Things I Would Like Parents of Eating Disordered Children to Know….Part I

I received so much positive feedback regarding my last “Top 10 List” that I thought I would attempt another, shorter list with my thoughts on what could be helpful for parents of ED children. There are many suggestions or lists to parents who have recently had their child diagnosed. What to do, what type of therapist to look for, how to get the child to eat. I thought I could add something new to this information by offering my thoughts on what I would like parents to know who are currently already in some type of family therapy with their child, helping them to fight this illness. I hope this is helpful!

1. Guilt (in you)- A lot is now being said about the fact that finally, many (but not all) professionals are “getting it” that you, the parent did not cause your child’s eating disorder. This is highly important and has been a long time coming. But that being said, even though I do not blame the parent for the ED, I do try to educate them on how to be the most supportive they can be during the recovery process. This interaction can feel like I am blaming them, criticizing them, or invalidating what they are doing to help their child already. It is a very delicate balance of evaluating the present dynamic in the family, and seeing what everyone can do differently to minimize the impact of this deadly disorder. As much as I try to offer this information in a non-critical manner, many parents end up feeling “blamed” for something they are “doing wrong”. They then often generalize this to thinking “I just caused the whole problem, it is all my fault”. This process of the parent being overwhelmed by their own guilt is not only bad for them but it is unhelpful to the whole therapy process.

My best advice: Do not allow yourself to mistakenly buy into something that is not real. You did not know this ED was there, you did the best to get your child help as soon as you knew, you are trying your hardest now. The fact that you are showing up in therapy means everything. Just that alone is a tremendous gift to your child. Guilt makes you paralyzed. It doesn’t allow you to move forward. Instead of swimming in guilt, trade it in for anger. Anger at the ED for wanting to destroy your child and the life of your family. Anger will motivate you. Anger will move you. Guilt will imprison you and make you ineffective in trying to be the best parent when your child needs you the most, when they are sick.

2. Frustration (in your child). One of the primary beliefs of the family based work is that “the ED is not your child”. This is very clear in practice, but again like I spoke of above with guilt, in the therapy room it can be more messy than that. We all believe that the ED is a separate entity from your child and thus are clear that we want to “punish” the ED while we support and love your child. But, the reality is when we are trying to “kill off” the ED, we are still affecting your child. Many, many children will say to me “When you get mad at the ED, you are getting mad at me too!”. This is a common occurrence, especially at the beginning of treatment. It is very hard on the children who are bewildered and confused most of the time. They never meant to fall down this rabbit hole. They just wanted to lose weight or “become healthy”. They certainly didn’t want or expect to have to meet with all these annoying therapists and they certainly didn’t want their families to become so upset. It just happened and they feel lost and powerless and often hide behind the defiant, strong facade of the anorexia. So, knowing how their child is sad, lost, and anxious most parents are extremely reluctant to upset them anymore. This is totally understandable. However, this thinking needs to be challenged. Yes, the child who is hosting the ED will get upset when they are “made to eat”, yes they will cry when they lose privileges because they are not sticking to the meal plan. Yes, they will initially experience the therapy as horrible and “only wanting to make them fat”. But…..this is ALL O.K.

It seems counter intuitive to parents to “further frustrate their child” with this type of treatment. But, they must. I am NOT saying to be abusive, shaming, or to terrify the child. These things traumatize the child. They leave an imprint on the psyche and on the developing brain. We never want to do that. But, parents who are strong, unwavering, and yes, sometimes frustrating to the child are what is needed. Time and again, after the storm passes and the ED is gone I process the child/parent relationship. It is very common that the child acknowledges then that they need the parent’s strength, they needed it all along. They were dying, unable to fight this illness. They couldn’t ask for help. They just needed the parent and treatment team to “get rid of it for them”. This process of the child being frustrated with limits or consequences or firmness from the parent in an appropriate manner has NEVER led to a worse relationship. In fact, it has only led to more openness, more trust, and more connection.

