Emma’s father was short and compact—he was a soccer player, I learned. He looked a little like Hitler, I realized with unease—he had a thin mustache and dark, pressed hair, and a way of barking when he talked, as though behind every communication was the insistence on not being ignored. Later I would have individual sessions with each of Emma’s parents, and I would ask her father how he had decided on his career as a police officer. He told me that as a boy he had walked with a limp, and his father had called him Shrimpy-Limpy. He chose to be a police officer because it required risk taking and physical strength; he wanted to prove to his father that he wasn’t a shrimp or a cripple. When you have something to prove, you aren’t free. Even though I didn’t yet know anything about his childhood during our first visit, I could tell that Emma’s father was living in a prison of his own making—he was living within a limited image of who he should be. He behaved more like a drill sergeant than a supportive husband or concerned father. He didn’t ask questions; he ran an interrogation. He didn’t acknowledge his fears or vulnerabilities; he asserted his ego.
His wife, who wore a tailored cotton dress with buttons down the front and a thin belt, a look that was both timeless and no-nonsense, seemed hyperattuned to his tone and speech. He talked for a few minutes about his frustrations at work when he was skipped over for a promotion, and I could see her searching for a careful balance point between affirming his indignation and stoking his anger. She had clearly learned that her husband needed to be right, that he couldn’t handle being confronted or contradicted. In our private session, I would be impressed by her resourcefulness—she mowed the lawn and did many of their home repairs, she made her own clothes—and the seeming contradiction between her skills and the power she gave over to her husband, the price she paid to keep the peace. Her habit of avoiding conflict with her husband at all costs was as damaging to her daughter’s health and their family dynamic as were his domineering behaviors. They were partners in making control—not empathic connection, not unconditional love—the language of the family.
“This is a waste of time,” Emma’s father finally said during our first visit, after answering my questions about his job, their family routines, how they celebrated holidays. “Just tell us what to do.”
“Yes, just tell us how we can get Emma to come to the table at mealtime,” her mother begged. “Tell us how we can make her eat.”
“I can see how worried you are about Emma. I can see how desperate you are for answers and fixes. And I can tell you that if you want Emma to get well, your first job is to understand that with anorexia, the issue isn’t only what Emma eats; it’s also about what’s eating her.” I couldn’t just fix her and send her back, her healthy self, I told them. I invited them to help me, to be my cotherapists, to observe their daughter, but not with the agenda of making her do or be anything different, just paying attention to her emotional states and behaviors. Together we could build a clearer picture of her emotional landscape and get more familiar with the psychological aspects of the disease. By enlisting their help and cooperation, I hoped to lead them toward an understanding of their part in her illness. I was nudging them toward taking responsibility for the way they contributed to what was eating Emma.
The following week, I met Emma for the first time. She was fourteen years old. It was like meeting my own ghost. She looked like I had at Auschwitz—skeletal, pale. She was wasting away. Her long, stringy blond hair made her face look even thinner. She stood in the doorway of my office, her too-long sleeves pulled all the way down over her hands. She looked like a person with a secret.
With any new patient, it’s important to be sensitive to his or her psychological boundaries from the very first moments of our initial encounter. I must intuit immediately if this is a person who wants me to take her hand or keep my physical distance, if this is a person who needs me to give him an order or a gentle suggestion. For a patient with anorexia—a disease that is all about control, about relentless rules for what and when you eat or don’t eat, for what you reveal or conceal—these first moments are critical. For one thing, anorexia has an inescapable physiological dimension. Because of the lack of nutrients entering the body, and because the bulk of the few calories consumed go to autonomic functions (breathing, elimination), the brain is deprived of blood flow, and this leads to distorted thinking and, in severe cases, paranoia. As a psychologist beginning a therapeutic relationship with a person with anorexia, I have to remember that I’m communicating with a person who likely has distorted cognitive functioning. It’s easy for a habitual gesture—putting a hand on someone’s shoulder as I guide her to a comfortable chair, for example—to be misinterpreted as threatening or invasive. As I greeted Emma for the first time, I tried to simultaneously warm and neutralize my body language. Because someone with anorexia is an expert at control, it’s important to disarm her need for control by offering freedom. At the same time, it’s vital to create a structured environment where there is safety in clear rules and rituals.
Having met her parents, I knew that the home language was full of criticisms and blame, so I began our session with a compliment. “Thank you for coming,” I said. “I’m so happy to finally meet you. And thank you for being right on time.”
When she had chosen a seat on the couch, I told her that anything she told me was confidential—unless her life was in danger. And then I made a soft, open-ended invitation. “You know, your parents are so worried about you. I’m interested to know the real story. Is there anything you’d like to tell me?”
Emma didn’t respond. She stared at the carpet, tugging her sleeves even farther over her hands.
“It’s okay to be silent,” I said.
More silence stretched between us. I waited. I waited some more. “You know,” I said after a while, “it’s fine for you to take as long as you need. I have a little paperwork I need to do. I’m going to go work in the other room. When you’re ready, let me know.”
