When it comes to the treatment of Anorexia, one of the biggest challenges I face as a therapist is that the patient does not want to get better and she will often stop at nothing to protect her eating disorder, up to and including throwing me, under the bus if necessary. She can’t help it. It feels like a life or death situation for her and I am simply a casualty of the war between her and those who would deprive her of her eating disorder (ED) which is why I need your buy-in as her parents. When we are united, we can win the war even if we lose a few of the battles. But we have to stick together. We are the team and the eating disorder is the opponent.
The Nature of the Beast
I view Anorexia as a painful form of anxiety but with a focus. Most anxiety is unfocused, even very intense anxiety, which is why we call it “generalized anxiety.” The lack of focus makes the anxiety more difficult to manage, increasing the discomfort. You don’t know what you are afraid of, or why, you just know that you are afraid, all the time, with no end in sight.
The eating disorder, on the other hand, gives the anxious person a focus, a solution, something to do, a sense of control, a strategy with a set of easy to follow rules that really work to decrease your anxiety. These rules include: Don’t eat unless it is absolutely necessary; If you have to eat, eat as little as possible; Learn how to “fake eat”; Distract yourself to avoid eating by sleeping more, afterall you can’t eat if you’re asleep!; Fake an illness if necessary to get people to back off and give you space; Drink water to avoid feeling hungry” and on and on. This list of rules is endless.
The function of the rules is to restore one’s sense of accomplishment along with a sense of control. Another important set of rules is to be able to lose weight by over-exercising, abusing laxatives, which are both forms of purging, or actually purging by vomiting. These rules/tactics/strategies also ease the anxiety in such a profound way that modifying them at all, let alone giving them up, seems like diving into the anxiety abyss all over again, but this time with no safety net.
Parents and loved ones have difficulty understanding the terror that the Anorexic is experiencing. Part of the reason for this is that they are experiencing their own terror as they watch someone they love waste away to nothing right in front of their eyes. Talk about feeling helpless. Bottom line, the condition is mired in fear, for the loved ones as well as for the victims.
Intensive Outpatient Treatment
I offer intensive outpatient treatment as an alternative to residential treatment. Given that the patient is not motivated to be in therapy in order to restore her weight, often the best we can hope for is that she perceives intensive outpatient treatment to be a better alternative than residential. With intensive outpatient treatment, which may include up to 10 hours a week of actual therapy, she remains at home and has more control over what she eats. Residential treatment, on the other hand, where she will be forced to eat large amounts of food or be threatened with an NG tube, is hopefully less attractive.
I get teased a lot by my colleagues for treating the impossible. But I love what I do and I’m good at it. I think the trick is taking a non-judging stance, i.e. I neither judge the patient (as so many clinicians and medical practitioners do) nor the parents, who may even fire me from the case, because they are so worried or frustrated. Although I don’t like it, I completely understand.
Most parents want a “quick fix.” The problem is, there isn’t one. Treatment for eating disorders, according to the research, takes 2-5 years. My track record cuts that time in half or better but that still seems like an eternity to the parents. They want relief now, not 6 months let alone 2 years from now. Actually, that is the one thing that the child and the parent can agree on, treatment takes too long.
When it comes to the treatment of eating disorders, there is also a quick fix. It is called residential treatment. In the residential treatment programs that I have interviewed, the patients are forced to eat huge numbers of calories in order to quickly gain weight. The goal in many residential treatment programs is to have the patient gain 20 pounds in 21 days. A normal person would struggle with that, imagine how traumatic it is for an Anorexic.
This approach treats the symptom, weight loss, but not the underlying problems such as body dysmorphia, OCD, control issues, painful family dynamics, or underlying medical conditions that mask as an eating disorder, just to name a few. As you might imagine, this rapid weight gain approach makes many of the underlying problems, or actual causes, even worse.
Very little is accomplished in most residential treatment programs. The likelihood of treating the underlying problem (or the cause) is slim to none in such a setting, as patients in residential treatment are not living their real lives. They have been removed. Everything is suspended; responsibilities, friendships, temptations, school-work, and basic decision-making when it comes to eating, etc.
As expensive as residential treatment is, the patients are lucky if they see a trained professional for half an hour a week. They aren’t allowed to exercise (which is considered a threat to recovery) and end up watching a lot of TV. The lack of responsibility can grow on them, in which case, some will even attempt to manipulate their parents into sending them back again and again. That’s really not good.
For this and many other reasons, residential treatment has had a singularly damaging impact on the patient in the majority of the cases that I have seen over the years. The individual often leaves “treatment”, and I use the term loosely, with a terrible attitude towards any and all treatment and a lack of trust in the helping community, along with a strong desire for junk food. It is not uncommon to see a patient who has gained 15 to 20 pounds with this type of treatment come out and lose 20 to 25 pounds in a matter of weeks. I have rarely in my 30 years of treating eating disorders seen inpatient treatment work long term. Unfortunately, there is a very strong correlation between dying from Anorexia and the number of times you have been in residential treatment. (This is a correlation and does not imply causation.)
These are just some of the reasons that the success rates for eating disorders in residential programs are so abysmal, right around 35 to 40%. My outcomes for intensive outpatient, which take 1 to 2 years, are significantly better for those who stay in treatment with me, as I can boast a 90 to 95% success rate. Why? Because I am treating the underlying problem(s), or the reason my patient has hit upon the disordered eating as a focus for her anxiety. Even more importantly, she has time to adjust to the healthy new behaviors she is learning, as well as the weight gain, which of necessity, is very slow, especially compared to the rapid weight gain in residential treatment.
