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Top 10 Mistakes in Mental Health Care

Very early in my blogging career, I wrote about The Top 10 Mistakes in Eating Disorders Treatment. Bad treatment, however, is not limited to eating disorders. Here are the most common mistakes I have observed in the treatment of other mental illnesses:

1. Failure to conduct a thorough assessment at the beginning of treatment. This contributes to missed diagnoses, incorrect diagnoses, and ultimately to ineffective or inappropriate treatment.

2. Failure to assess for behavioral, lifestyle, and environmental factors that may be contributing to the patient’s symptoms. This generally corresponds with the failure to recommend simple lifestyle changes which have a powerful impact on psychological wellbeing. Sleep deprivation, excess alcohol or caffeine intake, lack of exercise, poor nutrition, and increased stress at work, school, or home create symptoms that appear identical to those of depression and anxiety. For many people, these symptoms can be alleviated by making behavioral changes. For others, psychotherapy and medication may be necessary.

3. Lack of basic, scientifically-sound education for patients and their families regarding the patient’s disorder(s) and the efficacy of various treatment options. It never ceases to amaze me how many patients and families come to me, after months or years of therapy, without a basic science-based explanation of their mental illness, and without ever being informed that evidence-based treatment exists. Perhaps the most common example of this phenomenon is the patient whose four years of previous therapy focused on the “why” or the “root cause” of her mental disorder without providing any symptom relief. Insight is important, but insight itself does not cure mental illness. These patients are not provided with the simple (and in my mind, very liberating) explanation that mental illnesses are caused by certain biological and genetic vulnerabilities which are often expressed when certain environmental circumstances are present. They are not told that, regardless of the reasons why they developed their illness, they can learn skills to help them manage their symptoms and feel better.

4. Failure to use effective, evidence-based psychological treatments (EBT’s). For the majority of mental illnesses, there is research demonstrating which treatments are most effective. The problem is that the majority of therapists do not use EBT’s. There are several reasons for this: A.) Some therapists have not been trained in evidence-based treatments. This is the result of a three-pronged failure: on the part of the graduate programs which do not teach EBT’s, on the part of the therapists who do not take the initiative to keep up with the literature or seek out the proper continuing education courses, and on the part of the state licensing boards, which do not require that therapists learn about or practice EBTs. B.) Some therapists have been trained in EBT’s but choose not to use them because they value their own clinical judgment more than they value science. This is faulty logic, because research shows that statistical prediction consistently outperforms clinical judgment. Translation: therapists are far more effective when they select their interventions on the basis of scientific research (e.g., what works best for most people with this particular disorder) rather than using their own judgment to decide how to help a patient. C.) Some therapists protest: “But EBT’s don’t work for everyone.” Well, of course they don’t. Nothing works for everyone. But if research consistently shows that treatment A is effective for 80% of people with OCD, while treatment B is effective for 25% of people with OCD, and treatment C is based upon a psychological theory but has never been studied scientifically, it’s a no brainer. Use treatment A with OCD patients unless you have a specific, convincing reason not to. It makes no logical, mathematical, ethical, or scientific sense to do otherwise.

5. Insufficient amount or intensity of psychological treatment. Sessions may begin too late in the course of a mental illness; sessions may be held less frequently than needed; treatment may be terminated before the patient is fully recovered; patients may not receive the level of care (e.g., hospitalization, residential treatment, day treatment) that they need in order to recover. Financial issues and insurance limits are largely to blame for this problem. However, our attitudes about mental illness and personal autonomy play a major role as well. I don’t believe in the “least restrictive environment” criterion. I do not believe that a person should have to be imminently suicidal, homicidal, or floridly psychotic to warrant inpatient treatment. I do not believe that residential and day treatment programs should be reserved for those who have had multiple failed attempts at outpatient treatment. I believe that providing intensive, aggressive treatment at initial diagnosis (which often requires more than your typical weekly therapy sessions) would greatly reduce the severity and duration of mental illnesses.

6. Focusing on “underlying issues” rather than symptoms early in treatment. It makes no sense to do intensive psychotherapy with a drug addict while she is high or while she is actively using drugs. Her mental state is too compromised for her to do meaningful psychological work, and the psychological work detracts time and attention away from the most glaring, life-threatening problem: the drug use. This patient would need to go through detox and rehab before she could really benefit from psychotherapy. Similarly, if a person is severely depressed, severely anxious, or engaging in self-injurious behavior, it makes no sense to spend the therapy hour processing inner conflicts or exploring childhood memories. She cannot think rationally or process emotional information accurately while such acute symptoms are present. The first step must be to alleviate the symptoms. To do otherwise simply serves to delay her recovery and prolong her misery.

7. Failure to address underlying issues, if they exist, later in treatment. Once symptoms are under control, it is important to assess for and treat any underlying issues which could make the patient vulnerable to relapse. I do not mean to imply that every patient has deep, dark secrets of trauma or major internal conflicts. Many patients have simpler underlying problems, such as poor communication skills, unhelpful relationship patterns, low self-esteem, perfectionism, unhealthy core beliefs, or overly stressful jobs or home lives. Regardless of the nature of the patient’s issues, they must be treated if the patient is to heal fully and maintain a lasting recovery. Disclaimer: It is a huge mistake for therapists to presume that all patients have serious underlying issues that must be addressed in treatment. This assumption leads to endless exploration of the past, digging around for some buried treasure that often does not exist. This can be a waste of time and money, can lead to over-focus on the past at the exclusion of full engagement in the present, and can actually make patients feel worse. Sometimes a cigar is just a cigar.

8. Over-prescribing, or inappropriately prescribing, psychotropic medication. A lot of this has to do with insurance companies and financial issues: it is cheaper to medicate than to treat holistically with psychological therapy, at least in the short term. We know that for many mental illnesses, certain evidence-based psychological treatments are more effective than medications (i.e., DBT for borderline personality disorder, CBT, ACT, and exercise for mild to moderate depression, exposure and response prevention for OCD, behavior therapy for panic disorder, CBT-E for bulimia nervosa). And yet many patients are medicated for these illnesses without being offered psychological treatment, and without being informed that certain psychological treatments for certain conditions are actually superior to medication. Recent statistics show that 80% of prescriptions for psychotropic medications are written by general care physicians (internists and pediatricians). This appalls me. While GPs are allowed to prescribe psychotropic medication, they lack specialized training in the diagnosis and treatment of mental illness. The ideal situation is for a psychiatrist to prescribe the psychotropic medication, follow up with the patient regularly to monitor her response to the medication, and remain in close contact with the patient’s GP and therapist in order to ensure seamless coordination of care.

9. Failure to involve family members in a young patient’s treatment. Yes, the primary developmental task of adolescence is separation / individuation. But this developmental reality in no way precludes involving family members in an adolescent’s treatment. I believe that a child or adolescent’s treatment works best when family members are fully informed and actively involved. The patient may be with the therapist for 1 hour a week, but she is with her family for the other 167 hours. Therapists are most effective when they strengthen a family unit (rather than weakening it by pointing the finger of blame), communicate openly with parents (rather than hiding behind the cloak of confidentiality), and provide them with tools to help their children (rather than urging them to back off). Therapy is temporary; family is forever.

10. Blaming patients, either subtly or overtly, for their mental illnesses. This causes so much harm. Many therapists are of the opinion that if patients just tried a little harder, dug a little deeper, or stayed in therapy just a few months (or years) longer, they would get better. Patients are often held responsible for their own lack of therapeutic progress (Remember the old joke – “How many shrinks does it take to change a light bulb? Just one, but the light bulb has to WANT to change”). As a result, patients blame themselves when they do not recover. Guilt is paralyzing and depressing and disempowering. In what other illness would a patient be held responsible for her lack of improvement? Obviously, therapy is a collaborative process which requires tremendous courage and dedication from the patient. That said, the therapist is responsible for providing the patient with effective treatment and guiding her towards recovery.

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What’s Wrong With Mental Health Care in America?

Just about everything.

I can sum up our country’s mental health care problem in one sentence: Failure to provide local, high-quality, comprehensive, affordable, evidence-based mental healthcare for every American citizen, at the appropriate level of intensity, for as long as necessary for full recovery and relapse prevention.

Few Americans have access to local high-quality, evidence-based mental healthcare. Some people find mental health care cost-prohibitive. Others struggle to make ends meet, dipping into their savings, wiping out their retirement accounts or college funds in order to afford appropriate mental health treatment for themselves or their loved ones.

Societal ignorance is partially to blame for this problem. Although “the stigma” of mental illness has allegedly been reduced in recent decades, I see it all around. Like racism and sexism, the stigma of mental illness is perhaps less overt now than it was in previous generations, but it is alive and well today in all of its subtler forms. Many insurance plans do not provide coverage for mental health care. This conveys the message that mental health treatment somehow optional, unimportant, or extracurricular. The brain is arguably the most important part of the body, so why should treatment of brain diseases be viewed as less essential than ophthalmology, endocrinology, or dermatology?

