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Shift, Approach, Support

“I got a text from Sophie’s best friend telling me that Sophie is throwing away her lunch at school.  Should I confront her?”

“The toilet smelled like vomit after Andy took his shower last night.  He ate so much food at dinnertime.  I think he might be purging.  Should I confront him?”

“I thought I saw some cuts on Bianca’s wrist this morning, but she pulled her sleeves down before I could get a better look.  Should I confront her?”

Parents of my adolescent patients frequently ask me if they should confront their child when they receive concerning information about their child from a third party, or when they have a worrisome suspicion about their child but no actual proof.    

Let’s take a closer look.  The word “confront” typically connotes facing someone with hostile or argumentative intent.  Confrontation often conveys anger, suggests an accusation of wrongdoing, and brings up defensiveness in the child.  Confrontations can lead to explosive arguments, lashing out, or shutting down.  These reactions create or exacerbate the rift between parent and child, thus making it much harder for the parent to provide – and harder for the child to receive – the support and assistance that they need. For these reasons, I don’t recommend confrontation.

On the other hand, failing to act on information or suspicions about a child’s concerning behavior does not help the child either.  Keeping quiet may keep the peace, but it deprives the child of an opportunity to discuss what is troubling them, receive much-needed help, and overcome the problem.

Instead of confronting their teenager, I recommend that parents take the following steps when they have concerning information or suspicions:

Shift your perspective.  Rather than viewing your child as doing something wrong or deceptive, recognize their behaviors as signs of suffering, symptoms of an illness, or cries for help.   Think about how you would view your child if they had a more tangible ailment, such as a seizure, or a broken ankle, or an asthma attack. Most parents would view these symptoms not with blame, shame, or anger, but with concern and compassion. This is the same concern and compassion with which you should view a child who is secretly disposing of food, throwing up after meals, or harming themselves.

Approach your child privately, in a calm moment, with compassion and curiosity.  Share the information or suspicions that you have in a nonjudgmental, non-accusatory way.

“Sophie, someone at school saw you throw away your lunch in the cafeteria.  I’m curious about what is happening at lunchtime.”

“Andy, I thought I smelled some vomit in your bathroom last night.  I promise I’m not mad.  But I am worried about you.  Can you help me understand what’s going on?”

“Bianca, I could be mistaken, but thought I saw some cuts on your wrist yesterday.  I wanted to check in with you.  I know you’ve been feeling really depressed lately.  I wonder if you have been hurting yourself?”

Support your child. Express your love and concern for your child and ask how you can help them.  This may involve having an in-depth conversation with your child in that moment, if they are willing, and letting them know that you are always willing to talk with them about the issue in the future.   Ideally, you and your child can collaborate to help create a safer environment and work through the problem together.

“I love you very much, and I want to help you stop purging.  How can we work together to make this happen?  Would you like to walk the dog with me tonight after dinner?”

“I understand that this is difficult to talk about, so I won’t push you.  But please know that you can always come to me in the future whenever you are ready to talk.” 

 If your child shuts down or refuses your help, you may need to step in and provide support anyway.  Even without your child’s permission or buy-in, you can create a safer environment at home or at school by removing sharp objects, providing post-meal support, or arranging supported lunches.  In most cases, it will be helpful – or even necessary – for you to inform your child’s other caregivers and healthcare team about the symptoms, or arrange for your child to see a mental health professional if they are not currently working with someone.

“I am going to hide the sharp objects for a period of time to keep you safe, until you can get a handle on this symptom.  Also, Dr. Ravin needs to know about the self-harm so that she can help you.  Would you like to tell her yourself in your next session?  Would you like me to come to the session with you so we can tell her together?  Or would you rather I call and tell her about the cutting before you meet with her?”

The SHIFT, APPROACH, SUPPORT strategy helps to disarm anxious or angry teens, nurture connectedness and trust, and empower parents to help their children.

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For Teens, Smartphone Dependence Predicts Later Depression

We have known for years that excessive smartphone use is correlated with depression. However, until recently, the direction of causality was not known. Does excessive smartphone use cause people to become depressed? Or do people who are already depressed use their smartphones more often, leading to unhealthy dependence? A recent study published in the Journal of Adolescent Health lends support to the former hypothesis. This study, which followed adolescents between the ages of 17-20, found that dependence on smartphones at the start of the study predicted depression and loneliness three months later.

Although the mechanism of action here is not yet known, I have several thoughts about why and how excessive smartphone use can lead to depression. First, there’s the neurobiological effect of the smartphone use itself, which activates the Sympathetic Nervous System (“fight or flight” response), increases threat perception, and disrupts sleep. The Sympathetic Nervous System (SNS) is designed to protect us from danger by elevating heart rate, increasing levels of cortisol, and giving us the burst of energy we need to fight off a predator or flee from danger. The SNS is meant to be activated periodically, and for limited durations of time, when danger is present until danger passes. It is not meant to be activated every few seconds, all day long, each time we receive a notification on our iPhone. Over time, chronic SNS activation leads to depletion and depression. So does sleep deprivation.

