A Treatment for Anorexia

Nearly two decades ago I ran into an old friend at a party. We had not seen each for quite some time, but instead of catching up, he wanted to tell me about an experience his family had had. Given the profession I was practicing at the time, he thought that it would be useful for me to hear about how he and his wife had helped their college-aged daughter to overcome anorexia.

When my friend's daughter developed anorexia in college, her worried and affluent parents sent her to a first rate clinic specializing in eating disorders.

During the course of her stay they had the opportunity to visit with her, to see how she was doing. After a few weeks, however, they noticed that she was getting worse. Her condition was deteriorating.

As you know, anorexia is a dangerous and potentially fatal disorder. My friend and his wife did not know what to do, but they knew that they could not leave their daughter in the hands of physicians who were not helping her.

They decided that they could do better. So they took her out of the clinic and brought her home.

They invented their own treatment. As my friend described it to me, he and his wife sat her down at the kitchen table, presented her with some food, and told her to eat. If necessary, they would force her to eat. They told her in no uncertain terms that she was not going anywhere until she had eaten what was in front of her.

It is fair to say that this process did not run smoothly. Parents who are going to try it should seek out the advice of a professional who can provide guidance.

Evidently, there is more to their approach. For now I want to follow my friend's description and isolate the concept that was defining their treatment.

Was this treatment successful? Yes, it was.

I have occasionally written about how impressed I am by everyday people who manage to discover psychological treatments for emotional and behavioral problems that escape the theoretical dragnet that most therapists use.

The most obvious example is the 12-step programs that were developed, not by the luminaries of the therapy world, but by a couple of drunks in Ohio.

I count my friend and his wife's work with their anorexic daughter in the same category.

At roughly the same time, psychiatrists at Maudsley Hospital in Great Britain were working on the same approach. Nowadays it is called the Maudsley approach, or else, family-based treatment (FBT).

I would emphasize the fact that FBT can be practiced within a hospital, and that for some anorexics the health risk is sufficient grave to require strict medical supervision.

If psychotherapy involves working on the mental processes that are supposed to be causing the eating disorder, I think it fair to say that FBT is a lot closer to coaching than to psychotherapy.

I recalled this conversation yesterday while reading a report on the Jezebel site about Harriet Brown's experience using FBT to treat her own daughter's anorexia. Link here.

Brown has written a book on her experience: Brave Girl Eating: A Family's Struggle with Anorexia. It is going to be published in a couple of weeks.

In the Jezebel article I linked above, Brown tells Anna North that follow up studies have shown that 90% of the girls (anorexia is very largely a female disorder) who have had FBT are doing well five years after treatment, while the same can only be said of 36% of those who were treated by individual psychotherapy.

The extent of this disparity tells me that one form of treatment works while the other does not. Consistency is the hallmark of an effective treatment. When you compare relapse rates of around 10% with rates of64% you can only conclude that individual therapy may provide something of a respite, but that it does not resolve the problem.

And this is ironic, indeed. Anyone who practices psychoanalysis or any of the therapies that derive from it will tell you that long term in-depth therapy takes so long because it is not just working on the surface; it is treating the underlying causes of the problem.

It tells you that once you have resolved the underlying infantile issues, you will be less apt to suffer its recurrence.

The evidence, however, suggests that this is a convenient fiction, a rationalization for clinical failure.

Individual psychotherapy sees eating disorders as symptoms of developmental difficulties-- oral stage fixations or the like-- or as symptoms of a toxic family environment.

In lieu of cure they offer what Brown calls a "parentectomy." The anorexic is either placed in a clinic setting that controls parental access or is induced in individual psychotherapy to believe that her parents are the problem. Once she understands why her mother wants her to starve to death, she will start eating again.

FBT coaching is based on an entirely different principle. It sees the eating disorder as a bad habit, one that need not mean anything at all, but that needs to be replaced by a good habit, by any means necessary.

A girl can develop an eating disorder if she starts too radical a diet, if she gets caught up in the experience of dieting, if all of her friends are competing to see who can eat the least. And she can do so to the point where fasting feels normal.

It does not necessarily mean that she has a problem with her mother or that she was molested as a child or that she is being manipulated by Anna Wintour.

In comparison to most individual therapies, FBT coaching takes the child's parents to be part of the solution, not the problem. It makes them the primary instruments of treatment. It rejects the notion that parents want to starve their children, or that they are unconsciously motivated to do so.

FBT coaching relies on parental good will, along with parental willpower. It sets up a battle of wills between a defiant young woman and her even more defiant parents.

Obviously, this form of treatment does not involve respecting the child's wishes, her independent judgment or her autonomy. It is much closer to force-feeding than to: Please eat your vegetables.

It also does not assume that the bad habit is trying to say something, that the child has a hidden or repressed grievance, or that the disorder will be cured as soon as she expresses her pain or guilt or anger.

But if FBT works so well, why is it not practiced more widely. Anna North asks Harriet Brown that question in her Jezebel interview.

Surely, one reason is that anorexia has the potential to produce severe medical complications, and thus, that physicians are not enthusiastic about giving these patients over to unlicensed parents.

The other reason, Brown explains, is that the people who are treating eating disorders most often have suffered from eating disorders and have undergone standard, but not very effective, psychotherapy for them.

They have learned to think if their illness in terms of psychodynamics. In Brown's words: "You know, 'I had a wretched mother, and an absent father, and this happened to me when I was a child.' You know, that's your personal narrative, and I think that it's human nature to impose yourself on the world."

I am convinced, as Brown is, that people who have learned to think one way will continue to think that way, regardless of whether it works or not. And I agree with her when she says that many therapists have been trained to construct narratives, to fill symptoms and other disorders full of meaning.

But I do not agree with her that it is human nature to want to impose this narrative on others. It is not human nature that leads people to that extremity, but psychotherapy and its attendant culture.