Even more infuriating to me is the reality that mental illness itself is not nearly as stigmatizing as GETTING TREATMENT FOR MENTAL ILLNESS. Consider the following:

• As a graduate student, I read about a medical insurance policy that parents of college students can take out for their children. This policy allows parents to receive a full tuition refund if their child withdraws from school mid-semester for medical reasons. However, the policy specified that, if the student withdraws due to “a nervous or mental disorder,” the parents would receive only a 60% refund. The implication here, as I see it, is that students with mono or renal failure or cancer have “legitimate” illnesses that are neither their fault nor their choice, whereas students with bipolar disorder or anorexia nervosa or major depression are at least partially to blame for their problems, which are seen as less “real,” and they could stick it out for the rest of the semester if they really wanted to. This policy creates a situation in which students struggling with severe mental illnesses feel pressured to remain at school, away from their primary support system, with inadequate treatment, for the duration of the semester, rather than returning home to their families to recover and pursue more intensive treatment.

• Many universities require students who have been out on medical leave for mental health reasons to have a readmission assessment with a mental health professional before being permitted to matriculate once again. Students who were out on medical leave for physical illnesses are not required to submit to a physical exam upon their return to school.

• In the state of Florida (and perhaps in other states), aspiring attorneys must answer a question on their bar application asking whether they have had treatment for a mental disorder. [OBJECTION, YOUR HONOR! RELEVANCE?] If they answer “yes” (and they must answer truthfully under penalty of perjury, they must submit a letter to the bar from their treatment provider describing the nature of their symptoms and course of treatment. Law school is a virtual breeding ground for depression, anxiety, substance abuse, and various stress-related ailments, but many law students will not seek treatment because they don’t want their law careers to be jeopardized by answering “yes” to that question. And I can’t say that I blame them.

• Some adoption agencies, particularly those that deal with international adoptions, categorically refuse to consider individuals who have been diagnosed with or treated for any mental disorder as potential adoptive parents. For example, taking medication for any mental illness, including anxiety or depression, automatically disqualifies hopeful adoptive parents from adopting Chinese orphans. Because, of course, isn’t it better for a child to grow up in an impoverished orphanage without access to modern medical care or higher education, rather than in a loving, stable home with a dad or mom who has responsibly sought treatment for A VERY COMMON, VERY TREATABLE MEDICAL CONDITION? Notably, having an undiagnosed, untreated mental illness does not disqualify potential adoptive parents from adopting Chinese orphans. This policy clearly discriminates against those who have sought treatment.

• Receiving mental health treatment is potentially damaging to a soldier’s military career. This creates a catch-22, because the very act of serving in the military during times of war is a huge trigger for mental illnesses like PTSD, depression, and substance abuse. Few people escape from deadly combat without some mental scars. Yet seeking treatment and risking a diagnosis of a mental disorder is too risky, and too humiliating, for those who have made a career out of protecting and defending our country.

In each of these instances, people who do not seek treatment for their symptoms seem to have a distinct advantage over those who do. For what other disease is it preferable to stay sick than to get healthy? People with mental illnesses who receive good treatment obviously fare better, on the whole, than those who receive no treatment or insufficient treatment. The ultimate irony here is that many people who have been treated for mental illnesses are at least as “mentally fit” as people without mental illnesses, if not more so, BECAUSE they have been through treatment. In general, those who seek out and receive good mental health treatment tend to develop more self-awareness, better coping skills, and a more positive perspective. Certainly these qualities are beneficial to a student, an attorney, a parent, or a soldier.

The National Institute of Mental Health estimates that more than ¼ of American adults suffer from a DSM-IV diagnosable mental disorder in any given year. Further, mental disorders are the leading cause of disability in the US and Canada for individuals ages 15-44. Most upsettingly, only 41% of Americans with diagnosable mental disorders have received any mental health treatment at all in the previous 12-month period. The vast majority of mental illnesses are treatable and manageable – and some are even curable – when the patient receives appropriate care. Imagine how many lives are destroyed, how much productivity is lost, and how much suffering is perpetuated not by mental illness per se, but by people’s refusal or inability to get proper mental health care.

At times, the state of affairs in mental health care looks so bleak that I ask myself why I have chosen this field. My conclusion: the awful state of mental health care is precisely the reason why I have chosen this field. As I ponder this issue, I am reminded of an inspiring quotation from Neale Donald Walsch: “Be a light unto the darkness, and curse it not.” I’m doing my very best to be a light unto the darkness. It’s the “curse it not” that I find much more challenging.

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In Defense of Helicopter Parenting

Last month, Time Magazine ran an article about the dangers of over-involved, over-protective parenting (otherwise known as “helicopter parenting” because these parents tend to hover over their children). The article is well-researched, well-written, and very interesting. As a therapist who frequently encounters this phenomenon in the parents of my adolescent and young adult patients, and as a product of this type of parenting myself, I have a few thoughts and observations on the issue.

I agree wholeheartedly with the author that today’s parents are far too over-involved and over-protective, and this is particularly true amongst middle- to upper-class families with well-educated parents. According to psychologist Eric Ericson, the primary developmental task of middle adulthood (ages 30-50) is seeking satisfaction through productivity in career, family, and civic interests. This is precisely the age at which adults are parenting young children and adolescents, and for helicopter parents, their striving for productivity is channeled into their children. Parents’ intentions are good, but the outcome can be problematic. You see, the middle adulthood psychosocial task of productivity stands in diametric opposition to the adolescent developmental task of identity formation. Children need to play, explore, relax, and interact with their surroundings in creative, imaginative ways. Adolescents need to loaf, “hang out,” date, experience “teen angst,” spend quality time with family and friends, develop their social skills, make their own choices (within reason), make mistakes, and learn from them.

Ideally, a healthy person will emerge from adolescence with a solid self-identity, resilience, confidence, good problem-solving skills, and the ability to tolerate discomfort and failure. Having worked in several college counseling centers, I can attest that many kids arrive at college without these skills and attributes. Their lives have been geared entirely towards achievement in academics, arts, and athletics, often not for the love of science or music or soccer, but because their parents pushed them and/or because they believed it would improve their chances of gaining admission to a prestigious college. Quite often, they don’t know how to structure their time, study properly, deal with disappointment, or make decisions independently. Sadly, many of them do not know who they are or what they enjoy.

Helicopter parenting has the potential to be quite harmful to children by increasing their stress and anxiety and preventing them from developing self-confidence, resourcefulness, problem-solving skills, distress tolerance skills, emotion regulation skills, and creativity. Children and adolescents are over-scheduled, over-worked, and pushed to succeed, often at the expense of their emotional health. There is not enough unstructured time for kids to play, explore, or create. There is little room for adolescent identity formation in between AP classes, Princeton Review SAT prep courses, college applications, three varsity sports, band practice, clubs, and mandatory community service hours.

These issues notwithstanding, one problem I have seen far too often in my profession is the tendency for therapists to blame helicopter parents for causing their child’s eating disorder. It is easy to look at over-involved parents and an adolescent’s misguided search for control and identity through self-starvation and conclude that the former caused the latter. But the belief that over-involved, controlling, or enmeshed parents cause children to develop anorexia nervosa (AN) or bulimia nervosa (BN) lacks solid scientific evidence. What’s worse, this belief has the potential to undermine treatment, disempower parents, confuse children, perpetuate deadly symptoms, erode physical and mental health, destroy families, and turn an acute illness into a chronic and disabling one.

There is a correlation between over-involved, over-protective parenting and the development of AN, but correlation does not necessarily indicate causation. If variable A (helicopter parenting) and variable B (child’s development of AN) are correlated, there are several possible explanations for the relationship between these two variables:

1.) A causes B
2.) B causes A
3.) Variable C causes both A and B
4.) Variables D, E, F, G, H, I, J, K, L, M, and N work together in complex ways to influence the development of both A and B.

Let’s examine each possible explanation.

1.) Explanation 1: Helicopter parenting causes children to develop AN. There is no reliable scientific evidence to support this explanation. Ironically, this explanation is touted far more frequently than the others, even by clinicians who specialize in treating eating disorders.
2.) Explanation 2: A child’s AN causes parents to become over-involved or over-protective. There is some evidence to support this explanation. If parents were not anxious, cautious, protective, or hovering before their child developed AN, you’d better believe they will be once their child becomes ill. This phenomenon is not unique to AN. Parents of children with any illness or medical condition naturally worry about their child and do whatever they can to protect her.
3.) Explanation 3: A third variable causes both helicopter parenting and AN in children. There is a wealth of evidence to support the genetic transmission of AN as well as related personality traits. The personality traits that predispose people to developing AN – anxiety, obsessiveness, perfectionism, and harm-avoidance – are largely genetic. In an adolescent female, these traits are likely to manifest as an eating disorder. In a middle-aged, middle-class, intelligent, well-educated parent, these traits are likely to manifest as over-involvement, over-protection, and over-investment in their child.
4.) Explanation 4: A complex interaction of other variables work together to produce both helicopter parenting and AN in children. This is the most thorough, and probably the most accurate explanation. As stated in explanation #3, genetics plays a major role in the development of AN. A wealth of environmental variables are also believed to influence the development of parenting style as well as AN (e.g., level of education, income, culture, peer group, family background, exposure to stressful life events).

