Brave Girl Eating

by Harriet Brown

  Patients at the Maudsley Hospital ate and gained weight. But once they went home, they invariably relapsed, because parents were traditionally told not to sit and eat with them. In fact, eating-disorders specialists often recommended (and many still do) “parentectomies,” physical and emotional separation between parents and a child with anorexia. Parents are still advised by therapists like Dr. V. not to pressure their child to eat, not to talk about food, not to be the “food police,” to find other subjects to discuss. They’re told to butt out, stand down, give their teenager space and autonomy.

  They’re told, in essence, to watch their child starve to death.

  Anorexia, parents are often told, isn’t about food; it’s about control. Their children need to feel that they’re in control of their eating, or, more likely, their noneating. They’ll eat when they’re ready. They’ll eat when the underlying issues that caused the anorexia in the first place have been resolved.

  Except a lot of them die before that happens. If it ever does.

  Like Salvador Minuchin, both Chris Dare and Ivan Eisler are family therapists. They believed from the start that families played a key role in the recovery process. Unlike Minuchin, they didn’t assume that families therefore caused eating disorders. On the contrary. “[Dare and Eisler] always had the whole family present,” explains Le Grange. “So there’s the kid who has anorexia, but you also see the other two who are perfectly healthy. It’s not that the parents don’t know how to raise their kids and feed them; something just went awry with this one.”

  I think I understand what Le Grange is getting at. For the last two months Jamie and I have been trying to get Kitty to eat, mostly without success. The process has felt adversarial—us against the anorexia—rather than supportive, both because we’ve been told by therapists like Dr. V. that we’re not supposed to get involved with Kitty’s eating and because we feel like we screwed up in the first place. That sense of self-blame and disempowerment is part of what’s preventing us from being effective. But what if we approach Kitty’s eating from a different point of view? What if we, like the nurses at the Maudsley Hospital, make it impossible for her not to eat?

  That was Dare and Eisler’s idea. Patients in the hospital ate with the support and encouragement of nurses; teens at home could eat if their parents supported and encouraged them. Parents love their children, and they have an enormous stake in their child’s recovery. No family’s perfect. But maybe they don’t need to be perfect. Maybe they just need to be able to get the job done.

  This perspective marked a paradigm shift in the treatment of eating disorders. Historically, anorexia has been viewed as a biological “solution” to a psychological conflict: a teen starves herself in an attempt to resolve emotional issues, including loss, family conflict, fear of independence, and confusion about sexuality. This case history, cited in 1984 by Pauline S. Powers, M.D., professor of psychiatry and behavioral medicine at the University of South Florida in Tampa, is pretty typical:

  Ms. E., age 21, could not choose a career, but thought she might become an airline stewardess. Her mother rejected this idea as “not good enough,” and described the job as “only a waitress in the sky.” This is an isolated example in a woman whose choices had been rejected as poor throughout her life. As a consequence, she felt empty and unable to direct her own life.*

  I wonder if there’s a mother anywhere in America who has actively supported every single one of her daughter’s choices.

  Or how about this case history, also cited by Powers:

  Laura is a 14-year-old girl…. Her father was a soft-spoken, highly successful lawyer. Her mother was a guilt-ridden woman with inflexible rules for her daughters and teenage son. She bitterly resented her role as a housewife and mother…. The family interaction patterns commonly described in anorexia nervosa were present. There was an absence of intergenerational boundaries (e.g. the father covertly sided with the patient against the mother) and there were rigid fixed patterns of interaction (e.g. attempts to change Laura’s violin practice schedule met with overt resistance from the entire family). Enmeshment was present (e.g. when a cold remedy for Laura’s sister was prescribed, the father dosed both daughters “to prevent” Laura from developing a cold) and there was a lack of conflict resolution (i.e. either emotionally charged topics were avoided or occasionally there were prolonged unresolved quarrels).*

  More recently, here’s what clinical psychologist Richard A. Gordon, author of Anorexia and Bulimia: Anatomy of a Social Epidemic, has to say about eating disorders:

