Katharine Loeb, PhD responds:
I want to start by commending you on several fronts. First, you mobilized quickly to begin getting your daughter the help she needs and sound determined to see her recovery through. Second, even if what you are currently facing and what lies ahead seems daunting, you are presenting a calm and committed front to your daughter, already sending a message that you will not be deterred or frightened by the eating disorder in the process of restoring her to health. You are also separating the illness from your daughter, which will make it easier for you to take action that is met with extreme conflict, knowing that it is the anorexia nervosa, not your daughter, pushing back. Third, you are already implementing specific and effective strategies such as supervised meals, even if she protests. This combination of attitude and strategy will serve you very well in the face of this significant challenge.
I would also like to normalize your experiences thus far. Most of the patients we see in family-based treatment for anorexia nervosa are, by definition, resistant to the idea of nutritional rehabilitation. The cardinal feature of this disorder is fear of weight gain. This fear can manifest in all the ways you describe, and typically is exacerbated by active attempts at refeeding. In other words, your daughter’s response to your efforts indicates that you are doing something right, not wrong. Not only can you be personally assured of this, but you can also be comforted knowing that the healthy part of your daughter – even if it significantly occluded by the anorexia nervosa at this point – does not want you to back down. I know this from my professional perspective as a clinician and researcher, and, most importantly, directly from adolescents who have thanked me and their parents in later phases of treatment for not giving up early on when the illness made them emotionally dysregulated, irrational, or unpleasant.
To sustain the Maudsley framework and work effectively within it, the help and support of a practitioner trained in or supportive of the approach will undoubtedly be very useful to you, and I hope one is available in your area. Maintaining a judicious blend of firmness and empathy with your daughter will also be key, as will presenting an extremely united front with your husband around issues of refeeding so the illness has no room to negotiate. Parents are often surprised at how effective these pieces of advice are when implemented, but they reflect exactly how an inpatient staff operates. Moreover, you have an important incremental advantage over a professional staff in that you love your daughter and are more motivated than anyone to see her well again. Your daughter’s complaints of heartburn may be objective, subjective, an excuse of the eating disorder, or a combination thereof, but should not distract you from your efforts, especially if she was able to eat in the hospital and is cleared by her physician for a range of foods. Please think of every meal and snack as a unique opportunity to reverse the illness by a measurable degree, and feed your daughter the most densely caloric and nutritious foods as possible to meet her level of starvation and medical complications. Hopefully, with professional assistance in expanding on what you are doing already, another hospitalization can be avoided.
