High-Stakes Therapy

Any therapist who has worked with eating disorders (EDs) knows not only that treatment can be a rocky journey, but that sometimes the stakes can be a matter of life or death. For the most part, clients with EDs are ambivalent at best about recovery, making the process even more tortuous and challenging. This is especially true with children and adolescents, whose development can be frozen by their struggles with the illness, their thought processes seriously distorted by the neurobiological effects of severe weight loss. So, as a specialist in EDs, I receive referrals from pediatricians with a mix of emotions: pleased when someone has caught symptoms early, scared about the lethal potential of this illness, impatient to get the adolescent brain and body back on track, empathic toward panic-stricken parents overwhelmed by the intensity with which this illness takes hold, and frustrated by the way our society and its seductive ideals of physical perfection can contribute so perniciously to this condition. While I know that recovery is possible, I also know that the treatment journey can be unpredictable, scary, and slow.

Getting Started

Ashley’s parents began speaking before they’d even sat down in my office. “She doesn’t want to eat anymore, and we don’t know what to do,” said her mother, Judy. “She’s wasting away before our eyes, and her doctor agrees.” Ashley’s father, Frank, added, “She doesn’t even want to drink water in case it makes her stomach expand.” Judy and Frank were both well-dressed professionals in their mid-40’s and clearly distraught over their daughter’s state.

According to them, Ashley had seemed to be a cheerful, social child until her body and food obsessions had taken hold in recent months. They knew of no recent traumas or transitions that might’ve triggered the sudden onset of symptoms. I asked them other basic questions, including how long this had been going on, if the symptoms had gone beyond restricting eating, what the family had been doing to help, how Ashley had reacted to these interventions, and whether there was a family history of EDs. Very soon, it was clear to me that Ashley, at age 13, was displaying many of the classic symptoms of anorexia.

The feelings of parental guilt were subtler. Through tears, Frank and Judy described how happy they’d been when Ashley had started exercising, and they’d praised her for her efforts. But soon after, she’d become obsessive about running, with ever-increasing mileage and no rest days. Recently, they’d even found her sneaking exercise after bedtime, which alarmed them. Further, when confronted, Ashley would snap, “If I don’t exercise, I’m not going to be able to eat anything at all.” So like most parents in these cases, they relented and negotiated with her, and now worried about their role in contributing to her illness.

Although all three of us were anxious to develop a treatment plan, I wanted them first to understand two important things: they hadn’t caused this illness, and they themselves were needed as part of the treatment. “We need to get Ashley to eat more so we can get her brain working at full potential again,” I explained. “Her ED is going to resist this, and it’ll likely become harder before it gets easier, but I’m so glad you’re supporting her at this stage.” Although I always share my optimism about the recovery process, I also need to be realistic and clear with parents that the situation is grave and that it’s not clear that we’ll be able to turn this situation around without residential or inpatient treatment.

While EDs are complex illnesses that can’t be “fixed” with changes in eating alone, the focus on eating is the critical start of the process. So I gave Ashley’s parents permission to be more directive in increasing her caloric intake. Together, we considered ways they could share truthful expressions of concern about her eating in ways that would be supportive but not condoning. For instance, we discussed staying away from retorts about her fears of not having a flat stomach being silly and instead concentrating on the message that she needed enough nutrition to have the energy to stay healthy. I also suggested to Frank that he stop weighing Ashley at home, as the pediatrician had suggested, explaining that we’d be doing blind weights in my office to stop Ashley from engaging in number distortion and panicking at the slightest increase in her weight. Finally, I passed along the names of two local nutritionists with ED specialization and suggested they get the labs ordered by the pediatrician as soon as possible.

The next morning, Ashley sat in my waiting room. She had long, stringy hair pulled back in a ponytail, and had her arms tucked inside a thick sweatshirt, draped on her frail body. I made some initial attempts to engage in rapport building, but her slightly dazed, unresponsive manner, typical of those who are undereating, blocked this effort.

“I think something’s wrong with my stomach,” she said finally. I reassured her that we were working on ruling out potential medical issues, but told her that we needed to look into other factors underlying her stomach concerns, such as her restrictive eating over recent months. I suspected that her “bloated stomach” was her ED overfocusing on the normative digestive process and distorting her perceptions.