Second, there’s social comparison. Adolescents are especially vulnerable to peer influence and frequently compare themselves to others to gain a sense of their social standing. Teens who spend excessive amounts of time scrolling through social media are likely to judge themselves unfavorably compared to others. It is all too easy for these teens to conclude that other people are prettier, thinner, happier, more successful, and having more fun than they are. Of course, most people only post pictures of themselves looking great, having fun, and doing interesting things, even if the majority of their lives are spent looking average and completing mundane tasks like homework and chores. Nonetheless, upward social comparisons such as these tend to lower self-regard, and poor self-esteem fuels depression.

Finally, excessive smartphone use has to replace other activities. There are only 24 hours in a day. If a teen is spending 15 hours per day on his smartphone, what is he NOT doing? Well, for starters, he is probably not getting a good night’s sleep. He is probably not eating balanced meals with his family, or if he is, he’s eating mindlessly while scrolling through social media rather than engaging in meaningful conversation with his parents and siblings. He is probably not present or engaged in class, and he is constantly distracted while doing homework (if he even does homework), which means he is not learning much nor reaching his academic potential. He is not getting much physical activity or time outdoors. He may not be participating in social activities (of the in-person variety), or clubs, or hobbies, or lessons, or volunteer work, or religious services. In other words, the habits and activities that have been proven to help us stay healthy and balanced and socially connected, that give us a sense of meaning and purpose in life, are notably absent in those who are dependent on smartphones.

In my clinical practice, I strongly encourage teens and young adults to limit their screen time. To promote restful sleep, which is essential for both physical and mental wellbeing, I recommend turning off all electronic devices one hour before bedtime and leaving them off overnight. It is remarkable how much better teenagers sleep, and how much better they feel during the day, when they turn off their phones and computers by 10:00 pm, relax before bedtime, and sleep a full 8 hours.

For individuals who experience body image distress or social anxiety, limiting use of social media can help reduce symptoms. This could involve unfollowing certain people who are especially triggering, or simply limiting the amount of time spent on social media to 30 minutes per day, for example. I will never forget the 15-year-old girl who suffered from Generalized Anxiety Disorder who, upon getting rid of SnapChat for a week, experienced complete relief from her symptoms! Unfortunately, she later returned to SnapChat and began experiencing more anxiety. Eventually, she figured out a way to set limits on her SnapChat use, which allowed her to remain connected with her friends while causing only a slight increase in anxiety. Personally, I would have gotten rid of SnapChat completely and permanently, but try telling that to a very social, strong-willed 15-year-old.

Like many technological advances that preceded it (the automobile, the television, the internet), the smartphone is a wonderful invention that has improved the quality and efficiency of our lives. But there is a fallout from many technological advances, particularly when they are used carelessly or in excess (e.g., global climate change, couch potatoes, cyber-bullying). The smartphone is no exception.

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

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

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

Why? Let me count the reasons.

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

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

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

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

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

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Empowering Parents to Support Adolescent Eating Disorder Recovery

I am honored to be spotlighted by LEAD, inc as a mental health advocate.  LEAD is a nonprofit mental health advocacy organization founded in 2012 by a group of high school students.   LEAD offers innovative, engaging, evidence-based programs which improve early intervention for mental illness.

As a clinical psychologist treating children, adolescents, and young adults, I am a strong proponent of early, aggressive, evidence-based interventions for young people who are struggling with mental illnesses.  My personal and professional values align closely with those of LEAD, so I was thrilled when LEAD asked me to publish a VIP guest post for their blog!  My post went live yesterday.  This piece describes a topic about which I am passionate: Empowering Parents to Support Adolescent Eating Disorder Recovery. 

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Parent-Focused Treatment: An Attractive Alternative to FBT

The results of a randomized clinical trial (RCT) comparing Parent-Focused Treatment (PFT) and Family-Based Treatment (FBT) for adolescent Anorexia Nervosa (AN) were published this month in the Journal of the American Academy of Child & Adolescent Psychiatry.  As a practitioner of FBT, and as a clinician who is always looking for ways to improve patient outcomes, I read this article with great interest.

Family-Based Treatment (FBT), when applied strictly according to the manual, entails a psychologist or other mental health professional meeting with the family as a whole – the adolescent patient, both parents, and siblings – in a single session.  In contrast, Parent-Focused Treatment (PFT) involves the psychologist meeting privately with the parents, while the patient’s weight, vitals, and mental status are monitored by a nurse.

