Yesterday I explained what makes eating disorders so difficult to treat. With this, it is also important to explain that just as not all patients with eating disorders are the same, treatment for them isn’t either. In this week’s article, I will be explaining what makes my approach to treating eating disorders different from others. 

I view anorexia as an anxiety disorder with a focus which is what makes it so unique. The victims are completely bought into the idea that restricting will alleviate their anxiety. It makes sense when you understand how anxiety works. Anxiety is uncomfortable because it is amorphous and free-floating. Fear is easier to manage because it is focused. Many people experiencing high levels of anxiety choose to focus on a specific fear for that reason. In the case of anorexia, it is the fear of gaining weight or getting fat. 

In other words, the fear provides focus and direction; Eat less and lose weight. The added benefit is all of the attention, some of which is positive and some of which is not. Irrespective of how people react, the rewards are built-in as the individual suffering from anorexia quickly learns that she can excel at something easy to define and simple to put into motion. Over time it becomes easier and easier to restrict which leads to relentless weight loss. Body dysmorphia prevents her from understanding how thin she has become or how dangerous it is.

Losing weight in a society that worships thinness makes the anorexic feel powerful, in control, accomplished even. At some point, what started as a way to manage anxiety, becomes full-blown anorexia or bulimarexia, and that changes every aspect of the anorexic’s life. When this happens s/he will do anything to protect the disorder.

That is why asking the anorexic to give up the anorexia makes no sense to them. The patterns of behavior, the rituals, and the isolation quickly become addicting because they are so comforting. The issue then is how to treat a patient who does not wish to “get well.” This is where the rubber meets the road for parents and therapists. In order to help the child/patient both the parent and the practitioner have to stay in their lanes, but they also have to work closely together for treatment to be effective. 

Most treatment for these disorders fails. The only approach shown to be effective is a family systems-based approach that recognizes the importance of these two roles (parent and practitioner) and the need to keep them separate. It is called the Maudsley approach. It is one in which the parents mandate eating and treatment, while the therapist supports the patient as well as the parents in their journey.

That sounds easy enough, right? Not really. Remember, individuals suffering from anorexia do not want to get well. On the contrary, they will protect the eating disorder at all costs. To do so, they have to be vigilant, always staying two steps ahead of their parents, significant others, and therapists. Their stance, which is one of full cooperation for everything and anything except gaining weight, is often misunderstood by an inexperienced therapist or by someone who doesn’t understand the anorexic mindset. The key is to appear very compliant, while simultaneously restricting and losing weight. If the therapist is onto them, then the goal is to get rid of the therapist. 

This is where the relationship between the parent and the practitioner becomes critical. For starters, the parents and the therapist must be on the same team in order to be effective in fighting the anorexia. Notice I’m not saying in order to fight the anorexic, I’m saying the anorexia. I make this distinction because anorexia creates a mindset that is psychotic-like, ergo the diagnosis “anorexia nervosa psychosis” and therefore very difficult to understand. However, never underestimate this anorexia mindset because it wields great power. Often the patient manipulates everyone in the family as well as healthcare providers in truly masterful ways to prevent them from getting in the way of losing more weight or giving up control. 

Come back next week to find out how working as a team with your MD, therapist, and family members really makes a difference in treatment.