Over the course of our discussion, Ashley admitted that she was silently obsessing about calories, fat grams, weight, and size much more than she’d articulated to her parents. She also circled around several common ED notions, such as thinking she wasn’t supposed to enjoy food, feeling guilty after eating anything, and believing she needed to eat under 1,000 calories per day. As we continued to talk, she stated, “I like it when people notice me for being super thin. I don’t care about having an illness if it means I can have a perfect stomach.” Later she said, “I don’t really want to throw up, but if my parents make me eat, that’s what I’ll have to do.”

I responded in a measured way to each of these statements: “Thank you for your honesty and openness about your worries and goals.” I wanted to help Ashley challenge and gain perspective about each of these ideas, but I knew that doing so too early would only create more resistance and make the situation worse. Instead, I slowly began to make references to “disordered eating,” not to pathologize her, but to help her begin to understand that her behavior was problematic. After a while, she said she’d noticed some of the common side effects of decreased eating, such as her brittle nails, hair loss, concentration difficulties, irregular menstrual cycle, and irritability. Although I was eager to educate her about the many other dangerous consequences, I knew she wasn’t ready to take those in, since she’d been ignoring such concerns presented by others for months. I also knew that information alone can’t turn the ED process around.

As we neared the end of this first session, I asked Ashley to list some pros and cons about the prospect of recovering from the ED, letting her know that even as we embarked on the recovery path, I wanted to hear and honor her hesitations about this process. As we were walking out, I gave her several handouts, including a definition of normative eating and information about what really happens when people diet. “I’d love for you to read these and let me know what you think,” I said.

Supporting Stabilization

The beginning stage of ED treatment is focused on turning the weight-loss trend around, disrupting negative behavioral routines, and stabilizing physical well-being. As eager as I was to jump into the exploration portion of the treatment, much of that would be premature for someone in Ashley’s situation, given how months of slow starvation reduce the ability to address emotionally charged issues. Many people with EDs can perform well enough in school, but the distorted single-mindedness and confusion around anything related to self-care is usually far off base—and Ashley was no exception.

In our twice-weekly sessions, I sometimes met with Ashley alone, sometimes with Ashley and her parents, and sometimes with her parents alone. During the portions of the sessions with only her parents, we role-played responses to Ashley’s resistances and discussed ways to stay patient in this stage of recovery. We reviewed how an ED is an illness, not a choice, to help them to better understand that Ashley’s shouting and pouting were part of the illness but likely to resolve as she moves through her recovery. They met with a nutrionist several times, but found they had better results with established meal plans and recipes from an ED website geared toward family-based treatment.

In sessions with Ashley alone, we focused on managing her distress with the new mealtime routines. Since she seemed particularly intrigued by the idea of seeing her ED as a bully inside her, we rehearsed some healthy comebacks for her to use when it threatened her with statements such as “You’re getting fat.” We practiced being able to say, “I need more food to think clearly” and “My parents are feeding me what I need” and “My body needs to be replenished.” And we explored soothing activities during and after meals, with Ashley choosing to watch funny internet videos as her go-to activity to distract her in peak times of anxiety. She didn’t connect with some of the breathing and grounding techniques we practiced in session, but she eventually found a meditation app on her phone that she loved.

In sessions that involved Ashley and her parents, I facilitated conversations in which Ashley expressed how she felt misunderstood when her parents inferred that her worries were ridiculous. After a while, Ashley was able to tell them, “I know I have to eat, but sometimes I just don’t want to. I just feel so full so much of the time. Please be gentle and patient with me.” In those moments, Ashley really did seem to be trying to pull out her smart, rational side, and it improved communication all around.

Responding to Regression

About two months into our work, Ashley’s weight gain stagnated for a few weeks in a row. Although weight sometimes neutralizes or even declines slightly in the early stages of recovery, Ashley’s behaviors suggested there was more going on: her guidance counselor called to say she’d been throwing out her lunches, and when her parents caught her doing sit-ups in the bathtub one night, she’d screamed, “I’ve gained enough weight. Why can’t everyone just back off?”

So we began to discuss the possibility of needing a higher level of care. Some people use discussion about inpatient treatment as a bluff, but Ashley and her family were clear that we might have to move in this direction if we couldn’t get past this current sticking point. But when they visited an ED treatment facility, they found it to be a sobering experience. At that point, Ashley understood that her family wasn’t going to back off, and her parents accepted how much harder they might need to work at home to keep her out of a residential program. I wanted Ashley to have permission to express her ambivalence about recovery, but I also wanted her to know that we’d be responding with the needed support if the ED got too big to manage at home.