While FBT and PFT therapy sessions are conducted in different formats, the essence of the treatment – which is implemented by parents in the home – is the same.  Both treatments empower parents to work together to increase their adolescent’s food intake, restore him or her to a healthy weight, interrupt eating disordered behaviors, re-establish normal eating patterns, and return him or her to a state of healthy adolescent development.

The results of this study demonstrated that PFT is more efficacious than FBT.  At the end of treatment, patients receiving PFT were twice as likely to be in remission from AN compared with patients receiving FBT.  In addition to being published in the Journal of the American Academy of Child & Adolescent Psychiatry, the article was summarized nicely by the Murdoch Children’s Research Institute.

As I was reading this article, it occurred to me that I have been utilizing a version of PFT with some families in my private practice for years, as I have adapted FBT to suit the needs of each individual family.   For example, it is not uncommon for an adolescent patient with AN to refuse to attend some or all of the family sessions during Phase I (the re-feeding and weight restoration phase).  Personally, I have not found this to be problematic.  After all, in an FBT model, the parents are the primary agents of change in early recovery from AN.   The patient is more of a passive recipient of care – his or her job is simply to show up at the table and eat.

In my experience, most parents make excellent use of the Phase I sessions to receive support, learn more about AN, brainstorm and problem-solve, and collaborate with their spouse in the re-feeding process.  All of these things can be done with or without the child present, so long as the child’s weight is monitored weekly.  The weekly weigh-ins can be completed at the pediatrician’s office or under parental supervision at home.

As another example, many patients are so anxious about eating high-calorie foods, gaining weight, and eliminating exercise that attending sessions –during which these topics are discussed at length – is just too overwhelming.  Increasing a patient’s anxiety can sometimes be counterproductive to treatment goals.  For instance, if the patient is present during discussions of “fortifying” foods (e.g., increasing the caloric density by adding cream, oil, butter, or Benecalorie) or discussions of weight goals, this may heighten her anxiety to the point that she cannot eat these fortified foods, or she may become even more resistant to gaining weight.    For an underweight patient with AN, talking and listening are over-rated.  Eating and gaining weight are essential.

In my experience, patients who do not attend sessions during Phase I tend to have just as much success in recovery as patients who attend every single session.  Furthermore, the vast majority of the time, the kids who refuse to attend sessions in Phase I will begin to attend sessions voluntarily after weight restoration occurs and their treatment progresses through Phase II and Phase III.  By that time, most patients have the cognitive and emotional capacity to participate in their own recovery process and have some interest in getting better.

On the other hand, there are some cases in which it makes more sense to have the patient attend all of the FBT sessions, cases in which her participation in the treatment enhances her success in recovery.  Often (though not always), these are cases in which the patient is older, more independent, less cognitively impaired, less anxious, more curious about the process, and/or has some degree of personal motivation to recover at the outset.

I have also found that it is also very important for the patient to attend all sessions in cases where the parents are less willing or less able to take full responsibility for their child’s recovery.   For instance, I’ve worked with families in FBT in which both parents have active addictions to drugs or alcohol, families in which another member is coping with a health crisis (e.g., a parent with a recent cancer diagnosis), families in which the parents are going through an acrimonious divorce, and large families with many young children.   These have been cases in which the parents, while supportive in theory, were unable to invest as much time and energy into their child’s recovery as other families.  The patients from these families, in my observation, tended to be more resilient and more autonomous than other teens, likely .as a result of growing up in challenging environments.  I have observed that the adolescents in these more challenging situations have been able to (or perhaps required to) take on a greater degree of independence earlier in the recovery process.

The outcomes of this clinical trial were disappointingly low for both forms of treatment.  At the end of treatment, only 43% of patients receiving PFT had achieved remission, and only 22% of patients receiving FBT achieved remission.   Before you become discouraged, however, please allow me to explain my theories as to why remission rates were so low.

First, I believe that the poor outcomes of this study were, at least in part, due to the fact that families were randomly assigned to one type of treatment or the other.   Of course, in conducting a controlled clinical trial to study the efficacy of treatments, it is necessary to use random assignment to control for confounding variables and increase the validity of the results.  I suspect that if families were able to choose between PFT and FBT based on their own needs, desires, circumstances, and knowledge of their child, the outcomes would have been significantly more promising.  This has certainly proven to be true in my practice.

Consider the “treatment refusers” I described above, with whom I have effectively used PFT essentially by default.  On the other hand, consider the teens who come from more challenging family environments, whose participation early in treatment is instrumental to their recovery.  If the families with “treatment refusers” were randomly assigned to Family-Based Treatment, or if families with other significant challenges were randomly assigned to Parent-Focused Treatment, I suspect that the patient would be much less likely to occur.