My best advice: Be confident in yourself that you would never abuse your child. You are only doing what is needed to pull them from the depths of this hole where they are failing in their attempts to fight this illness. Being firm, consistent, strong, and more insistent than the voice in their head is not only important, it is crucial to their full recovery.

Please let me know your thoughts and if this is helpful I would be happy to continue this series….Take care. Dr. Davis

Using the Anorexic’s Need to Please to Aid in Treatment

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.

10 Things I Would Like Every Therapist to Know About Eating Disorders

….My own version of a “Top 10 List” of what I wish all therapists knew……

  1. Patients who develop eating disorders did not choose to be sick. Also, it is very rare for them to be able to choose to get better. Some patients who are older and have some maturity may indeed be truly on board with recovery. However, most of them, including the adolescents, have no interest in giving up their ED. Treatment should be focused on using external motivation if needed (consequences and reinforcers) vs. waiting for any signs of internal motivation to change.
  2. Patients who are sick with eating disorders have a brain imbalance from starvation or from severe symptom use such as bingeing and purging. This initial brain imbalance does not recover from talk therapy. This brain imbalance, however, responds to structure and re-feeding. Talk therapy comes into play once the brain is re-fed and in balance.
  3. Patients who are sick with eating disorders know very well how to “talk the talk” and to please the therapist by saying what they want to hear. Do not be fooled by this “pseudo-recovery” stance into thinking there is not a raging eating disorder hidden underneath this rational exterior.
  4. Patients with eating disorders are very invested in being the “good girl” but often struggle with intense rage and critical judgments of self and others. They often project these judgments onto the external world and think that others are as critical of them as they are of themselves. This personality trait often pre-dates the ED and needs to be addressed in their therapy.
  5. Many therapists who enter the field of treating eating disorders do so for a reason. Some may have a history of an ED but many come with a heightened sensitivity to cultural issues that judge the female body. Many therapists have a history of dieting, being sensitive to food issues, and in general disliking their own bodies. It is a trap to think that what we as therapists may experience (“I feel fat too”,  or “I also should eat healthier”) is anywhere near the realm of what our eating disorder patients experience who are under the influence of the disease (“You are a big fat pig and you must now run on the treadmill until you drop”). We may have internalized the toxic culture but our patients are sick and are under the influence of an illness. This is a very important distinction.
  6. For patients with eating disorders, it is very tempting to focus initial therapy time on figuring out the “whys” of the ED. The origins, the underlying issues, the dynamics. This is what we have been trained to do. However, the initial treatment should involve two things and two things only – 1- the re-feeding of the patient and the re-structuring of their eating behaviors and 2-effectively handling the patient’s resistance to these changes. Insight, past trauma, and psychodynamics should all be put on the back burner until the patient’s brain and body are healed from these illnesses.
  7. Our views of the parents of these patients needs to completely change. Instead of seeing the parents as “the cause of the illness” we need to see them as the patient’s best shot for recovery. The parents are the “catalysts for change” that can propel the patient into recovery through structure, support, and re-feeding. Parents need to be empowered to take on this role and we need to increase our sensitivity to their own experience during their child’s illness.
  8. Most of the behavioral/cognitive/ and emotional symptoms that we equate with the anorexic patient can be attributed to their physiological state of starvation. Once this state is relieved via proper nutrition, these symptoms disappear. The patients need to get to their full body weight to get this symptomatic relief. Being “10 pounds away from their goal” is unfairly placing them in an eternal limbo where they can never truly recover.
  9. Fathers have a very important role in their child’s treatment. Oftentimes when a family first presents for treatment of an ED, the father is “out of the loop” of their child’s struggle.  Effective treatment requires us to empower these fathers via education and support of their own unique experience. These children need their fathers actively involved in their treatment.
  10. It is a myth that eating disorder patients don’t get better. It is a myth that they will always be “a little sick”. It is a myth that treatment should take 5-7 years. These patients can fully recovery in much less time than one would think. It is our job to hold to this belief and to bring our patients to this place of truly living their lives in freedom and joy.

