The road to full recovery - Ch 10 of 'Anorexia and other eating disorders'

This is a section from Chapter 10 of 'Anorexia and other eating disorders – how to help your child eat well and be well'

This chapter really matters as this phase of the treatment is often badly done. If you're tired of reading you can hear me cover the main bits in my Bitesize audios. You can also jump onto my next 'Phase 2′ workshop':

Once eating and weight gain are secure, what else do we need to do? How do we guide our children towards normality and autonomy? What is too much, too soon? What safeguards are needed as we experiment? We look at school, exercise, holidays, recovering ‘normal’ eating, behaviours, beliefs and body image, preparation for college, relapse prevention, and total recovery..

Steps to independence and total recovery

Table of Contents

Anorexia: should my child go to school? — Return to school?

So far we’ve addressed the first tasks of treatment, where we take responsibility for meals and behaviours and restoring our child’s health. Eventually we aim to hand back to our child age-appropriate independence. The work to get there is usually called ‘Phase 2’ of a family-based approach.[1] You will not go overnight from Phase 1 to Phase 2 – rather you will be on the lookout for aspects of your child’s life that they can steer for themselves with wise coaching, supervision and judicious risk assessment. Working towards increasing normality is the focus of this chapter.

Someone with a broken leg can’t and shouldn’t run as soon as the cast has gone. Likewise, there has to be a period of learning, practicing and consolidating after refeeding.

Here are some milestones to recovery, or reasons why your child may be stuck:

Her weight or fat/muscle ratio might need to be higher (her personal needs – not BMI charts – are what matters)

If you were refeeding for weight recovery, she’ll have learned that eating without restriction causes weight gain. Now she needs to experience that when she eats freely (and without compensating with exercise), her weight stays stable.

She needs to experience that it’s safe (and lovely) to eat a wide variety of normal foods in normal (or festive) quantities.

She needs to experience the pleasure of exercise that is not about body shape or weight-control.

Her metabolism may not return to normal for a while, so she may need to continue eating similar amounts as she did when weight gain was the goal. Indeed she may still be very hungry and she needs to experience that eating when hungry is safe.

She may not have normal satiety cues for a (long) while, so she needs guidance to choose sufficient quantities. Otherwise she may involuntarily lose weight.

She may need to maintain the snack habit, because a long gap between meals can re-activate the eating disorder.

She needs time to experience that her body shape is fine, that it doesn’t define her, and that there’s a wonderful life to be lived beyond the world of shape and of food rules. She also needs time to develop wisdom and resilience in a world that is weight and diet-obsessed.

If in spite of all this she continues to suffer from anxiety or depression, or if she has had traumas in her early life, she may now benefit from psychotherapy.

You’re working towards your child’s independence

You should continue to be responsible for your child’s progress, but now you are experimenting with returning small amounts of independence to your child. Compile a list of all the ‘normal’ things that have been derailed by the illness and work your way through it.[3] For instance you might ask your child to choose between two foods, building up to the day she can choose from a restaurant menu. You could let her select her snacks. If a main course is accompanied by peas, you could have her help herself to an adequate portion of those, while you serve the rest. You could ask her if she fancies a second helping. At first, you will be watching closely. Keep your authority to guide and correct. If the outcome is negative, no great harm will have been done. Put yourself back in the driving seat and retry days or weeks later. Don’t blame your child. Keep your cool. It was just an experiment.

Some children need parents to continue making many of the decisions for a long time. If they’re young, there should be no pressure to rush the process, and indeed some children show little desire to make their own food choices. Be guided by their needs, capabilities and emotional age more than by their calendar age. At the other end of the spectrum there are youngsters who are in a hurry to get more autonomy than they can safely handle. Don’t assume your child can suddenly manage any situation wisely. Don’t assume they will tell you the truth if they fail. Early on your child needs to know they cannot misuse their freedom, because you or others are monitoring. For instance I describe further down how meals in school can be supervised. Later you can take more risks (such as allowing meals out with friends) while checking that weight, behaviours, beliefs and mood are improving. Eventually, your monitoring will be done discreetly, with a light touch, so that your child can take pride in their autonomy and in their ability to take good care of themselves.

Practice ‘normal’

This whole phase of treatment and consolidation rests on principles of exposure (Chapter 9). Behaviours become normal and safe as they are repeated and the brain rewires itself. If your son or daughter is soon due to leave for college, you may speed up their autonomy by systematically working on exposure to everything they will need to do independently. If they can’t keep up, better you find out now than after they’ve left.

Too soon or too fast

When there’s not enough consultation with parents and patient, some clinicians push for the child’s independence too early or too fast, leading to restriction and weight loss. That can happen if the clinician hasn’t had much training on this phase, or because they don’t have the complete picture to do a good risk assessment. If they’re not consulting you, perhaps all they see is a smart kid who presents well and who complains that their parents are overbearing. I suggest you meet the therapist alone and describe your child’s behaviours.

According to the FBT manual, if the patient returns to dieting or loses weight, therapists should swiftly motivate parents to re-establish control over eating. So neither you nor your child should get the message that you are stepping back once and for all. You have to be responsive to what your child can manage. What’s too early? the FBT manual advises that Phase 2 can’t begin until the child’s weight has reached a minimum level, and until parents report no significant struggles with meals, and demonstrate a sense of relief that they can manage the illness. If you know these criteria are not yet met, make sure your therapist knows. Usually, ‘significant struggles’ with meals continue until our children are close to weight-recovered, so Phase 2 begins some time after that. If you suspect your child isn’t yet weight-restored, bring all the data you have – pre-illness photos can help too. I know of cases where such a meeting made all the difference.