  Anorexics and bulimics draw upon the common cultural vocabulary of their time, through latching onto the contemporary mania about dieting, thinness, and food control that have become endemic to the advanced industrial societies. They utilize these cultural preoccupations as defenses that enable them to escape from—and achieve some sense of control over—unmanageable personal distress, most of which revolves around issues of identity. [S]imilar to hysteria, anorexia and bulimia are socially patterned, the fashionable style of achieving specialness through deviance.†

  It’s no wonder the clinical literature reflects this perspective, though, given that Hilde Bruch’s book The Golden Cage has been considered the definitive text on eating disorders since it was first published in 1978. Bruch, who was a professor of psychiatry at Baylor College of Medicine, described the typical anorexic as a sparrow in a golden cage, a child of privilege who seems to have everything but who deep down feels stifled by her parents’ expectations and often unspoken demands, unable to express her feelings directly. The classic anorexia patient, writes Bruch, “was not seen or acknowledged as an individual in her own right, but was valued mainly as someone who would make the life and experiences of the parents more satisfying and complete.” Bruch describes families where “clinging attachment” and “a peculiarly intense sharing of ideas and feelings develop,” where parents overdirect and overcontrol, pressuring the child to meet their expectations and heal their own emotional neediness.*

  The more I read Bruch and Minuchin and others, the worse I feel. Le Grange helps me put things in perspective by pointing out that by the time a family comes in to therapy with an anorexic child, the usual family dynamics no longer apply: parents are anxious, the patient is irrational, the other children are traumatized. So what you see in family therapy for anorexia is not a family’s typical modus operandi.

  Once upon a time, and not all that long ago, our family ate together, talked and joked and kibitzed at the table. At this point, though, we probably look pretty damn pathological. I think of our last month of family dinners: Jamie and I begging Kitty to eat. Tears and tension. Emma slouching lower and lower in her chair or bolting from the table. I wonder if we’ll ever have a normal family dinner again. Or at least one that doesn’t leave me shaking and sick to my stomach.

  Eisler and his colleagues understood the way family dynamics change when a child has anorexia. In the early 1980s, they developed a set of protocols for weekly family therapy that put parents in charge of their anorexic child’s eating, making them, in effect, the food police. Their findings echoed Minuchin’s: 90 percent of the adolescents treated with FBT were still doing well five years later, compared with 36 percent of the teens who got individual therapy. (A later Canadian study shows that “involving adolescents’ parents in treatment might be necessary, particularly for adolescents who describe the greatest resistance to treatment…. Adolescents who perceived their relationship with their parents more positively also reported greater motivation to change their eating disorder.”)*

  That number—90 percent—is the one that catches my eye. It represents the best news I’ve gotten since Kitty was diagnosed. Why wouldn’t we try a treatment with such a high recovery rate—especially if the alternative is treatment with only a one in three chance for full recovery?

  And there’s another reason to try it: chronic anorexia is notoriously tough to treat. Years of malnutrition, restricting, and altered social interactions s
et up a potent and self-reinforcing pattern that becomes part of an adult’s identity and physiology. After five or ten or fifteen years of anorexia, recovery is far less likely.

  All the more reason to take this on aggressively and fast. If we can help Kitty recover now, while she’s still a teenager, while she hasn’t been sick for very long, her chances are way better.

  We can do this, I know we can—if Jamie gets behind it too. One of the key criteria for the success of FBT is that parents present a united front. Consistency and persistence, as Le Grange told me. That makes sense; all child-rearing efforts, whether they involve potty training or curfew setting or eating disorders, require that parents be on the same page. I know from our experiences so far how hard it is to keep at Kitty to eat another bite, have another sip, finish the milk shake or pasta or cheese. You feel like you’re torturing your child by pushing, pressing, insisting. And you are, in the short term. But the long-term stakes are so high. It seems to me a fair trade-off: X number of days, weeks, months of hell, in exchange for a lifetime of recovery. I know what I want to do. What we need to do.

  For the next several days, Jamie and I talk and argue and grieve together. “I can’t understand it,” he says, over and over. “Why won’t she just eat?” I can’t understand it either. But my gut tells me that we’re asking the wrong question. The question isn’t why but what: What do we do now?