Working Backwards

I am always thinking about ways we can summarize and simplify the huge amounts of data that are being thrown at us every minute. The often conflicting data, the hundreds of inspirational quotations that we should follow, the reams of parenting advice……. and this is just on our twitter feed! Let alone books, research articles, and good old verbal advice. How do we make sense of all of this? How do we know what advice to follow when one finding looks as good as the next?

With these thoughts in mind, I was consulting the DSM-5, the “bible” for psychologists and people in the mental health field. It is our “map”, our way of trying to understand the complexity of human nature that often is presented in front of us. I was consulting the section on Personality Disorders to try and find some diagnostic clarity regarding a particularly challenging client, and I turned to the back of the book. There was a section on a proposed new way to classify and understand personality disorders which caught my attention. Instead of the current classification system, it proposes an overarching system of understanding personalty dysfunction: classifying if and how severely patients are struggling in four central areas of their lives: their overall sense of self, their ability to get things done, their sense of empathy, and the quality of relationships in their lives. Patients are classified along a continuum of mildly to severely impaired in these four areas. Pervasive dysfunction represents the most severe pathology.

I started thinking about the parents of my eating disordered patients and how we as a field are finally getting to the point of not blaming them for their child’s illness. I am very clear in my sessions that these parents have not caused the suffering in their child. This has been extremely helpful in the entire therapeutic process – alleviating guilt and allowing the parents to become empowered catalysts of change for their children. However, while we are moving on from blame and causal issues, we are still left with the fact that parents DO influence their children. They may not cause a particular illness, but they certainly leave an imprint on their child. In the world of eating disorder treatment, there are many times that the ED is lifted and the patient still struggles with some underlying personality dysfunction. The parents want to know – “What are we doing that is not helpful to our child?”. The child is now re-fed and their brain and body has come back to life. But the child continues to struggle. The parents continue to struggle. What next?

Instead of re-inventing the wheel each time wouldn’t it be nice if we could take what we know and work backwards. If we know that dysfunction in these four above mentioned areas can create ongoing issues, why not target these four issues? Why not help parents learn to parent better across these 4 domains? Why couldn’t we teach these (and all) parents to parent “better” in the areas that they struggle the most:

  • do they have good enough boundaries to create a child with a clear sense of self?
  • do they create enough structure (both consequences and reinforcements) to help the child manage the things they have to do, even if they don’t want to do them?
  • do they model compassion and empathy to the child through their relationship with their self and their child?
  • do they engage in truly reciprocal and mutually validating relationships with the child so that the child can take this model out into the world?

Helping a parent accomplish this on a consistent basis is extremely challenging in the world we live in. But how empowering it could be to give parents this map as well, to let them know what we know….and to show them that they can create health in their child not only by re-feeding them but also by supporting their emotional growth. Parents (and all of us) have a limited amount of energy to give – let’s help them figure out the most effective way to put this energy into action to best support their child.

Meet ED

In my last post I talked about how I am on a mission (#Beedinformed) to do my part in educating parents and professionals about my intimate experience with anorexia via my immersion in the mindset of my patients for the last 16 years. I think it is one thing to think that your patients with this disease “think they are fat” and it is quite another to “walk in their shoes” and experience exactly what they do each waking moment of their lives. There was a time when I really didn’t believe that these girls were in so much pain. I am ashamed to admit it but I actually thought these girls were “superficial” and that they had somehow chosen to be part of this lifestyle that promotes the “perfect body”. I was, I think quite intolerant of the whole thing. Like many others, I judged them. They were the “pretty girls” who had it “all together”. What could be so bad for them?

That was before I vicariously experienced “the voice”. The voice of ED, Ana, and a host of other names that represent the same vile entity. Part of the work I do with the families is I have the patient actually speak for the voice. Letting the parents know, often for the first time, what is going on in their heads. It is usually a turning point for the parents when they realize their child who smiles on the outside is going through this hell on the inside. Here are some examples of what patients have said over the years when describing what the voice says to them:

“You are a disgusting fat sack of shit” “You know nothing and nobody cares about you” “You must be punished for what you ate today by running on the tread mill until you drop” “Your treatment team lies to you. I am the only one who will take care of you” “Don’t trust anyone. Lie to them, always” “If you do not listen to me I will punish you more” “You have eaten that cracker, no more food for you for the next 2 days” “You do not even deserve to drink water, you are repulsive”.