As a solution, we created some increased supervision methods at home, instituted supplemental nutrition drinks when she was refusing a snack, and repeated the labs with her pediatrician. The family decided that Ashley should get a medical leave for the remainder of her eighth-grade year, and that her father would activate the family medical leave act provision to take time off from work for the next few months. In this way, they bravely dug into the process of providing full-time supervision and support.

Uncovering Underlying Connections

Over the course of the next six months, Ashley slowly gained weight. Her parents continued to supervise meals but began to experiment with letting her make some plating decisions and allowing some meals away from home to see how she coped. Since Ashley would sometimes ask nervously during sessions, “What if I gain too much? What if I can’t stop eating? What if my stomach gets fat?” I coached her in practicing more compassionate attention to the what-if thoughts. Soon we noticed that her comments had shifted from “I can’t” to “I’m not sure if I can.” This was progress. And given that her parents were gaining confidence in their meal preparation routines and seeing evidence of the increased nutritional intake, we shifted to once-a-week sessions, with more of the time being spent with Ashley herself, rather than shared with her parents.

At this middle phase of treatment, we were able to go beyond the basics of case management, psychoeducation, and discussing only food in most sessions to delve into more personal factors that may have created her vulnerability to the ED. The more energy she had in sessions, the more curious she became about the root cause of the ED. She’d experienced no major “big T” trauma, but the ED did bring forth some critical issues she needed to address, such as finding her voice and special identity, her fear about launching into teenage years, and her desire to communicate differently with her family. But she insisted she still had no idea how it all started.

Then one day, quite suddenly, Ashley told me, “I’m worried that I might try to hurt myself with my razor or the knives in the kitchen.” This was the first time I’d heard anything about self-harm in this way, and it materialized just as the eating was starting to get easier more of the time. While this was a source of concern, requiring increased supervision from Ashley’s parents, it led her to the recognition that, as she put it, “a part of me knows I can’t undereat anymore, so now it’s bugging me about doing harm in another way.” As we further reviewed her history with anxiety and obsessiveness, Ashley and her family began to see how these symptoms had been peppered throughout much of her childhood—from difficulty with simple decision-making to perfectionism about schoolwork to extremes in black-or-white thinking. Recognizing this backdrop put the ED into a new context, with Ashley herself seeing that the eating issues had been yet one more way that an OCD part of her was attempting to boss her around.

With this new awareness, we worked on her being able to zoom out from her obsessions and allow the thoughts to roll off her mental screen “like movie credits at the end of a movie.” Soon Ashley got better at reducing the intensity of these thoughts. She realized she had a number of rituals and behaviors to which she’d been tied for years, and these provided excellent opportunities for challenging them. Compared to the life-and-death eating issues that had been so acute earlier in the year, these new challenges felt more enjoyable and interesting to her.

Finding Her Voice

About a year into treatment, Ashley’s weight gain seemed to have stabilized to her ideal body weight. She’d become accustomed to eating at predetermined mealtimes and now wanted to experiment more with intuitive eating, moving away from letting her parents decide the portions at each meal and listening instead to her own body signals for hunger. Understandably, her parents were nervous.

“This is an essential experiment and important next step,” I explained. “We’re monitoring her and can certainly return to more structure if needed, but she needs to practice this so we can uncover future hurdles.” In this way, Ashley launched into a new phase of rediscovering foods she hadn’t eaten in quite some time, and she began the process of more natural eating.

“I wonder what the ED part of you might have been trying to communicate,” I asked her one day when she reported a sudden surge of symptoms over the weekend. Ashley processed several possible options. Was it protecting her from a hurt, assisting in regulating anxiety, asserting its position? Finally, she furrowed her brow and said, “My friends aren’t listening to me. It’s always about little things like what movie to see, but it feels really bad.” We role-played some possible ways for her to use her own voice to speak up instead of lapsing into more ED symptoms.

After this session, Ashley figured out that she no longer wanted to play soccer, and her father gracefully gave up his position as her soccer coach. She changed the color of her bedroom and began exploring new recreational pursuits, such as learning to play the piano and creating videos with her sister. She spoke up more about movie preferences with her friends and about game-night options with her family, tentatively at first, but then with increasing confidence. Simultaneously, she found herself less annoyed, less angry, and less drawn into retreating to symptoms.

