A large portion of my private patient load are challenged with disordered eating - these precious people suffer with an array of symptoms: restriction, binging and purging, chewing and spitting, laxative abuse, overeating and so on. The bottom line remains the same - there is a deep void of self love and leading on from that, self worth: something in life has wounded them and shrivelled up the positive self view they were born with. I seek to replant that in their hearts and minds during our work together.
The pathway towards a place of peaceful healing is incredibly bumpy with disordered eating. The symptoms are simply the top tip of the iceberg - these sensitive souls are in deep pain and anxiety (sometimes they don't even know it consciously). Sorting through the issues which are starting to endanger their lives, and most certainly destroy their experience of all which is vital in life, takes time. Patience, as ever, is key.
The health service, for a number of reasons, doesn't have much room for this fundamental patience. The results of that can mean that often times, when a patient has been through the conventional treatment for an eating disorder (whether inpatient or outpatient), the problem is far from solved, and sometimes it is made much, much worse. I get to see many of these patients in my private practice.
I am not writing this post in blame of other specialist practitioners in eating disorders; it is a universal fact that these are tremendously hard problems to heal with and with limited resources it can become quite challenging. I am, however, pondering in this post the importance of acting strongly on the 'first do no harm' principle when treating these patients. Because the harm done in some facilities, though probably not poorly intended, can scar for life. It is a problem which needs to be addressed.
One major challenge is the perception that a return to a healthy body weight represents healing. Anorexia, for example, masks itself as an illness where the sufferer is terrified of becoming 'fat'. The patient even verbalises it this way - 'I can't get fat' 'I'll kill myself if I gain a kilo' (- said when tens of kg's underweight). What the patient is really saying is that they cannot surrender control in this aspect, because it is almost the last strand of control and value they feel they have in the entire tapestry of their currently painful life. It is simply terrifying to let this strand go - though the truth is, once returned to a vibrantly nourished status, much greater control and joy can be achieved through work, play, relationships and so on and the anorexic urges organically ebb away.
So the real question is, how to get the patient to eat enough to get there? Force feeding a patient (though necessary if at deaths door) is almost like a final violation of a sacred (though misguided) space - and I feel this is done too liberally in inpatient facilities, whether by food, beverage or feeding tube. We are speaking about a population who are tremendously uncomfortable in their skin - how much more so when forced to eat an unreasonable amount of calories (to make the weight gain as fast as possible - not beneficial for the patient, but perhaps for the cost implications), or when made to stand naked in front of strangers for a weigh in.
One of my patients has been kind enough to write for me her account of her stay at a treatment facility (Rhode's Farm) in 1994, when she was a tender eleven years old. A classic example: Suffering in 1994 and still suffering today, immensely brave, due to the damage done by misguided professionals.
"My first memory is of being left there aged eleven by my parents and sitting in the kitchen overwhelmed. All the other patients over 16 years old are throwing questions at me i.e. what is my target weight and how many weeks had I been given? (1 week for ever kg you have to gain - 26 weeks for me). If you fail to gain 1kg each week you are then punished. You're put on 1:1 supervision where a nurse follows you everywhere, even to the shower and toilet, visits are stopped and calories are increased.
The first two weeks no contact with my parents was allowed and then after that a phone call twice a week at a set time for half an hour was allowed. It was in a room with 6 pay phones with other patients also on the phone - so distracting and hard to hear. Staff were watching you and if you cried or got angry the call would be disconnected. You had to wait for your parents to call you and sometimes I remember that my parents would call late and all I could think of was the fact that I would get less time talking to them as a result.
Every Monday and Thursday I was weighed. I was woken at 6am to sit on the stairs for one hour so you couldn't water load and then you had to strip naked in front of two staff two be weighed (so humiliating).
Staff never spoke to you, just sat at the kitchen table watching you eat. One hour supervision after and I had to eat chicken (I had been vegetarian for ages and I remember the first time I ate chicken vomiting into my plate and being forced to re eat it).
All food was from M&S - a portion was huge and all scary food that I'd never eaten before e.g. fish and chips, 1/3rd cheese cake and 2 scoops of ice cream for lunch.