For starters, I promote clean eating. Polluted food causes eating disorders by attacking the parts of the brain that manage eating behavior and attacking the gut where 70% of the body’s Serotonin, our most important mood neurotransmitter, is found. Whereas clean food heals and nurtures both the brain and the gut. It truly acts like medicine. It behaves. It does not cause a food baby, which is a nightmare for someone with fears about their body size, and it supports the neurotransmitters that regulate mood.
The alternative to clean eating is conventional eating, US style. Let’s talk about that for a minute. The US diet has the distinction of being one of, if not the, unhealthiest diet in the developed world today.
Clean food allows for weight gain that is slow and steady, and one that promotes muscle instead of love handles, making it easier for the ED patient to tolerate. My ED patients are often “foodies” at heart, so the clean food makes sense to them, which opens up all sorts of food options where none existed previously. Do they overreact and over-focus on how clean the food needs to be? Of course. Or how ruthless they have to be in eating clean 100% of the time, yes, sometimes they do, especially in the beginning while they are still very anxious and/or OCD.
Another advantage I have is that I am a family therapist. Unlike many therapists, who will not even talk to the parents or spouse, I see family members as my best therapeutic asset. They have access and control over what their loved one is eating. They also have leverage, which I can help them use effectively rather than punitively. Finally, family dynamics can play a huge role in the eating disorder and must be addressed in order for the patient to fully recover.
Finally, I understand ED. Eating disordered thinking is very difficult for most people to understand. I understand it and can therefore empathize accurately with my patient. Usually the treating practitioner makes many incorrect assumptions about the patient, things such as assuming that the patient will feel good about succeeding. She won’t. She’ll be terrified. Or that she is telling you the truth. She isn’t. She is telling you what you want to hear, or whatever she needs to tell you to get you off her back so she can restrict in peace.
The role of the parent is critical to the success of treatment with adolescents and young adults. As difficult as it is to treat individuals with eating disorders, it is the parent that makes the difference between success and failure. When the parents are onboard with clean eating, my success rate is very high. Even when the parents are not onboard with the clean eating, if they trust the process and communicate their fears, we can create a force that the ED cannot overcome and we win.
Unfortunately, this is very hard for some parents for many reasons. Even when they are bought in to the clean eating, they may want the process to go faster, sometimes because they cannot afford treatment, but other times because they are too afraid to stay the course; or they are having their own issues with food or weight.
Then there is the amazing ability of the patient to derail treatment by manipulating her parents. Often, once she realizes that the path we are on is going to force her to give up her ED, the patient believes that she has no choice but to sabotage therapy. If she panics, this is usually where she throws me (therapy) under the bus. If the parents and I are on the same team, it doesn’t work.
If on the other hand, the parent is very anxious, all the patient has to say is “I feel guilty if my food is not all organic and it is making me want to restrict even more.” Parents, who are already frustrated with a process that seems to be taking a long time, or who feel burdened with the idea of clean eating, have a perfect excuse for bailing.
Although I hate getting fired, over the years a pattern has emerged that makes me feel better; the patient often comes back to me as an adult. Ironic since it is usually the patient who got me fired by convincing her parents that my approach was “triggering” her. What the parents have no way of knowing/accepting is that “getting triggered” pre-dates her treatment with me, as just about everything food related “triggered” her. Nonetheless, for the anxious parent in desperate need of an immediate solution, it is a very convincing tactic to use against treatment.
So why does she come back to me as an adult when she now has the freedom to avoid treatment altogether? Because she is ready for the cure and recognizes that I can indeed help her. In fact, what my returning patients have explained to me is that the reason they left or got me fired in the first place, was that I was a threat to the eating disorder, or ED, and they felt compelled to get rid of me to protect it.
So I got fired because the patient recognized my skills. Effectively, this means that the better I am at what I am doing, the greater the risk of failing? Yes, but not always and only temporarily in some cases. This is the quintessential tortoise and hare story where slow and steady wins the race. Although I wouldn’t wish this work on anyone, as it is not for the faint of heart, I cannot imagine doing anything that is as gratifying as helping someone conquer an eating disorder.
More About Emotional Arousal
More About Residential Treatment
More About The Polluted US Food Supply
Does someone you love suffer from an eating disorder?
Dr. Renae Norton specializes in the treatment of eating disorders. Located in Cincinnati, Ohio. Call 513-205-6543 to schedule an appointment or fill out our online contact form for someone to call you to discuss your concerns. Tele-therapy sessions available. Individual and family sessions also available.
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Materials contained on this site are made available solely for educational purposes and as part of an effort to raise general awareness of the psychological treatments available to individuals with health issues. These materials are not intended to be, and are not a substitute for, direct professional medical or psychological care based on your individual condition and circumstances. Dr. J. Renae Norton does not diagnose or treat medical conditions. While this site may contain descriptions of pharmacological, psychiatric and psychological treatments, such descriptions and any related materials should not be used to diagnose or treat a mental health problem without consulting a qualified mental health care provider. You are advised to consult your medical health provider about your personal questions or concerns.