  What it boils down to is that we have three choices: Send Kitty away. Keep doing what we’re doing. Or try some version of FBT, the Maudsley approach.

  In the end the decision is easy.

  The next morning I call Dr. Beth and Ms. Susan and tell them our plan to begin family-based treatment with Kitty. Ms. Susan has heard of FBT and thinks it could be a good option for Kitty because she’s young and hasn’t been sick for long. (How long is long, I wonder? Because I feel as though Kitty’s already been sick a long time. Too long.) Dr. Beth has never heard of it but promises to do some reading and call me.

  FBT comprises three phases: Phase 1 is weight restoration, Phase 2 is returning control over eating to the adolescent, and Phase 3 is resuming normal adolescent development. Phase 2 seems a long way off; there’s no way we’re letting Kitty control her eating anytime soon. I have no idea what “resuming normal adolescent development” means, and frankly, at the moment, I don’t care. We are solidly in Phase 1.

  Kitty has lost only six or seven pounds since June, but it’s painfully clear that she’ll need to gain a lot more than that to recover. Dr. Beth graphs Kitty’s height and weight from birth, plotting her natural growth curve, and gives us a number to start with: twenty-five pounds. That’s how much Kitty needs to gain, at least for now.

  In true FBT, I read, a therapist meets weekly with a family, supporting them as they figure out how to get their child to eat. The therapist doesn’t tell the parents how to do this but rather empowers them to find strategies that work. I think back over the last few months of family dinners, remembering one in particular, a week or so before Kitty’s official diagnosis, during the time I knew something was wrong but didn’t yet understand what. We had company—my mother-in-law was visiting, along with my best friend from college and her young daughter—and we’d gone out to a restaurant, seven of us sitting at a round table. We had to send the waiter away three times because Kitty was negotiating, in a tone of rising hysteria, what she would order. The menu was full of dishes she had once loved: mussels in buttery broth, spaghetti carbonara, salmon in creamy dill sauce. She wanted a salad with grilled chicken, dressing on the side. I looked at my emaciated daughter, the flat hollows under her eyes, the protruding knobs of her shoulder bones. I looked across the table at friends and family who had traveled thousands of miles to see us, whose eyes reflected their concern and bewilderment even as they pretended not to hear our agitated whispers. If we’d been alone, I probably would have let her order the salad, thinking At least she’s eating something. But in front of the people who knew us best in the world, I felt sudden shame. Kitty was too thin; we knew it, they could see it. We weren’t doing our job as parents, Jamie and I. We were failing our daughter.

  And so we argued, behind our menus: You love mussels—order that! Or the carbonara. Remember how much you used to love carbonara? The more we pushed, the more frantic Kitty became, and the more determined I felt that she would order something reasonable and eat it. Now I was embarrassed about the scene we were making too.

  Finally Jamie put his hand on my wrist. He’s more private than I; his tolerance for public scenes is low. He shook his head. I knew what he meant. What did it matter, really, what Kitty ordered? We both knew the problem went far beyond one dinner.

  And so she ordered the salad, and pushed it around her plate, while the rest of us, as if to compensate, ate heartily, sopping up sauce with slabs of Italian bread, forcing the conversation away from the drama we couldn’t talk about. It was as if my daughter’s ghost sat at that table, untouchable and alone, watching through an impenetrable scrim. We drove home that night in despairing silence. Another meal—or, rather, another no-meal. Another turn of the screw pulling Kitty’s skin tight across her sharpening bones. Another twist of the knife that now sawed away at my heart, night and day.

  And now, I think, what next? I’d give anything to avoid another dinner like that. We’ve been failing with Kitty for weeks. How will things be different? How will we get Kitty to eat? I want someone to tell me exactly what to do.

  We have no FBT therapist, because there are none in our small midwestern city. But we do have Ms. Susan and Dr. Beth. And we also have something no one else in the world has: we love Kitty best. No one else in the world can possibly want her to get better as much as we do. No one else loves her as fiercely, as nonjudgmentally, as unconditionally as we do.