I had individual therapy once a week for the first time in my life and I had no idea what I was supposed to talk about. It was an hour long and then therapist never said anything other than 'hello' and 'time's up'. He was a stranger and I'd never opened up to anyone before so I sat in complete silence every time and studied the clock and the patterns on the carpet.
Once I was 80% of my target weight I was allowed out of the house and garden for the first time for a half an hour walk and one afternoon with my parents two weeks in a row where I had to have lunch with them at either TGI Friday's or Bella Italia. The first time I didn't eat enough in the staff's eyes so on top of my supper I had to eat a muffin.
The whole time I was there just made me withdraw into myself even more.
No groups or anything, just school work sent from my school in a room full of different ages doing different work and a nun as a teacher who was no help.
Once I left my mum weighed me every Thursday and if I'd lost a kg or more (pretty much every week) then I was driven back to Rhode's Farm to stay in a room Friday night to Sunday night; it was a room at the top of an alarmed staircase so no other patients could visit me. I had to sleep on the floor, be in isolation and only allowed down to eat on my own with a staff member on 4500 calories per day. As a result I'd then eat very little all week once I got home.
Monday morning I had to go back to school and pretend I'd had a normal weekend like everyone else. I always had to make excuses as to why I couldn't come to someone else's house as no one knew.
I was readmitted a second time to Rhodes Farm for 12 weeks for a top up as I kept losing weight. I just remember when I arrived, Dee Dawson (the then owner) taking me into her office and shouting at me for being a bad girl and a disappointment"
How wrong on so many levels. To shame, blame, punish and induce further isolation in a person who already shames, blames, punishes and isolates themselves shows such a gross lack of understanding. Sufferers of disordered eating have virtually nothing nice to say about themselves - an inner dialogue which bullies the self is a cornerstone of the condition.
To provide a person who is already looking at food as the enemy an even greater reason to be terrified of indulgent foods, or calories in general, by over aggressive refeeding is thinking about the service costs and not the patient at hand. There is no reason not to refeed at a reasonable 2000 calories per day of healthy foods - this approach will teach a person self respect. None of us eat 4500 calories a day unless we're super-duper sports men/women, so why them, if we want to return them to vitality - 4500kcal/day does not a vital person make! Why should someone who is so vulnerable have to be punished by eating unhealthy food for every single meal? And the criminal, sadistic act of making a poor child who needs mothering eat her own vomit....how is this supposed to create recovery? It makes things worse. Much worse.
A person with an eating disorder has an aura which has shrivelled in pain; what they require is loving expansion. Most of their life's interests have disappeared in the depression and fatigue that an eating disorder has caused - socialising, sexual intimacy, hobbies and more tend to fall away as extra hassles or at worst, represent a risk of more emotional injury which needs to be avoided because life is painful enough. Because life does cause pain - it's just part of it - and sometimes people feel they cannot take the risk; so the eating disorder becomes the best friend, the full time pursuit.
Love is the cure: self love being top of the list. Those which come from loving families tend to heal faster and smoother then those who do not but the biggest step in healing is the acknowledgement and the subsequent embracing/giving the self permission to hug life and all it offers - pleasure especially. To end the covalent bond with unachievable, perfectionist derived goals which only serve to further destroy an already fragile self esteem. For these goals to be replaced with respectable, moderate goals.
One great example of a moderate goal as practitioners is to turn our backs on refeeding disordered eating patients with as many calories as we can (this only teaches them to calorie count towards restriction once released from these facilities anyway). And to step away from using pro inflammatory foods as the main calorie givers. Every single patient I have ever had with an eating disorder has been a highly conscientious, intelligent, sensitive person and although their situation has become extreme, it is not wrong of them to care about what they eat; we should all care. To expect them to suddenly embrace a diet rife in inflammatory fats, grease, sugary syrups and crappy juices is an insult to their intelligence and disrespectful of them as autonomous human beings. Teaching an responsible way of eating and nourishment (Michael Pollan's 'eat food, mostly plants' is perfect) is a better way forward. How can you treat a disease of a lack of self esteem with foods which in their very essence are an insult to the act of high self esteem - feeding ourselves well because that's what we deserve!
And to my patients and other sufferers of disordered eating: Love yourselves; please love yourselves. Have the courage to connect - step by step - with whole, natural foods, with good, uplifting people who make you