who were disgusted by, and ashamed of, the victim parent in childhood and vowed never to be like that role model, adapted a more aggressive defense system.   So we go charging through life being the bull in the china shop - being the perpetrator who blames other people for not allowing us to be in control.     The perpetrator that feels like a victim of other people not doing things aright - which is what forces us to bulldoze our way through life.

And, of course, some of us go first one way and then the other.   (We all have our own personal spectrum of extremes that we swing between - sometimes being the victim, sometimes being the perpetrator.   Being a passive victim is perpetrating on those around us.)

The only way we can be whole is to own all of the parts of ourselves.   By owning all the parts we can then have choices about how we respond to life.   By denying, hiding, and suppressing parts of ourselves we doom ourselves to live life in reaction.

A technique I have found very valuable in this healing process is to relate to the different wounded parts of our self as different ages of the inner child.   These different ages of the child may be literally tied to an event that happened at that age - i.e. when I was 7 I tried to commit suicide. Or the age of the child might be a symbolic designator for a pattern of abuse/deprivation that occurred throughout our childhood - i.e. the 9 year old within me feels completely emotionally isolated and desperately needy/lonely, a condition which was true for most of my childhood and not tied to any specific incident (that I know of) that happened when I was 9.

By searching out, getting acquainted with, owning the feelings of, and building a relationship with, these different emotional wounds/ages of the inner child, we can start being a loving parent to ourselves instead of an abusive one.   We can have boundaries with ourselves that allow us to:   take responsibility for being a co-creator of our life (grow up);   protect our inner children from the perpetrator within/critical parent (be loving to ourselves); stop letting our childhood wounds control our life (take loving action for ourselves); and own the Truth of who we really are (Spiritual Beings) so that we can open up to receive the Love and Joy we deserve.

It is impossible to Truly love the adult that we are without owning the child that we were.   In order to do that we need to detach from our inner process (and stop the disease from abusing us) so that we can have some objectivity and discernment that will allow us to have compassion for our own childhood wounds.   Then we need to grieve those wounds and own our right to be angry about what happened to us in childhood - so that we can Truly know in our gut that it wasn't our fault - we were just innocent little kids.

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Children who paint or write in cursive, but who are unable to write legibly and consistently, in spite of repeated admonitions, require special approaches to the solution of their special difficulties. These are youngsters who are unable to properly form their letters, who have difficulty keeping their letters on the line, who may not seem to understand the relative sizes of letters, who either crowd letters within words together, or who space so poorly that it is almost impossible to determine where one word ends and another begins. The net result is that what they have written is often difficult or near impossible to decode, even when it is spelled correctly. Here are suggestions other parents have successfully used to help their children.

Our alphabet is based on geometric shapes-the circle, cross, square, and triangle. Get a large chalkboard, or make one. Dad can purchase a sheet of masonite from the local lumber company and then get a can of chalkboard paint from the hardware store. Use at least a four-by-four surface (larger would be even better). Select a wall in your home that is convenient and, after it is dry, tack it up. Let your child practice drawing circles and other geometric forms, nice and large.

Finger painting is a messy activity unless you have a law area that won't be too difficult to clean. Oil cloth on an old table or on concrete or vinyl floor works quite well. Use a plastic apron on yourself and your child. Have him roll the paint around in huge circles so that not only his hands, but his elbows and shoulders are involved. Just playing with shapes on the slippery surface helps tremendously. Making shape designs is fun and reinforces the development of shape constancy.

When children just can't seem to stay "on the line" as they print or write, try using a red felt tip pen to rule across the lines that will be the bottoms of letters. You may also want to use a green felt tip pen just to remind your child when to begin his strokes, since printed letters start basically at the top and go down.

Clay can be purchased from crafts stores in twenty-five pound sacks, often for under $5.00. Letting children mold the clay into forms gives them another kind of experience with shapes, but in a three- form that is helpful for form recognition. They can also form "snakes" and make letters, even their own names.

Quite often children hold pencils and crayons in an awkward manner and grasp. To develop the strength in the hands and fingers for proper grasp, let your child do activities that require holding or hanging. Make good use of your school play yard. Let him hang by his hands from the jungle gym to develop strength in the shoulder girdle as well as his hands. Squeezing objects, such as little rubber balls, or playing with wooden clothespins help to develop finger coordination and strength.