I love working with adolescent children of helicopter parents. I require parents to be fully informed and actively involved in their child’s treatment, and helicopter parents slide seamlessly into this role. They are excellent candidates for Maudsley Family-Based Treatment because their anxiety level is high enough to propel them towards action, they thoroughly educate themselves on their child’s condition, they seek out the best treatment and resources, they are vigilant and persistent, they maintain a very high level of involvement and supervision, and they are tremendously invested in their child’s recovery. Misguided, ill-informed, old-school therapists argue that these characteristics caused the child’s AN, and they advise parents to “back off” and allow the child to make her own choices about food and weight and treatment. This approach rarely leads to lasting recovery.

While helicopter parenting certainly has the potential to cause harm, it can also be used to the child’s advantage in recovery if channeled properly. Helicopter parents tend to be wildly successful in Maudsley Phase I (re-feeding / weight restoration), and largely successful in Phase II (helping the adolescent eat properly on her own). Some of these parents are eager to step back in Phase III as their child deals with psychological and social issues and develops a healthy adolescent identity. Other parents struggle to let go when the time comes. With proper guidance from a good therapist, however, most helicopter parents can learn to manage their own anxiety enough to allow their children to blossom and develop as healthy, independent young adults. This does not come naturally for them, but never underestimate the power of the helicopter parent. If the therapist who helped save their beloved child from a life threatening illness coaches them to step back and let go, they’ll do it.

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Eating Disorders: Prevention and Early Intervention Tips for Parents

There is a fair amount of internet advice for parents on how to prevent eating disorders in their children. The majority of this advice centers around teaching children about healthy eating habits, moderate exercise, positive body image, and media literacy. This is great advice for parents to follow, but it does not prevent eating disorders. It may help to prevent body dissatisfaction and dieting, but these things are not the same as an eating disorder.

Ironically, many children and adolescents who are in treatment for anorexia nervosa or bulimia nervosa report that their illness was triggered by a health or nutrition class at school, training for a sport, or a general desire to adopt the much-touted principles of “healthy eating and exercise.” Unfortunately, most of the information children receive on the benefits of “healthy eating and exercise” is really our fat-phobic society’s disguised attempt to shield our precious children from this horrible “obesity epidemic.” To make matters worse, this information is delivered to children by teachers, physicians, coaches, and parents – supposedly knowledgeable authority figures whose job is to educate, protect, and nurture them. Children who are predisposed to eating disorders are usually compliant, rule-bound, anxious, obsessive, perfectionistic, driven, and eager to please. They are virtual sponges who soak up this “healthy eating and exercise” information and follow it to the letter. The obesity hysteria terrifies them, and their obsessive, perfectionistic temperament makes them stellar dieters. This is the perfect storm for the development of an eating disorder.

I do not believe we should stop educating children about nutrition and exercise out of fear that they will develop eating disorders, much as I don’t believe we should stop educating adolescents about safe sex and contraception out of fear that they will become sexually active. More information is usually better than less, as long as the information is accurate, useful, and effective. The middle school and high school syllabi on sex education provide information which is accurate, useful, and effective (whether kids act on that information is another story). The information kids receive on “healthy eating and exercise” has not succeeded in improving their overall health, preventing eating disorders, or combating this alleged “obesity epidemic.”

I believe that, in terms of nutrition, kids should be taught about what to embrace rather than what to avoid. They should learn the importance of eating lots of fruit, vegetables, dairy products, protein, fat, and grains, and drinking plenty of water. They should be taught to enjoy their favorite snacks and deserts as well. They should not be taught about calories or the evils of sugar and fat; they should not be advised to avoid any foods, they should not learn to label foods as “good” or “bad,” and they should not be taught about the dangers of obesity or the virtue of thinness. Most importantly, I believe children should be taught about the dangers of dieting, much as they are taught about the dangers of drugs, alcohol, and unprotected sex. The dangers of dieting are grossly underrated.

Even if nutrition education is accurate, useful, and effective, it will not prevent eating disorders. That being said, what steps can parents take to prevent their children from developing eating disorders? In my opinion, it all boils down to three basic principles: 1.) accurate information, 2.) vigilance, and 3.) immediate, aggressive, effective intervention.

Accurate information
The pop-psychology literature will have you believe that if you have a healthy body image yourself, encourage healthy body image in your children, nurture positive self-esteem, and preach the importance of healthy eating habits and exercise, your child will not develop an eating disorder. This assumption is simply untrue. Parents need to know that seemingly healthy, well-adjusted children with positive body images and excellent parents develop eating disorders all the time. Good parenting does not make your child immune. It can, however, improve your child’s chances of full recovery.

If your child develops an eating disorder, let go of guilt, shame, and self-blame. While it is natural for parents to blame themselves, guilt is a hindrance to effective action. Of course you have made mistakes in parenting – everyone has! You may be an imperfect parent, but this does not mean you caused your child’s illness. Despite what you may have heard in the media, there is no reliable scientific evidence to suggest that parents cause eating disorders. If your child’s pediatrician, dietician, or therapist suggests that the eating disorder is your fault, this is an indication that he or she is not aware of recent research on the etiology of eating disorders and effective treatments. Get a second opinion. Anorexia nervosa and bulimia nervosa are biologically-based brain disorders, just like autism and schizophrenia. Although you are not to blame for causing your child’s eating disorder, it is your responsibility as a parent to ensure that she gets proper treatment. This responsibility includes protecting your child from outdated, ineffective treatments, which can often do more harm than good.

Parents also need to know that eating disorders are not limited to rich, white teenage girls. This stereotype is antiquated and dangerous, as it prevents individuals outside these demographic categories from being diagnosed and properly treated. Eating disorders strike children, adolescents, and adults; girls and boys, men and women; people of all ethnic, cultural, and economic backgrounds. Several years ago, during my training, I treated a severely underweight teenage boy with anorexia nervosa whose previous pediatrician had told him: “If you were a girl, I’d say you were anorexic.” As a result of this doctor’s failure to intervene, the patient’s condition rapidly deteriorated over the next two years, and by the time he presented in my office, he was in horrible shape.

Vigilance
Here are some concrete steps that parents can take to help prevent eating disorders. You may notice that, unlike other prevention tips you may have read, these tips center around proper nutrition and exercise. This is because all the feminist, feel-good, positive-body image talk in the world is not going to prevent eating disorders. Remember, anorexia nervosa has existed for centuries, long before thinness became fashionable. Eating disorders are triggered by an energy imbalance (consuming fewer calories than you expend) and perpetuated by malnutrition. If a child never becomes malnourished, she is extremely unlikely to develop an eating disorder.
• Make family meals a priority. As a parent, it is your job to prepare and serve nutritious foods. It is far better for a family to sit down to a balanced breakfast of cereal, milk, fruit, juice, and yogurt instead of grabbing a nutrigrain bar and running out the door.
• Closely monitor any changes in your child’s eating habits. Even seemingly “positive” dietary changes such as skipping desert, becoming vegetarian, or reducing fat intake can signal the onset of an eating disorder.
• Adopt a zero-tolerance policy towards any level of malnutrition. Do not allow your child to diet, skip meals, or cut out entire food groups. Children and teenagers need to eat three substantial, nutritious, well-balanced meals every day. Supervised, supported full nutrition is the best defense against an eating disorder.
• Be aware that eating disorders are sometimes triggered by unintentional malnourishment (for example, weight loss due to physical illness, depression, anxiety, stress, or surgery; fasting for religious purposes; side effects of a medication; intense physical exercise without a commensurate increase in nutrition). This type of malnourishment must be taken equally seriously. Dieting is not the only pathway to eating disorders (although it is the most common pathway in modern Western cultures).

Parents need to be on guard for early signs of eating disorders, especially during early adolescence, when most eating disorders develop. Since eating disorders are genetically transmitted, your child is much more vulnerable to developing an eating disorder if you or a relative has suffered from an eating disorder. Family histories of major depression and other mood disorders, anxiety disorders, OCD, and addictions are also risk factors for developing eating disorders. If you have a family history of eating disorders or other mental illnesses, you should know that your child is at greater risk for developing an eating disorder, and you should be extra vigilant.