She eyed me suspiciously. In a home with punitive discipline, children grow accustomed to hearing threats, and these threats can escalate quickly or, at the other extreme, prove empty. Although I was speaking kindly, she was looking to see if my words and tone were going to escalate into an angry criticism or admonition, or if I wasn’t really going to leave the room, if I was just a pushover.
I think she was surprised when I simply stood up, crossed the room, and opened the door. Only then, my hand on the doorknob, did she speak.
“I’m ready,” she said.
“Thank you,” I said, returning to my chair. “I’m happy to hear that. We have forty minutes left. Let’s use them well. Is it okay if I ask you a couple questions?”
She shrugged.
“Tell me about a typical day. What time do you wake up?”
She rolled her eyes, but she answered my question. I continued in this vein. Did she have a clock radio, or an alarm clock, or did her mother or father come to wake her up? Did she like to lie in bed for a while under the covers, or did she jump right out of bed? I asked her mundane questions, getting a sense of her daily life—but none of my questions had anything to do with food. It is so hard for someone with anorexia to see anything in life outside of food. I already knew from her parents that her focus on food was controlling her family, that all of their attention was consumed by her illness. I had a feeling she expected me, too, to be interested only in her illness. With my questions I was trying to shift her attention to other parts of her life, and to dismantle or at least soften her defensive structures.
When I had worked through a day in her life, I asked her a question that she didn’t know how to answer. “What do you like to do?” I asked.
“I don’t know,” she said.
“What are your hobbies? What do you like to do in your free time?”
“I don’t know.”
I walked over to the whiteboard that I keep in my office. I wrote, I don’t know. As I asked her more questions about her interests, her passions, her desire
s, I put a check mark for every time she said, “I don’t know.”
“What are your dreams for your life?”
“I don’t know.”
“If you don’t know, then guess.”
“I don’t know. I’ll think about it.”
“A lot of girls your age write poems. Do you write poems?”
Emma shrugged. “Sometimes.”
“Where would you like to be in five years? What kind of a life and career appeal to you?”
“I don’t know.”
“I’m noticing that you say these words a lot: I don’t know. But when the only thing you can think is I don’t know, that saddens me. It means you’re not aware of your options. And without options or choices, you aren’t really living. Can you do something for me? Can you take this pen and draw me a picture?”
“I guess.” She walked to the board and pushed her thin hand out from her sleeve to take the pen.
“Draw me a picture of yourself, right now. How do you see yourself?”
She uncapped the pen and drew quickly, her lips pursed. She turned so I could see her drawing: a short, fat girl with a void, blank face. It was a devastating contrast—skeletal Emma beside a blank, fat cartoon.
“Can you remember a time when you felt different? When you felt happy and pretty and fun loving?”
She thought and thought. But she didn’t say, “I don’t know.” Finally she nodded her head. “When I was five.”
“Could you draw me a picture of that happy girl?”
When she stepped away from the board, I saw a picture of a dancing, twirling girl in a tutu. I felt my throat catch, a spasm of recognition.
“Did you take ballet?”
“Yes.”
“I’d love to hear more about that. How did you feel when you were dancing?”
She closed her eyes. I saw her heels pull together in first position. It was an unconscious motion, her body remembering.
“What are you feeling right now as you remember? Can you give that feeling a word?”
She nodded, her eyes still closed. “Free.”
“Would you like to feel that way again? Free? Full of life?”
She nodded. She put the pen on the tray and tugged her sleeves down over her hands again.
“And how does starving yourself get you closer to this goal of freedom?” I said it as warmly, as kindly as I could. It wasn’t a recrimination. It was an effort to bring her into an unflinching awareness of her self-sabotage and of how far she had taken it. And it was an effort to help her answer the most important questions at the outset of any journey toward freedom: What am I doing now? Is it working? Is it bringing me closer to my goals, or farther away? Emma didn’t answer my question in words. But in her teary silence I could sense her recognizing that she needed and wanted to change.
When I met with Emma and her parents all together for the first time, I greeted them with enthusiasm. “I have very good news!” I said. I shared with them my hope, my confidence in their ability to work as a team. And I made my own participation in the teamwork conditional upon their agreeing that Emma would also be in the care of the medical staff at an eating disorder clinic, because anorexia is a serious, potentially fatal condition. If Emma ever got below a certain weight, which would be determined in consultation with the staff at the clinic, she would have to be hospitalized. “I can’t risk you losing your life over something that can be prevented,” I told Emma.
A month or two after I started working with Emma, her parents invited me to their home for a family meal. I met all of Emma’s siblings. I noticed that Emma’s mother introduced each of her children with qualifiers: this is Gretchen, the shy one, and Peter, the funny one, and Derek, the responsible one. (Emma had already been introduced to me: the sick one.) You give children a name, and they play the game. This is why I find it useful to ask my patients, “What was your ticket of admission in your family?” (In my childhood, Klara was the prodigy, Magda was the rebel, and I was the confidante. I was most valuable to my parents when I was a listener, a container for their feelings, when I was invisible.) Sure enough, at the table Gretchen was shy, Peter was funny, Derek was responsible.