Building Relapse Prevention

Shifting negative body image is often one of the last and most difficult parts of the recovery path. The ideal resolution would be a client learning to love her body, but sometimes just getting to the point of respecting or appreciating it is more realistic. Although Ashley and I had addressed body image quite frequently throughout treatment, the most meaningful interventions for Ashley came when I asked her to write down her reply to the question “What is my body capable of?” As she focused on this question over a period of weeks, she began to experience her body as dynamic and instrumental, rather than only an object to be seen. She’d sometimes still struggle with moments of body insecurity, but having her own words to look back on helped her step away from the ideals of slimness and physical perfection so celebrated in our culture.

Almost two years into treatment, Ashley is nearing the relapse-prevention stage of recovery. Given that the typical recovery for an ED is said to be in the 5-to-10-year range, she’s actually ahead of the curve, and she’s increasingly attuned to when her ED or OCD taps her on the shoulder. Now, we see each other once every other week. At one of our most recent sessions after her last day of 10th grade, she remarked, “I did so much less work than in past years but my grades are just as good.” She beamed with pride, knowing that her OCD perfectionism no longer commanded her attention as it had in the past. In preparation for the summer, which she planned to spend as an assistant counselor at a day camp for young children, she reaffirmed her interest in honoring hunger signals and avoiding obsessing over food and weight.

As we ended the session, with Ashley talking about an upcoming pool party, she said, “I’ve figured out that if my thoughts about my body are negative, then I walk away and ignore them. But if I’m feeling positive about how I look in a bathing suit, then I choose to let myself linger in the positive mindset a bit longer.” We celebrated this as a sign of her continued progress.

Ashley is currently back on track with her eating, her teenager life, and her overall functioning. Of course, we’ll continue to monitor her progress over the upcoming years, and she’ll need to stay alert to her ED triggers and vulnerabilities, especially in times of stress, like breakups with future boyfriends and difficult transitions, such as leaving for college. Not all cases work out as well as Ashley’s, but my work with her helps reinforce my optimism that recovery is possible, a guiding light that’s critical as I walk this difficult journey with other clients.

Case Commentary

By Judith Matz

I usually feel trepidation when I read case studies about anorexia, which too often reflect myths and misconceptions about eating disorders (EDs). I was pleased, however, to read Sandra Wartski’s insightful description of her work with Ashley. Without any of the parent blaming or unwarranted assumptions about underlying trauma that often surrounds this disorder, Wartski skillfully educates and engages Ashley’s parents to be part of the treatment team, along with a medical professional and dietitian—all of whom are absolutely necessary for recovery.

Next, her focus on refeeding begins with restoring caloric intake so Ashley’s brain can function properly, which, as Wartski acknowledges, can not only be challenging, but downright scary, given that anorexia has the highest death rate of any mental illness. This is absolutely the right place to start, and once Ashley was out of the danger zone, I was glad to see that Wartski focused on intuitive eating as a lifelong way for her to develop a more positive and satisfying relationship with food. In recovery, clients are often given a meal plan to follow that relies on external rules and regulations, which frequently reinforces disordered thinking. Instead, Wartski emphasizes the role of intuitive eating skills in guiding Ashley to reconnect with her natural signals for hunger and fullness as she learns to trust her body.

My only concern is Wartski’s reference to Ashley achieving her “ideal weight” one year into treatment. The term implies that there’s a proper weight where Ashley should remain, and that notion can interfere with clients finding their natural weight—known as set point—as well as accepting that bodies will change over time. I’ve seen clients’ ED behaviors retriggered after being told, sometimes by ED specialists, to stop gaining more weight once they reached a certain number on the scale, although this wasn’t the case here. I’ve also heard ED therapists comment on their own diet concerns in front of clients or discuss their fear of fat with each other. These attitudes can contribute to messages that trigger and sustain eating-disordered thinking, communicating to clients that there’s a specific weight that they’re supposed to maintain. I believe it’s imperative that therapists who treat EDs continually examine their own attitudes toward food and weight to make sure they don’t—even unintentionally—promote weight stigma, which is the cultural backdrop for all EDs.

As Wartski states, not all ED cases have such positive endings as Ashley’s. And not all clients have the same characteristics as Ashley, so we need to keep in mind that EDs affect people of color, different age groups and gender identities, and males. It’s also important to think of EDs as behavioral rather than only weight-based, as they can be missed in people who are severely restricting food intake but have a higher body weight. Of course, the most effective treatment for anorexia occurs when it’s caught early, as happened in this case. While Ashley’s parents could afford the full range of treatment options, we should bear in mind that many insurance companies will turn down in-patient claims for EDs. Thus, we all need to advocate for reform that guarantees that everyone has access to appropriate care, regardless of income level.

Illustration © Sally Wern Comport