Some early signs of eating disorders masquerade as “healthy” behaviors or extreme dedication, or can easily be dismissed as typical teenage behavior. However, parents know their kids well. Most parents recognize, long before formal diagnosis, that something is “not quite right” with their child, but they aren’t sure what is wrong or they don’t know what to do. Here are some early signs and symptoms:
• Change in eating habits. This can take many forms, including following a formal diet plan, skipping meals, eating only at certain times, refusing to eat with other people, or anxiety around food. Even seemingly positive dietary changes, such as becoming vegetarian, reducing fat intake, skipping snacks and deserts, and eating only organic foods, can be early signs of an eating disorder.
• Increased preoccupation with food: taking about food, reading diet books, collecting recipes, cooking, serving food to others, sudden interest in what other people are eating.
• Change in mood or behavior. Parents often notice dramatic changes in their child’s personality, such as irritability, anxiety, depression, moodiness, frequent crying, restlessness, withdrawal, changes in sleeping patterns, or loss of interest. Increased dedication to schoolwork, sports, or other extracurricular activities and obsessive behavior in other areas can also be early signs.
• Increase in exercise. The child may begin solo running, take up a new sport, or show increased dedication to her current sports. If she is an athlete, she may begin training excessively outside of team practices. If she is a dancer, she may begin practicing at home, signing up for more dance classes, and auditioning for every possible performance opportunity.
• Weight loss, failure to gain weight, or failure to make expected gains in height. ANY weight loss in a child or adolescent, even a few pounds, may be cause for alarm. ANY failure to grow or gain weight as expected warrants further examination.
• Loss of menstrual periods.
• Signs of binge eating (for example, large amounts of food disappearing overnight).
• Signs of purging (for example, discovering laxatives in your child’s purse or smells of vomit in her bathroom).

Immediate, Aggressive, Effective intervention
I have never heard a parent say: “I wish I had waited longer before getting my child into treatment.” Most parents whose children are in treatment for eating disorders regret not intervening sooner. In addition, many parents report that they wish they had sought out evidence-based treatment immediately, rather than continuing with ineffective treatment as their child’s health declines. If you notice any of the signs or symptoms listed above, take action immediately. Here’s how:
• Educate yourself about eating disorders and evidence-based treatment. FEAST (Families Empowered and Supporting Treatment for Eating Disorders) is an excellent resource for parents.
• Do not praise your child for her “healthy eating” habits or willpower around food. Instead, tell her that you have noticed a change in her eating habits and that you are concerned. For example: “I notice that you’re not enjoying ice cream with our family anymore. What has changed?”
• Be prepared for your child to insist that she is just trying to eat healthily, exercise more, or improve her performance in sports or dance. Many eating disorders begin this way but quickly spiral into deadly obsessions.
• Be prepared for your child to be in denial or to resist your efforts to intervene. Teenagers never say: “Mom, I think I’m developing anorexia nervosa, and I’m worried about my recent weight loss.” Denial, resistance, and lack of insight are symptoms of this disease, NOT indications that everything is OK. Don’t back down.
• Don’t waste time on “why.” When your child is developing an eating disorder, it is tempting to try to understand the reasons for it. Resist this temptation and tackle the symptoms immediately. The very foundation of ineffective eating disorder treatment begins with endless search for the “root cause” while the child continues to starve, binge, purge, and over-exercise as her physical and mental health deteriorate. A patient with an active eating disorder is generally unable to make effective use of psychotherapy because her brain is not functioning properly. Eating disorders are life-threatening illnesses with serious mental and physical risks. Think of your child’s eating disorder as a tumor. It must be removed immediately, or it will grow and metastasize. The surgeon does not need to know the reason for the tumor in order to operate and remove it. The sooner you intervene, the better your child’s chances for complete recovery. There will be plenty of time for psychological work, including an exploration of potential triggers, later on in recovery, once your child is well-nourished and physically healthy.
• As soon as you suspect a problem, take your child to the pediatrician for a complete physical exam. Unfortunately, most physicians do not have specialized training in eating disorders and are unlikely to notice an eating disorder until it is in its advanced stages. Thus, you cannot always trust your child’s pediatrician to spot a problem. I have had many patients whose physicians have completely overlooked telltale signs such as weight loss, missed menstrual periods, or failure to grow. Consider taking your child to a pediatrician or adolescent medicine physician who specializes in eating disorders. Remember, trust your parental instincts. If you think there is something wrong with your child, you are probably right. It is far better to intervene immediately and later discover that everything is fine, rather than waiting until your child is in the acute phase of a life-threatening mental illness.
• If you intervene at the first sign of an eating disorder, your child may not meet full criteria for anorexia nervosa or bulimia nervosa. Thus, she may be diagnosed with Eating Disorder Not Otherwise Specified, or she may not be diagnosed with an eating disorder at all. This does not mean that your child’s problem isn’t serious or that immediate, aggressive intervention isn’t necessary. It simply means that your child is in the beginning stages of what is likely to become a severe, life-threatening mental illness if left untreated (or improperly treated). Your child is most likely to achieve complete, lasting recovery treatment begins immediately, rather than waiting for her to develop full-syndrome anorexia nervosa or bulimia nervosa and the myriad of psychological and physical problems these illnesses entail.
• If your child has been in therapy for a while and she continues to restrict her diet, lose weight, binge, or purge, therapy is not working. In early recovery, it does not matter if your child has a good relationship with her therapist, enjoys speaking with her, or trusts her. The therapeutic relationship is only therapeutic insofar as it promotes health, wellness, and recovery. Insight, self-exploration, and rapport are useless in the wake of malnutrition. Speak with your child’s therapist about taking a different approach. If your child’s therapist refuses to talk to you, or if you are not satisfied with the results of treatment, find a different therapist.
• Seek evidence-based psychological treatment for your child and your family. Most therapists, even ones who specialize in eating disorders, are not up-to-date on the latest research and most effective treatments. I have worked with many families who have taken their child to multiple eating disorders specialists over a period of several years and seen no symptom improvement whatsoever. This is usually because the therapists were not aware of recent scientific research on eating disorders and were not using evidence-based treatments. For children and adolescents, the strongest evidence base is for Maudsley Family-Based Treatment (FBT). Maudsley FBT is a highly practical, empirically-validated treatment method which empowers the family to help the patient recover and focuses on immediate restoration of nutritional and physical health before tackling psychological issues. Research has shown that 75-90% of adolescents treated with Maudsley FBT recover within 12 months and maintain their recovery at 5-year follow-up. In contrast, traditional treatment generally takes 5-7 years and only 33% of patients achieve full recovery.
• Remember that you are an essential member of your child’s treatment team. Your child’s treatment will be most effective if you are fully informed and actively involved. Interview any potential physicians, dieticians, therapists, and psychiatrists without your child present before your child meets them. Make sure that you are comfortable with their philosophy of eating disorders and their approach to treatment. Insist on being informed about your child’s progress in treatment and ask what you can do to help her recover. If the therapist will not inform you or include you in treatment decisions, find a new therapist.
• Recognize that your child’s eating disorder is neither her fault nor her choice. Do not wait for her to “choose” recovery, because she can’t. It is your job to choose recovery for her until she is well enough to take ownership of her treatment. Try to separate the disorder from the child you know and love. She is in there somewhere, and some day, she will thank you.

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Fighting the Wrong Battles

I’ve become increasingly annoyed at the conflation of “body dissatisfaction” with “eating disorder.” The former is a culturally-driven socio-political phenomenon, whereas the latter is a severe, biologically-based mental illness. The former afflicts over 85% of American females, whereas the latter strikes only a small fraction of us (less than 1% for anorexia nervosa and 2-3% for bulimia nervosa).

There has been a great deal of controversy surrounding supermodel Kate Moss’s comment that “Nothing tastes as good as being thin feels,” and around Ralph Lauren’s ridiculously photo-shopped ads. Eating disorder clinicians and activists have been quite vocal about their opposition to these media bytes, arguing that they encourage eating disorders. I know that these professionals and activists have noble intentions, but I believe they are fighting the wrong battles.

I object to underweight models not because I believe they cause eating disorders, but because being underweight is harmful to the models’ physical and mental health, and viewing these images on a regular basis contributes to body dissatisfaction in most people. I refuse to have magazines in my office waiting room not because I believe they cause eating disorders, but because I am opposed to the blatant objectification of women. Besides, I think that fashion magazines are sexist, superficial, and boring.

Hanging in my office is a certificate of membership from NEDA (National Eating Disorders Association) which thanks me for my “support in the effort to eliminate eating disorders and body dissatisfaction.” I really wish they had eliminated those last three words.

