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.

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 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.