Closing the {Thigh} Gap – Part I.

Since I have been writing this blog and reading what is written about anorexia, I realize what many of you already know – as a field, we are extremely inconsistent when it comes to a clear understanding of this illness, let alone a consensus of how to treat it effectively. I certainly don’t know all the answers. However, I think what I do represent is someone who has been thoughtful in my professional journey. I have begun my process as we all do – by using the tools I was taught by my mentors. Some of these worked, most did not. I then tried to “follow the science” and find the best tools that the field has to offer, even with the limited outcome research that we have. I was determined to “do better’ as a treatment provider. I took my treatment failures personally. I always believed in full recovery for these patients even though the field itself is not fully supportive of this idea. I felt a sense of urgency with these patients, especially when I began to be a referral source for the younger patients. When you have a 10-year-old in your office who is slowly dying of this illness, your mind explodes with an urgency you never thought possible…..So, I am going to attempt to summarize what I perceive as the major “turning point” for me in my professional life, and more specifically, how I got to where I am today.

It all started many years ago with a patient I will call Stacey. She was 15 when I started seeing her for anorexia. She had all the classic signs and symptoms: restricting, over-exercising, sneaking, body image distortion, fear of fat, hiding food, food rituals, perfectionism, rigid thinking, and an ongoing narrative of self-attack for her latest “indulgence” in eating too much food. At this time in my work, I was completely unaware of the disease of anorexia in the way that I am now. I really thought it was something that was “caused” by poor parenting, exposure to trauma, and/or our unhealthy thin focused culture. Therefore, if I could help the patient become media savvy, help the family become less intrusive and controlling, and help the patient process their trauma, the patient’s illness would go away, or at least get smaller. So, this is what I did. I spent two years treating Stacey this way. Her mother would bring her to sessions and I would have her wait in the waiting room. I only included her for bi-monthly traditional family therapy where I would try and tackle the dynamics that I thought “caused Stacey to be sick”. I mostly saw Stacey alone. I spent most sessions trying to convince her in one way or another to give up this eating disorder. Stacey was also followed by a nutritionist who suggested ongoing ways that Stacey could tackle her anorexia.

Stacey came in, week after week and was willing to talk about the issues I raised: her childhood, her traumatic experiences, her social isolation, her frustration with her controlling mother, her fears of growing up, and her academic pressures. We would spend the session following the greatest stressor of the previous week from this list of topics. She would talk, complain, explore, cry, get frustrated, gain insight, confront her family, gain knowledge, use her voice, become empowered with the language of recovery, reach out to friends, and work on her often strained relationship with me during the sessions. She would do this every week, for two years. And here is the thing: many things changed in that time. She became more assertive, she became less stressed with school, she became better at making decisions, she was less agitated in her relationships, and her social anxiety decreased. This is all good, right? This was my goal, right? I was not so sure….

I decided to begin to more closely track three things I had never  tracked before during our sessions: Stacey’s weight, her eating patterns, and her obsession with her body and her fear of fat. Basically, the symptoms that make up this illness. And every week it would be the same. She never gained weight and hovered about 10-15 pounds below her ideal body weight. She ate in the exact same way and the exact same limited foods. She expressed severe disgust at her body whenever given the opportunity. What I started to realize is that despite all of these aforementioned changes in Stacey, one thing never changed – the strength of her anorexia. It was like it was never even touched by the treatment. It was surviving very nicely despite everything I was throwing at it. How could this be? Her family treated her better. Her trauma was mostly resolved. Her self esteem was better. She was savvy about the effects of the media….What was I doing wrong here?

