First Bite: How We Learn to Eat

by Wilson, Bee

  The only good thing about anorexia hitting the very young—and admittedly it’s not much of a silver lining—is that they tend to have better rates of recovery and a shorter duration of illness than older sufferers. In some ways, being a child helps the situation. “If they are to recover,” says Ringwood, “children with anorexia do need to be made to eat.” The advantage of being a child is that you are already in the habit of having other people feeding you. You are also in the habit of listening to adults telling you what to do, so it’s not so strange when they tell you there is simply no option but to eat. In recovery, this childish obedience can be very helpful, for as long as it lasts.

  When a child has an eating disorder, family meals can be miserable, soul-sapping occasions where children lie and parents wheedle and very little is eaten by anybody. Or they can be exercises in make-believe, where everyone politely pretends not to notice that one person has eaten no more than a couple of pieces of cucumber and half a yogurt.

  But family dinner is also a child’s best hope of getting better. Viewed through the prism of anorexia, you see just what a powerful and therapeutic thing a meal can be. When it goes right, a child is, all at once, being given nutrition and love and a way to escape a prison of misery. It isn’t easy to reach this point, for any of the parties concerned. A mother of a daughter who was severely anorexic for nine years described her frustration at reading overly optimistic accounts of “parents who just insisted that the child ate, the child did, and roses grew around the door and life was lovely again.”

  With anorexia and related eating disorders, the stakes are even higher than with selective eating. Restrictive eaters are not actively trying to starve themselves; anorexics are. One of the horrible truths about anorexia is that not to recover so often means death. A systematic review of the literature in 2002 looked at studies involving more than 5,000 anorexics. It found that while there was a “good outcome” for around half of anorexia sufferers (meaning that all symptoms had disappeared), and a “fair outcome” for around 30 percent (meaning improvement, but with some residual symptoms), there was a “poor outcome” for over 20 percent, meaning that the disorder was chronic. With anorexia, a poor outcome means death in some cases.

  At the Maudsley Hospital in South London in the 1980s, some therapists discovered that they could achieve much more hopeful outcomes with anorexic patients than the statistical norm would predict. They did this by focusing more intensively on the symptoms of the disorder: the eating itself. Therapists noticed that when nurses sat with the patients as they ate, talking to them and sometimes rubbing their backs, they could create an atmosphere of such kind persistence that it was “impossible . . . not to eat.” These Maudsley doctors had the shrewd thought that perhaps parents could be taught to perform the same role at home. This was the kernel of the current movement of “family-based treatment” (FBT), sometimes called “the Maudsley approach,” although most of the research on which it is based was done in America at Stanford and the University of Chicago in the 1990s. FBT works on the basis that a child with anorexia needs to be systematically “refed” by her parents, until she is well enough to take responsibility for her own eating again. Research by Daniel Le Grange and James Lock, two of the leading lights of FBT, suggests that for anorexic patients who are younger than eighteen who have had the illness for a relatively short amount of time, recovery rates can be as good as 90 percent, with full remission after a year and even after five years. FBT—when followed very systematically—achieves these remarkable recovery rates by doing exactly what most eating disorder therapists had been trained not to do: allowing the parent to take control of the child’s eating.

  Traditional eating disorder treatment was based on the idea that parents were to blame. The Golden Cage, by Hilde Bruch (1978), a German psychoanalyst working in America, was an influential book that described the parents—especially the mothers—of anorexic girls as monsters who stifled their children with impossibly high expectations and an atmosphere of neurosis. Bruch felt that in order to recover, a patient needed to separate from the family. Individual therapy would encourage a patient “towards independence.” There was no question of family meals being used as part of the treatment, because family meals were seen as the thing that had caused the anorexia in the first place. On Bruch’s model, parents were often warned that they must not sit and eat with their children, lest their presence be oppressive. They should offer no judgment on what their children ate, but must allow them to make their own eating decisions. In some cases, therapists felt that a “parentectomy” was advisable: a total separation of parent and child. The thinking was that since anorexia was not really “about” the food, the child would choose to eat once she had worked through her other issues. But the point about having an eating disorder is that the child is not in control of her own eating. Left to her own devices, she will, likely as not, revert to the disordered behavior, whether it is bingeing or starving. With the traditional treatment, anorexia clinics found that their patients might recover in the hospital, where they were being actively fed—either by tube or with real food—and then relapse very quickly when they got home. Which was hardly surprising given that the parents were being told not to interfere in their child’s eating.

  FBT turns this dynamic around. It is predicated on a nonjudgmental attitude toward parents. This is not to say that a family dynamic never contributes to an eating disorder, but that what very sick children need is urgent treatment rather than endless discussions of what made them ill. Guilt is a crippling emotion that makes parents feel hopeless and unable to act. The idea of FBT is that parents must feel in charge of getting their child to eat again and must therefore stop blaming themselves. Once they forgive themselves, they are in a position—with the help of a therapist—to start the hard task of “refeeding,” which is a little bit like teaching an infant how to eat solid food again. Again, the needs of the eating disorder sufferer are like a warped version of the travails we all face when learning to eat.

