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.
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.
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.
Over the course of our initial session, 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.
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.
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.
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.
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.
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.
This blog is excerpted from "High-Stakes Therapy" by Sandra Wartski. The full version is available in the September/October 2016 issue, Courage in Everyday Life: An Interview with Brené Brown.
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