And then one day, not long after her second hospitalization for her anorexia occurred due to acute periods of weight loss, I had a revelation. It was the Spring. Stacey was sitting in the chair she always sat in. She was wearing shorts and she made it clear to me that this was a “big step for her”. You see, Stacey hated her thighs. In fact, this was the only body part that she truly hated. She said she could stand her stomach, her arms, and even her face. But, her thighs had to go. Why? Because they touched. They touched when she stood up, and of course when she was sitting down. She didn’t have the thigh gap that was acknowledged to be the end all and be all for anorexics. She had failed  and she was miserable. She didn’t want to participate in her own life as she hated herself so much for allowing this to happen. So each session she would attempt to put her fingers around her thigh and talk about how she could no longer do this and how she just wanted to die. She did this every session. Every one. No matter what I did, no matter what her family did. No matter how many times she was hospitalized. She just kept doing it. The disease never stopped, never got smaller. And in September, she was supposed to go away to college. She had worked so hard and she and her family were so proud. But, how could I participate in sending a child away across the country to college when she couldn’t eat and when she couldn’t think right. I felt a sense of urgency unlike anything I had ever felt. I did not have much time before her start date at school. How could I help her turn this around?? Was it even possible? I had tried everything I had in my tool belt….

But, something inside me clicked. I could no longer sit here passively and let this disease win. I knew about exposure based treatment as I had previously done individual and group work using food exposure sessions with patients with anorexia. I still liked the idea of using food in the sessions. But I also liked the idea of using the family. I started reading about family based treatment and everything it had to say about treating anorexia. It incorporated family meals (although not as many as I would like) and it incorporated a very clear protocol for focusing on treating the way the patient currently ate which then resulted in an increase in weight. The treatment also proposed that when this re-feeding occurs, the patient begins to think differently as the disease is diminished via the weight gain. I was fascinated by a treatment that actually highlighted the issues that I saw as immovable in my patient.

I was ready to start something new.

(Please tune in next Tuesday for Closing the {Thigh} Gap: Part II).

Thank you.

A Mother’s Instinct.

Many topics have been swirling in my head this past week that I want to share but after seeing a very moving video, one took precedence. A mother in Australia gave birth to twins and was told that one, the baby boy, had died upon coming into the world. She told the doctors that she wanted to say good-bye and also wanted to try and “entice” him to possibly stay with her in the world by talking to him and telling him how much he was loved. She and her husband lay there, bare chested to give off their heat and scent, with the baby for two hours. Within 5 minutes, the baby started making movements but the doctors continued to tell the couple that the baby was dead and these were just “reflexes”. The mom continued to talk to the baby, hold him, and soon the baby opened his eyes. The doctor STILL didn’t believe that the baby was alive until he finally came back into the room and saw the proof in front of him. The couple has their baby back and it is being hailed as a medical miracle.

My thoughts? It is a miracle, no doubt. But this miracle would never have happened if the mom in this case did not follow her instincts to interact with her baby in the way that felt right to her. Despite the doctors, despite the medical precedent, despite the pressure to move on. This mother knew what was best for her baby. I am so touched by this story because in my line of work I see this every day. Moms (and sometimes Dads) will call me crying on the phone saying they don’t know what to do to help their child. All they know is their child is sick and possibly dying from this illness called anorexia. The children have been often hospitalized multiple times and remain sick. The mother sees the child suffering, drowning in something much bigger than they are. They are losing the child they once knew. They are terrified and have been told at best that there is “nothing they can do to help” or at worst that “they are the cause of the child’s illness”. They are overwhelmed with guilt, confusion, helplessness and terror.

Traditionally, our field has done these mothers wrong. We have marginalized them, made them the “bad guys”, and kept them in the dark about their child’s anorexia. If their child was diagnosed with diabetes, the team would not think twice about empowering the parent with knowledge and strength to be a key team member to help with their child’s illness. We would give them the insulin syringes and teach them how to inject the medicine into their children. We would empower them by teaching them about how the illness has overtaken the child and what they can do to help manage its effects. We would never think to keep them out in the waiting room, in the dark, unaware of the treatment plan. But this happens every day with parents of children and adolescents with anorexia. Family based treatment turns this practice on its head. Not only are parents acknowledged, they are empowered. Not only are they not blamed for causing their child’s illness, they are taught that they are often the key to turning this illness around.

