Metamorphosis: Long-Term Therapy with Young Adults

One of the most rewarding aspects of my job is the opportunity to engage with patients in long-term therapy.  In my practice today, I have a number of patients who began treatment with me years ago, in adolescence, and are now in their 20’s.  These patients first presented in my office with their parents during middle school or high school, suffering from severe eating disorders or depression or debilitating anxiety or, in some cases, all of the above.  Some entered treatment kicking and screaming; others reluctant but resigned; still others wanting help and suffering desperately but requiring immense parental support to stay afloat.

 In many cases, these adolescent patients received intensive Family-Based Treatment for six months or a year or more.  In other cases, the teenage patients received individual Cognitive-Behavioral Therapy with active parental involvement.   All of them made substantial progress in treatment.  The majority recovered fully from their initial presenting diagnosis.  Those who have not recovered fully are doing significantly better, living independent, fulfilling lives, but still experiencing symptoms and receiving ongoing care to keep their illness at bay.  Now, years later, some of them continue with weekly therapy sessions.  Others come in once or twice a month, or perhaps biannually like dental cleanings (we call this “mental hygiene”).  Still others elect come in on an “as needed” basis, scheduling a few sessions here and there to help them cope with life events, navigate relationships, manage stress, or deal skillfully with bouts of depression or anxiety. 

What unites these incredible young men and women is the fact that they have taken full responsibility for their well-being.  They have chosen to engage in long-term individual therapy as an act of self-care.  Through their adolescent suffering, they have become acutely aware of their susceptibility to mental illness.  They are choosing to receive therapy not only to prevent relapse of illness but also to pursue optimal health.   Many of these young adults have chosen to abstain from drugs and alcohol, even as their peers regularly smoke pot and drink to excess.  Many of them have adopted consistent home practices of meditation or yoga.  They make conscious, health-promoting choices when it comes to sleep, nutrition, stress management, and physical activity.  When faced with an important decision about which graduate program to pursue, which job offer to take, which city to live in, or even which person to date, they carefully consider the impact of these choices on their quality of life.

Engaging in long-term therapy with patients like these involves a number of gradual but significant transitions for all members of the therapeutic relationship: the patient, the parents, and me.   For the parents and for me, there is the progression from the crisis management of an acutely ill adolescent to the joy of stepping back into a supportive role for young adult in his own quest for greater levels of well-being.  The parents and I often begin our relationship communicating multiple times per week to put out fires and to ensure that we are in lock-step as we form a circle of safety around a suicidal or eating disordered patient.  As the patient gradually assumes responsibility for her own well-being (which often takes several years for those with adolescent-onset mental illness), communication between parents and me subsides into an occasional email or phone call.   The patient is now a much healthier, more mature young adult, and is trusted to schedule, attend, participate meaningfully in her own therapy sessions.  In many cases, she pays for her own treatment as well.

The therapy itself goes through a significant evolution as I shift from being directive and prescriptive, setting firm limits around dangerous or debilitating symptoms, to engaging with the patient in deep psychological work and collaborative goal setting.  For the patient, there is the very welcome shift from being told what she must do, in therapy and at home, to deciding what issues are important to her and taking the initiative to seek support, both therapeutic and familial, in achieving personally relevant goals.    For the patient, this shift brings with it a transformation from a defensive posture (as evidenced by panicking, shutting down, or lashing out in therapy and at home) to a stance of openness and receptivity (as evidenced by increased self-disclosure and self-awareness along with the display of more vulnerable emotions). 

I cannot begin to describe how rewarding it feels to support a frightened, malnourished, deeply depressed teenager as she blossoms into a healthy, confident, independent young woman who is attending college or graduate school in another state, working at an exciting full-time job, getting married, or giving birth to her first child.  It is fulfilling beyond words to join with young adult patients in the journey of long-term wellness as they clarify their personal values, decide who they want to be in this world, and take concrete steps towards achieving their dreams.

Those of you who have engaged in long-term therapy, either as a therapist, as a patient, know well how deeply personal and meaningful these relationships can be.  There is a level of emotional intimacy that surpasses even that between spouses, between parent and child, or between the best of friends.   In many ways, engaging in long-term therapy with self-motivated young adults is the polar opposite of Family-Based Treatment (FBT) for Adolescent Anorexia Nervosa.   For most patients in my practice, the former would not have been possible without the latter.   

