Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

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Tag: re-feeding

Monday, January 25th, 2016

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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Monday, April 14th, 2014

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.

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Tuesday, December 4th, 2012

A Seat at the Table: Understanding and Helping the Siblings of Eating Disorder Patients

I feel honored to serve on the Professional Advisory Panel for FEAST, a nonprofit organization which provides support and information to the parents and families of people with eating disorders. Last weekend, I had the privilege of presenting at the second annual FEAST conference in Alexandria, VA. I spoke to a group of parents about understanding and helping their other children while also caring for their eating disordered child. Below are some of the major points from my presentation.

Eating disorders can impact the patient’s siblings from various angles:

• Through their parents. When a child is ill with an eating disorder, her siblings often receive less attention from their parents. The parents may be physically absent from the home, traveling to faraway treatment centers and attending many different appointments locally. Parents often feel worried, stressed, and irritable, and these emotions can easily spill over into their relationships with their other children.

• By impacting family life. Family meals with an eating disordered person can be tense or explosive. For this reason, siblings may begin to dread family meals or avoid them altogether. Family trips may be cancelled or ruined by the eating disorder. The financial burden of ED treatment impacts the entire family, including siblings.

• Through their social environment. Parents may not be available to drive siblings to their lessons, sports events, and social activities when they are spending long hours preparing and supervising meals and driving the ill sibling to appointments. Siblings may feel embarrassed to invite friends over when their ill sister or brother is acting particularly bizarre. Siblings may have to deal with gossip from friends and neighbors. They may feel conflicted about telling their friends about their family’s situation, and they have to deal with the stigma of mental illness.

• Through the change in eating habits. Parents are encouraged to serve their anorexic children high-calorie foods to restore their weight. Sometimes siblings over-indulge in these foods and gain unneeded weight.

• Through their genes. Biological siblings of eating disorder patients are 10 times more likely to develop an eating disorder compared to the general population. Additionally, siblings of eating disorder patients may inherit genes that predispose them to other psychiatric illnesses, including depression, OCD and other anxiety disorders, substance abuse, ADHD, and autism.

Brothers and sisters may experience a variety of emotions while their sibling is ill with an eating disorder. They may worry that their sibling will get sicker or die. They may grieve for the loss of their sibling’s true personality while she is consumed by the illness, and they may miss her terribly if she is away from home for a lengthy hospitalization or residential treatment stay. They may worry about their own risk for developing an eating disorder. They may feel angry at their sibling for putting the family through hell or making mealtimes miserable. They may feel jealous because of all of the attention their ill sibling is getting. Siblings may react by withdrawing from friends and family members, having difficulty at school, or acting out. They may feel sad or hopeless. They may have difficulty concentrating. Very young siblings may manifest their distress through physical symptoms (e.g., tummy aches, trouble sleeping).

It may not be possible for parents to shield siblings completely from the impact of the eating disorder. However, there are some steps that parents can take to minimize the damage and help siblings cope:

• Immediately upon diagnosis, provide siblings with age-appropriate information on their sibling’s diagnosis, symptoms, and treatment. Explain that the disorder is biologically-based and that the child did not chose to have it. I have a Sibling reading list, as well as a list of Q & A for siblings of AN patients. Even preschool-age siblings can understand a few basic points: “Your sister has a disease in her brain called anorexia which has made her very sick. She is acting different because of her sick brain; it is not her fault. We need to help her get better. Mommy and Daddy will be very busy taking care of her, but we still love you very much.”

• Be frank with siblings about the seriousness of the eating disorder, including the possibility of death. This honesty helps siblings understand why it is so important that the family intervenes immediately and aggressively, and why other activities have to take a back seat for now.

• Be honest with siblings about the reality of dealing with the eating disorder. Acknowledge that, for a period of time, the whole family will be under stress, family life will change, and you may not be able to spend as much time with them.

• Bring siblings to some Family-Based Treatment (FBT) sessions so that the therapist can explain the eating disorder to them, describe the treatment process, answer their questions, and tell them how they can support their ill sister or brother.

• Make a point of scheduling one-on-one time with each sibling and talking with them about their lives apart from the eating disorder.

• Talk with siblings about their feelings and reactions to the eating disorder. Let them know that it is totally normal and understandable for siblings to feel worried, angry, jealous, resentful, or sad in this type of situation.

• Ensure that siblings remain in a support role, rather than taking on a parent’s role. Lock and LeGrange, authors of the FBT manual, call this process “maintaining intergenerational boundaries.” Siblings can help their ill sister by providing her with distraction before, during, and after meals, by being good listeners and providing empathy, and by engaging her in normal sibling activities. Siblings can help by taking over kitchen chores that the eating disordered person is not well enough to do, such as setting the table or doing the dishes. Do not involve siblings in the actual process of re-feeding or supervising meals, as this can put them in a delicate position of being torn between “loyalty” to their ill sister and the responsibility of reporting ED behaviors to their parents.