I wanted to see what would happen if I broke the code, if I invited one of the children into a different role. “You know,” I said to Gretchen, “you have such a beautiful profile.”
Their mother kicked me under the table. “Don’t say that,” she admonished me under her breath. “She’ll end up conceited.”
After dinner, while Emma’s mother cleaned up in the kitchen, Peter, who was still a toddler, was pulling on her skirt, asking for her attention. She kept putting him off, and his attempts to get her to stop what she was doing and pick him up became more and more frantic. Finally he toddled out of the kitchen and went straight for the coffee table, where there were some porcelain knickknacks. His mom ran after him, swooped him up, spanked him, and said, “Didn’t I tell you not to touch those?”
The spare-the-rod-spoil-the-child approach to discipline had created a climate in which the children seemed to get only negative attention (bad attention, after all, is better than no attention). The strict environment, the black-and-white nature of the rules and roles imposed on the children, the palpable tension between the parents—all made for an emotional famine in the home.
I also witnessed the highly inappropriate attention that Emma’s father paid her. “Hey there, Hottie,” he said to her when she joined us in the living room after dinner. I saw her shrink into the couch, trying to cover herself. Control, punitive discipline, emotional incest—no wonder Emma was dying in the midst of plenty.
Like all families, Emma and her family needed rules, but very different ones from those they were operating under. So I helped Emma and her parents to make a family constitution that they would help one another to enforce, a list of family rules that would improve the climate in their home. First, they talked about the behaviors that weren’t working. Emma told her parents how much hearing them yell and blame frightened her, and how resentful she felt when they changed the rules or expectations at the last minute—what time she had to be home, what chores she had to finish before she could watch TV. Her father talked about how isolated he felt in the family—he felt like the only one disciplining the kids. Interestingly, Emma’s mother said something similar, that she felt like she was parenting all alone. From the list of hurtful habits and behaviors—the things they wanted to stop doing—we built a short list of things they agreed to start doing:
1. Instead of blaming others, take responsibility for your own actions and speech. Before you say or do something, ask, Is it kind? Is it important? Does it help?
2. Use teamwork to reach common goals. If the house needs cleaning, each member of the family has an age-appropriate job. If the family is going out to a movie, choose together which movie to see, or take turns getting to choose. Think of the family as a car where all the wheels are integrated and work together to move where it needs to go—no one wheel takes control, no one wheel bears all the weight.
3. Be consistent. If curfew has already been established, the rule can’t change at the last minute.
In general, Emma’s family’s constitution was about giving up the need to control someone else.
I treated Emma for two years. In that time she completed the out-patient program at the eating disorder clinic. She stopped playing soccer—something her father had forced her into when she started middle school—and went back to ballet class (and then on to more dance classes: belly dancing, salsa). The creative expression, the pleasure she took in moving to the music and rhythm, led to an enjoyment of her body, which gave her a healthier self-image. Near the end of our time together, when she was sixteen, she met a boy in school and fell in love, and this relationship gave her another motivation to live and to be healthy. By the time she stopped working with me, her body had filled out and her hair was thick and shining. She had become the present-day version of her picture of the twirling, dancing girl.
The summer after Emma’s junior year of high school, her family invited me to a barbeque at their house. They put out a wonderful spread—ribs, beans, German potato salad, homemade rolls. Emma stood with her boyfriend, filling a plate with food, laughing, flirting. Her parents, siblings, and friends sprawled on the lawn and in folding chairs, feasting. Food was no longer the negative language of the family. Emma’s parents, though they hadn’t completely transformed the tone of their parenting or their marriage, had learned to give Emma what she had learned to give herself—the space and trust to find her way toward the good in life. And without having to live consumed by their fear of what might happen to Emma, they had grown free to live their own lives. They had a weekly bridge night with a group of friends and had let go of much of the worry and anger and need to control that had poisoned their family life for so long.
I was relieved and moved to see Emma restored to Emma. And her journey also prompted me to reflect on me. Edie. Was I at one with my own inner dancing girl? Was I living with her curiosity and ecstasy? Around the same time that Emma left my practice, my first grandchild, Marianne’s daughter, Lindsey, began a toddler ballet class. Marianne sent me a picture of Lindsey in a little pink tutu, her sweet chubby feet tucked into a pair of tiny pink slippers. I wept when I saw the picture. Joyful tears, yes. But there was also an ache in my chest that had more to do with loss. I could picture Lindsey’s life spreading out from this moment—her performances and recitals (sure enough, she would continue to study ballet and perform in The Nutcracker every winter of her childhood and adolescence)—and the happiness I felt for her in anticipation of all she had to look forward to could not be uncoupled from the sorrow I felt at my own interrupted life. When we grieve, it’s not just over what happened—we grieve for what didn’t happen. I housed a year of horror within me. And I housed a vacant, empty place, the vast dark of the life that would never be. I held the trauma and the absence, I couldn’t let go of either piece of my truth, nor could I hold either easily.
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