One of the prerequisites for handwriting is the ability of the eyes to work in close cooperation with the hands. This means that the eyes themselves must be able to move smoothly and must be able to follow moving targets. General motor coordination (balancing, hopping, running, skipping, et cetera) is necessary for laying the groundwork for smooth, fine muscle control. Play, for example, flashlight tag with your child. This requires two flashlights and a dark room. You be "It" and see if your child can, with his flashlight, "tag" your light.

Play tracing games. Have your child sit next to you with his eyes closed. Take his writing hand, index and middle fingers pointing and the other fingers flexed, and a-ace a shape or letter on a large surface. See if he can guess what shape or letter you traced.

If you're prepared to be squirted, and it's a warm day, and your back yard has a sunny wall, try this one. Get a squirt gun and let your child "write" letters with water on the wall. The sun will dry the letters reasonably fast. This allows your child to use space and estimate, on a large surface, just how he will execute the proper formation of the letter.

Observe the way your child sits when he writes. As a check, try this yourself. Sit at a table so that your elbows comfortably rest on the surface. Then fold your hands in front of you, flat on the desk so that your body and folded hands form a triangle. If you are right-handed, the paper would go directly under that folded arm. If you are left-handed, the paper would go directly under that folded arm. Notice that when you old the pencil, after this experiment, that the writing hand touches the surface of the paper directly along the line of the little finger and wrist. If you are right-handed, your back and head will be slightly curved to the left. (Vice-versa for the left-hander.) If your child is doing anything other than this, it means that he is not ready for the activity, or it is too demanding for him. It may also suggest that he has visual difficulties in the way he uses his eyes. (This does not necessarily mean that he has poor vision.)

If a child continues to reverse letters, even as his handwriting improves, give him opportunities to identify left and right on his own body. Play games requiring use of just the left hand or the right hand or the left foot or the right foot. Play "blind man's bluff, in which you must direct him across a room by giving him turns to make. Have him direct you when it's your turn.

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If you notice that your child continually holds his pencil right at the tip, it ran suggest that too much pressure is required for holding it properly. Try using a rubber band, twisted several times, and place it just above the shaved area. This will provide a tactile reminder on where to hold it.

"Rhythmic writing" is a term applied to law handwriting at a chalkboard. On the chalkboard you've made for home use, have your child stand so that he is facing the center of the board. Then, if he is right-handed, have him start a series of "e" letters, all connected, and all moving from left-to-right. As he moves from left-to-right with his writing hand, he should keep his feet firmly planted in one spot, and move his arms as far as he can. Then he can practice with "y" letters, and then combine "e" and "y" across the board.

If you have a large sink area with a Formica top, carefully "Soap" it. Don't make it too wet or you'll have a mess in the kitchen. Let your child stand by it and practice writing his letters, one at a time. Again, it is good for getting the "feel" of the letters. You can also take his hand, as in finger-painting, and move it through the slick surface, to form specific letters that are difficult for him.

Encourage your child to use what he learns. Go on a sign-making spree. Let him write (and decorate) signs that say, for example, "This is Jimmy's room. Enter at your own risk," et cetera. He can help you prepare a shopping list or birthday list. You'll undoubtedly have dozens of ways your child can use his developing skill in a practical way.

Play games with plastic letters that can be purchased at most local variety and school supply houses. These come in two forms both manuscript-upper (capitals) case and lower (small letters) case.

In order to print a letter a child must be able to visualize the shape of the letter. Let your child take one of the plastic letters and feel it with his eyes dosed. Can he recognize and name it? Can he draw it even if he is unable to name it? Let him describe it as he is feeling the surface and the sides. On confusing letters such as "h" and "n," which many children have difficulty with, let him feet them, one at a time, and help him feet the difference between the two.

When a child develops proper formation of letters, particularly in cursive, but does not maintain a constant slant, try this. Even though it takes a little time, it is worth it. With a ruler, pencil-in diagonal lines, very lightly, across the paper. These diagonal lines should be carefully done so that they provide "guidelines" for your child. As he writes, he has a visual set of "clues" to use to make sure his letters all slant the same way.