An eating disorder can also impact siblings in a positive way. For example, they may grow closer to their ill sibling and value her more after almost losing her. They may feel needed and important in the process of supporting their ill sister or brother. Siblings may become more aware of EDs and other psychiatric illnesses in their friends and try to intervene whenever they see concerning behaviors. They may have improved body image after witnessing the disturbing body image distress of their ill sibling. Often, siblings benefit from having more frequent family meals and structured eating habits. They may grow and mature from the experience, developing more autonomy when parents’ focus is on the eating disorder treatment. Siblings benefit from strengthened parental unity. If a sibling develops an eating disorder or another illness in the future, their parents tend to intervene immediately and are much more equipped to deal with it.

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Wednesday, August 11th, 2010

About the Food

“It’s not about the food.”

This phrase, used widely in eating disorder recovery, is misleading and potentially harmful.

Here’s the truth – anorexia nervosa (AN) is not “about” anything other than being born with a certain neurobiological predisposition to this particular brain disorder, which lays dormant until activated by insufficient nutrition. Given that food restriction has a calming and mood-elevating effect in people with this type of brain chemistry, anorexics may restrict their food intake (either consciously or unconsciously) as a way of coping with uncomfortable feelings or stressful events.

So it isn’t JUST about the food; it’s about feelings and circumstances as well. People with AN must learn healthy ways to regulate their emotions. Most of them will require psychotherapy to help them tackle anxiety and perfectionism, build healthy relationships, challenge their distorted thoughts and beliefs, or treat coexisting conditions such as depression or OCD. But it is the disturbance in eating behavior and weight, rather than feelings or events per se, which cause immense physical and psychological damage.

An initial period of low nutrition sets the disorder in motion. Continued low nutrition and low body weight perpetuate the symptoms. Sustained full nutrition and weight restoration are essential for mental and physical recovery. Continued good nutrition and maintenance of a healthy body weight for life protect patients against relapse. At every step of the process, nutrition (or lack thereof) plays a functional role.

The relationship between food and AN is analogous to the relationship between alcohol and alcoholism. To state that AN “isn’t about the food” is like stating that alcoholism “isn’t about drinking.” A person may be born with a predisposition to developing alcoholism due to her genetic makeup and her particular brain chemistry. However, if that person never takes a sip of alcohol, the disease will never be activated in the first place. Similarly, a person predisposed to AN will not develop the disorder in the absence of a nutritional deficit.

I like to think about the development of eating disorders in terms of the “four P’s:”

Predisposing factors
Recent research indicates that 50-80% of the risk of developing AN is genetic. Individuals with AN have a certain genetically-transmitted neurobiological predisposition. Personality traits which make an individual more susceptible to developing AN include anxiety, perfectionism, obsessiveness, behavioral inhibition, and cognitive rigidity. Most patients with AN have exhibited one or more of these traits since early childhood, long before the development of an eating disorder. These traits tend to be exacerbated during bouts of malnutrition and persist long after recovery, albeit to a lesser degree.

Precipitating factors
Anorexia nervosa is always precipitated by a period of low nutrition. The precursor to the low nutrition will vary from person to person. In modern American culture, where most girls and young women experience a drive for thinness, dieting is the most common pathway to AN.

Not every episode of AN is triggered by dieting, however. A simple desire to “eat healthy,” participation in sports without appropriate caloric compensation, a bout with the stomach flu, or simply loss of appetite during a period of stress – any one of these unintentional, seemingly benign periods of low nutrition can trigger AN in a vulnerable child.

Weight and shape concerns are culturally mediated phenomenon and are not necessarily part of the symptom picture for all anorexics. In medieval times, fasting for religious purposes triggered what we now call anorexia nervosa. AN is seen in cultures as diverse as China, where sufferers report loss of appetite or physical complaints, and Ghana, where sufferers view their self-starvation in terms of religion and self-control.

Puberty, which involves dramatic hormonal, neurological, and physical changes coupled with new social and academic demands, is often a precipitating factor for AN. Neurobiological researchers have hypothesized that puberty-related hormonal changes may exacerbate serotonin dysregulation, explaining why AN usually begins in adolescence.

Perpetuating factors
Continued malnutrition is largely responsible for the self-perpetuating cycle of eating disorder symptoms. A starved brain is a sick brain, and people who are undernourished for any reason display many of the symptoms commonly associated with AN: preoccupation with food, unusual food rituals, social withdrawal, irritability, and depression.

In addition to these symptoms of starvation, body dysmorphia, drive for thinness, and fear of weight gain serve as perpetuating factors. Individuals with AN are unable to recognize how thin they are and may perceive themselves as normal or fat, despite emaciation. They are terrified of eating and morbidly afraid of gaining weight. They cope with these fears by continuing to restrict their diet and remaining underweight, which of course perpetuates the symptoms of starvation. It is a vicious cycle.

Psychological problems such as depression, anxiety, post-traumatic stress, ADHD, and bipolar disorder may also serve as perpetuating factors. Food restriction and compulsive exercise act as a “drug” for certain individuals, providing them with temporary relief from anxiety and negative moods. An anorexic who is suffering from other psychological problems may use her eating disorder symptoms in attempt to alleviate her intolerable emotions. This makes re-feeding and recovery excruciatingly difficult, as the anorexic is required to face extremely painful thoughts and feelings as she endures the two things she fears most: eating more and gaining weight.