Second, the course of treatment in this study was 18 sessions over the course of 6 months.  This sounds woefully insufficient to me.  In my experience, some patients do achieve full remission within 6 months, but this is certainly not the norm.  In my practice, most patients with AN are fully weight-restored within 3 or 4 months, but full remission of cognitive, emotional, and behavioral symptoms generally takes 12-18 months of treatment.   It is not unusual for patients to require 2 or 3 years of treatment in order to attain full remission and become ready to manage their eating independently.

I point out these time frames because I do not want patients or their families to feel discouraged when recovery takes so much longer than they expected.  The patients in these clinical trials who did not achieve full remission at end of treatment are the NORM, not the exception, and this is not due to any failure on the part of the patient or the parents.  Rather, the research study itself places unrealistic expectations on individuals with AN and their families.   Any clinician who has treated many patients with AN could tell you that full remission after 6 months is simply unrealistic for a majority of AN sufferers.  Individuals who have gone through treatment for AN, and parents who have helped their children recover, know all too well that vestiges of AN are often present for many months after weight has been fully restored.

I am confident that the majority of adolescents with AN who are not in full remission after 6 months of treatment will go on to achieve full remission within two or three years, especially when they utilize evidence-based, family-centered care.

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Fighting Stigma: The Gift of a New Generation

Somehow, sometime in the past several years, I crossed some invisible line from “young adult” to simply “adult.”  Polite strangers call me “ma’am” at least as often as they call me “miss.”  Shopping at Forever 21 now seems scandalously inappropriate.  And I can’t remember the last time I was still awake to watch Saturday Night Live.  Now that I seem to be old enough to complain about the younger generation (They think women’s empowerment is posting bikini-clad selfies!  They use social media excessively! Their pivotal relationship conversations take place over text message!), it seems only fair that I also recognize the strengths of this cohort.  And they do have tremendous strengths.

Teenagers and young adults these days, for the most part, have grown up in an era where it is socially acceptable, even encouraged, to speak openly about mental health issues.  Just about every high school and college student who walks into my office has at least a couple of friends with mental health diagnoses.   Most of my patients have one or more members of their extended family, if not their immediate family, who has dealt with a mental illness.   And they know this because they talk openly about it.

And that excessive use of social media I complained about a minute ago?  Well, social media has allowed famous people to speak candidly to a wide audience about their experiences with mental illness, seeking treatment, and ultimately recovering.   Actress Kristen Bell has struggled with depression.   Writer/producer/actress Lena Dunham has received treatment for OCD.  Singer Demi Lovato has spoken openly about her struggles with bipolar disorder and her recovery from an eating disorder.  John Green, author of The Fault in Our Stars, has chronic anxiety which he is able to control with therapy and medication.  Olympic swimmer Michael Phelps has a diagnosis of ADHD.  These individuals have been extremely successful in their professions and have had the courage to speak publicly about their psychiatric problems.

Even more courageous than these celebrities, though, are the regular people who attend school, play sports, hold down jobs, pay bills, raise families, volunteer in their communities, and maintain friendships while also dealing with mental illness.  These are the people who have a lot to lose from the stigma surrounding mental health issues.  These are also the people who have the most to gain from breaking down the stigma.

The younger generation is fighting this stigma.  Australia’s National Youth Mental Health foundation has created an organization called Headspace dedicated to supporting adolescents and young adults with mental illnesses as well as combating stigma surrounding these issues.  In the UK, Prince William, Princess Kate, and Prince Harry have created Heads Together, a charity dedicated to fighting stigma surrounding mental illness and improving the mental well-being of all citizens.  Here in the US, the National Alliance on Mental Illness (NAMI) is running a Stigma-Free campaign.

The message of these organizations is simple and straightforward: mental illness is common and treatable.  Mental health problems are as much a part of the human condition as any other health problem.  Untreated mental illness can have dire effects on the individual, on the family, on the community, and on society as a whole.  People who have psychiatric diagnoses can overcome them and live fulfilling, successful, meaningful lives.  Learn about it.  Talk about it.  Seek treatment when needed, and support others in doing so as well.  Silence and shame help no one.

I can’t recall ever hearing these messages as a teenager or young adult.  If these messages existed at all back in my day, they were eclipsed by the OJ Simpson trial, overshadowed by the Clinton/Lewinsky scandal, drowned out by the Spice Girls and ignored amidst episodes of Friends.  It is an honor and a privilege for me to treat the teens of this generation, who live their lives with more knowledge, understanding, and acceptance than the generation before them.

If you’d like to read an interesting perspective from a highly experienced clinician from a previous generation who has over 40 years of experience treating anxiety and eating disorders, see Dr. Paula Levine’s blog.