Keep in touch with your child's teacher as your youngster works at home with you to develop his skills in handwriting. Try not to make your child feel that he isn't "trying hard enough" or that you "just can't read it, it's so bad. Words of encouragement go a long way with children, just as they do with adults, and they are truly a significant part of any home activity that is designed to help a child.

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t is no fun to worry all the time about how much you weigh, how much you eat, or whether you are thin. Here are some things you can do.

Be healthy and fit! Have fun! Feel good about how you look!

• Eat when you are hungry. Stop eating when you are full.
• All foods can be part of healthy eating. There are no "good" or "bad" foods, so try to eat lots of different foods, including fruits, vegetables, and even sweets sometimes.
• When having a snack try to eat different types. Sometimes raisins might be good, sometimes cheese, sometimes a cookie, sometimes carrot sticks or celery dipped in peanut butter.
• If you are sad or mad or have nothing to do - and you are not really hungry - find something to do other than eating. Often, talking with a friend, or parent, or teacher is helpful.
• Remember: kids and adults who exercise and stay active are healthier and better able to do what they want to do, no matter what they weigh or how they look.
• Try to find a sport (like basketball or soccer) or an activity (like dancing or karate) that you like and do it! Join a team, join the YMCA, join in with a friend or practice by yourself - Just do it!
• Good health, feeling good about yourself, and having fun go hand in hand. Try out different hobbies, like drawing, reading, playing music, or making things. See what you're good at and enjoy these things.
• Remind yourself that healthy bodies and happy people come in all sizes, and that no one body shape or body size is a healthy one or the right one for everybody.
• Some people believe that fat people are bad, sick, and out of control, while thin people are good, healthy, and in control. This is not true and it is unfair and hurtful.
• Do not tease people about being too fat, too thin, too short, or too tall. And, don't laugh at other people's jokes about fat (or thin) people or short (or tall) people. Teasing is unfair and it hurts.
• If you hear someone (your mom or dad, a sister or a friend) say they are "too fat and need to go on a diet,"
  TELL THEM - Please don't, because dieting to lose weight is not healthy - and no fun - for kids or adults.
  TELL THEM - You think they look great just the way they are.
  TELL THEM - Don't diet; eat a variety of foods and get some exercise.
  TELL THEM - Remember, being "thinner" is not the same as being healthier and happier
• Appreciate yourself for all you are - Å“ everyone should respect and like themselves, enjoy playing and being active, and eat a variety of healthy foods.

next: Tips for Parents: Recognition and Prevention of Eating Disorders in Your Child
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The first step in developing your own Wellness Recovery Action Plan [WRAP] is to develop a Wellness Toolbox. This is a listing of things you have done in the past, or could do, to help yourself stay well, and things you could do to help yourself feel better when you are not doing well. You will use these "tools" to develop your own WRAP.

Insert several sheets of paper in the front of your binder. List on these sheets the tools, strategies and skills you need to use on a daily basis to keep yourself well, along with those you use frequently or occasionally to help yourself feel better and to relieve troubling symptoms. Include things that you have done in the past, things that you have heard of and thought you might like to try, and things that have been recommended to you by healthcare providers and other supporters. You can get ideas on other tools from self-help books, including those by Mary Ellen Copeland:

• The Depression Workbook: A Guide to Living With Depression and Manic Depression,
• Living Without Depression and Manic Depression: A Guide to Maintaining Mood Stability,
• The Worry Control Book,
• Winning Against Relapse,
• Healing the Trauma of Abuse,
• The Loneliness Workbook.

You can get other ideas from the audio- tapes

• Winning Against Relapse Program and
• Strategies for Living with Depression and Manic Depression.