I think the conflation of sadness with depression is analogous. The former, in its extreme and persistent form, is one symptom of the latter. The former is a natural, healthy emotional state that every human being experiences from time to time, while the latter is a serious mental illness caused by a combination of neurobiological, psychological, and environmental factors. I remember an incident that illustrates this principle beautifully. I was conducting an initial evaluation with an adolescent girl and her parents. When I asked the father whether he thought his daughter was depressed, he replied: “I don’t believe in depression.” Interesting response, I thought. As if depression were something like God or heaven or Santa Clause, something to be believed in or not. I asked the father to elaborate on his beliefs. He replied: “I think we all get sad sometimes, and that’s OK.” I smiled and gently responded that I agree with him – yes, all of us do get sad sometimes, and yes, that’s OK. However, some people experience prolonged, intense feelings of sadness accompanied by sleep and appetite disturbances, fatigue, thoughts of suicide, loss of interest, and difficulty concentrating. These people are experiencing major depression.”

Imagine if, in exchange for my membership in the National Depression Association, I received a certificate thanking me for my support in the effort to eliminate Major Depressive Disorder and sadness.” Laughable, isn’t it? Well, so is the ED/Body Dissatisfaction comparison. It trivializes the anguish that eating disordered people experience, and it falsely encourages those whose lives have not been touched by eating disorders to think that they “know how it feels.” Well, guess what. They don’t.

Eliminating all sadness in the world would probably not affect the prevalence of Major Depressive Disorder because sadness is but one symptom of depression, whereas depression is not a result of sadness. Likewise, eliminating body dissatisfaction would be fantastic for everyone, but it would not result in the elimination of eating disorders.

Contrary to popular belief (and, sadly enough, the belief of many eating disorders professionals), the media’s glorification of thinness is not responsible for the so-called “epidemic” of anorexia nervosa. Also contrary to popular belief, the incidence of anorexia nervosa has not increased dramatically in recent decades. Cases of what would now be diagnosed as anorexia nervosa have been documented as early as the medieval times, long before thinness was considered fashionable. These fasting saints shunned all sustenance to the point of emaciation not because they wanted to be skinny, but because they believed it brought them closer to God.

Unbeknownst to many, anorexia nervosa occurs in many non-western cultures. For example, recent studies have shown that the prevalence of anorexia nervosa in China and Ghana is equal to its prevalence in the US. The major difference is that patients in non-western cultures relate their starvation to profound self-control, moral superiority, and spiritual wholeness rather than to a desire to be thinner. Today’s American anorexics, like their medieval predecessors and non-western counterparts, all experience prolonged inability to nourish themselves, dramatic weight loss to the point of emaciation, amenorrhea, and denial of the seriousness of their condition. The self-reported reasons for starvation, it seems, are the only things that change across time and culture. I believe that an anorexic’s so-called reasons for starvation are simply her attempts to derive meaning from her symptoms, which are always filtered through a cultural lens. An anorexic does not starve herself because she wants to be thin, or because she wants to be holy, or because she wants to show supreme self-control. She starves herself because she suffers from a brain disease, of which self-starvation is a symptom.

Recent research suggests that anorexia nervosa is not a culture-bound syndrome, but bulimia nervosa is. Anorexia nervosa seems to be a distinct genotype that has been around for centuries and that manifests itself in various cultures and eras. Bulimia nervosa, on the other hand, appears to occur in individuals with a certain genetic / neurobiological predisposition who are exposed to a culture which combines massive amounts of readily available, highly palatable foods with a cultural mandate for thinness. This research implies that reducing or eliminating the cultural glorification of thinness may indeed reduce the prevalence of bulimia nervosa, but will have no effect on the prevalence of anorexia nervosa. I suppose that, once this awful waif model craze blows over, anorexics will simply find another “reason” to starve.

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Emotional Anorexia

Most patients with anorexia nervosa (AN) experience an ostensible “loss of appetite,” if you will, for all human needs. During refeeding, some patients with AN become uncharacteristically violent and hostile towards their parents, shunning all attempts at comfort or affection. Some therapists have referred to this phenomenon as “emotional anorexia.” While I’m not aware of any empirical literature on this topic, I do have some hypotheses of my own.

Like AN and other mental illnesses, the etiology of emotional anorexia is complex and multifaceted. I believe that the factors which contribute to emotional anorexia are, in order of relevance: 1.) Genetic predisposition, 2.) Neurobiological changes associated with malnutrition and refeeding, 3.) Psychological symptoms of AN, and 4.) Developmental and familial issues. Let’s examine each of these issues in turn.

GENETIC PREDISPOSITION. Between 50%-80% of the risk of developing AN is genetic. It is very likely, then, that genes play the most significant role in the development of emotional anorexia as well. The character traits which predispose people to AN: anxiety, obsessiveness, perfectionism, and harm avoidance, are present at birth and are determined primarily by genetics. People with this character structure tend to exercise restraint not just with their food, but also in other areas of their lives. They tend to be emotionally inhibited, most likely because they tend to be overly fearful of making mistakes.

Further, recent research has demonstrated that individuals with AN have difficulty processing emotional information. They tend to misperceive others’ emotions (for example, they are likely to think someone is angry with them when in reality the person is concerned about them), and they avoid emotionally intense situations. This type of personality creates the perfect template for the development of emotional anorexia.

Brain imaging studies have shown that individuals with AN have alterations in their anterior insula, a region of the brain which is critically important for interoception (the self-awareness of internal bodily signals). During the acute phase of their illness, individuals with AN are literally unable to sense hunger, fullness, tiredness, and changes in body temperature. Additionally, they have an imbalance between circuits in the brain that regulate reward and emotion (the ventral or limbic circuit) and circuits that are associated with consequences and planning ahead (the dorsal or cognitive circuit).

This combination of difficulty processing emotional information, disrupted interoceptive awareness, and disregulated reward-emotion circuitry renders anorexics incapable of experiencing pleasure from food, rest, sex, physical affection, or fun activities the way healthy people do. A hug may feel the same as a slap in the face; a smile may look like a sneer; a piece of chocolate cake may be as punishing as a tablespoon of cod liver oil; words of encouragement may sting like salt in a wound. People with AN feel safer and calmer when they shrug off affection and shun human contact as well as food.

NEUROBIOLOGICAL CHANGES ASSOCIATED WITH MALNUTRITION AND REFEEDING. Since the Minnesota Starvation Study, we have known that malnutrition causes biochemical changes in the brain which result in dramatic personality and behavior changes, such as depression, anxiety, irritability, apathy, loss of interest, isolation, and social withdrawal. The neurobiological changes associated with re-feeding are equally profound. Because starvation numbs emotions, many patients experience a resurgence of depression, anxiety, irritability, anger, and loss of control when food is reintroduced. Dr. Walter Kaye hypothesizes that individuals with AN have a shortage of serotonin in the brain, since serotonin is derived partially from food. More serotonin receptors are created in effort to harvest the scanty amount of serotonin available. Thus, when food is reintroduced and serotonin levels rise, the large number of receptors causes too much serotonin to be taken up, making the person feel extremely agitated and irritable. This makes eating a terrible emotional ordeal. It is very difficult to give or receive love and affection when you are struggling with intolerable anxiety and irritability.

PSYCHOLOGICAL SYMPTOMS OF ANOREXIA NERVOSA. So now we have a teenager with the perfect genetic template for emotional anorexia who is experiencing the profound neurobiological effects of malnutrition. In addition to these physiological effects, she is experiencing debilitating depression, feelings of worthlessness and inadequacy, she has lost interest in socializing, she has withdrawn from friends and family, and she has difficulty accurately perceiving emotions. When she isolates herself, she experiences less social reinforcement, which confirms the depressive schema that she is worthless and inadequate. Her athletic performance begins to decline, she has difficulty concentrating, and she is no longer asked out on dates. Her friends are alarmed by the changes in her physical appearance and mood, so they stop talking to her. Parents, teachers, coaches, and friends express extreme concern, which she misinterprets as anger, jealousy, or criticism. All of these things reinforce her feelings of worthlessness and inadequacy. I have had several patients with AN cry to me that their parents didn’t visit them at all while they were away at summer camp or college. Meanwhile, their parents confided to me that they wanted desperately to visit their daughter, but she told them not to, and they wanted to respect her autonomy. The patients insisted that they didn’t want their parents, yet lamented their absence. Clearly, there’s a disconnect here. The patient either a.) is not aware of her emotional needs, b.) doesn’t know how to express these needs, or c.) chooses not to express her needs because she is afraid, embarrassed, or ashamed. I believe that a, b, and c are all true.