Kids who Diet: There’s an App for That, But Shouldn’t Be

WW International, the company formerly known as Weight Watchers, recently launched an app called Kurbo which is designed to help children ages 8-18 to diet and lose weight. The app is marketed as a “health coaching” tool, but a closer look at the company’s website reveals testimonials of children losing weight and dropping BMI points, complete with “before” and “after” photos. In recent years, the words “diet” and “dieting” have been replaced with words like “wellness” and “healthy eating” in popular nomenclature. But more often than not, when people refer to “eating healthy,” they are talking about restricting calories, reducing carbohydrates, and decreasing portion sizes. In other words, dieting in pursuit of weight loss. The brilliant marketing team at Weight Watchers, aware of this cultural shift in nomenclature, re-branded themselves as WW (Wellness that Works) to stay in vogue with their client base: people living in larger bodies.

But make no mistake: Kurbo is a diet app designed to help children lose weight. Although the app is touted as being based on years of scientific research, the very existence of this app defies the best available scientific evidence, which strongly suggests that CHILDREN AND ADOLESCENTS SHOULD NOT DIET.

Why? Let me count the reasons.

  1. Bodies are meant to be diverse in size and shape. The very notion that a child or adolescent should lose weight in order to have an acceptable body flies in the face of genetics and natural size diversity.
  2. Weight loss disrupts crucial physiological processes in the growing bodies of children and adolescents. Puberty requires significant weight gain to ensure proper development of the brain, bones, reproductive organs, and other vital body systems. Losing weight during adolescence can halt puberty, stunt vertical growth, and alter hormone levels.
  3. Dieting is not effective at producing long-term weight loss, but it reliably predicts weight gain and depression. More often than not, dieting leads to weight cycling: losing weight in the short-term but regaining weight and ending up at the same weight, or a higher weight, in the longer-term. Our bodies have evolved to protect us against famine by slowing down metabolic processes when food is scarce (such as, when we are dieting and losing weight) and ramping up hunger signals and cravings, which often leads to overindulgence or binge eating. Weight cycling is associated with negative health outcomes, including increased risk of depression. Individuals who diet frequently experience cycles of shame, guilt, and feelings of failure each time they regain lost weight.
  4. The normalization and glorification of diet culture is harmful and toxic to all children. When a person in a position of authority (e.g., doctor, parent, teacher, coach) tells a child or adolescent to lose weight, or places that child or adolescent on a diet, the message being sent (either subtly or overtly) is: “Your body is not acceptable as it is, and you must work very hard change your body in order to be attractive, healthy, happy, or socially accepted.” This message is damaging to a young person’s self-esteem, confidence, and body image.
  5. Diet culture disproportionately targets and stigmatizes individuals in larger bodies, thus perpetuating weight stigma.
  6. Although dieting itself does not cause eating disorders, dieting (or food restriction of any kind) can trigger the onset of an eating disorder in a child who is genetically vulnerable. Further, diet culture creates a toxic environment for individuals who are recovering from eating disorders. Eating disorders are dangerous, debilitating, difficult to treat illnesses that have the highest mortality rate of any psychiatric disorder.

Thankfully, there are many other individuals and organizations who share my sentiments on this matter and are publicly condemning this app.

  1. Healthcare Providers Against Kurbo. A group of physicians, psychologists, therapists, and dietitians who specialize in treating eating disorders has formed a petition protesting the Kurbo app. You can read and sign the petition here.
  2. Registered Dietitian Christy Harrison published an article in the New York Times explaining why the Kurbo app is harmful to children.
  3. FEAST (Families Empowered and Supporting Treatment for Eating Disorders) posted a position statement condemning this app.
  4. NEDA (National Eating Disorders Association) published a position statement expressing grave concerns about the app.

So, you might ask, if dieting is not the answer, then what should we do about childhood obesity? The answer, based on the best available scientific research, is that obesity per se is not the problem, and thus the pursuit of weight loss per se is not the solution. Instead, adults who are charged with the task of caring for our youth (e.g., parents, teachers, coaches, and doctors) should encourage health-promoting behaviors in children across the weight spectrum. Children of all weights will benefit from eating balanced family meals containing a wide variety of foods from all food groups. Children of all weights benefit from adequate sleep, daily physical activity, and limited screen time. Children of all weights should be taught body acceptance and should be educated about size diversity. This is true health promotion. In some cases, these health-promoting behaviors will result in weight loss for higher-weight children, and in some cases, they will not. But regardless of what happens to the child’s weight, these health-promoting behaviors bring about genuine improvements in the child’s physical and mental well-being. And – this is important – NO HARM IS DONE.

Sorry, WW Kurbo app – you’ve got it all wrong.