The following list includes the tools that are most commonly used to stay well and help relieve symptoms:

1. Talk to a friend - many people find this to be really helpful
2. Talk to a health care professional
3. Peer counseling or exchange listening
4. Focusing exercises
5. Relaxation and stress reduction exercises
6. Guided imagery
7. Journaling - writing in a notebook
8. Creative affirming activities
9. Exercise
10. Diet considerations
11. Light through your eyes
12. Extra rest
13. Take time off from home or work responsibilities
14. Hot packs or cold packs
15. Take medications, vitamins, minerals, herbal supplements
16. Attend a support group
17. See your counselor
18. Do something "normal" like washing your hair, shaving or going to work
19. Get a medication check
20. Get a second opinion
21. Call a warm or hot line
22. Surround yourself with people who are positive, affirming and loving
23. Wear something that makes you feel good
24. Look through old pictures, scrapbooks and photo albums
25. Make a list of your accomplishments
26. Spend ten minutes writing down everything good you can think of about yourself
27. Do something that makes you laugh
28. Do something special for someone else
29. Get some little things done
30. Repeat positive affirmations
31. Focus on and appreciate what is happening right now
32. Take a warm bath
33. Listen to music, make music or sing

Your list of tools could also include things you want to avoid like:

1. alcohol, sugar and caffeine
2. going to bars
3. getting overtired
4. certain people

Refer to these lists as you develop your Wellness Recovery Action Plan. Keep it in the front of your binder so you can use it whenever you feel you need to revise all or parts of your plan.

Note: I'm also using Advocacy as a wellness tool.

Mental Health Recovery homepage

The following handout will serve as a guide to developing Wellness Recovery Action Plans (WRAPs). It can be used by people who are experiencing psychiatric symptoms to develop their own guide, or by health care professionals who are helping others to develop Wellness Recovery Action Plans.

This handout, or any part of this handout, may be copied for use in working with individuals or groups.

Getting Started with a WRAP

The following supplies will be needed to develop a Wellness Recovery Action Plan:

1. a three-ring binder, one inch thick
2. a set of five dividers or tabs
3. a package of three-ring filler paper
4. a writing instrument of some kind
5. (optional) a friend or other supporter to give you assistance and feedback

Section 1-Daily Maintenance List

On the first tab write Daily Maintenance List. Insert it in the binder followed by several sheets of filler paper.

On the first page, describe, in list form, yourself when you are feeling alright.

On the next page make a list of things you need to do for yourself every day to keep yourself feeling alright.

On the next page, make a reminder list for things you might need to do. Reading through this list daily helps keep us on track.

Section 2-Triggers

External events or circumstances that, if they happen, may produce serious symptoms that make you feel like you are getting ill. These are normal reactions to events in our lives, but if we don't respond to them and deal with them in some way, they may actually cause a worsening in our symptoms.

On the next tab write "Triggers" and put in several sheets of binder paper.

On the first page, write down those things that, if they happened, might cause an increase in your symptoms. They may have triggered or increased symptoms in the past.

On the next page, write an action plan to use if triggers come up, using the Wellness Toolbox at the end of this handout as a guide.

Section 3-Early Warning Signs

Early warning signs are internal and may be unrelated to reactions to stressful situations. In spite of our best efforts at reducing symptoms, we may begin to experience early warning signs, subtle signs of change that indicate we may need to take some further action.

On the next tab write "Early Warning Signs". On the first page of this section, make a list of early warning signs you have noticed.

On the next page, write an action plan to use if early warning signs come up, using the Wellness Toolbox at the end of this handout as a guide.

Section 4-Things are Breaking Down or Getting Worse

In spite of our best efforts, our psychiatric symptoms may progress to the point where they are very uncomfortable, serious and even dangerous, but we are still able to take some action on our own behalf. This is a very important time. It is necessary to take immediate action to prevent a crisis.

On the next tab write, "When Things are Breaking Down". Then make a list of the symptoms which, for you, mean that things have worsened and are close to the crisis stage.

On the next page, write an action plan to use "When Things are Breaking Down" using the Wellness Toolbox at the end of this handout as a guide.

Section 5 - Crisis Planning

In spite of our best planning and assertive action, we may find ourselves in a crisis situation where others will need to take over responsibility for our care. We may feel like we are totally out of control.

