Brave Girl Eating

by Harriet Brown

  Which is not to say that residential care is never helpful; sometimes it can literally save a child’s life. But it’s usually a stopgap, a kick start to recovery, rather than recovery itself. Real recovery takes months, maybe years. It takes the regular application of food, lots of food, to break the self-reinforcing cycle of restricting, to alter the neurobiology that perpetuates the disease, to retrain the brain.

  There hasn’t been a lot of research on anorexia, but what little there is clearly shows that for kids eighteen and under, FBT nearly always constitutes the best shot at recovery. The trouble is, there are very few FBT therapists in the United States today. Which is why families in our small city often drive three hours each way for treatment in Chicago. Or do what we’ve done—put together a treatment team that’s open to FBT but not particularly knowledgeable about it.

  And that’s also why, in 2008, James Lock and Daniel le Grange created the Training Institute for Child and Adolescent Eating Disorders and began offering workshops and supervision for therapists who want to become certified in FBT. It’s the only way to make sure that therapists who say they offer FBT are actually doing it correctly. Le Grange has seen too many variations on the theme, including a therapist who, at a conference, encouraged parents to physically restrain young patients and force-feed them—a practice that’s diametrically opposed to both the spirit and the letter of FBT. Her words appalled him so much that this dapper, soft-spoken man stood up and publicly corrected her. At least people like that can’t say they practice FBT anymore.

  As I write, the institute has certified nineteen FBT therapists; many more are going through the several-years-long process. Five years from now, there should be more FBT therapists around the world. Still not enough, unfortunately. But a start.

  In early April we raise Kitty’s calories to four thousand a day, and she gains another four pounds. She’s also grown another inch, so she’s still below her goal weight. But she weighs twenty pounds more than she’s ever weighed in her life. She gets her first period. In the second half of April, her weight seesaws—up two pounds, down two—even as she grows another inch. This drawn-out process feels torturous. I wish we could speed things up, but I’m not sure Kitty can physically eat any more. I wonder if I’m going to spend the rest of my life thinking up ways to get more calories into her.

  She’s no longer at the bottom of the rabbit hole, but rather climbing her way laboriously up through the darkness. I want to reach down and pull her to the surface quickly, cleanly, in one motion. That’s always been my instinct with my daughters—to spare them as much of the world’s pain as possible. Of course I know I can’t do that, most of the time—and that, in fact, I shouldn’t. Without pain, they won’t grow and change and become who they truly are. Kitty’s life is her own and has been from the moment she was born. I respect that. I get it. I know she has to go through recovery at her own pace. It’s just hard to watch her suffer.

  Meanwhile, Kitty’s made a couple of new friends this spring, girlfriends she goes shopping with. Girls who have nothing to do with the world of eating disorders. She’s taken up scrapbooking. She’s been kinder to Emma, too, typing up an essay for her one night, helping her adjust the water in the shower another. Little things, but they mean a lot to Emma.

  The outbursts, when they come, are often triggered by subjects other than food these days—usually school. Kitty’s taking a full load this semester, with one study hall before lunch so she can come home and eat. It’s a stretch. One night she falls apart while studying after dinner, saying she can’t do her homework, she can’t concentrate, she’s falling behind and can’t keep up. She wrings her hands, says her chest feels tight with anxiety, rocks back and forth in her desk chair, and nothing I say can comfort her. So I sit with her for an hour, until she’s calmed down enough to go back to studying. A month ago, an outburst like this would have lasted the rest of the night. Progress? I think so.

  Another night, faced with a doughnut for her evening snack, Kitty begs for something different—a yogurt, toast, anything. I stand in the playroom, wondering what to do. Should I insist on the doughnut? If I don’t, am I pandering to the anorexia? If I give in to her fear, does that set her back? How much of her preference is “normal”—whatever that means, at this point—and how much is eating disordered?

  The answer to that last question comes quickly, as the demon’s twisted words begin spilling from my daughter’s mouth. “You’re trying to make me fat!” she says. “This is disgusting. I feel greasy just looking at it. I can’t eat this, it makes me feel sick.”

  On and on she goes. I stay calm, as I’ve learned to do, until she looks up and says, with real fear in her voice, “I’m afraid I’m going to be built like you!”

  I stand there, the plate in my hand, my heart hammering in my throat. I’m glad in a way she’s said it, because I’ve felt her thinking it for months now. I’ve seen it in the way her eyes sweep down my body and then her own, the pucker of anxiety that appears between her brows. Shame steams through me, hot and bitter, scouring away every other thought and feeling, leaving me immobilized in the face of my daughter’s judgment. It’s good that she’s expressing her feelings, I tell myself mechanically. I take away the doughnut and bring out a plate of cookies, and Kitty eats, not meeting my eyes, then goes silently to bed.

  That night in bed, I wonder if all daughters think that at some point. I don’t want to look like you. Girls rebel against their mothers; it’s part of how we figure out who we are. We push away from the flesh and blood that carried and bore us so we can move toward our own future, ourselves and not just another version of our mothers. We reject our mothers, body and spirit and soul, so we can find ourselves. I know all this, I really do, but still Kitty’s words rise up in the space between us. And they hurt.