One of the core features of AN which has persisted throughout the centuries is a sense of “needlessness,” of being “above” worldly pleasures and bodily needs. Medieval saints experienced this needlessness. They prayed for days on end without food, water, sleep, or socialization. Amongst these fasting saints, there are documented cases of what would today be diagnosed as AN. In certain non-western cultures such as China and Ghana, AN is as prevalent as it is in the US. The major difference is that patients in non-western cultures relate their starvation to profound self-control, moral superiority, and spiritual wholeness rather than to a desire to be skinny. Today’s American anorexics, like their medieval predecessors and non-western counterparts, experience some version of needlessness. Some anorexics have a grandiose sense of being “above” basic needs, including food, sleep, fun, love, and comfort. This grandiosity often stems from the extra burst of energy and euphoria that starvation brings them, coupled with the sense of pride and accomplishment that they have been able to override their body’s needs and diet to the point of emaciation. Other anorexics believe they are unworthy of food, sleep, fun, love, or comfort. These feelings stem from the debilitating depression that is triggered by malnourishment and exacerbated by body dysmorphia and self-loathing. Many anorexics vacillate between these two mind frames, but the end result is the same: emotional anorexia.

The neurobiological changes associated with refeeding cause most patients to experience intense mood swings, irritability, and anger. The psychological trauma of AN adds fuel to the fire. Eating more and gaining weight are an anorexic’s worst nightmares, and this is precisely what is required of her in order to recover. She gains weight, experiences tremendous fear as her appetite kicks into high gear once again, and she is no longer “allowed” to diet. Her body dysmorphia and self-loathing are more intense than ever. Her irritability, agitation, moodiness, and depression are at an all-time high. She withdraws and isolates herself even more, feeling as though she is “too fat” to be seen in public and undeserving of love, comfort, friends, or fun.

Enter the old-school therapist. The young patient is absolutely miserable and desperate to feel better. She has little insight into her symptoms and trusts the therapist completely. The therapist searches through the patient’s past to uncover the “root cause” of her AN. Lo and behold, it is discovered that her parents were too controlling, too overbearing, too overprotective, too critical, too mean, too distant, too neglectful, or too abusive (often some combination of the above). The patient, who is in the midst of the neurobiological hurricane that is re-feeding, becomes angry and hostile towards her parents once she “realizes” that they have caused her current misery. Her parents take her to appointments, prepare her food, and insist that she eats it, thus making her even more fat and unlovable. Her parents try to comfort her; she pushes them away. She is, at times, violently angry with them. After all, they made her anorexic, and now they are making her fat. The same pattern also develops with certain members of her treatment team. She views their interpretations as criticisms. She perceives their requirement of weight restoration as their attempts to fatten her up. Her parents and her treatment team are ruining her life as they chip away at the one thing that has ever made her feel good: the AN.

DEVELOPMENTAL ISSUES. The concept of mother is inextricably intertwined with the concept of food. As developing fetuses in our mother’s womb, we receive nourishment from her. We are born with a rooting reflex, which prompts us to suck our mother’s breast or a bottle. Without this reflex, and without a mother or other caregiver to provide the nourishment, we would die. As infants, we cry when we are hungry. Mother comes running; she holds us and feeds us. Throughout our childhood and adolescence, mother is probably responsible for most of the food shopping and meal preparation.

When a teenager develops AN, her mother is often the first to notice a problem. Mother may encourage or require her to begin treatment. Mother often prepares and serves her food during re-feeding. Mother may ask when and what she last ate, and may require that she eat just a little bit more. Is it any wonder, then, that an anorexic’s feelings about food spill over into her feelings about her mother?

Some psychoanalysts postulate that AN develops from a lack of empathic attunement between mother and child. The mother is not attuned to her child’s emotional needs, so the child is unable to meet her own needs, and this is manifested in her inability to feed herself. There are no empirical data to support the theory that lack of maternal empathic attunement causes AN, and in fact, I believe that this theory is 100% false in terms of explaining the etiology of AN. However, I can understand how this principal may operate subconsciously in the mind of an ill patient. Individuals with AN have great difficulty getting their needs met. They may be unaware of their own needs, they may feel as though they don’t deserve to have their needs met, or they may believe they are “above” having needs. This applies to emotional needs as well as nutritional ones.

I suspect that there is a modest correlation (which does NOT imply causation) between a mother’s inability to provide for her child’s physical or emotional needs and the child’s development of AN. Remember, 50-80% of the risk for developing AN is genetic, so it is very likely that a patient with AN has a first-degree relative (often the mother) who also has a history of AN. If the mother is currently struggling with AN, her fear of food and intolerable anxiety may render her unable to provide for her child’s basic physical and emotional needs. Even if the mother is currently healthy but has a personal history of AN, she will likely share the biochemical and temperamental traits of her ill daughter, albeit to a lesser degree. The recovered AN mother’s deficit in interoceptive awareness may spill over onto her child. She may struggle to meet her daughter’s needs because she has difficulty sensing and meeting her own needs.

Teenagers who develop AN tend to be “model children.” They are almost universally intelligent, well-behaved, hard-working, and gifted at athletics or artistic endeavors. They follow all the rules to the letter. They have never caused a problem for their parents or teachers. The development of AN and the process of recovery leads to an examination of one’s life. The experience of having a life-threatening, soul-killing, personality-destroying illness is enough to make any teenager step back and take stock. Teenagers who are recovering from AN may begin to feel resentful that they have lived a “faked existence” and “played by everyone else’s rules.” They may realize that they have missed out on a lot of fun and excitement by being so straight-laced. With their therapist’s encouragement to express their emotions authentically, they unleash their fury onto the people who have been there through it all: their parents.

This is not a cohesive or well-articulated theory, just a compilation of related thoughts. I hope that research will shed some light onto this phenomenon in the near future.

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Force feeding?

The idea of force-feeding in eating disorder treatment is highly controversial. It is ironic that the idea of requiring sustenance, which all living things need to survive anyway, has the power to create such extreme revulsion. Perhaps it is not so surprising that old-school treatment professionals object to force-feeding. You know the types – those who believe that eating disorders are “not about food,” that sufferers are the victims of over-controlling parents or a size-0 obsessed society or a fear of growing up. The idea that eating disorder patients have willfully chosen self-starvation, and will begin to eat again once their “underlying issues” have been resolved, follows logically from these unsubstantiated theories.

What really boggles my mind is that the very mention of force-feeding creates a visceral reaction even in well-informed clinicians who practice evidence-based treatment and parent advocates of Maudsley Family-Based Treatment. These individuals are fully aware that eating disorders render victims temporarily unable to nourish themselves, and they know from empirical literature and personal or clinical experience that re-feeding is the essential first step in successful eating disorders treatment. To me, it seems to follow logically from this knowledge that most patients with eating disorders cannot choose to eat and therefore must be forced to eat in order to recover. And yet, when confronted with the term “force-feeding,” Maudsley parent advocates and clinicians reframe the statement or circumvent the issue altogether. For example, a parent advocate whom I greatly admire states that “It is not forcing them to eat, it is letting them eat and live.” A clinician who practices Maudsley FBT writes that “Describing what we do in the Maudsley approach as “force feeding” is very misleading and I hope that we are able to continue to get the word out that this is a misconception.”

Most families encounter extreme resistance during re-feeding. I have heard stories of previously sweet, compliant, well-behaved young girls hurling swear words and spewing horrid insults at their parents during re-feeding. I myself have been on the receiving end of my share of f-bombs and hateful remarks from patients when I maintain an uncompromising stance of full nutrition and complete weight restoration. I have heard stories of girls running away from home, throwing ravioli across the room, smashing plates, locking themselves in rooms, and attempting to jump out of moving vehicles – all in response to the intolerable anxiety of re-feeding. And these scenarios are the norm, not the exception. I believe that families need to be fully informed of what is likely to happen during re-feeding so that they can prepare themselves to deal with what lies ahead. They need to know that what they are encountering is not evidence that they are doing something wrong, but rather is par for the course with this illness. But I digress.

The process of re-feeding an anorexic very often involves force. It has to, because most anorexics are not able to eat unless they are given no other alternative. In hospitals, this may require nasogastric tubes or IV nutrition. In residential or day treatment settings, it may involve earning privileges by finishing meals. In home-based re-feeding, it may involve not leaving the table until the meal or snack is 100% complete. The patient cannot choose to eat, but she will eat when she is forced. And she absolutely must eat a sufficient amount and variety of foods in order to recover. For those who have never experienced or witnessed the agony of an eating disorder, the idea of forcing someone to eat may sound inhumane. For those of us who have been in the trenches, we know that it is quite the opposite.