Writing a crisis plan when you are well to instruct others about how to care for you when you are not well, keeps you in control even when it seems like things are out of control. Others will know what to do, saving everyone time and frustration, while insuring that your needs will be met. Develop this plan slowly when you are feeling well. The crisis planning form includes space to write:

• those symptoms that would indicate to others they need to take action in your behalf
• who you would want to take this action
• medications you are currently taking, those that might help in a crisis, and those that should be avoided
• treatments that you prefer and those that should be avoided
• a workable plan for at home care
• acceptable and unacceptable treatment facilities
• actions that others can take that would be helpful
• actions that should be avoided
• instructions on when the plan no longer needs to be used

next: Post-Crisis Planning For After Your Psychiatric Crisis
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Many adult women have eating disorders. Discover how eating disorders therapy works and how to engage in healthy eating.

Most everyone thinks of anorexia, bulimia, and other eating disorders as conditions only young women face, but new evidence shows that many women over 35 suffer from these afflictions throughout their lives.

When I was about 14 years old and just beginning my initiation into the mysterious rites of passage toward becoming a woman, one of the very first "secrets" I learned was how to diet. Here was a way, or so I thought in my innocence, that I could eat whatever I wanted and make up for it later by dieting it all off. How clever were these older women who taught us youngsters how to have our cake and eat it too! As it turned out, not only did I enjoy dieting, with all its deprivations and strict rules, but I had a real talent for it. When I embarked upon a diet, my willpower was resolute and unshakable. But when the diet was over and I'd reached my preferred number on the scale, I couldn't wait to run into the kitchen and start scarfing down all the foods I'd forbidden myself during the diet. That was how I discovered firsthand what so many women have known throughout the ages—forbidden fruits do taste sweeter.

Dangerous Hidden Secrets of Dieting

By the time I'd gotten older, into my late 20s and early 30s, this routine, which had started out as an innocent game, had developed sinister overtones. Now I know the name for what I was doing: yo-yo dieting, which is the practice of losing pounds and regaining them over and over again, moving up and down in weight like a spinning toy on a string. I managed to keep my weight more or less stable into my 40s using this method—it just meant I was perpetually on a diet.

When I looked around at most of the women I knew, both older and younger, I saw a secret society whose members seemed to have the same unspoken agreement (which I personally didn't recall signing) that looks counted above all else. And I realized that the wish I'd long been secretly harboring—that there would be some age limit on this crazy way of looking at food and my body, some point at which I would finally be old enough to opt out of the whole insanity—was not going to come true. I was going to either have to find my own way out or this could easily go on for the rest of my life.

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I now know that I was hardly alone in continuing to face serious food and body issues well into midlife. Conventional wisdom in the medical community used to posit that eating disorders were something that happened only to younger girls, and that most women in their mid-30s would certainly have outgrown them. But now those who specialize in the treatment of eating disorders have come to understand that there is no age limit. Eating disorders can and frequently do occur in women that age and beyond. In fact, for the most part, as happened with me, these are eating disorders that women developed as adolescents or young women and never resolved.

This new definition of eating disorders as a condition that can affect any woman at any age may come as a huge relief to the leagues of older women who thought they were all alone, suffering from a disorder they should have outgrown. The good news? When it comes time for treatment, older women bring a mature perspective on life and a resourcefulness to the process that younger women don't yet possess.

Defining eating disorders

The most common eating disorders include anorexia nervosa—in which a person consumes too little food and suffers extreme weight loss—and bulimia—in which a person repeatedly forces herself to vomit after eating, typically after binge eating. Bulimics may also use laxatives to purge themselves. A more general category is binge eating disorder, which, according to Diane Mickley, MD, director of the Wilkins Center for Eating Disorders in Greenwich, Connecticut, shares features with bulimic behavior, such as binging, placing too high a value on food and body issues, and having increased anxiety around food. The general category known as "EDNOS" (Eating Disorders Not Otherwise Specified) includes a wide variety of eating behaviors that don't otherwise have a name but have one thing in common: spending an inordinate amount of time and energy obsessing about food and body. Overexercising, overemphasizing thinness, obsessive thinking, repeated "cleansing," yo-yo dieting, and other forms of excessively restricted eating fall into this catchall category.