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Iatrogenic Effects

The year is 1892. Emily, age 14, is the second of six children in a Midwestern farming family. One evening in March, Emily’s mother catches a glimpse of her daughter undressing and is taken aback by how slim she looks. Over the next few days, mother notices that Emily eats very little at family meals. She mostly just pushes her food around the plate and slips pieces of her food under the table to the family’s two dogs.

Later that week, Emily’s older sister, Cora, confides in her mother that Emily is no longer getting her monthly cycles. Now mother is greatly concerned, and she has a talk with her husband, who is equally worried. Both parents sit down with Emily and express their concern over her poor eating habits, weight loss, and absence of menstrual cycles. In response to her parents’ talk, Emily bursts into tears. “I just can’t eat,” she cries. “I just can’t.” Mother and father hug their daughter, comfort her, and let her know that they will be taking her to the family doctor the next morning.

When Dr. Benson examines Emily the following day, he is alarmed by his young patient’s gaunt appearance and flat affect. She is no longer the bubbly, robust young girl he has known since birth. Emily’s pulse is much lower than normal, her muscles have wasted, and her adolescent figure has shrunken to a pre-pubescent one.

“Emily is gravely ill and melancholy,” Dr. Benson tells the worried parents. “She is malnourished, and she will need lots of food and rest to recover. She needs complete bed rest for the next three months, plenty of food at each meal, and six tall glasses of milk per day. I will see her again next week.”

Emily cries heavily all the way home, burying her head in her mother’s skirt. As soon as the family gets back to their house, her mother prepares her a large plate of food with extra bread and butter and a tall glass of milk. Mother sits beside Emily and strokes her daughter’s hair as she stares – terrified – at the heaping plate of food. “You will not be doing any chores this spring,” her father tells her firmly. “Cora will do your indoor chores and Ethan will take over your outdoor chores. You will not be returning to school this year – the 2-mile walk is too strenuous for you in this condition. Cora will speak with your teachers and bring home your assignments. You will study from home. You will return to school and chores when you are well.”

“But Papa…” pleads Emily. “I have to –“

“That’s enough, young lady. You know better than to take that tone with me. This is final.” With that, Emily’s father abruptly leaves the room. Tears stream down Emily’s cheeks as she weeps silently. Mother strokes her back and whispers: “Come on, sweetie. Eat.” Hands shaking, Emily picks up her fork and takes a bite. Mother waits with her at the table for the next two hours as she finishes every last bite of food and every last drop of milk.

19th century family

Dr. Benson makes house calls weekly over the next few months. Emily is always lying on her bed, reading and sipping a glass of milk, when he arrives. He watches the young girl slowly put on weight, regain her strength and stamina, begin to smile again, and then blossom into the cheerful teenager she was meant to be. By the time June rolls around, Emily has resumed her monthly cycle and returned to her normal weight. At this point, Dr. Benson gives her permission to begin doing some light chores around the house.

By September, Emily is eating with gusto. She has had three monthly cycles in a row and has regained her curvy figure. She returns to school and resumes all of her farm chores. Her parents are relieved to have their daughter back.

The vignette above illustrates how Anorexia Nervosa (AN) would have been treated several generations ago. Quite a stark contrast from how AN is treated today, isn’t it? The illness itself has remained basically the same throughout time, but the way that people conceptualize it and respond to it has changed dramatically. Consider the following differences between Emily’s treatment in 1892 and the treatment Emily’s great-great-granddaughter Marissa received in modern times:

1.) Emily’s parents are immediately concerned by her weight loss and dwindling food intake. They view weight loss in a growing adolescent as a sign of illness and take her to the doctor immediately. Marissa’s parents are pleased when they notice her becoming slimmer shortly after her 14th birthday. They praise her for foregoing desserts and snack foods. They encourage her interest in athletics and bring her jogging with them in the morning.

2.) Emily’s family doctor is immediately concerned by his young patient’s weight loss, lack of menses, and changed demeanor. At her 15-year-check-up, Marissa’s pediatrician commends her on her 12-pound weight loss. When Marissa’s mother expresses concern to the pediatrician about her daughter’s low heart rate and absence of menses for the past three months, the doctor explains that it is common for female athletes to lose their monthly cycle, and that Marissa’s low heart rate is also due to being a runner.

3.) The prescribed treatment for Emily – full nutrition and complete bed rest – is commenced immediately and aggressively. Eating more food is not recommended, or even suggested, for Marissa. Marissa continues running with the blessing of her doctor and the encouragement of her coach.

4.) The doctor views Emily’s parents as competent agents to re-feed their starving daughter and enforce bed rest for a prolonged period of time. Marissa’s parents are advised to “stay out of the food business” and admonished not to be the “food police.”

5.) Dr. Benson monitors Emily’s condition weekly and supports the family throughout the recovery process. Emily’s menstrual periods return naturally as she restores a healthy weight. Marissa’s pediatrician does not see her again until she develops a stress fracture 5 months later. Marissa has now lost a total of 20 pounds, and her pediatrician gently suggests that she tries to eat a little more. The pediatrician also refers her to a gynecologist, who prescribes birth control pills to re-start her periods.

