Concerns About Current Treatments for Anorexia

Concerns About Treatment Approaches

As a victim of anorexia nervosa now in my 50th year of recovery, I have had a difficult, sometimes painful, but rich and fulfilling life. As a result, I am an unwilling "expert" who becomes dismayed and indignant about the plight of today’s patients whenever re-confronted (as in the Nov. 28, 2005 Newsweek magazine cover story) by our continuing inability to agree on how to treat this deadly disease.

In the words of my children and friends, I am a "survivor" who has lived to tell the tale. I have been a clinical psychologist in private practice in North Carolina for more than 25 years. In that role, I have successfully treated a few mild cases of anorexia and witnessed the devastating failure of cases in which family conflict and insurance pressures, compounded by the poor judgment of an inexperienced internist, quickly led to institutionalizing the patient and treating her with extreme measures, such as ECT, in order to best use insurance benefits. Because of my history, I receive phone calls from time to time from former classmates or friends distressed about the severe condition of an anorexic family member in the second or third decade of her illness. I am also a writer who has published five books, three after the 30-year writer’s block that stopped me from writing (as anorexia had from eating) when I was a Guggenheim fellow and the best-selling novelist of Caleb, My Son in my 20s. Even more significant for a female who nearly died of anorexia, I have four grown children and seven grandchildren.

I developed anorexia at age 12, several weeks after beginning to menstruate. At first it stood out, like my excellent school performance, as an attempt for independence in a family where my three sisters were all overweight and not high achievers. My parents were unable to recognize the seriousness of my condition, but at the end of 11th grade, the boarding school I’d been sent to insisted I be treated before I returned the next fall. At home I lost another 40 pounds, down to just over 50. Then, thanks to a physician uncle, I was hospitalized for nearly five years far from home.

There I was treated with electroconvulsive shock, insulin shock, and tube feeding, but no psychotherapy. What ultimately freed me to understand the anorexia and to overcome my writer’s block was psychoanalysis, which I entered 20 years after my discharge from the hospital. Having struggled all that time on my own, I sought analysis at that point because I was in clinical training and wanted to become the kind of therapist I had never had the good fortune to encounter. Now, as a practicing clinical psychologist, former patient, and continuing-in-recovery anorectic, I want to share the understanding of this disorder that I believe is needed before we can focus on one therapy rather than jerk back and forth between several different ones.

1. Anorexia Nervosa, like any other disease, has slightly different meanings at different points in history. In Holy Anorexia, Rudolf Bell wrote about how many of the female saints in the middle ages suffered from anorexia. When supported and empathized with, they typically improved over time and ate more reasonably. When others made strong efforts to control them and forced them to eat, they typically died. Unfortunately, today we still seem to refuse to learn from this experience, perhaps out of a need to feel better ourselves by combating the starvation.
2. In recent decades, a number of clinicians have written in detail about anorexia. Fear of Being Fat and Psychodynamic Techniques in the Treatment of the Eating Disorders, both by C. Philip Wilson, Charles C. Hogan, and Ira L. Mintz, provide important information for effective treatment. Among other significant points, these writers document the different types of anorectic patients. They also illustrate how eating disorders often occur in the context of other symptoms and diagnoses such as schizophrenia, depression, and post-traumatic stress disorder.
3. In general, behavioral treatment is destructive with these disorders. Even if the patient begins to eat in response to behavior modification techniques, these methods often only exacerbate the control issues inherent in the disease. I am convinced that after a patient has succumbed to such treatments more than once, she may well cling to the self-control of starvation so tightly that other treatments cannot be effective either.
4. Ideally, these cases need to be simultaneously treated by a physician who manages the physical aspects, including hospitalization and feeding when necessary, and a psychotherapist who assists the patient in understanding and dealing with feelings such as fear of fat and response to forced feedings. While these clinicians need to work independently, communication between the two, with neither seeming to control the other, is helpful when therapeutically possible. While anti-depressant or other psychotropic drugs may be of temporary benefit to anorectics, they should never be substituted for psychotherapy. This illness typically requires long-term treatment.
5. Family involvement in treatment is useful and sometimes imperative. But how this is managed needs to be carefully considered, because families often contribute to the patient’s problems without knowing it, and families differ considerably in how they respond to assistance. In my view, it is also therapeutically beneficial, when at all possible, to treat patients at home, in the community where they live. This is far better than abandoning them in a treatment center from which they will have to make an adjustment to both a new setting and a new therapist when they return home.
6. While it is important that anorexia not be seen as the fault of either the patient or the family, the roots of the disorder frequently lie in misunderstandings or unconscious issues that need to be brought to light and dealt with openly and constructively. Very often, too, eating disorders are the result of unconscious issues, family circumstances, or secrets that have been considered minor but that the child’s unconscious has magnified.
7. Food is related emotionally to many life circumstances including love, money, nurturing, satisfaction, fullness, fat, and sexual and physical development; in many individuals, these can become unconsciously connected to other personal issues as well. I, for instance, had been afraid to develop sexually because my father’s first wife had died in childbirth bearing a son who also died. As the first child of the next marriage, I unconsciously needed to be both my parents’ lost son and not overshadow my writer father. My anorexia and writing block were connected through an unconscious fear of the power of my voice after a conversation with my father that revealed to me (at age four) the family secret of the existence of his first wife, her terrifying death, and his intense love for her.
8. In today’s world, it’s not surprising that anorexia now afflicts males as well as females and, and like sexual development and obesity, occurs at an earlier age than ever before. Yet in the case of the anorectic, this could be an advantage, if we respond by considering the child’s feelings and unconscious fears rather than by just comforting ourselves by forcing him or her to gain weight. If anorexia is treated appropriately as soon as the condition is diagnosed, we might save these children and adolescents from facing the lifelong struggle of a recovering anorectic that I know only too well.

About Lucy Daniels

Lucy Daniels is a writer and clinical psychologist who uses the lessons learned in her personal victory over anorexia nervosa and writer’s block to assist others. Her novels include the best-seller Caleb, My Son (1956), High on a Hill (1961), and The Eyes of the Father (2005). A memoir, With a Woman’s Voice (2002) and Dreaming Your Way to Creative Freedom (2005) chronicle her empowerment. Dr. Daniels is also the founder of the Lucy Daniels Foundation, a non-profit organization dedicated to fostering emotional and creative freedom through education, outreach, research, and psychoanalytic treatment; and the Lucy Daniels Center for Early Childhood, a preschool program that uses psychoanalytic principles to promote the emotional development of young children and their parents.

Editor’s Note on Other Materials and Balance

Interested readers can find more materials about other approaches to treating anorexia nervosa in the eating disorders section of our research library. Also check the eating disorders section of our web resources. In the interests of balance, I am not aware of any evidence supporting the contention that psychoanalytic approaches are more effective than other approaches in this area; for a broad and accessible look at research evidence on the effectiveness of different approaches, see Hubble, Duncan and Miller’s The Heart & Soul of Change.

Our earlier article “Pro Anorexia on Xanga and Across the Web” has, as of this writing, elicited more visitor comments than any other article in this section.

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