One of the worrisome new eating disorders to which women in midlife and beyond may be especially susceptible is orthoexia nervosa, which is defined as a "fixation on righteous eating." This occurs when an obsession with healthy eating begins to dominate a person's thoughts and life to the point where the behavior itself becomes unhealthy. According to Tacie Vergara, clinical supervisor at the Renfrew Center's Thirty-Something and Beyond Group (an inpatient eating disorders program in Philadelphia and other East Coast locations), orthoexia "can start for older women when they've got a life crisis—fear of mortality, a cancer diagnosis, or maybe their husband just got diagnosed with a cardiac problem," Vergara explains. "It starts out as a healthy impulse to eat better, but before you know it, it's out of control."

Whatever the eating disorder, experts agree that most of these conditions don't just come out of nowhere in midlife. "The vast majority of affected people have their first onset in adolescence," says Mickley. "Some may have had longtime food and weight concerns; they may have had low-grade problems that hid out under the radar for a long time. But it's extremely rare for an eating disorder to manifest for the first time in middle age."

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Most afflicted women manage to cope for years with the many different forms of eating disorders, and many of them don't even realize that they're suffering from one.

"It didn't dawn on me I had any kind of eating disorder until I was in my 30s," says Karen Franklin, a woman who has struggled off and on with anorexia since she was a young girl. "I thought that I was just some kind of freak around food—I didn't know how to nourish myself. But then I came across some articles on anorexia, and I had an amazing awakening that I was like those girls."

Franklin thought her problem was behind her until she saw her child develop an eating disorder of her own. "I felt like I had things under control—my life felt really full—but when my daughter started having eating problems, something really clicked for me," Karen recalls. "All my old body issues came tumbling back."

Sorelle Marsh also saw her long-standing eating disorder spin out of control in midlife. "I started out as an anorexic when I was about 17 or 18," Marsh explains. "But then I learned about bulimia, and I thought, 'Wow, this is a great way to have it all and still be thin!'" Marsh says the bulimia continued off and on until, at age 41, she found it increasingly difficult to hide her behavior from her husband and children. She went to see a therapist who gave her some drugs to help with her anxiety and depression. However, the drugs sent her into a suicidal depression.

"I was very depleted in every way, shape, and form from the binging and purging," says Marsh. "I thought to myself, 'You can't go on like this,, you need help,' and I decided that I needed to go somewhere, away from my life, to get help."

According to Mickley, eating disorders reassert themselves in midlife for myriad reasons. "Number one is if you feel that your self-worth is heavily based on your appearance, as you get older it inevitably means the loss of your youthful appearance," she says, "and there are so many other kinds of losses that can occur in midlife, such as the end of a relationship or a divorce, the stress of remaining in an unhappy relationship, or a medical illness. There are also so many issues around kids—kids growing up, kids with problems, or kids going off to college."

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Whatever the cause of a relapse, the number of women over 35 seeking help for eating disorders is rapidly increasing. According to Vergara, from 1985 to 2000 approximately 3 to 5 percent of those seeking treatment at the Renfrew Center were over 35. From 2003 on, that number skyrocketed to 30 percent. Vergara credits this in part to Renfrew creating a special program called the Thirty-Something and Beyond Group. "We'd always served these women but never specifically targeted them before," Vergara explains. "Once we gave them permission and let them know there was a place for them to come, they were there waiting and hungry for our services."

Getting help for an Eating Disorder

Eating disorder clinics and specialists generally don't use any special therapeutic tricks when treating older women with eating disorders. The same techniques and approaches work with younger and older women alike. "In treating eating disorders in general, one of the common myths is that there are underlying psychological problems, you work them out, and the illness will evaporate," says Mickley. "But it's the reverse. If you have an eating disorder, you must first manage food, weight, and eating symptoms if you want to do good work in therapy. The notion that you'll take someone who is throwing up all day and build her confidence makes no sense—that act of vomiting provides her with emotional Novocaine, and if you numb your feelings, how are you going to learn what you feel? So the first line of defense in folks of all ages is symptom management."

Still, peer-group programs work especially well for women in midlife. "These women have lost so much in midlife that they're not going to get back," says the Renfrew Center's Vergara. "So we have groups specifically geared for their unique life situations, such as how do you be a mom on the go and also provide sound nutrition for you and your family, how do you learn to care for yourself as well as others, and all the unique issues that come up over not being fed and being out of balance in midlife."