It is a beautiful thing to see these mothers and fathers with their children at the conclusion of treatment. Not only are the children now better and the parent says to me “my kid is back,” but the parent feels wonderfully empowered and victorious over this illness that wanted to claim their child as its own. Just like the mom holding her new born son who is now opening his eyes in response to her warmth and voice, these parents experience incredible joy in knowing that they were the key in bringing their once sick child back to life. It has been my honor to help these parents experience such triumph.


There is so much confusion and controversy when it comes to the issue of choice and anorexia. Some believe that getting the illness is “a choice.” Some feel that you do not choose the illness but  you can choose to get better from it. I believe that this comes from a significant misunderstanding of what the disease is. I don’t think most of us would say becoming schizophrenic is a “choice.” However, many of us (or most of us if we are women) have tried to “look better,” or “lose weight,” or “be thin.” So unfortunately, we project this very common occurrence of trying to change our bodies onto those who have fallen down the rabbit hole of anorexia. For those of us who do not have the switch that flips in our brain to anorexia, it is indeed a choice. We can choose to lose more weight, stop losing weight, and change our eating to reflect more or less healthy choices during our day. However, those folks who are unfortunate enough to have their brain switch into this illness no longer have this luxury of control. What once started as something that was a choice – “I would like to become healthier and eat better,” has now moved into a very different realm of lack of choice. The disease now dictates, “you will not eat any fat and if you do, you will burn it off by running until you drop.”  The disease also makes choosing anything that has to do with food impossible – “you will not eat that, but, you are hungry so you will cook for others and watch them eat,” or “you are a big fat pig and you will stare in the refrigerator but not be able to decide to eat anything, as any calories are too much for you!” The disease takes away all clarity of choice. It imprisons the patients it affects, totally and completely.

Choices. “The patient can choose to get better, but needs more insight.”  “The patient can choose to get better but their dysfunctional family is holding them back.” “The patient can choose to get better but our sick culture is impacting them”. I disagree with all of the above. The patient can NOT choose, they are too sick. They need help! We must make the choice for them. We must relieve them of the torture of making food choices. We must relieve them of the burden of trying to fight this illness in one breath and then in the next succumb to its power. We must make the choices. We, the treatment team. We, the parents. We, the spouses. We are the ones who can lend the patients our strength and our voice while they have neither. We need to pull them from the depths of the rabbit hole. They CAN NOT do this on their own. I am completely stunned as to why the field hasn’t caught up to this thinking but instead feels it is “disrespectful” and “invalidating” to offer this type of help. I believe this utter lack of understanding of the illness is linked to the fact that this disease has the highest mortality rate. These patients can not turn this around themselves. This is NOT another diet. This is NOT a self-indulgent “vanity” that the child or adult needs to “just get over”. They can not. I will write more about the illness over time and everything I have learned about it. The darkness and the ugliness and the relentlessness that kills these patients.

It is the most confusing thing that the goal of most of our culture is to obtain what this disease wants as well  – thinness. How can we truly see the viciousness in the illness when most of us want what it proclaims as its ultimate goal – to be thin, to be powerful, to be confident, to be beautiful. I don’t think there is any other mental illness that promotes something that all of us envy like anorexia does. Most mental illnesses result in confusion, loss, isolation, and decreased functioning. There is nothing very attractive about that. So, we understand that these illnesses are something we need to help with. We have empathy, compassion and are willing to take a leadership role in helping these patients. But, what about those “pretty girls” who complain about “being too fat?” Sometimes it is hard to feel sorry for someone who is achieving what the whole world wants to achieve….

We need to gain a clearer perspective. The disease needs to be the focus, not the thinness that results from the disease.  We need to be educated. We need to take control and help eradicate this illness. Patients are dying and they need our help.

The Power of Words…..