  At Dr. Beth’s the next day, Kitty’s weight is the same as it’s been for four weeks, and she’s grown a bit. Four weeks of four thousand calories a day and she hasn’t gained an ounce. In fact, if you consider the height change, she’s lost weight. And she’s still eight or ten pounds shy of her current target.

  How is it possible that Kitty can eat that much food and not be gaining weight? Except for trying to make herself throw up back at the beginning (and, luckily, not succeeding), Kitty hasn’t done any purging; I know, because we’ve stayed with her in the critical hour after every meal and snack. It’s not unusual for someone with anorexia or bulimia to throw up, use laxatives, or overexercise compulsively to get rid of the calories consumed. Last summer Kitty did hundreds of sit-ups in her room each night; that was purging. Since then we’ve kept a pretty close eye on her bathroom and exercise habits. But maybe we’re missing something. Dr. Beth suggests another possibility: maybe Kitty’s energy is going toward growing taller at the moment rather than gaining weight. Or maybe all of these are true to some extent.

  I think, for the thousandth time, about what a mystery anorexia is. How many times have I heard the expression “Calories in, calories out”? It’s usually offered in the context of dieting—that is, if you want to lose weight, eat fewer calories or burn more. But this, it turns out, is a gross oversimplification, and not necessarily true. Gina Kolata, a science reporter for the New York Times, explored some of the paradoxes of human metabolism in her 2007 book, Rethinking Thin. She wrote about a study done by Ethan Sims of the University of Vermont, who turned Ancel Keys’s Minnesota Experiment on its head: Sims made volunteers fat in order to understand the physiological changes involved in gaining weight and keeping it on.

  Sims expected to find a variation on the “calories in, calories out” theme; he confidently hypothesized that by letting his volunteers eat as much as they wanted, he could quickly and easily make them fat. And they couldn’t cheat and jog off the calories because they were prisoners in the Vermont penal system whose actions were closely monitored.

  Sims did make his volunteers fat, but it was a lot harder than he expected. The process took four to six months and required f
eeding some of the men a staggering ten thousand calories a day. When Sims did the math he discovered that each man gained weight at a different rate, despite the fact that they were eating the same number of calories. Not only that: the men who had been thin before the study began needed almost twice as many calories to maintain their higher weights as they had to sustain their ordinary lower weights.

  Sims’s experiment highlights the fact that each person’s metabolism has a kind of set point, a natural range. Trying to alter that range—making a thin person fatter, or a fat person thin—takes nearly superhuman effort and blows the calories in, calories out theory right out of the water.

  Maybe one of the effects of anorexia is to reset a person’s metabolism to an unnaturally low range. Which might explain why it’s so hard for Kitty to gain weight, despite eating large numbers of calories. And why even a very minor dip in calories seems to make her fragile and volatile.

  The next morning, as she gets ready to leave for school, I ask if she has her midmorning snack with her. “I always pack it,” she says. I tell her I want to see it. I’m not in the habit, these days, of checking up on her. But my intuition is rarely wrong. And it’s not wrong this time: Kitty says she forgot to pack it, just this once. She pops a protein bar in her bag and runs out the door. But will she eat it?

  I want to lie down and weep with weariness. Our friends have been commenting on how good Kitty looks, how much happier she seems. “She’s doing so well!” they say, and I want to say yes, but she still wrestles with the anorexia every single day. Yes, but if we let up for a few days, she’d go right back down the rabbit hole. Yes, but she’s not safe yet. Nowhere near it. Before, the illness was visible on her face, in her body. Now only Jamie and Emma and Kitty and I know the real distance between how she looks and how she feels. “You must be feeling so much better!” they say. I muster a smile and say as little as possible, because I have neither the energy nor the heart to tell them the truth.

  If you fall ill with pneumonia, the treatment is fairly straightforward: a course of antibiotics. And so are the signs of recovery. You’re recovered from pneumonia when you feel better, when there’s no fluid in your lungs, when your blood count returns to normal. Three simple measures.

  But when are you recovered from anorexia? I mean really recovered, not the 90 percent of ideal body weight that insurance companies and many doctors hold up as a goal. Some doctors talk about weight restoration as a mark of recovery—getting a child back to the weight she was before she started restricting. The trouble is, teenagers are still growing. They’re supposed to put on weight even after they stop growing vertically. So the healthy weight for an eighteen-year-old is unlikely to be the same as it was for that same child four years earlier.

  The whole question of target weight is complex and much debated. Experts in the field often refer to body mass index, BMI, as a measure of restored health. But BMI is a crude measure, a simple ratio between height and weight. It says nothing about a person’s body type. Athletes score high on the BMI chart because muscle weighs more than fat and tissue; you can be “normal” on the BMI chart and still lack enough fat and mass. Kitty, for example, now has a BMI of 18.8, which puts her—barely—into the “normal” category for her age on the BMI chart. By this one standard, she’d be considered recovered. But it’s clear to both Jamie and me that she’s not.