6.) Emily is expected to comply with the prescribed treatment, and parents are expected to enforce it. Marissa restricts her food intake even more. She is now eating nothing but fruit, vegetables, and chicken breast. Scared to make matters worse, her parents say nothing.

7.) Emily eats hearty meals with her family every day for breakfast, lunch, and dinner, plus plenty of whole milk in between. Unable to watch her daughter starve herself any longer, Marissa’s mother takes her to a local therapist who was recommended by a neighbor. This therapist begins meeting with Marissa weekly, and also refers them to a family therapist and a dietitian. Marissa is now attending multiple appointments each week and following a 1600-calorie exchange plan created by her dietitian. She prepares her own meals, weighing and measuring everything.

8.) The doctor recommends chamomile tea with honey to soothe Emily’s nerves. Neither Emily nor her parents are blamed for her AN. The etiology of the illness is not discussed with Emily or her family, as it is not known. Marissa’s weight does not change, but her mood deteriorates. The therapist refers Marissa to a psychiatrist, who prescribes Lexapro and Klonopin. The family therapist suggests that Marissa’s AN is a cry for attention, as her father works long hours at his law firm and her mother is very preoccupied caring for her younger son with autism.

9.) Emily’s weight was restored to her normal range within three months of commencing treatment. She remains home with her family throughout and maintains good physical and mental health for the rest of her teenage years. By her 16th birthday, Marissa has lost 4 more pounds (a total loss of 24 pounds in 2 years). Her therapist recommends residential treatment at a well-marketed eating disorder treatment center in another state. Marissa spends 3 months at this residential treatment center. The psychiatrist there prescribes two additional psychotropic medications. Within a month of returning home, Marissa relapses and returns to the center for another 3 months.

10.) Emily maintains good relationships with her parents and siblings. She trusts her family to help her when she needs them. By the time she turns 18, Marissa has had three psychiatric hospitalizations, four stays in residential eating disorder treatment, and is taking five different psychotropic medications in addition to Ambien for sleep and birth control pills to regulate periods. She barely speaks to her parents and refuses to sign consents to allow them to access her healthcare information.

Emily and Marissa developed the same illness at the same age but received very different treatments and thus had very different outcomes. Emily’s AN was completely resolved within 6 months, whereas Marissa remains gravely ill and in intensive treatment four years later. Marissa experienced the iatrogenic effects that are so prevalent in modern eating disorder treatment. Iatrogenic effects are harmful outcomes caused by a medical intervention. In other words, a treatment which is intended to help a patient ends up making her condition worse or creating a new problem that wasn’t there before.

Marissa’s story is all too common. The adults around her – with good intentions – inflicted harm by prolonging her state of semi-starvation, prioritizing her adolescent autonomy above her physical health, disempowering her parents, alienating her from her family, subjecting her to time-consuming, costly, and ineffective therapies, prescribing powerful psychotropic drugs that may not have been necessary, isolating her from her primary support system, and surrounding her with other mentally ill teenagers.

modern girl

Clearly, some teenagers with Anorexia Nervosa have complicated presentations with multiple comorbidities which require a team of professionals and specialized care. But there are also many cases in which a simple and straightforward intervention would be far more effective and efficient than the iatrogenic treatments that so many kids and families endure. This is precisely why Family-Based Treatment (FBT) is so effective: it minimizes the iatrogenic effects of other eating disorder treatments. Mainstream eating disorder treatment often morphs Emilys into Marissas.

What would have happened to Marissa if she had been provided with the same treatment as her great- great-grandmother Emily? Would she, too, have regained full health in a matter of six months, and bounced back into a vibrant adolescent life? It’s impossible to know for sure, but it seems likely that she could have. It’s definitely worth a try. Our 21st century Marissas need and deserve treatment that is AT LEAST as effective as 19th century Emilys.

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After Weight Restoration: What About Body Image?

Body image disturbance is one of the most insidious and painful symptoms of Anorexia Nervosa (AN). In many cases, body dissatisfaction is the last symptom to abate. However, the relationship between body image and recovery from Anorexia Nervosa (AN) is fairly complex. Many individuals with Anorexia Nervosa (AN) do not experience body image problems as a symptom of their illness. Most people with AN, however, do have some degree of body image disturbance which changes in intensity over the course of their illness and recovery.

A recent randomized controlled trial of adolescent AN treatment found that weight and shape concerns did not change significantly over the course of treatment. The authors of the study point out that, on the one hand, these results suggest that weight and shape concerns do not get worse over the course of treatment. This finding may come as a relief to patients who are terrified that they will hate their bodies if they gain weight. The authors conclude that “weight restoration alone is not sufficient to ameliorate the weight and shape concerns characteristic to AN.”