I have been wanting to write about my thoughts on this topic for years now. I have just been too reluctant for many reasons, mostly neurotic ones – “No one will read it”, “No one will care”, “There are so many amazing thinkers and writers out there, how can I make a difference?” These ideas were sitting in my mind, brewing, without direction and I was lacking the confidence to move them from my inner voice to paper. But like so many things in life, this self-hindering process changed in a moment. I have a client, let’s call her Michelle, who recently finished a year of treatment with me. She came in as a “chronic” anorexic – a history of 14 years of the illness- and went through my intensive program in which her husband helped to re-feed her until she was able to eat normally on her own (yes, you read that right, her husband was instrumental in supervising her eating while she was sick). It is now a year later and she is for the most part anorexic free. She exercises and eats on her own, accepts her body where it is even if she doesn’t love it, is no longer feeling trapped or depressed, and is fully empowered to step into her life. One day, we were talking about her recovery and she declared emphatically “I don’t want to be in recovery from anorexia, I want to be fully recovered!”

It was a powerful moment, a true shift in her self-perception and clearly it impacted me as well. I had never had a patient clarify things for me like this. But, this statement summarized so beautifully all of the work I had been doing with her so far. Everything I had said, done, implied, wished, and hoped for when it came to her and all my other patients. I didn’t want them to be on an alternate path of the anorexia titled “I am in recovery”. I wanted them done with it, finished with it, competely and totally. Full Recovery. It is what I had been taught as a young psychologist to never hope for when it came to these patients. I would hear “Ellen, these patients never really get better, they just learn to manage their illness”. Or, “Ellen, this is the hardest mental illness to treat with the highest mortality rate, don’t kid yourself that you can actually cure it”. So, I admit for the first part of my career, I, like many patients never peeked beyond the partition that separates this partially recovered state from true complete healing. This lack of truly getting better was something I had come to accept as part of working in this specialized field.

But everything changed about twelve years ago when I shifted radically from my more psychodynamic thoughts on anorexia to a family based and behavioral paradigm (much more about this transition later…..). Long story short, for the first time, not only did the patients respond quite rapidly to this change in intervention but when treatment was over, they were done with the illness. I mean DONE. I don’t mean acting “as if” they were done or hoping they were done but just plain done. I began to say in my sessions “The anorexia has left the building” and the loved ones and patients would nod their heads in agreement but quickly shake their heads in disbelief as to “how this could have happened” as they were told their loved ones would “never really get better”.

So, my goals for this blog are twofold so far – 1-to not have it run too long (which I already am at risk for not achieving), and 2- to highlight for you the reader my thinking as to what leads to the ultimate outcome of true recovery. Why have I named it the 10 pound blog? Again, without getting into all of my thoughts right away, I am now, after 12 years, utterly and totally convinced that the difference between many patients being in a partially recovered vs. fully recovered state is just that – about 10 pounds. Yes, some need more, but most don’t. This was also a surprise to me. I was sure that these “sick” patients would need to gain much more (and to them 10 pounds feels like 100) but objectively, I was shocked that time and time again they were simply walking around 10 pounds under their full goal weight. As soon as these patients were pushed to gained this weight, I saw a significant shift in their thinking – the disease receded – and the veil was lifted that revealed true recovery.

A key phrase you may have noticed above is “the patient was pushed” to gain weight. This speaks to my allegiance to conceptualizing anorexia as a brain based illness which needs to be actively treated with its medicine – food. I used to be of a very different ilk – I used to think that “pushing” a patient to eat was disrespectful and invalidating of the person. I used to wait and wait (…..and wait and wait and wait and wait)… until the patient herself declared that they were ready to eat on their own (if this even ever happened). I am now very clear that this pushing to eat is an invalidation of the disease which has overtaken the person. The patient needs help, even when the disease won’t let them ask for any help.

I hope in some small way the wisdom that is shared here from me and sometimes gleaned from my patients or other colleagues will be a small influence in even one patient’s quest for full recovery. I would like to reassure even one person that full recovery is not a mirage.  It can truly be reached through the influence of an informed, compassionate treatment team.