  As with weaning, refeeding is a slow process, requiring stamina. To start with, a parent may be happy if the child manages a meal of mashed pumpkin with a teaspoon (many anorexics revert to using baby cutlery). As time goes on, you expect more of her, upping the calories in stages. She needs to add new foods to her repertoire, like a selective eater. You refuse to give her low-fat options. No meals are to be skipped, and the child is encouraged to take one more bite beyond what she wanted to eat. The food is never forced, but nor is the child allowed to say that she doesn’t feel like eating. James Lock argues that it is a mistake to respect the voice of the child when she says she does not want to eat, because that is the illness talking.

  At the start of the FBT process, the family will have one or more “coached meals” at which a therapist counsels parents in how to manage family food, such that a child will eat. By the time they arrive at an eating disorders clinic, families often say they have “tried everything” at mealtimes; but the odds are that—as with parents of selective eaters—they haven’t felt able to pursue any of the techniques consistently. Many of the families seen by James Lock do not have regular mealtimes, instead just grazing on food at ad hoc moments. The whole family, not just the patient, needs to relearn how to eat breakfast, lunch, and dinner, with structured snacks in between. Siblings, too, must be included, though parents are trained not to fall into the trap of comparing what different people around the table are eating. The “coached meal” teaches parents how to stop treading on eggshells around their child’s eating: to sit close and repeat calmly and assertively that she must eat the meal in front of her, even if she refuses or cries or says she hates you. The parents need to agree among themselves before the meal starts about how much they expect the child to eat and what the consequences will be if she doesn’t (no computer games for a day, for example). With divorced parents, Lock goes so far as to say that the child should live for the time being with the parent who is better able to
manage the meals.

  In her memoir of living with her then fourteen-year-old anorexic daughter Kitty, Brave Girl Eating, Harriet Brown, an advocate for FBT, describes how a refeeding meal might go. Brown lays out Kitty’s breakfast of a bowl of cereal with milk and strawberries. Kitty says she wanted cottage cheese instead. Brown says there is none. Kitty complains that the cereal is soggy. Brown makes a fresh bowl but then insists as calmly as she can that Kitty “sit down and start eating.” This whole rigmarole goes on many times a day, with Kitty often sobbing that the food will make her fat, and Brown protesting that food is her “medicine” and she must eat. Brown or her husband take it in turns to stay with Kitty for an hour after each meal to prevent her from running to the bathroom to purge. There are many such meals each day—Kitty needs to eat a snack every couple of hours. Four years on, Kitty has recovered to the point where her parents feel it is safe for her to go off to college by herself and take responsibility for her own meals. There are still relapses when the “demon” returns to the dinner table and Kitty’s weight drops, but at least they all feel they have done everything they can to normalize her relationship with food. More importantly, Kitty herself now has an approach to food that she can follow to turn her situation back around when she starts to slip into losing weight. Food is medicine.

  One of the many hard aspects of refeeding is that it isn’t enough for the patient to eat an amount of food that would be healthy for a person of normal weight. Someone with anorexia needs vastly more calories than before to regain the weight needed for the body and brain to recover. Anorexics would never “choose” of their own accord to drink a 1,000-calorie milkshake, but after they recover, they often say that it was strangely liberating to have their parents telling them that they had no option but to eat, because it reduced the shame. Families need to become experts in which foods offer the most calories without filling their children up to the point where their stomachs hurt. It is the opposite of the way most of us try to eat, seeking out the maximum food for the minimum calories.

  This refeeding process may be even harder for those anorexics who develop the disease later in life and are without parents at hand to help them. Some years ago, I wrote an article on women who were battling anorexia in their thirties, forties, and fifties. Among those I met was Jane, a reticent fifty-three-year-old teaching assistant who described the humiliation of being a middle-aged anorexic. For her, the misery of anorexia was compounded by a sense of shame that, at her age, she should have “known better,” as she put it. At her lowest point, Jane lost five stones (about seventy pounds) from an already slim body. Once, she felt so despairing that she took a hammer and smashed her own hand. She was put in a therapy group with six “trendy” teenage girls and expected to open up about how she felt. How Jane felt was: “Why should I share my innermost feelings with a group of strangers?” Another obstacle to Jane’s recovery—in common with the other older anorexics I interviewed—was that she was the one in the family who provided for everyone else. Jane was very good at feeding others, but feeding herself was another matter. She prepared lavish, ambitious meals for her husband and two sons, while she nibbled on an apple or a yogurt. On the rare occasions that she ate out with her husband, she could be reduced to tears by the arrival of a bowl of soup. When I met her, Jane was slowly teaching herself to eat again. She had managed to edge up to 1,000 calories a day: not enough—she was still painfully thin—but just sufficient to keep her out of the hospital.

  For some adult anorexics, the best course of treatment may be a residential program where the patients—of whatever age—can enact the role of children in the protective setting of a family meal once again. I visited Newmarket House in Norwich in England, a specialist treatment center for anorexia that felt more like a spacious home than a clinic, with colorful sofas and appetizing cooking smells in the air. I met Beth, who was in her thirties, a mother of four. Like Jane, Beth was a confident cook, and took great pride in the birthday cakes she baked for her children, but she struggled to allow herself to eat anything but lettuce and tomatoes. She wished she could disappear, she said, and was still far from fully recovered. But at least the structured meals of Newmarket House—at which the nurses feel more like family members than therapists—gave Beth an environment where others took care of her eating for a change.