  And so we make a plan, Jamie and I. We’ll take charge of Kitty’s eating. We’ll serve her breakfast, lunch, snack, dinner, and snack, starting at about fifteen hundred calories a day, and we’ll bump up the calories by three hundred every couple of days, until she’s getting enough. Until she starts to gain weight. Even though I have no idea how, exactly, we’re going to pull this off, how tomorrow will be different from yesterday, I feel an immense relief at the thought of starting over. These weeks of wondering and worrying and feeling helpless, of feeling stalled and in limbo, have taken a toll on all of us—Jamie, Emma, and me. Now, however hard it is, we’ll be doing something.

  The next morning, as Emma sleeps late, Kitty comes downstairs to a bowl of cereal, milk, and some strawberries—a small breakfast by ordinary standards. But when she sees that the cereal is already in the bowl, that she doesn’t get to measure it herself, her resistance begins.

  “I could have done that,” she says in a good-girl, wanting-to-be-helpful tone of voice. “You didn’t have to.”

  I’m ready for this. “I don’t mind,” I say cheerily. “That’s my job. All you have to do is eat.” I pull out the chair, gesturing grandly for her to sit down. I’m inhabiting my role—the happy, helpful mom—to the hilt. There’s no such thing as overacting in this play.

  Kitty grips the seat back, her knuckles white with effort. “I don’t feel like cereal today,” she says. “I was really looking forward to some cottage cheese.”

  “Oh, I’m sorry,” I say. “I finished the cottage cheese yesterday.” Actually the cottage cheese now resides at the bottom of a large garbage bag by the curb, along with twelve packages of ramen noodles, a frozen loaf of reduced-fat bread, two bottles of nonfat salad dressing, two bottles of low-fat salad dressing, a bag of pretzels, six cartons of yogurt, and a bunch of grapes. Last night, when I couldn’t sleep, I purged the kitchen of every nonfat, low-calorie diet food I could find. The grapes I regret, but they had to go; they were one of Kitty’s lunchtime standbys.

  We move into Act Two: bargaining. “I’ll eat some of the cereal and all the strawberries,” says Kitty. “I can’t eat all that cereal today. I’ll eat more tomorrow. I promise.”

  I muste
r a sympathetic look. “I know it’s hard for you to eat,” I say. “But this is your breakfast today. Please sit down.”

  Kitty’s eyes gleam suddenly. The good-girl façade is slipping. I brace myself for Act Three: refusal.

  “I don’t want cereal,” she says mutinously. “I want cottage cheese.”

  I think back to all the times over the last few months I’ve rushed to the store to get Kitty cottage cheese or yogurt or grapes—“safe” foods, foods she feels comfortable eating. Of course she expects me to do it again; why wouldn’t she?

  “This is your breakfast today,” I repeat. “Please sit down and start eating.”

  She sits down, to my surprise, and peers into the bowl. Act Four begins: distraction. “It’s all soggy now,” she complains. “I can’t eat this.”

  The cereal can’t be that soggy; it’s only been out for a minute or two. I go to the cupboard, pour another bowl of cereal about the same size, and place it on the table in front of Kitty. I get out the milk, which she tries to take from me. “I’ll pour,” I say brightly, staying in character.

  “You gave me more this time,” she says in alarm.

  “I gave you exactly the same amount,” I lie. I have no idea how the bowls compare. I may be new at the refeeding process, but I’ve been a parent long enough to have mastered the art of authoritative pronouncements.

  Kitty picks up the spoon and dips it into the cereal here and there, inspecting each flake as if she’s looking for contamination.

  “Please eat before this bowl gets soggy too,” I say.

  Kitty puts down her spoon and looks up at me. Act Five: pathos. “I’m trying,” she says in a pitiful voice. “It’s hard, Mommy!” Tears well up in her large brown eyes.

  I want more than anything to put my arms around her and say, Never mind, Kitty. You don’t have to do it; I know it’s too hard. But she does have to. And I have to help her do it. Even if it means being tough.