This is a section from Chapter 9 of ‘Anorexia and other eating disorders – how to help your child eat well and be well’
Our children can remain stuck in an eating disorder while they’re scared of certain foods or situations. In this chapter I describe how they can be desensitised to their fears through systematic exposure. Then I give you a practical example of a desensitisation session.
A common treatment for phobias is exposure[i] to the object of fear. Repeated exposure makes us desensitised. It’s like we get bored. We know nothing bad happened, so we stop being alert. The brain creates new connections, and fear reactions don’t get activated any more.
This is why fairground rides lose their edge when we go on them repeatedly. Recently, my daughter and I went down a dramatic water slide, the kind where you’re sitting on a rubber ring and clinging on for dear life. First time, you come out of it with your body shaking even while you’re laughing and telling everyone else they absolutely must have a go. Second time, it’s fun. Third time, the attendant says, ‘You’ve been here before.’ And then he spins you. You come out shaking and raving about it all over again.
What the attendant knows is that after two exposures, there’s not much fear to be had. The brain has worked it out. ‘This is OK. It feels like you’re falling and you scream and your heart rate shoots up, but nothing bad happens.’
I found the same when I went for some MRI scans. I feared I might be claustrophobic, so first time round I had to work quite hard at keeping calm. In the same session, I was put back in for another twenty minutes. I’d been lying there for a while when I noticed I was day-dreaming. When I had a third scan a few months later I practically fell asleep.
Desensitising to fear foods
We need to do something similar to free our kids of the many rules created by anorexia. Chances are that the eerie compulsive behaviours that popped up with the illness will fade away with weight recovery, but most of us need to be more pro-active when it comes to the long list of foods our kids cannot eat. This is not our priority when we’re desperate for our kids to eat anything because they’re terribly unwell[ii]. But after you’ve established a bit of a feeding habit, you might want to consider introducing some variety. For one thing, if you need to feed a massive amount of calories for weight-restoration, chances are you can’t do it without foods your child finds pretty scary.
As you know, my kid spent nearly a year bumbling along in hospital, mostly maintaining a good weight, but with anorexia keeping a grip on her thinking. I think that although she was well-enough weight-restored for the anorexia to recede, she was trapped by the fear responses her brain had become accustomed to. Her harmful behaviours were the only ways she had to cope with fear. I attribute the fast progress she made back home to our increased ability to give her unconditional love and support, but also to our DIY form of exposure therapy. We made it up as we went along, but since then I’ve learned more from other parents, and seen the principles of conditioning at work in – of all things – positive dog training.
Plan or surprise?
One approach to desensitisation is to help your child list all their ‘no’ foods in order of fearfulness. If your child finds it helpful to be involved in meal plans, you’d want to ensure fear foods feature on it. You could agree that once a week, you’ll serve one new food from the scary list, starting with the easiest. Presumably, you’d also start with small portions. I had heard of teens with a decent amount of motivation who were willing to plan and be challenged, and I’d assumed it couldn’t work with a young child, but since then I’ve learned of a seven-year old for whom this works.
Another approach is for you, the parent, to decide which foods to introduce when, without discussion. I talked about the ‘Magic Plate’ system earlier. This is what we did, because we knew that our daughter got no benefit from negotiation and forewarning. She’d had all that in hospital, and after a year the range of foods she could tolerate was still very small.
Everyone’s different, so observe your child when she’s involved in decisions to introduce new foods. My thinking, based on what I saw in my daughter, is that it would be remarkable if she was ready to commit to something utterly terrifying. You can forgive kids with anorexia for wanting to aim very low. Whereas as a parent, you can aim higher, and then help your child cope in the moment.
I experienced this myself when I had one-to-one phone conversations with our Family-Based Therapy specialist prior to our family meetings. I’d consider scrapping the stupid butter portions, I’d say I’d think about ditching the troublesome meal plan, but at that particular moment, I did not feel at all brave enough to commit. In my mind, these were ideas to consider for several weeks down the line. Then often as not, a perfect opportunity would present itself the next day, and I’d implement the change without a flutter of hesitation.
My daughter could cope much better with a fait-accompli than with discussion. Occasionally she asked ahead of time what was for dinner, and we learned to deny her the information. It seems that forewarning made her anorexic voice go on overdrive. Her stress levels shot up, and eating was harder.