Our society values an individual’s right to make her own decisions. Respect for individual autonomy and self-determination is a cornerstone of democracy. In addition, our society embraces paternalism, which is the belief that it is ethical, at times, to intervene in the life of another person who does not desire such intervention because intervening will protect the person from harm, much in the way a loving father would intervene against his child’s wishes in order to protect the child. Our healthcare system and our government embrace the ethics of self-determination as well as the ethics of paternalism. For example, mandated reporter laws require physicians, therapists, social workers, and teachers to report cases of suspected child abuse and elder abuse, even if the victim doesn’t want the abuse to be reported. Laws allow for the temporary involuntary hospitalization of individuals who are suicidal, homicidal, or floridly psychotic. Many newer state laws require drivers to wear seatbelts and to abstain from text-messaging while driving. Hospitalized patients who engage in self-injury are forced into physical or chemical restraints. Children are forced to attend school at least through the age of 16. Suffice it to say that our great country, which was founded on the values of liberty and independence, recognizes that autonomy is not limitless. Children are forced to get an education and forcibly removed from abusive or neglectful homes. People are forced into hospitals for their own protection when they are a danger to themselves or others. Drivers are forced to wear seatbelts and forced to wait until they reach their destination before sending that oh-so-important text message.

Remember the 13-year-old cancer patient who skipped town with his mother last spring in order to escape court-ordered chemotherapy and radiation treatment? Well, the police eventually found him and forced him into treatment. He has just finished his last round of radiation and he is now cancer-free. This boy’s type of cancer has a 90% cure rate in children when treated with chemo and radiation. His doctors reported that he probably would have died if he hadn’t received these treatments.

Anorexia nervosa is also deadly and disabling disorder. Research shows us that most cases of adolescent anorexia nervosa can be successfully treated with a combination of full nutrition, weight restoration, family support, and evidence-based psychotherapy. Without treatment, or with “traditional” treatment which doesn’t aggressively push full nutrition, only 33% of patients ever fully recover.

I think I understand why people are frightened or repulsed by the idea of force-feeding. The idea of pushing full nutrition immediately after eating disorder diagnosis is still controversial, and to many people, the word “force” seems punitive or even abusive. It may conjure up images of physical torture and it may seem to conflict with the aforementioned democratic values. Eating disorder treatment should never be punitive or abusive (although it may feel punitive and abusive to the patient). Re-feeding is only one component of successful treatment. Cognitive, emotional, and behavioral symptoms and co-morbid conditions must be addressed as well. We all want to help patients recover rather than inflict further anguish. The illness itself is pure hell, and the recovery process can be even worse. But allowing the patient to engage in eating disorder symptoms is far more inhumane than force-feeding a patient to save her life, improve her health, and propel her towards full recovery.

Perhaps we are splitting hairs or just arguing over semantics. The American Heritage Dictionary provides several definitions of the verb “force,” including 1.) to compel to perform an action, 2.) to move something against resistance, and 3.) to produce with effort. Anyone who has witnessed, experienced, or been involved with the process of re-feeding an anorexic would undoubtedly agree that it involves 1.) compelling them to perform an action (eating), 2.) moving against resistance (the eating disorder thoughts, feelings, and behaviors, and 3.) an extreme amount of effort for both the caregiver and the patient. Call it whatever you want – supported nutrition, letting them eat, helping them recover, empowering parents to combat eating disorder symptoms – all of these labels are quite accurate and descriptive. So is force-feeding. And I don’t believe it is a bad thing.

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The Power of Expectations

A recent study found that parents’ stereotypes about teen rebelliousness fuel’s teens’ misbehavior. In this longitudinal study, researchers interviewed a large sample of 6th and 7th graders and their parents regarding expectations for the child’s behavior as he or she enters adolescence. At the one-year follow-up, teens whose parents had negative expectations about their child falling into stereotypical teenage behavior (e.g., drugs, premature sexual activity, rule-breaking) were more likely to have engaged in these behaviors. This was true even after controlling for many other predictors of such behaviors.

My guess is that several factors may be at play here:

1.) Parents whose sons and daughters had behavior problems during childhood may be more likely to have negative expectations as their child enters adolescence. Indeed, having a history of childhood conduct problems does increase the likelihood of engaging in substance use, premature sex, and rule-breaking behavior in adolescence.

2.) Parents with a personal history of adolescent misbehavior and parents with older adolescents who misbehave may presume that their child will follow a similar path. Children whose parents and older siblings engage in drug or alcohol use, delinquency, or early sexual activity are, in fact, more likely to engage in these behaviors themselves. Genetics play a powerful role in addictions, risk-taking, and impulsive behaviors. In addition, children whose family members engage in substance use have easier access to drugs and alcohol themselves. Finally, parents and older siblings are powerful role models who teach their children, through example, what is and is not acceptable behavior.

3.) Parents’ negative expectations become self-fulfilling prophecies. Some parents convey, whether subtly or overtly, that drug use, drinking, and sex are as much an inevitable part of adolescence as menarche and chest hair. These parents may be less likely to set firm limits with their children and may not impose consistent consequences for engaging in misbehavior. Perhaps the children of these parents are more likely to internalize their parents’ negative expectations and engage in misbehavior.

So, in addition to genetics and social learning, stereotypes and negative expectations play a powerful role in shaping children’s behavior. The same phenomenon, I’m afraid, is present between therapist and patient (minus the genetics, of course). Stereotypes and negative expectations play a powerful role in bad psychotherapy. There are many unsubstantiated theories of psychopathology that, when espoused by therapists and used in “treatment,” can easily become self-fulfilling prophecies. Here are a few examples:

1.) A therapist presumes that a teenager’s depression is the result of family dysfunction. In order to give the patient a sense of autonomy and protect his confidentiality, the therapist does not involve the family and instead focuses exclusively on the patient. Sessions are spent discussing the problems in the patient’s relationship with his parents. Meanwhile, the parents are growing increasingly worried about their son’s frequent crying, social withdrawal, angry outbursts, and declining school performance. The patient tells his parents that his depression is their fault. Mother blames father for working too much and not spending enough time with the patient. Father blames mother for coddling the patient. The parents’ marriage becomes strained, and the younger brother begins to act out as well.

2.) A therapist asserts that a patient suffering from anorexia nervosa or substance abuse will recover “when she wants to” or “when she’s ready.” The therapist then waits to see signs of “readiness” before pursuing aggressive intervention. Meanwhile, the patient is in the grips of a powerfully self-rewarding, self-perpetuating cycle of starvation or substance abuse and is thus rendered, by virtue of the illness, unable to “choose” recovery. The patient’s symptoms do not abate. Thus, the therapist continues to espouse the belief that the patient is not ready to choose recovery. The patient does not improve, and she concludes that she was not ready for treatment. Now, in addition to her life-threatening and agonizing symptoms, she is carrying around a massive load of guilt, self-blame, and probably blame from her loved ones as well, who don’t understand why she won’t choose recovery. Her symptoms worsen.

3.) A therapist presumes that a patient’s symptoms are the result of a grave trauma, although the patient does not report a history of trauma and there is no other evidence to suggest trauma. Therapy focuses on uncovering this trauma in order to resolve the patient’s symptoms. The therapist asks leading questions in order to confirm her hypothesis that the patient has been abused. The patient, who trusts the therapist and believes in her methods, develops a false memory of abuse. The patient continues to struggle with her symptoms. The therapist tells the patient that she must unravel the roots of her problems, and that it will take many years for her to recover. It does.

4.) A therapist presumes that a patient’s eating disorder is the result of over-controlling parents or relentless boundary violations. The patient is told that, in order to recover, she must break free from her parents’ tyranny and set boundaries for herself. The patient wants desperately to recover but struggles with restrictive eating and drastic weight loss. The therapist helps the patient explore various events of her childhood which supposedly demonstrate parental over-control (“My dad wouldn’t let me wear short skirts to school!”) or boundary violations (“My mom read my diary when I was 13!”). The patient recalls more and more of these types of incidents and discusses them in therapy while she continues to starve and lose weight. Meanwhile, her parents are doing everything in their power to ensure that she eats more: they force her to attend family meals, they pack her lunch for her, they cook for her. These “controlling” behaviors provide more grist for the therapy mill. Eventually, at the therapist’s encouragement, the patient moves out of her parents’ house, gets her own apartment, and stops coming to therapy. The therapist assumes that, released from her overbearing parents, the patient has addressed the root of her illness and has recovered. She has not.

These theories perpetuate themselves, and some practitioners cling to them like religious dogma. Like religious zealots, they latch onto evidence that confirms their belief, and they disregard any evidence to the contrary. They view every patient through the lens of their theory and structure their treatment accordingly. When your only tool is a hammer, everything looks like a nail.

Unless you have suffered from a mental illness, it is difficult to imagine how much it crushes your spirit, distorts your thoughts, warps your perception of reality, and alters your behavior. Unless you have sought therapy yourself, you may not realize just how vulnerable you are, especially as an adolescent or young adult, when you are sitting on the therapist’s couch with all of those distorted thoughts and feelings and perceptions. You are absolutely miserable, and you can’t stand feeling this way any more. The therapist is the expert, the savior, the one who will rescue you from your despair. She comes to know you better than anyone else in your life, and you are certain that she has your best interest in mind. You tell her your deepest secrets, you listen, you trust her, and you do whatever she says you need to do.