  Dr. Beth says the best way to gauge a child’s weight is to plot her height and weight since birth, find her natural growth curve, and aim to get her back on it. It’s sensible advice, especially compared with the gobbledygook of BMI charts and percentiles of ideal body weight. It’s not always enough, though. Kitty at thirteen was still on her growth curve. She didn’t fall off it until she lost five pounds, last April or May. And Kitty now, having gained twenty-five pounds, weighs far more than she ever did, and still has five or six pounds to go. For her it’s less a question of weight restoration than it is a question of weight correction.

  Carolyn Hodges, a nutritionist and director of the Sol Stone Center in Elmira, New York, suggests that each person has a kind of magic number, a weight that signals true recovery for her. “Below that body weight, the thought process is very obsessive,” she explains. “I’ve seen this in several patients. Above that weight, they are much less obsessive; one to two pounds below, they will be very obsessive.”

  We’ve noticed this with Kitty. And it’s not all about weight gain, especially for teenagers. There have been times over the last nine months when the number on the scale has stayed the same but Kitty’s grown taller, putting her further from her target weight. Every time, her mood has deteriorated and she’s seemed sicker again.

  Another measure of recovery often suggested for women is menstruation. When body fat drops below a certain level, menstrual cycles stop. The problem is, this happens at a different point in the process for everyone. One teen may lose her period at 90 percent of her goal weight, while another may continue to have it even at 75 percent. Some women with anorexia never stop menstruating.

  Maybe I’m deluding myself, but I have a sense that I’ll know when Kitty is really well again. I probably am deluding myself, because even the experts don’t seem to have a good grip on who is and isn’t recovered. This has ramifications not only for the patients themselves but for the ongoing research, much of which compares people who are actively ill with recovered anorexics. Often, the criterion for recovery is “being weight restored for a year.” But it all depends on what you mean by weight restored, doesn’t it? Who’s measuring, at what age, and how much growth has taken place? Pediatricians and doctors seem inclined to lowball weight. They’re often all too willing to settle for keeping a kid on the edge of normal; I suspect this is because everyone’s so obsessed with obesity in children these days. Doctors, especially, have internalized the notion of “thinner is better.” Whereas I think for a child like Kitty, having an “extra” five pounds is insurance against relapse.

  Physically she looks healthy and strong, if still on the thin side. She’s developed more of a womanly shape. Her hair, which fell out in clumps all last summer and fall, is now shiny and long. Her eyes sparkle, her face is nicely full; she’s alive again.

  She still says she feels no physical hunger; she says she can’t remember the last time she felt hungry. It’s been well over a year. Does she truly feel no hunger, or does she just not connect the physical feelings with the idea of appetite? I think of people with brain injuries, who, if given a math problem, say they don’t know how to solve it even as their hand writes the correct answer; they’ve suffered some crucial disconnect between speech and motor movements. I wonder if it’s that way for Kitty, if malnutrition has broken the connections between body and mind, and, if so, if they will ever be healed. I wonder if Kitty will ever feel hunger again, ever feel comfortable with her own appetite, or if eating will forever remain a necessary but unpleasant chore.

  Emotionally she’s still volatile, still prone to anxiety attacks about everything from homework to friends to how she looks. But she smiles more these days; she laughs. After months of ignoring the three-year-old across the street, Joe, she now makes a fuss when she sees him. One day in early May she tells me she feels happy some of the time now—a huge improvement over ten months ago.

  She’s come along in other ways as well. She sees Ms. Susan by herself, and she seems a little more open, more willing to talk about the eating disorder. One day she says she’s trying to keep the eating disorder in check by not “talking e.d.” Two months ago, she didn’t have the self-awareness to make a comment like that.

  By mid-May she’s eating her afternoon snack alone in her room every day, at her request. Once a day, at least, she seems able to marshal her inner resources and overcome the inner compulsion not to eat. I’m pretty sure she’s actually eating it because in the last month she’s gained another four pounds, which puts her close to her goal weight.

  And I think that compulsion to not eat is growing weaker. She hasn’t tal
ked as much about needing us to watch her, though she still asks me to measure out her portions at breakfast and dinner. One morning I ask whether she’d like cereal or granola for breakfast. “Granola,” she says, and then, with real anguish, “Oh, no, I could have had cereal and it would have been fewer calories!”

  “Not true,” I say at once. “I would have served you more cereal so you got exactly the same number of calories.”

  So the anorexic thoughts are still with her. But they are—dare I say it?—beginning to lose their power.

  On Mother’s Day, we do not go for a family bike ride, as we did so disastrously last year. We stay in, because it’s raining, and Kitty and Emma put on a treasure hunt for me, complete with clues hidden all through the house and coupons for foot massages and breakfast in bed. We laugh. We play Scrabble. We spend hours reading together in the living room. We eat Japanese takeout for dinner and ice cream for dessert.

  We do not say the word anorexia all day.

  More ups and downs follow in the next few weeks, as they have all year. Kitty comes home from school one day and reports that a girl in her Latin class brought in a cake shaped like the Parthenon, and that she ate a piece. She actually ate a piece of cake that we did not serve her or insist she eat. That we didn’t even know she was eating.