For that reason, we did not introduce foods in order of scariness, but varied the difficulty. Otherwise she’d have kept fearing how much harder it was going to get.
Now I’ve told you about my daughter, remember, once again, that your child might be totally different:
“If she knows what is coming for the next day, she seems to get most of the feelings out at that time and then sitting down for the meal is OK. It’s like she needs to rage against it before it is OK for her to eat it.”
Rip or Tug the Band Aid?
Exposure therapy for phobia is typically a gradual process, starting with the least scary situation and moving towards the most terrifying one at the end. Each new situation is like a step up a ladder. You move up a step when you’ve become desensitised to the fear around the previous step. That way you never have to cope with a huge amount of fear. Bear in mind that the method is normally used with patients who are highly motivated to rid themselves of the phobia and are willing to put some work into it. Not a luxury we enjoy with anorexia.
Another approach to phobias is ‘flooding’: a full-on exposure to the object of fear. It’s said to be more traumatic, but give faster results. In our case, something close to flooding wasn’t just a faster route, it was the only route. If my kid was allowed any amount of time on one step of the ladder, she was driven to step down to a lower rung. Going slowly meant going backwards.
For example, when my daughter was dependent on her old hospital meal plan, we replaced her beloved, packaged, butter portions (which were hard to source) with our own butter cut from a normal packet. We stooped as low as telling her we were weighing the damn butter and the quantity was identical. The rest of her meal stayed the same. In terms of phobia desensitisation, that’s a pretty small step up the fear ladder. But her anorexic voice thought differently. An entire meal could become excruciating for her because the butter on the side of the plate was not a hospital portion.
We did a kind of flooding, or ‘ripping the Band Aid’, when we told her we were not weighing foods any more. Any foods. Ever again. Of course she was distressed and fought it for a few meals, but then, she had fought just as hard over just one piece of butter. The downside with flooding is you may have chaos for anything from a day to a week. We could take the risk of her refusing meals because she was, by then, pretty healthy and we had some confidence in our abilities to manage mealtimes come hell or high water. Within a few days, she’d overcome a whole lot of anxieties and stopped expecting her food to be weighed. This paved the way for the next challenges, such as the ability to eat food outside the home.
Family-Based Treatment, which gets good results, leaves it up to parents whether they want to flood or go more gradually. The message, basically, is that either is fine. An example that James Lock et al give of a small steps approach would be to give your child the correct amount of food for weight gain, but once a week, ask her to eat one new food, for example, cheese. The type of cheese could be up to her. My hunch is that if she is able to go along with this without too much resistance, fine, but if you have high drama at every step, you might as well make use of all that pain to go for big gains.
“We ripped. Every food was a fear food. Go with your gut and what you think will work.”[iii]
“When we were aiming for weight gain, we ripped. When we were working through the list of fear foods, we tugged.”
You can play with both approaches and learn from experience. Suppose your kid was so freaked out over a portion of beans that she ate none of her meal, you could ease up on the next day and include a small number of beans in an otherwise easy meal, gradually increasing quantities over a week. But you could also experiment with ‘flooding’ her again with a full portion of beans: with my daughter, I was often surprised how exposure resulting in failure one day could prepare her for success the next day.
“We started with ‘tugging the Band Aid’ to minimize the stress at meal time as husband was having a very hard time with the constant battles. Our FBT therapist was not in favor of this but it was putting weight on our daughter at a reasonable rate and not tearing our family apart. After about 6 weeks our daughter complained about the lack of variety. I took this as my cue to go ahead and rip: she scarfed down a bacon and cheese omelette. Now we are introducing fear foods almost daily.”
Can challenges be too stressful for your kid?
You may have got into the habit of walking on egg shells. If you demand something ‘too difficult’ of your child, will she have a tantrum and eat even less? Can you stress your kid too much? Will she sink further into depression or rebellion?
“My daughter’s mood went from upbeat and happy (when we first started refeeding) to absolute rages and depression about 7-10 days later. She was the lowest of the low at that point…..but it was the beginning of the long climb out. At the time, I remember thinking, ‘This isn’t helping…it’s only making her worse!’ But, the FBT therapist assured me it was within the bounds of normal, and that it was, in fact, a positive sign that the ED was on the run, and on the defensive.”[iv]
Clearly, parents must aim to feed quantities sufficient for their child to achieve weight gain. But should you launch a full-scale attack on anorexia, or should you proceed gradually and build on successes?