Prognostic factors
Research indicates that full nutrition and prompt weight restoration as soon as possible after AN diagnosis is a predictor of good outcome. Likewise, prolonged periods of time spent at a sub-optimal weight are associated with a protracted course of illness and increased risk of irreparable damage such as infertility, osteoporosis, and suicide.

A recent study of inpatients with AN found that the best predictors of weight maintenance during the first year post-discharge were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. Another study found that nutrient density and variety (eating a wide range of foods, including those that are high-calorie and high-fat) were significant predictors of positive long-term outcome in weight-restored anorexics.

All of the available data suggest that eating a complete, well-balanced diet and maintaining ideal body weight are of utmost importance in recovery from AN and in preventing relapse. Full nutrition and weight restoration alone will not cure AN, but full recovery cannot occur without these essential components.

In sum, nutrition plays a functional role in all stages of AN, from the initial onset and maintenance of symptoms to physical and mental recovery to relapse prevention.

Maybe it is about the food after all.

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Monday, June 14th, 2010

Recovery Timeline for Maudsley FBT

I recently conducted an informal survey of parents who had used the Maudsley Method of Family-Based Treatment to help their children recover from eating disorders. My intention was to gather some preliminary data on recovery milestones which I could share with patients and families who are just embarking on the recovery journey. Then I realized that other people may benefit from this information as well.

The following data were collected from parents of some of my patients (past and present) as well as from parents on FEAST’s caregiver forum, Around the Dinner Table. A total of 22 parents submitted responses. The patients (20 female, 2 male) ranged in age from 10 – 24 years when their family started Maudsley (mean age = 15.3 years).

The patients in my sample varied dramatically with regard to the length of their illness. Some parents reported that they began Maudsley within a month after their child’s first eating disorder symptoms appeared. Other parents had watched their child continue to suffer from the devastating effects of ED through many years of ineffective treatment and numerous hospitalizations before finally turning to Maudsley as a last resort.
Granted, this is not good science, but it is a start.

Length of time from onset of symptoms to beginning of refeeding
Mean = 18.8 months
Median = 6.25 months
Range = 1 – 132 months

Length of time from start of refeeding to weight restoration
Mean = 6.7 months
Median = 4.5 months
Range = 2 – 24 months

Length of time from weight restoration to acknowledgement of having ED
Mean = 1.1 months
Median = 0 (acknowledged having ED when he/she became weight restored)
Range = 0 – 16 months
(90 % of the sample acknowledged having ED at or before weight-restoration)

Length of time from weight restoration to developing motivation to recover
Mean = 4.6 months
Median = 0 months (motivation developed at the time of weight restoration)
Range = 0 – 24 months

Length of time from weight restoration to eating independently while maintaining weight
Mean = 7.8 months
Median = 6.5 months
Range = 0 – 36 months

Length of time from weight restoration to mood normalization
Mean = 3.3 months
Median = 2 months
Range = 0 – 12 months

Length of time from weight restoration to normalization in anxiety (return to pre-ED level)
Mean = 6.5 months
Median = 3 months
Range = 0 – 36 months

Length of time from weight-restoration to absence of body dysmorphia
Mean = 6.9 months
Median = 4 months
Range = 0 – 24 months

Clearly, more rigorous research is necessary in order to draw definitive conclusions. However, I’ve drawn some preliminary conclusions based on my data:

1.) The Maudsley Method can be effective for children, adolescents, and adults. It can be effective for both males and females.
2.) The Maudsley Method can be effective even for young adults who have been ill for 10 years or more.
3.) Most patients who are beginning Maudsley treatment have anosognosia – they do not recognize that they are ill and do not have motivation to recover. The patient does not have to “want to get better” in order for treatment to begin.
4.) The majority of patients develop insight and motivation to recover around the time that they reach a healthy body weight. For some patients, insight and motivation develop gradually after a number of months at ideal body weight.
5.) Patients generally require continued meal support for an average of 6 months after weight restoration.
6.) The manualized Maudsley approach (Lock, LeGrange, Agras, & Dare, 2001) recommends beginning to hand control of eating back to the patient when she reaches 90% of ideal body weight. This is probably too soon for most patients.
7.) The majority of patients must sustain a healthy body weight for 3-6 months before depression, anxiety, and body dysmorphia abate.

This is interesting food for thought (pun intended). I am interested in conducting a much larger survey on families that have used Maudsley. I’d like to gather enough participants and enough data points to be able to do some actual complex statistical analyses – maybe some ANOVA’s or multiple regressions. Through this study, I’d like to examine which variables contribute to recovery time. For example, what features differentiate patients who are able to eat independently at weight restoration vs. those who need continued meal support? What differentiates the patients whose psychological symptoms melt away with weight restoration vs. those who continue to struggle? Most importantly, I would like to use data from this future study to find ways in which the Maudsley method could be improved.

What questions would you like to see answered? I welcome any and all suggestions!

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Tuesday, December 29th, 2009

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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Sunday, December 6th, 2009

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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Wednesday, November 18th, 2009

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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