Imagine thinking this way, with every decision that has to be made about food and exercise, with every decision that has to be made about talking about feelings or not. It is beyond painful. Beyond exhausting. In traditional ED therapy we are trained to help these patients “talk back” to this ED voice. I used to do this at the beginning of treatment, when the patient was 70% of their ideal body weight. I never understood the bind I was putting these patients in. Sure, they can attempt to talk back to this bully. But, the bully eventually wins. I believe this is why we often see the pattern of weight gain followed by weight loss in traditional therapy. The patient just can’t endure the punishment they get for defying the ED. It is just too hard to maintain. So, they stop eating again or start to exercise more and they get instant relief from the voice.

With the family based approach and its focus on weight gain as the initial priority, I found a very different picture emerge regarding the way the voice affects the patients over time. I had always believed that the “battle” of talking back to the ED was one that would last forever, or for at least a very long time. However, the miracle of nutrition is a beautiful thing. With every 5-10 pounds gained, the patient will come in and describe a “lowering of the volume” of this voice. To the point where they say “it is now a whisper”. With weight getting in its normal range and especially after 1-3 cycles of the period, they then will tell me “it is gone.” “I don’t hear it anymore”. I can literally track a one to one correlation between the increase in weight and the decrease of the volume of the voice. They no longer have to fight it or talk back to it. There is nothing left to fight. All that is left is someone who “sometimes feels too fat in a bathing suit” or “sometimes doesn’t love their body”. What is left is a mirror of the condition of being a female in this culture – for all its good and bad points. We are taught from a very young age to be dissatisfied with something about ourselves, no matter how smart we are, how pretty we are, or how thin we are. I am not sure if we can ever fully rid ourselves of this internalized cultural voice. As far as my patients, I am very happy to have them go from “I am disgusting, repulsive, and need to protect the world from my ugliness” to “sometimes I don’t feel comfortable in a bathing suit”. I will take this as a victory.

#Beedinformed – My hope that families find this first…..

I have been doing a lot of thinking over the last week about how I can be most helpful to families that are struggling with a child who is diagnosed with the illness of anorexia. On this blog, I have begun to share my treatment approach, one that incorporates evidence based approaches offered within a framework of compassion and understanding. Over the last several entries, I shared the development of my current approach and where I have landed in my current thinking. However, I am always left with the feeling that I am not expressing myself as well as I would like to. You see, my thoughts about this disease spread beyond my ideas of how to treat it. It really begins with my thoughts on what it is. I learned in my training a long time ago that an accurate assessment drives an accurate treatment. But in this field, the lack of consensus of a clear understanding of what anorexia is daunting. How can we ever agree on how to treat it if we can’t even have a universal dialogue about what it is?

I have decided that part of my “mission” in this social media world is to try and bring some consensus to the field. This is a completely overwhelming task and I really sit here with no clear idea on how to even start such an undertaking on a large scale. However, I can start small…very small. And so my idea for #beedinformed was born. I am going to share my thoughts about what this disease is on facebook, twitter, and any other social media that I am part of. My sincere hope is that other professionals join in and share other pieces of relevant, current thinking about this disease. Wouldn’t it be wonderful if families could find this place as well? A place they could learn to trust as “the truth” about this disease. A place they would find first, instead of last.

My intention is to try and teach people what I see every day, all the time, in my office. The truth about the illness – its origins, its effects, and most importantly what things make it smaller and what things make it bigger. Things that families can do and things that therapists can do to extinguish it. I want to convey  my sense of responsibility to the families and to my colleagues. I truly understand this disease, even though I have never had it myself. I experience it all the time, from the inside out and have exclusively been “swimming in it” for the last 16 years of my professional life. I have absorbed this important information. I have been a diligent student.  And I am motivated to pass on this intimate knowledge of the illness to cause its demise, once and for all.

