What you describe as “bingeing” in your daughter sounds to me more like grazing. Some ED sufferers have what I call a “permission valve,” which is usually turned off (meaning they eat restrictively or according to rigid rules) but which gets turned on periodically, and while it is on they have “permission” from ED to eat whatever and whenever they want. The permission valve is dangerous because it often leads to a dysregulated cycle of restrict / over-eat / restrict / overeat. It can also very easily cause AN to morph into a binge / purge cycle.

While grazing is not necessarily a bad thing, it can be problematic for ED sufferers, who usually need quite a bit of structure to keep their eating regulated and nourish themselves properly. Also, if you are posting this question on my blog, I imagine that you and/or your daughter see it as a problem.

I would recommend viewing your daughter’s binges as symptoms, just like restricting, which she needs you to step in and help her stop. She may be ashamed and she may resist your help, but it sure sounds to me like she needs it.

The best way to stop grazing is to serve three balanced, satisfying meals with plenty of protein and fat, along with three nutritious snacks in between. She may need support from family members or friends to distract her between eating times and help her refrain from grazing.

While you can make your child eat more and gain weight, you can’t make her have insight or motivation. Those things come from within. However, you can encourage her to develop insight by talking with her about the illness (which you have tried) and by having her in therapy (which you have also tried).

I strongly recommend that patients live at home until they have demonstrated the insight and motivation to maintain their remission independently. Of course, a patient needs to be able to talk about her illness and demonstrate an understanding of what she needs to do to stay well in order for me to have confidence that she can manage on her own.

My recommendation to you would be to sit down and have a talk with your daughter now about what criteria you require her to meet in order for her to live independently. If she won’t talk, that’s fine, just as long as she listens. Let her know that, as things are now, she is not nearly ready to live on her own. Let her know that you will need to see much more insight from her in order to consider allowing her to live independently. Be specific about what this would entail – for example, conversations with you and her father about managing ED and preventing relapse, seeing a therapist and actually talking about managing her illness, etc. I would recommend encouraging her to apply to local schools in case she is not well enough to go away next year. If she really wants to go away, use that as a motivator to get her to demonstrate insight. Let her apply to the faraway schools of her dreams (but NOT early admission, which is a binding decision) and by the time spring rolls around, you will have a better idea of whether she will be ready to go away, and her final choice of college will be contingent upon her readiness.

It is unclear to me from your description whether your daughter lacks insight or whether she simply doesn’t wish to talk about her illness. If it is the former, you will have a much harder time getting her to come around. If it is the latter, then it is simply a matter of providing incentives for her to open up. It may be humiliating or upsetting for her to talk about her illness, and up until now there has been no real need for her to do so. What you need to do now is help her understand that the rewards of insight (a full, independent life) are worth the discomfort of opening up about her illness.

Our daughter has been recovering for 3 1/2 years (w/r since April 2009). She is in charge of her food with supervision from us. She is still not ready to talk about her illness and becomes extremely agitated any time we do. We have tried 3 different therapists and she will not talk. I think she would have with the last one but she would not accept our insurance. This is my biggest fear with her going away to college (potentially in one year) — that if she does not have any insight or maturity she will not be able to manage her illness. Any suggestions for moving her forward in talking about her illness?

I so appreciate your knowledge!

The criterion for entering Phase II which is “no longer engaging in ED behaviors” simply means that restricting, bingeing, purging, and over exercise are no longer occurring BECAUSE the parents have successfully gotten these symptoms under control. In Phase I, with the way I coach families, the patient would not have an opportunity to restrict because all meals and snacks are supervised. So “no restricting” in this context simply means that all food served is being eaten without significant resistance (no trips to the ER, etc).

Your daughter sounds like a kid who needs a nudge to move forward. However, it is hard to nudge someone who isn’t motivated by anything. There must be something she wants to do – spend time with friends, go on a trip, go away to college, do an activity – something to provide an incentive for her to start eating on her own.

With regards to not talking about ED, this is not uncommon. My opinion is that it isn’t important in early recovery for a young patient to be able to discuss or even acknowledge ED. However, it will be important for her to become fluent in the language of ED before she lives independently so that she can manage her symptoms on her own. If she is still not ready to talk about it when it comes time for college, I would recommend keeping her home until she has shown better insight and maturity.

I’m adding this to my “must reads” on my blog. It’s brilliant.