While the authors’ conclusion may be accurate in some cases, my clinical experience with AN patients as well as my knowledge of statistics leads me to a different conclusion. I have observed that the relationship between weight restoration and body image varies dramatically from person to person. When it comes to AN and body image, people tend to fall into one of the following categories:

1.) Those who do not have significant weight or shape concerns.

2.) Those who present for treatment with significant weight and shape concerns, which gradually abate over the course of weight restoration and may even disappear by the end of treatment.

3.) Those who become increasingly dissatisfied and distressed by their weight or shape as they restore weight.

My hypothesis is that the authors of the study found no significant change in body image over the course of treatment because patients in group 2 and group 3 essentially cancelled each other out, while those in group 1 did not impact the results in either direction.

As you can see from the groupings above, body image disturbance may not even be relevant for the patient (group 1), and if it is, weight restoration alone may be sufficient to improve body image (group 2). For this reason, I typically postpone addressing body image until after weight restoration has been accomplished and the patient has re-established normal eating patterns. By postponing body image work until the end of treatment, the patient and her family save a lot of time, money, and stress, as a substantial proportion of patients do not need it.

Individuals in group 3, however, may benefit from working on their body image in therapy. Helping these individuals improve their body image will be the topic of my next blog post.

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After Weight Restoration: The Role of Insight

One of the hallmark symptoms of Anorexia Nervosa (AN) is anosognosia, or a brain-based inability to recognize that one is sick. For this reason, most patients have little or no insight when they first present for treatment. Even months into effective treatment, most patients with AN continue to demonstrate anosognosia from time to time, if not consistently. The irony here is that most patients with AN do not believe they are sick until after they have gotten well.

I am outspoken in my belief that insight is unnecessary, not to mention unlikely, in early recovery from Anorexia Nervosa (AN). I do not expect my patients to have any insight whatsoever early on in their treatment with me. I expect kids with AN to present in my office denying that they have a problem. Their lack of insight does not delay or undermine treatment one bit.

In Family-Based Treatment (FBT), the patient is not required to demonstrate any insight at all during Phase I (Re-feeding and weight restoration). Phase II (returning control of eating to the adolescent) and even Phase III (establishing a healthy adolescent identity) can be successfully completed with a relatively small amount of insight on the patient’s part.

The re-feeding and weight-restoration components of treatment can be achieved without the patient’s consent or compliance. Through FBT and similar family-centered approaches, parents can feed their children complete, balanced nutrition and ensure that they maintain a healthy weight for as long as necessary. In theory, a patient could exist in an externally-maintained state of physical health forever, which would be far better than suffering the long-term medical and psychological consequences of AN. But this is not recovery.

Children and younger teens tend to lack the maturity to develop good insight even after their AN has been in remission for quite some time. Lack of insight is completely normal at this stage of development, even for kids who have never had a brain disorder. It is not necessarily problematic for recovering adolescents to lack insight as long as they are living safely under their parents’ roof.

For older adolescents and young adults, however, there comes a point later in recovery, after physical health is restored and most mental symptoms have subsided, when a patient does need to develop some insight about their illness and “own their recovery.” Patients do not need insight to get well, but they certainly do need insight in order to live a healthy, fulfilling, independent life.

As a side note here, the type of insight I am referring to here has nothing to do with “discovering the root cause” or “learning to love yourself” or “finding your voice” or any of the other talking points commonly referenced in ED recovery circles. The important insights to gain, in my opinion, are the following:

1.) Acknowledging and accepting that you have (or had) an eating disorder, which is a biologically-based brain illness that you did not choose to have and your parents did not cause

2.) Acknowledging and accepting the possibility of relapse

3.) Ability to recognize eating disordered thoughts, feelings, and behaviors in yourself

4.) Understanding the necessity of maintaining full nutrition, every day, for life

5.) Accepting the necessity of maintaining your ideal body weight in order to reduce the risk of relapse

How do you help a person who is recovering from AN to develop insight? It’s tricky, and it varies considerably based upon the patient’s own unique experience of having AN. Unlike full nutrition and weight restoration, insight cannot be thrust upon someone against their will. The patient must be an active participant in the process.

I find it helpful, as a therapist, to have frank conversations with patients and their parents about the biological basis of AN, potential triggers, vulnerability to relapse, and the importance of practicing good self-care. A single conversation at the start of treatment is rarely sufficient. Instead, I integrate these conversations into most of our sessions to help the patient absorb and internalize this information. For the first few months of treatment, these discussions are primarily for the benefit of the parents, as most kids are too malnourished and shut-down to process this information. However, after weight restoration and brain healing, these discussions can have a powerful impact on recovering kids.