Closing the {Thigh} Gap – Part III

“All Life Stops Until You Eat”……..

This was revolutionary for me and for Stacey’s treatment team. Up until that point, Stacey’s treatment consisted of pleading with her, begging her, trying to convince her, and in general influence her to eat on her own. She was to follow a nutritionist’s meal plan. She was to choose the food, prepare the food (except dinner), plate the food, and eat the food entirely on her own. I believed that she could “do it” if she wanted to badly enough. Using family based treatment, all of this stopped. Completely. During all of the years of my treating her, Stacey had been eating on her own and also exercising on her own, despite offered direction and advice from the team. She was a runner.  In essence, she ran the way she wanted to run. How much, how fast, how often. Now, it all stopped. Completely. No more running until she gained the 10 pounds she needed to, got into the suggested weight range, and began to menstruate normally again. We were squarely in Stage 1 of FBT and boy was it rocky.

Stacey was as furious as Mom and Dad were empowered by this new approach. Stacey’s parents began to see themselves as much more instrumental in their daughter’s recovery. They were freed from the chains of guilt and all the passivity that comes with it – they knew they did not cause this. They also began to believe that they could actually be the agents of change that turn this whole ship around. They started to give consequences if Stacey threatened to go off the plan. They truly embraced the mantra that all of their family life stops until their sick child eats. They had never had to consequence their daughter before as she as a “good girl”. No history of oppositional behavior, not an ounce. So they were in foreign territory and feared they were “making things worse”. But, they followed my lead and when the anorexia reared its head, they always had a consequence at hand. They learned to work together and rely on each other’s strength. One of them supervised all of Stacey’s snacks and meals. Stacey was required to hang out at home instead of driving her car and then exercising if she felt like it. The anorexia was miserable. Stacey was not that far behind. She yelled, she shut down, she threatened to run away from home, she threw the food on the floor. And yet, here was the miracle: she ate. All of it. Every time.

Her weight started going up. It took six weeks. Six weeks for her to get into her weight range. After years and years of gaining and losing, being hospitalized, and being followed by a team. Six weeks. Now, was she cured at that time? No. But what started happening was something I had never seen so clearly before. The anorexia began to leave the building – it started to visibly and palpably diminish. It started with her thoughts – I noticed that after Stacey had been in her weight range for a while she talked about different things during the session. I couldn’t believe it when I realized that an entire session had gone by without her mentioning her “disgusting thighs”. I asked her about it, almost afraid to bring it up myself. She said “Yeah, I still don’t like my thighs but I have other things to think about now”. I couldn’t believe it. There was now space for new things besides food and weight. She began to talk about her friends, and her struggle to be “popular”. She had always had some social anxiety, way before the anorexia started. And now, like a layer being lifted, the anorexia was disappearing and revealing what was always there – a sensitive, somewhat anxious girl who was afraid of not being quite good enough and being left behind. Despite years of me using my best tools and techniques, I had never been able to lift that obsessive/rigid layer like the weight gain was able to in a matter of months.

In our sessions, we began to focus on weight and food much less. We just didn’t need to anymore. When it came time to move into Stage 2 of FBT we were all a little bit nervous. Stacey handled it like a pro. She was motivated to run again and to “not be a baby” and have her parents supervising her meals any more. Over several months, she tried out a little bit at a time until she could eat her meal plan on her own. She worked with the nutritionist now (vs. her mom being the primary person working with the nutritionist) on creating more variety in her plan. She agreed on having 1-2 “fun foods” per week and she was always able to keep her anxiety from getting too high when she ate them. She said one day “I know that a cookie won’t make me fat”. When she got her period for the first time, there was a nice jump in her ability to tolerate new foods and an overall reduction in her anxiety over eating anything “not healthy”.  She began to run again and this is where I got very nervous. She had a history of running to the point of exhaustion. However, this time it was different. After months of staying away from it, returning this time was different for her. She reported that she liked to run now as it “makes me feel strong”. She no longer counted calories when she ran and seemed to enjoy it vs. thinking about it as a chore. The ED voice that had lived in her head for years was gone. She said one day, pointing to her head, “I only have me up here now”.