  With some eating disorders, being older and more independent seems to be beneficial for recovery. Bulimia tends to strike at a later age than anorexia (in a review of 5,653 cases of bulimia, the average age of onset was seventeen, but often it starts in the twenties). A study of forty women who had fully recovered from bulimia found that they tended to be self-motivated about getting better and did not like the view that “one is powerless over one’s problems.” Eighty percent of these recovered bulimics had ultimately been motivated to change by their own desire for a better life and weariness at the symptoms (when they were ill, they vomited, on average, twenty-two times a week). Although most of them benefited from professional help, nearly half of them backed this up by reading self-help books. Another study found that among a group of bulimics in Austria, more of the patients became symptom-free by using guided self-help, working through a manual by themselves, than by being given a course of cognitive behavioral therapy.

  Learning a new, more balanced way of eating after bulimia or binge eating is very different from recovery through refeeding as an anorexic. Instead of boosting calories, a bulimic needs to find a reliable way to limit each day’s food, avoiding anything that might trigger an episode of bingeing. Unlike selective eaters, bulimics need to teach themselves to become less omnivorous. One forty-five-year-old recovered bulimic described the strict regime she had created for herself as a way of keeping herself from backsliding into the bingeing and purging behavior. As a result of the methods she used, she had recently celebrated eighteen months without any symptoms. She shopped in very small quantities, to make bingeing impossible, and ate five small meals a day of fish, meat, fruit, and vegetables. She breakfasted on tinned tuna or cold chicken, because bread would remind her too much of bingeing and create a temptation to purge. Wheat and dairy were now eliminated from her diet. For an anorexic, such rigid food rules might be a dangerous path to take, but for a bulimic, there can be liberation in limits.

  There is at least one respect, however, in which the situation of anorexics and bulimics is very similar. Before addressing what to eat, the most urgent matter is how to eat. Phase one of recovery from bulimia is the reintroduction of regular mealtimes: no bingeing, no starving. Slowly, the days regain a sense of rhythm. As anyone who has ever suffered jetlag knows, few things are more disorienting than a warped sense of time. Some of what makes bulimia nightmarish—in common with other eating disorders—is that it disrupts the daily tempo of meals. One recovered binge eater spoke of how she used to live in a “food-fuelled haze,” but had now found that by allowing herself regular, clearly defined meals, she had regained a feeling of certainty. Lunch becomes a meaningless concept when you have already eaten—and possibly purged—a whole box of cereal by mid-morning. When you are eating all the time, food curiously loses much of its joy, along with its sense of ceremony and sociability.

  Once again, the experiences of eating disorder sufferers are on a continuum with the rest of us. It is hard for anyone to live well when meals are not given the attention they are due. As New Yorker writer Adam Gopnik has asserted, “the table comes first,” meaning that before we can resolve our endless quandaries about food—such as “where the zucchini came from and how far it had to travel”—we should first establish the basic paradigm that at certain times, every day, we stop, we sit, and we eat.

  In many ways, the needs of a bulimic or anorexic are not so different from those of an adult picky eater like Diane, or just an averagely screwed-up human being with a desire to lose weight. An individual with anorexia “is disconnected from her internal experiences,” and cannot read her internal hunger signals effectively,
notes one scholarly article on anorexia. But most of the population, as we have seen, is similarly disconnected from internal signals about when, what, and how much to eat. The difficulty is that those whose disordered eating is less extreme are likely to have less help: when you sit down to eat, you are both the parent and the child, the doctor and the patient. Like the anorexic patient faced with the 1,000-calorie milkshake, many of us would never “choose” to eat a plate of healthy food over a fast-food meal, but if we can give our bodies the food it needs often enough, in a kind and persistent enough way, we may eventually start to recover. Eating is about the food. What all of us need is to find a way to eat regular meals, to take pleasure in a variety of foods, and to be able to eat them without being consumed by negative emotions.

  It is startling to hear the message, from eating disorder therapists, that nourishing, health-giving family meals, eaten in loving company, are so important for a child’s well-being that everything else in life must be made secondary to them. Most families—most people—do not live like this. Gone—thankfully—are the days of a patriarch ruling the family from the head of the table. The breakdown of strict table manners—children should be seen and not heard!—has been emancipating in some ways. But as a society, we haven’t quite figured out what a new structure for meals would look like that isn’t just a hasty sandwich in the car on the way to something more important. The experience of eating each day around a table is given second billing to other activities: homework, after-school activities, Instagram, and email. In a busy life, the organization required for regular, shared dinners can seem unattainable; even if they can manage the shopping and the cooking, parents often hesitate to assume the authority to gather everyone together to eat, never mind to insist that everyone eat the same food. But the experience of eating disorders shows that this is partly a question of priorities. When eating becomes a matter of life or death, and each new bite is a celebration, you may discover that none of the other stuff was quite as important as sitting and breaking bread together.