The saga continues as we shifted our focus from Phase 1 (re-feeding) to Phase 2 of Family-Based Treatment (FBT) for our daughter’s anorexia. An important phase of her treatment continued at home after her release from the hospital.
During the re-feeding phase it was our job to feed Guzzy 3 meals and 3 snacks a day while monitoring her 24/7. Her role was to eat what we served her without question or negotiations. We allowed her 3 ‘refusals’, foods we agreed NOT to serve her. Her refusals were hot dogs, bacon and peanut butter. Other than that, I took her pre-ED preferences into account; but I served her many, many things she was uncomfortable eating.
Prior to going to Children’s Hospital in Minneapolis, our daughter was attending a day program at another ED treatment center that used a meal plan with a fairly complicated set of rules about what she needed to eat. Unfortunately, the meal plan became a battle ground of negotiations, confusion and debates. I will never forget the Great Cheese Debate: does a serving of cheese count as a fat or a dairy or BOTH? This was the cause of many arguments, requiring several emails to the program nutritionist, who MADDENINGLY, didn’t give a straight-forward yes or no answer.
Anorexics will fight to minimize what they eat any way they can–because they are mentally ill and are incapable of making healthy choices. The ED makes them very crafty and manipulative in their avoidance of food. As with most ED sufferers, Guzzy was hyper-aware of what she was eating, carefully assessing every item we fed her to make sure we weren’t giving her any more calories than the minimum required, and getting upset if we bought higher-calorie choices of bread or yogurt. Another ED parent told me that her daughter would count the blueberries on her cereal to make sure it was not even one berry more than was required. In our case the day-to-day battles over the meal plan distracted us from the war against the ED. We were winning most of the battles, but we were definitely losing the war.
Family Based Therapy (aka the Maudsley approach) puts the parents in charge of the feeding. This proved to be a difficult, yet effective approach. We quit negotiating with the ED and took charge. The expectations were clear and I became a brick wall against all the excuses complaints and tears that ED had to offer.
We removed all labels from foods right after coming home from the grocery store–it was the only way to stop the calorie counting. After starting FBT we forbade Guzzy from coming into the kitchen. I wouldn’t give her food (such as yogurt or applesauce) in the original container; everything went into a bowl – preferably in a large bowl so the serving looked smaller. I networked with other ED parents continuously to find new recipes, and other helpful hints for getting those precious calories into our children. My husband and I became experts at making a variety of calorie-dense smoothies, as for a long time Guzzy found it easier to drink calories rather than chew them.
It wasn’t all drudgery. I read several books aloud to pass the time during meals, and we got through several of the #1 Ladies Detective Agency series together. Guzzy and I played many energetic and competitive card games to pass the time, games that were punctuated by frequent giggling fits that often escalated to an incapacitating level of laughter and tears. It was the kind of laughter that can’t be explained to anyone who wasn’t in the moment, and often left my husband shaking his head in wonder.
After a couple months of re-feeding at home Guzzy’s physical symptoms improved significantly; her hair stopped falling out and started to return to its former luster; her menses returned and; one memorable afternoon she looked down at her lap, looked back up wide-eyed and announced “I HAVE CLEAVAGE!”
The physical cues as well as her improved mental state were the signals that it was time to move to phase 2. Phase 2 involves a gradual return of some control by giving her some choices with what she ate. This could be as simple as choosing between juice or milk for a beverage. It was really hard for me to shift into phase 2, since I was giving up the hard-won control I had (finally) established over the ED. It felt wrong for us to give her choices, since she had made such poor choices when she was very ill, and we were afraid she would backslide. This phase of the treatment has less well-defined parameters or guidance. I did a lot of research and found some guidance on line, but it boiled down to us following our instincts.
We had several parental conferences, and struggled to define parameters that we all felt comfortable with across the two households. Ever so cautiously, we gave Guzzy limited choices. we setup a snack box from which she could select item(s) for her snacks. She often asked for me to purchase something as a snack choice, and I accommodated reasonable requests. She went back to school for one class a day and she would eat morning snack at school with a trusted friend who would report back to me and her dad.
Phase 2 (like phase 1) was a see-saw journey. She started attending school for one class a day. Going back to school was really hard, and there were days she just wasn’t up to it. As long as she was eating we didn’t always insist on school attendance; we were still picking our battles. There were some bad days, like when we found a stash of uneaten food in her room; but as the weeks progressed she continued to get healthier.
By the time second semester started in January, Guzzy returned to school full-time. We arranged her schedule so she could come home for lunch every-other-day, and eat with her friend on the alternate days. Her very first class of the semester was gym, and the first unit was… (wait for it)… swimming, in a boy/girl gym class, wearing swimsuits… in front of other high schoolers. You had to be kidding me!!! Fortunately, Guzzy’s Doctor agreed it was simply too much, too soon, and wrote her a pass to get out of swimming. She spent the unit running errands for the teacher.
The first few weeks back in school were rocky, but she persevered and really wanted to resume a more ‘normal’ healthy lifestyle. She relished the relative freedom of Phase 2, and as long as her weight stayed at a good mark, we continued to loosen the reins.
This brings us to February of 2014… things are about to take a tropical turn for the better.