Section 4: Clinical and Practical Ways to Talk to Your Patient (Part 2)

10 - Not eating the food carefully prepared following the recipes but insisting that others do eat it.

This is can spark a conversation about self-deprivation and about giving to others what the patient cannot give him. At this point, the patient has a full-blown eating disorder.

This point is an extension of point 9 in which the patient prepares food for the whole family and insists that others eat it. Families dealing with this would do well in not changing their normal eating behaviors to cater the disordered behavior.

The family of the patient may accept eat what was prepared by the patient if they would eat that food anyway. The family may want to consult with the patient’s therapist and medical team to see where is the patient in his recovery process to see if he or she can eat with the family. Some schools of thought stress that patients can eat alone at the family table while other professionals want the patients to eat with the whole family, during meal times.

In any event, patients need to be made aware that they will not be allowed to feed others while starving themselves.

11 - Not eating the food regularly prepared for the family by the person in charge of cooking in the family.

By the time teenagers are isolated and not eating meals with the family, they may have a full blown eating problem. At the point this sign occurs, the primary work in handling the problem may consist of consultation with the family – in conjunction with referring the client for specialized services.

There are three essential items for the family to make clear to the child with the eating disturbance: 1) The child will not be allowed to starve themselves to death; 2) The child will not be allowed to turn the family life upside down; and 3) Outside of those parameters, the child will be given some – but only some - latitude in choosing certain foods according to their preferences.
If patients choose not to eat what has been prepared for the family, then they become utterly responsible for purchasing and taking care of their meals.

Parents must be helped to understand not only the content of these discussions, but also the manner in which these items are to be discussed. Generally speaking, it is best if these items are presented in a very matter of fact approach – calmly, positively and supportively.

It is important that parents be helped to understand the importance of not turning this conversation with their child into a fight. Anorexia nervosa and bulimia nervosa are diseases. If their child could, they would not choose to be anorectic.

As we have mentioned above, under point 10, different techniques allow for different approaches. Some allow the teenager to eat at her own pace and alone, provided that there is an agreement that the food will not be thrown out by the child. If food is thrown the patient will have to deal with consequences such as having to eat with the family.

Other more behavioral approaches demand that the patient eats all meals with the family or the group.

When patients are at a point with their obsession that family life is no longer a possibility, it is sometimes best to allow them to be in the contained secure environment of an eating disorder mental health facility.

12 - Turning into a vegetarian, while cutting back the fat content of foods.

Some teenagers have a phase in which they turn into vegetarians. Parents need to gauge if this is a phase, or a part of a bigger picture: the incubation of an eating disorder.

A vegetarian teenager may be a vegetarian, but eat pasta and eggs and fruits and ice creams. She may have a philosophical position sustaining her behavior. She may read and be knowledgeable about animal rights and animal liberation. Fat content may not be a part of her discourse. However, if the vegetarian teenager reads labels and she is concerned with every morsel of food she ingests, then parents may well set up an appointment to assess an eating problem.

Sometimes, parents come into a consultation very anxious because their son or daughter has become a vegetarian. Clinicians may want to make parents feel less anxious by letting them know that not any one behavior is problematic in itself. They may tell parents that clusters of behaviors or degrees are what they need to look for.

Furthermore, teenagers may have different understandings of what it means to be a vegetarian. For some it means not to eat meat and for others it includes meat and everything that is dairy. Some teenagers become vegetarian as a way to control something about their environment.

Others may become vegetarians for philosophical or religious reasons. For some it may be a phase; while for others it may become a way of life.
However, parents should be made aware though, that the vegetarianism should not be an excuse to cut out other important nutrients from the teenager’s food intake.

In other words, parents should be aware if their child is cutting first red meat, then all meat, then fat and diary, and later carbohydrates. If this is the case, the vegetarianism is no longer a belief based on a philosophy but a rationale that is an excuse for the eating disorder to take hold of the patient.

13 - Extreme Dieting.

Many teenagers move from being a vegetarian to extreme dieting. They feel grossed out seeing meat, flesh and fat, and little by little they eat not much else than lettuce. Parents need to know that eating disordered patients cut out or try to cut out:

- fat
- carbohydrates
- protein
- cheeses

When patients engage in cooking, but not eating, they show that they are denying their desires and that they are at the same time desperately trying to get a glimpse of what they are denying themselves.

Depending on the approach, therapists may need to work with their patients in what are the foods that they may feel safe eating. Some patients may allow themselves a taste of something, while others may need a nutritionist to begin the road to eating healthily.

As we have discussed before, it is important that parents know what their child’s friends are doing. This is true in the case of adults as well. If a person is friends with a group of people who are into appearance, chances are that the person will also be concerned about his or her looks.

It is important to know, for instance, that in some public schools there are cracker lunches. Cracker lunches mean that the most popular girl in the class brings crackers and water for lunch. Pretty soon, her friend does the same, and her friend’s friend does it, too. Anybody that brings in a normal lunch is considered ‘a pig’ by the popular group. No one, of course, wants to be considered a pig by the popular group.