Parents often have these insight-building conversations with their recovering teens at home. Often, teens will get defensive, shut down, or lash out when parents bring up these topics. But sometimes kids actually listen!

Many weight-restored patients go through a phase of romanticizing their AN, longing to return to the days of extreme thinness, perpetual motion, and hyper-focus on academics and athletics. While these feelings are understandable and typical at a certain stage of recovery, they need to be counterbalanced with conversations about the negative impact AN had on their bodies, their minds, and their lives. Otherwise, it is all too easy for recovering people to view AN through “rose-colored glasses.”

Bear in mind that the development of insight can take years. Recovered teens who initially presented for treatment at age 13-14 (the typical age of onset) will often show a blossoming of insight around age 17-18, just as they are preparing to leave home for college. This newfound insight is often the result of a variety of factors, including consistent full nutrition, brain healing, normal adolescent developmental processes, maturity, frontal lobe development, and successful therapy. I have worked with many adolescents for whom this happens beautifully, organically, and right on time. These kids go off to college in other states and thrive.

In other cases, however, the timing may be far less convenient. Those who develop AN at 16 or 17 years of age may not be sufficiently recovered to develop the insight needed to manage their illness independently at that magical age of 18. Similarly, who relapse during their junior or senior year of high school may have a setback in the process of insight development and thus may not be ready for independence right after high school.

In some cases, kids are diagnosed in childhood or early adolescence but don’t receive effective treatment until late adolescence. In these cases, it may take even longer for insight to develop if the illness has become entrenched and emotional maturity lags far behind chronological age.

Further, teens who have suffered through months or years of ineffective treatment may have built up an arsenal of bogus myth-based insight that has nothing to do with the reality of their illness. For example:

• “I developed AN as a way to cope with feeling out of control in life.”

• “I have to want to get better on my own. I have to do this for myself.”

• “Re-feeding doesn’t help us discover the root cause of your illness.”

• “I am enmeshed with my parents and this is keeping me sick. I need to become more independent.”

These myth-based “insights” very often result in parental alienation and protracted illness.

As you can see, all insight is not equal. The insights worth having are those that are based in empirical science, those that empower parents to help their offspring recover, and those that serve to help patients achieve and maintain their physical and mental health while living a full and meaningful life.

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Weight Gain Predicts Psychological Improvement in Anorexia Nervosa

A recent study published in the journal Behavior Research and Therapy demonstrated that weight gain was a significant predictor of improved psychological functioning in adolescents undergoing treatment for anorexia nervosa (AN). In other words, adolescents who gained more weight during treatment did better mentally than those who gained less weight. This study also showed that weight gain early in the course of treatment had a greater impact on psychological recovery than weight gain later in the course of treatment.

This finding is extremely relevant not only to clinicians who treat adolescent AN, but also to the adolescent patients themselves and their families. The process of re-feeding and restoring weight often feels agonizing for patients and may cause tremendous stress to caregivers. Psychological recovery lags behind physical recovery, so patients often feel worse before they start to feel better. This study provides objective evidence that it is in the patient’s best interest – both physically and psychologically – to eat more and gain weight as soon as possible after diagnosis.

Weight gain is an essential component of treatment for patients with AN. The knowledge that full nutrition is necessary to repair the physical damage caused by AN – including weakened heart, low blood pressure, hypothermia, osteoporosis, stress fractures, lanugo, amenorrhea, infertility, and risk of premature death – helps many patients and families to persevere through the difficult days of re-feeding. Now, patients and families can hold onto hope that weight restoration will bring about psychological improvement as well. This study provides families with direct scientific evidence that gaining weight gives their loved one a greater chance of recovering mentally, emerging from the fog of depression, and reclaiming a meaningful life free from food and weight preoccupation.

Patients in this study were randomly assigned to receive either Family-Based Treatment (FBT) or Adolescent Focused Treatment (AFT). The authors of this study found that weight gain predicted psychological recovery regardless of the type of treatment (FBT vs. AFT) the patient received. This finding may be especially relevant to clinicians who treat adolescent AN using individual therapy. A common criticism of FBT (usually made by clinicians who reject FBT without really understanding it) is that it focuses on weight gain at the expense of the adolescent’s psychological wellbeing. This study clearly demonstrates that weight gain and improved psychological functioning are not mutually exclusive. On the contrary, weight gain and improved psychological functioning are strongly correlated!

It is clear that FBT supports the adolescent’s psychological wellbeing indirectly by promoting regular nutrition and steady weight gain, which help to repair the brain damage caused by malnutrition. I would also argue that FBT has a direct impact on the adolescent’s psychological wellbeing by externalizing the illness, removing any sense of self-blame the adolescent may have, supporting her emotionally, and relieving her of the burden of fighting this deadly illness alone.