One of the ongoing – and most private – issues I address in my office is the issue of anorexia. Anorexia is generally defined as a pathological refusal to eat. According to Dr. Walter Kaye, professor of psychiatry at the University of Pittsburgh, people with anorexia use starvation as a way to self-medicate. Apparently, starvation prevents tryptophan, an amino acid that produces serotonin, from getting into the brain. By not eating, anorexics reduce their serotonin activity, creating a sense of calm as they slowly die of malnutrition.
But these findings don’t tell us that anorexia is caused by anything physical. They only suggest that once a person begins to starve him- or herself, medical factors bring about a dangerous sense of calm in the midst of a life-threatening situation.
Historically, many psychotherapists have held that anorexia is the product of an achievement-oriented “Type A” personality in (typically) a young woman who has reached adolescence. Expecting too much of herself and feeling put-upon by the expectations of others, she seeks control by starving herself. In recent years, however, anorexia is showing up in nine- and ten-year-old kids across racial and socioeconomic spectra. Well, so much for cultural and environmental explanations.
Customarily, treatment has focused on a combination of medical and Neo-Freudian methods. The medical solution is to force-feed the patient in the hospital. Fine, of course, until the patient goes home. The Neo-Freudians encourage the anorexic to look at how the parents might have created this mess. That invariably fails, because blaming – whether right or wrong – is not the route to mental health.
Recent developments are shifting toward family-centered approaches where parents are encouraged to be strong with their kids. Consider this excerpt from a past article in Newsweek: “I told my daughter, ‘You’re going to hate this,’ says Mitzi Miles, whose daughter Kaleigh began struggling with anorexia at 10. She said, ‘I could never hate you, Mom.’ And I said, ‘We’ll see.’ The first dinner at the Miles home was a battle. But Mitzi, convinced by Kaleigh’s doctor that she was doing the right thing, didn’t back down. After 45 minutes of yelling and crying, Kaleigh began to eat. Over the next 20 weeks, Kaleigh attended weekly therapy sessions, and Mitzi got support from the doctors, who instructed her to allow Kaleigh to make more food choices on her own. Eleven months later, Kaleigh was able to maintain a normal weight.”
The root premise here is (1) that parents must be involved, and (2) that objective reality overrides everything, including screaming and crying. Effective therapy flows from the principle that reality trumps emotions. Period. Parents are coached to be firm and unwavering. Mitzi operated on the premise of objective reality when she stayed the course with her daughter and quite literally forced her to eat. It’s not about authority; it’s about respecting reality, the core of mental health. When one’s desires contradict reality, especially in life-or-death situations, one must choose reality.
Of course, questions about this approach are already surfacing. For example, what if the parents are abusive? Then the child shouldn’t be with them. If the abuse is verbal rather than physical (and therefore not illegal), therapy should hold the parents accountable for their communication. Or, what if the child is already engaged in a power struggle with the parents and forcing her to eat only makes things worse? It’s doubtful that there are many things worse than death by starvation, but if a parent cannot effectively get anywhere, the only reasonable alternative is to put the child back in the hospital. But skilled therapists can often help families come up with other solutions, like the involvement of a trusted relative as a psychological buffer to break the deadlock.
This approach is consistent with other forms of child therapy. If a child develops a drug habit, a responsible parent will try to keep him or her away from drugs. Logic dictates the same when a child develops a starvation habit. Up until this breakthrough, parents and reality were ignored, so the misguided Freudian-based excuse-making and parent-bashing therapists took control.
That’s starting to change, and it’s good news not only for anorexics, but for psychotherapy in general.
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