An article was published  today that highlights the positive feelings that anorexics feel when they accomplish things like weight loss or a achieving a new level of restricting calories. The article states that this is a good thing because most research on these patients focuses on their negative feelings vs. their positive experiences. For any of us in the trenches treating these folks, it is no surprise that most of these patients will acknowledge that restricting and obtaining a goal to lose weight brings them pride, joy, and in general the only positive feelings they are experiencing once they have fallen down the rabbit hole of this disease. The article goes on to state that perhaps we should keep in mind these things that make them happy (like exercise) and shift their love for let’s say running on a treadmill for hours a day to a less aerobic yoga class. That way we can harness the things that continue to give them pleasure but offer them in a more moderate fashion.

From a family based perspective, the patient is not pleasing themselves by exercising or restricting. They are pleasing their master – the eating disorder. It is the anorexic mind that is driving them to exhaustion on the treadmill and telling them they are “better than everyone else” if they can run to the  point of falling over. It is the anorexia that is instilling the pride in them and I believe we need to be very careful at reinforcing this type of pride in any way. Once the patient’s brain is recovered, we can then help them “feel good” about accomplishing things or gain pride in achieving goals as these are usually the kind of kids that very much thrive on this. However, it is just this type of vulnerability to externally based pride in achievement that the anorexia exploits when it takes over the child’s being. I have had many patients tell me that when they first got sick, they couldn’t tell because they thought they were just pleasing themselves and their coaches and their parents with their achievements like being able to run faster and play harder at their sport. This pleasing of the adults in their lives moved quietly and often quickly to pleasing the voice in their head – the voice of the illness.

I would like to suggest another way in which we can harness the patient’s pride to aid in her treatment. When I have a new patient come to my office, I make it very clear that my job is to kill off the illness in their head. I make the parents very aware of the severity of the illness and how hard it is going to be to kill it off. However, I make it clear that I know how to do it and I will do it, I just need them to follow what I suggest in the treatment. Along those lines, I tell the patient that I am now going to become the person they need to please. I, along with their treatment team, will tell them what to do and our voices will become stronger than the anorexic voice in their heads. If we are not strong and persistent, we will easily be drowned out by the anorexic chatter. I have seen again and again the patients come to the place that once these new treatment rules are in place and once they see that their parents are fully on board, the healthy part of them gets on board with “pleasing us”. There remains the part of them that wants to please the anorexia but this part gets smaller and smaller with the weight gain until the only thing that is left is a child who actually gets upset if they step on my scale and lose weight. They get disappointed in themselves if they have not gained…..This is one point in treatment that I become quite confident that the anorexia is on its way out. It is no longer the master of the child.

Some may say that this approach seems wrong in that it reinforces dependency and even subservience from the patient. I agree, it goes against my grain to have a patient be so obedient. However, like many of my posts before, the key here is that eating disorder treatment is sequential and it has an order to it. I would never say a patient is “better” when they are still solely focused on pleasing me or any other person. The goal is for the patient to please herself and to internalize this process. However, this takes time and often lasts much longer than the original treatment for the anorexia. This is more long term work, both in individual and family domains. But I am well aware that this is my ultimate goal – to first free the child of her current master and to then help her to fly.