My point here is not to overly-dramatize the therapeutic relationship, because I think my description is actually quite realistic. My point is to convey just how harmful stereotypes, negative expectations, and unsubstantiated theories of mental illness can be. Bad therapy is not just ineffective – it has the potential to be every bit as harmful as a surgical error.

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Reflections from a Rocking Chair

The recent media frenzy over the “balloon boy” hoax has gotten me thinking about the use of the media in today’s society and how it impacts our youth. The explosion of mass media over the past 10 – 15 years, from 24-hour news networks to the internet and email to blackberries and cell phones for everyone, has undoubtedly had a positive impact in many ways. Vital information can be widely disseminated at the click of a button. Parents can keep close tabs on their children. Businesspeople can check their email and voicemail during the metro ride home. Practically anyone can contact anyone else in the world, anytime, from virtually anywhere, using at least two different forms of instant communication. So much has changed since the bygone days of my own adolescence (we’re talking mid-1990’s) that I am beginning to feel like a grandparent on a rocking chair, pontificating about how, back in my day, we had to walk 10 miles to school in the snow uphill both ways.

And then there’s the ugly side. We spend precious time surfing the internet, watching YouTube videos and facebooking and twittering and texting. This is time that could have been spent reading or playing outside or exercising or engaging in a hobby or spending quality time with family and friends. Going a day, or even a few hours, without internet access leaves some people paralyzed. We feel naked without our cell phones; out of touch without instant access to emails. The amount of time we spend chained to various electronic devices continues to increase exponentially to the point where many people can no longer really relax or get away from their work or their social obligations.

My greatest concern about the mass media explosion is the impact it has on youth – their perceptions of reality, their aspirations for fame or recognition, their interpersonal boundaries, their privacy, their sense of what is normal and reasonable and right. I find it disconcerting when a young patient decorates her myspace with pictures of the scars on her wrists or photos of herself at a dangerously low weight. I am frightened when a teenage girl shares intimate details of her abuse history and her multiple psychiatric hospitalizations with her “friends” on facebook. “Everyone does it,” they say. “It’s not a big deal. It’s who I am.” It IS a big deal, I argue. And no, it’s NOT who you are. Therein lies the rub.

A person who presents herself online in this fashion is engaging in a disturbing form of emotional exhibitionism that has proliferated alongside recent technological advances. She is promoting dangerous stereotypes, over-identifying with her illness, and encouraging others to do the same. I do my best to chip away at the silence and stigma surrounding mental illness, and I firmly believe that having depression or bulimia or borderline personality disorder is not something to be ashamed of. But it’s also not something to advertise to a world-wide audience of anonymous viewers with questionable motives. These are issues to be discussed with a therapist, with family members, with a select group of long-time, trusted friends.

I am ambivalent about the proliferation of websites and blogs about personal experiences with mental illnesses. On one hand, as a therapist, I fully appreciate the healing power of writing, sharing, and connecting. Individuals who share their personal stories of psychological disorders with a worldwide audience are providing hope, support, and inspiration to others who are in similar positions, while slowly chipping away at the shame, secrecy, and stigma that continues to surround mental illness.

I frequent several blogs (Carrie Arnold’s ED Bites, Laura Collins’ Eating With Your Anorexic, and Harriet Brown’s Feed Me) authored by individuals who have personally struggled with eating disorders or helped loved ones recover. I admire these authors’ commitment to advocating for improved awareness, understanding, information, and evidence-based treatment for eating disorders. The authors’ personal experiences are interwoven with scientific research in ways that educate, enlighten, and inspire.

On the other hand, I have also read numerous websites and blogs, authored by individuals with mental illnesses, which I can only characterize as glaring emotional exhibitionism. These blogs are not-so-subtle cries for help, yearnings for deeper connection through a superficial medium. I am not quite sure who is benefitting from a young woman’s blog posts detailing her various creative methods of purging or her meager consumption of carrot sticks for days on end. How about writing in a good old fashioned journal? Seeing a therapist? Joining a support group? Calling a friend? Meanwhile, how about developing a healthy identity apart from your symptoms and making real-life friends outside your diagnostic category?

The individuals who use the internet in this way are not the source of the problem. They are the victims of a society that fails to teach appropriate interpersonal boundaries and encourages people to sacrifice their self-respect for a chance at instant notoriety. What happens ten years down the road, when the teenage “cutter” with a provocative personal website applies for a job as a high school teacher? How will this deeply personal, globally publicized information impact the course of her life? Only time will tell. For now, I’ll step away from my computer, get back on my rocking chair, and try to remember what life was like before blogging.

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Helping College Students With Mental Illnesses

Yesterday I blogged about the issue of confidentiality in psychotherapy with adolescents. The issue of confidentiality becomes more problematic once patients turn 18 because laws and ethical guidelines seem to work in opposition to family involvement. Having completed most of my training in university counseling centers, I can safely say that whatever law designated 18 as the “age of majority” is clearly in need of revision. Teenagers don’t suddenly become more responsible, more mature, more mentally stable, more independent, or more capable on their 18th birthday. Our knowledge of neuroscience supports this: the brain’s frontal lobes, which govern higher-level cognitive functioning (e.g., planning, decision-making, and impulse control), are not fully developed until the early- to mid- twenties. Moreover, the financial and social realities of our generation have extended adolescence well beyond the tender age of 18.

Most normally developing college students without mental illnesses rely on their parents for financial, emotional, and practical support, not to mention a roof over their heads during holidays and summer vacations. Now add to that the immense strain of being at a new school in a new environment in a faraway city, without your friends or family or the professionals who have treated you for years, while dealing with a mental illness. In previous generations, most of these students with mental illnesses would not have made it to college, but with the advent of more effective medications and evidence-based psychological treatments, most of them can live independently and lead relatively normal lives as long as proactive steps are taken to manage their disorders. Their chances of succeeding are far greater when their families remain fully informed and actively involved in their treatment, at whatever level is clinically indicated given the nature of their illness and mental state, NOT THEIR CHRONOLOGICAL AGE.

University counseling centers have been slow to adapt to the changing realities of their student bodies. Just a generation ago, college counseling centers dealt primarily with breakups, homesickness, test anxiety, and roommate quarrels. Under these circumstances, there is usually no need to involve parents in treatment, and students are generally capable of reaching out to their parents for help if needed. Nowadays, the typical university counseling center client has already been diagnosed with and treated for at least one, if not two or three, mental illnesses prior to entering college, such as bipolar disorder, OCD, ADHD, major depression, or anorexia nervosa. Many more clients have no history of treatment prior to college, but are experiencing the first signs and symptoms mental illness. After all, the average age of onset for many mental disorders is late adolescence to early adulthood, which happens to coincide with the college years.

Here’s the problem: many university counseling centers operate AS IF their clients were dealing with typical adjustment problems or social concerns. They view their clients’ problems as manifestations of typical developmental issues or of difficulty adjustment to the college environment. They treat 18-year-old students with mental illnesses AS IF they are healthy, independent, insightful adults who can and should make appropriate decisions about their mental health care. OFTEN, THEY CANNOT.

Unless a college student signs a waiver, her parents are not even permitted to know whether she is in treatment at all. If parents are not informed about their child’s symptoms and progress, they cannot intervene when necessary. Unfortunately, many mental illnesses, in their acute stages, impair judgment and insight or render the patient incapable of accurately reporting her symptoms or seeking the necessary help. The administration rarely intervenes unless a student is in imminent danger of killing herself or others. The end result? Many college students struggle for months or years before entering appropriate treatment. This delay in getting adequate care wastes time, exacerbates the student’s misery and the parents’ worry, and prolongs the recovery process.

Universities have come so far over the past couple of decades in terms of welcoming and embracing students of color, students of non-traditional age, students from foreign countries, students from disadvantaged backgrounds, students of all religions and races and sexual orientations. Universities have also made tremendous strides in terms of understanding and accommodating students with learning disabilities, ADHD, sensory impairments, and physical disabilities. Universities offer testing accommodations, build wheelchair ramps, hire sign language interpreters, offer classes on line and on weekends, recruit students from poor minority neighborhoods, and organize GLBT alliances. These changes have benefitted the universities, their students, and the nation as a whole.

I would like to see universities institute similar changes to help students with mental illnesses. For starters, they could really start to examine what students with mental illnesses need in order to thrive in college and make the necessary changes to ensure that these students’ needs are met. They could expand their mental health services to include larger counseling center buildings, offer more intensive and comprehensive mental health services, hire more psychologists and psychiatrists, and attract better psychologists and psychiatrists by offering competitive salaries. When an incoming freshman has been previously diagnosed with a mental illness, the university counseling center staff could meet with the student and her parents during orientation to obtain her history, develop a treatment plan collaboratively, open the lines of communication between home and school, and plan ahead for any potential problems or relapses.