Extreme dieting can take many forms. The cracker lunch is one. Parents may need to monitor their children’s behaviors without infantilizing them. Conflict about dependency needs is common at this age. Teenagers may be at once wanting and fearing independence. They may also feel insecure about their role in our society, even at school. The realm of eating and body is an area of their lives that can provide them with the illusion of control.

14 - Inability to sleep.

Some anorectic patients and bulimic patients cannot sleep. They are either exercising at night, or binging or purging. Sometimes their sleep is disturbed because they are either thinking about food, or feeling remorse about what they ate. Sometimes, patients are depressed and their sleep mechanism is disturbed.
By the time a patient has sleeping disturbances associated with their eating disorder, help from a professional is generally needed to address the problem. This may include the intervention of a psychiatrist to medicate them.

15 - Being awake in the middle of the night with thoughts of food.

As we have mentioned in point 14, eating disorders may bring inability to sleep to patients that suffer from them. Many patients are too hungry to be able to sleep. Others wake up to visit the refrigerator and binge. Some dream about the foods they forbid themselves to eat during the day.

It is important that therapists engage their patients in talking about what happens for them, at night. This needs to be done in a very gentle and non judgmental way since some patients are too ashamed of themselves to ‘confess’ that they eat at night or, that they dream about food.

Therapists may want to keep an ear to see if the patient’s stomach growls during sessions. He may want to gently ask about what the patient thinks the growling is all about.

Patients may be so tired and hungry during a session that they can barely stay awake and their stomachs do not stop growling. These are very hard sessions for a therapist to endure. It is time to discuss hospitalization while bringing up that the patient seems to have no relief from the disease - not even while others are sleeping.

Sometimes this realization shocks patients who then see the gravity of their problem. They also may welcome the idea that they will have some relief, although not many would be forthcoming with this relief.

16 - The visiting of pro-anorexia sites on the web.

Unfortunately there are anorexia sites in the internet that defend anorexia as a way of life. These sites entice young people to not eat and there are points won by eating less than 1000 and less than 500 calories a day.

Parents need to know what sites their teenagers visit. If possible, computers need to be in an area of the house where everybody comes and goes. Individuals who suffer from eating disorder individuals may isolate themselves further if they have the computer in their room.

17- The visiting of dieting sites on the web.

When patients spiral down into a full eating disorder they may visit dieting sites, in addition to sites that are pro-anorexia. Therapists might want to talk with parents about blocking computers to prevent access to these sites.

They may also want to talk to the patients about what these visits mean for the patients and what her or she is trying to achieve (or feels) while visiting these sites.

It is always illuminating for therapist to understand patient’s idiosyncrasies:

“My mother loves my sister more than she does me and she is so thin, I want to know how she is so thin so I can be thin too, she looks great!”

It is important for the clinician to know that sometimes mothers and daughters join these diet programs and try to lose weight together. As a therapist the clinician needs to stress that this is an activity not to be done by mothers and daughters or fathers and daughters.

In accordance with what has already been said, the clinician may want to stress that teenagers and young adults need to be accepted as they are by their parents, in order to have an appropriate self-esteem and good relationship with their bodies.

18 - Using layers of clothes to cover up the body regardless of temperature

Using layers of clothes to cover up the body already denotes a full blown eating disorder or one that is well on the way. When the layer of fat in a person’s body is minimal or non-existent, the person has no tolerance for cold. Many anorectic patients have no tolerance for cold. Some of these anorectic patients may be so thin that they need the extra cushion provided by clothing to be able to sit mildly comfortable in a hard surface.

Some bulimic patients may have used thyroid pills to speed up their metabolism. When the thyroid pills are withdrawn, they experience hypothyroid and suffer from cold due to these metabolic disturbances.

In any event, the clinician must be aware of and notice the amount of clothing that the patient is wearing in relation to the weather, as it will give her or him an idea of where the patient is standing with regard to her eating problem.

19 - Not allowing others to see the body.

This already denotes a full eating disorder and ironically the patient now, does not want to show the body that she so hard worked to have. When this happens the professional and the caregiver in charge needs to know that things are serious and that hospitalization might need to be the road to go.

If parents come into a consultation saying that their child does not allow them to see her without clothing or in a swimming suit, the clinician must inform the parents that the situation may call for immediate hospitalization.

Many times, anorectic patients get to be so thin that they refuse to be seen without clothing. If the clinician does not feel that the patient needs hospitalization yet, the fact that she is ashamed of how thin she is can be a token for leverage for the treating therapist. It may allow the clinician to bargain about services: if the patient herself does not want to be seen, then she needs to ‘do something about it’ not to be hospitalized yet. A plan for eating may be designed with the patient’s okay.

Some eating disorder inpatient units allow the patients to be involved in the cooking meal plans that they will have to consume. In collaboration with nutritionists, these facilities work daily with the eating disordered patients to make them feel as comfortable as possible with food.

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