[Jumping to another section of the chapter…]
Exposure therapy for other anxieties or phobias
You can tackle anorexic behaviours with desensitisation if you find they’re not shifting fast enough on their own. This could apply to OCD-type behaviours (my understanding is that exposure is a treatment of choice for OCD), but also to your kid being unable to sit, or her attachment to big baggy ultra-covering clothes, or to the way she chews. You could use exposure to tackle her fear of eating in company, of making food choices, of moderating her exercise, and even to her hateful or rejecting behaviour towards a parent. If once a week your child is shown how much she weighs, I imagine that is a form of exposure therapy.
[Jumping to another section of the chapter…]
Helpful principles of exposure
Exposure creates new connections in the brain
Ever since Pavlov and his dogs, scientists have studied how the mind is conditioned to react in certain ways to certain stimuli. I am guessing that at various stages of their anorexia, our kids have found safety and reassurance in certain behaviours, and any deviation gives rise to high anxiety.
I like the analogy of tracks in the snow. If you’ve ever gone cross-country skiing, you’ll know that if a trace has been laid, that’s where your skis will go. When we do exposure, we force the skier to go into unmarked snow and lay down new tracks. At first, the tracks are shallow, and the skis tend to go into the earlier, deeper grooves. But if we can get the skier to go over the new tracks again, these will eventually become the most natural route to follow.
For the brain, I believe that the equivalent of tracks in the snow is the creation of new pathways between neurons, the strengthening of synaptic connections. You may have heard that ‘As neurons fire together, they wire together’. The same mechanism that has locked your child in her fears is the mechanism that will free her.
[Jumping to another section of the chapter…]
Transformed through exposure: from fear to fun
If you like dogs you might enjoy watching a video[vii] showing how a little dog called Kiko, who had ‘learned’ to be fearful of crossing the kitchen floor after slipping on it, gets desensitised through gradual exposure and positive reinforcement. Every time the dog hears a click, she feels pleasure because she’s been conditioned to equate clicking with the likely arrival of a treat. The pleasurable feeling reinforces what the dog is doing. In other words, a click sends a direct message to the brain: whatever you’re doing right now, do more of it! With our kids, we can’t give pleasure with food treats, but with our words and body language, our humour, love and distractions. Clicker-training for dogs won’t give you a cure for anorexia, but it may just help you appreciate how much you can help your kid shift her behaviours.
[End of extract from the chapter]
In this chapter:
- Desentising to fear foods
- The magic of desensitisation
- Plan or surprise?
- Rip or tug the Band-Aid?
- Respond flexibly to present needs
- Can challenges be too stressful for your kid?
- Virtuous circles and lasting improvements
- Example: working systematically through a list of fear foods
- Example: from packaged food at home to the ability to order anything in a restaurant
- When can exhausted parents take a break?
- Exposure therapy for other anxieties or phobias
- How to make exposure work for you
- Be a fly on the wall: a desensitisation session
Next chapter: The road to full recovery
[i] A type of exposure therapy used with anorexia is Exposure and Response Prevention, abbreviated as ERP or EXPR. We weren’t given any particular approach, but made it up as we went along.
[ii] When a child is finding it hard to eat anything, we’re doing a kind of exposure therapy simply by getting them to eat something. The fact that this is repeated five or six times a day, every day, may be a reason why refeeding one’s child is part of the treatment for anorexia: we’re not just getting the calories in and the weight on, we’re changing how our child’s mind operates around food.
[iii] From alwaysvigilantCAN, posting on the Around the Dinner Table forum.
[iv] From ‘Minnesota Mom’, posting on the Around the Dinner Table forum
[vi] Modern dog training uses ‘classical’ and ‘operant’ conditioning, and is referred to as ‘positive’ because new neural paths are created through pleasure, while punishment, fear or coercion hinder progress. The classic text on these principles is ‘Don’t shoot the dog’ by Karen Pryor: http://amzn.to/Vtvqie, and if you’d like to see some of this in action, search for ‘clicker training’ videos, such as the delightful Kikopup’s: http://www.kikopup.com/Dogmantics/Free_Video_List.html