The Renfrew program has given Marsh a new outlook on life, food, and her own journey. "The first thing the Renfrew program did for me was get me out of my home and environment and stop the binging and purging," Marsh recalls. "I knew my time at Renfrew was my only and last chance. It causes me a lot of sadness that I couldn't have done this when I was 20 or 25 or any other time—but I've realized this is now my time to do it."

For all of us working with eating issues in midlife, it's important above all to remember that each of us is a work in progress. Life will continue to change, with new challenges, new joys, and new wrinkles—including those that line our skin. The point isn't to get it all figured out once and for all and rest on your laurels. Rather, you can achieve many levels of success and many levels of satisfaction. Waking up to all of the richness that life can offer when you are conscious can help you heal your eating disorder, as well as live a life with purpose and passion.

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Moving Into Healthy Eating

When I realized that I no longer wanted to spend my days obsessing about food and body, I had no idea how to go about making that change. At this same time I began to do yoga and to meditate. I found that both practices increased my ability to be conscious—not only around food—but also of seeing the kind of habitual thoughts that were etched deep in the recesses of my mind. When I ate consciously, it was very hard to accidentally eat a bag of cookies and wonder where they might have gone to, which enabled me to control my eating without even trying. And consciousness also proved to be the key for actively identifying what held meaning for me in life.

Mind/body practice, such as yoga, tai chi, meditation, or mindful walking can help a person who is struggling with any form of eating disorder learn consciousness in motion. This can directly impact the way one eats, since mind/body practices help us listen to what we're truly hungry for on our physical, emotional, and spiritual planes.The key is to use the mind/ body practice as a tool of self-discovery and as a means to develop consciousness—not as one more opportunity to beat yourself up about what a lousy meditator you are or how bad you look in your yoga outfit.

"Yoga brought me to a place where I could like myself without looking in the mirror," says Karen Franklin, who's struggled with anorexia for years. "It was so clear to me that yoga is about non-judgment and self-reflection, but it's also about action—I act, and then I can let it go. For me yoga is always a fresh start—I messed up today and tomorrow will be better. That's a very different point of view from when I used to think, 'I messed up today, and tomorrow I won't eat.' It's brought me a certain amount of wisdom around my actions and has also helped me discover what will nourish me."

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Awakening Conscious Eating

The following practice introduces you to some basic techniques for conscious eating. The seemingly simple act of having the intention to stay conscious as you eat and to maintain attention to the process of eating can completely alter your relationship with food. It will help you break food patterns that may otherwise feel all-powerful, overwhelming, destructive, and out of control.

The following practice introduces you to some basic techniques for conscious eating. The seemingly simple act of having the intention to stay conscious as you eat and to maintain attention to the process of eating can completely alter your relationship with food. It will help you break food patterns that may otherwise feel all-powerful, overwhelming, destructive, and out of control.

• Start out by selecting a food that you enjoy, both for its appearance and taste, but that doesn't hold conflict for you in any way. Place the food on the table and sit facing it. Take a moment to clear your mind and drink in the appearance and aroma of the food.
• Before you eat, set the intention to focus your complete attention on the first and last bites of the food and to note any feedback you receive as you eat. This sounds deceptively simple. Don't be surprised if it's challenging!
• As your teeth sink into the first bite, try to slow down the moment so you experience it fully and consciously. When you finish chewing the bite, savor the sensations, and listen to any feedback you may experience.
• For the rest of the food, just eat as you normally would, but as you prepare to finish the last bite, repeat the previous exercise, trying to focus all of your attention and to remain fully conscious.

After you've finished eating the food, take just a moment to reflect. Consider what percentage of the time you were conscious in between the first and last bites and what percentage of the time your thoughts were elsewhere. Did setting your intention to remain conscious for the first and last bites make you more conscious in between, or just for those bites?

Repeat this simple food practice once a day for a week. You may eat the same food or choose different foods each time. You'll probably notice that the amount of time you spend between bites being consciously aware of your food and the eating experience will increase gradually over the week.

Source: Adapted from the book, What Are You Hungry For? Women, Food and Spirituality, by Lynn Ginsburg and Mary Taylor (St. Martin's Press, 2002).

next: Helping Your Child With Obesity