I was amazed by all of these changes. I was still basically the same therapist, just adopting a new technique. But three things were now radically changed – I had no longer made it her choice whether to eat or not, I had empowered her parents to follow my lead in this, and I had given the parents structure and support throughout this daunting task. Unlike traditional FBT that only has one supervised meal during the assessment phase, I offered many supervised and coached eating experiences. This is where I saw so much change occur. Both in the growing strength and clarity of the parents and the growing weakness of Stacey’s disease, bending under the weight of the team’s demands. All of this led to a brain that was no longer starving. A brain which could now think and reason. It was truly a beautiful thing.

Stacey made it to college in the Fall. She had phone sessions with me  and her nutritionist weekly for the entire first semester, saw me in person when she was home on all holidays, and was followed by her student health center where she was weighed weekly and this weight was passed on to her home team. She had a contract that identified potential consequences if there were any significant weight loss, which included taking a semester off if we felt she needed to. It turns out, she didn’t need to. She graduated from college and considers herself “fully recovered”. She continues to let me know how she is doing every once in a while. She is a strong, beautiful, kind, smart young woman. I am so grateful for my experience with Stacey. It changed everything for me and I have never looked back.

Closing the {Thigh} Gap, Part II

I knew I needed to do something different. I had been seeing Stacey for years and while some changes had occurred in her life for the better, I truly believed the eating disorder remained untouched. I had never really seen it this way before. I had never really seen the disease as such a separate entity. I had utilized narrative techniques, externalizing the eating disorder to the patient so that they are not so tied up in it. I had referred to the eating disorder as “ED” or “Ana”. However, I had never experienced it as separate during the work with the patient. I had never seen so clearly that other things can change in the patient’s functioning (anxiety, depression, irritability, assertiveness, sense of self) and in the family functioning (communication, boundaries, loyalties) but that the anorexia just could sit there untouched. I began to see the pure presence of it. The reality of it. I even began to dream about it. Anorexia finally stepped forward in all of its ghastliness and power and I was truly overcome. All of my “tools” were ineffective. It was like throwing jello on a wall…nothing stuck. I really believe it was this experience that for the first time showed me the “enemy” in its true form, without being veiled by my own projections, prejudices, or anxieties.

I know this sounds dramatic. I am reading it and thinking that unless you work with clients like this (or are a client like this) you will think I am being unnecessarily strong in my language. But that is just the point. I, like most of you, would have thought the same thing…”It is not like they are possessed by something… they should be able to fight this themselves”. But, I began to realize on that day years ago that these girls are possessed. Their thoughts are not their own. Their will is not their own. No amount of telling themselves to “use your voice” or “love their body” is strong enough to fight this voice inside of them that is telling them everything, all the time. All the time. They have no choice but to listen and Stacey had no choice but to submit to its demands – to eat limited calories, to exercise until her body ached, and to hate her thighs with utter disgust and repulsion. This was the disease’s demands and Stacey was drowning, losing herself to its rules.

I started thinking in a different way: “If this disease is so strong and its voice is so strong, how can I be a stronger voice?” “How can I get this patient to listen to me instead of the disease?” I had tried every technique in the book and she still wouldn’t eat. Everyone knows that getting an anorexic to eat is impossible. Right?  Well, family based treatment (FBT) thinks differently. FBT says that we, the grown ups and the treatment team create a situation in which it becomes impossible for the patient to NOT eat. The environment is changed around the child. Contingencies are given for doing what they are told to do. The parents are viewed as the primary change agent, not the child (at least in the initial work). The parents (as part of the team) become stronger than the disease. The voice of the unified, empowered team becomes more compelling to the patient than the anorexia. Strong and unwavering – a brick wall. With one message and one message only: “All life stops until you eat”.

Please check in next week for Closing the {Thigh} Gap, Part III. Thank you!

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.