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.

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!