My 15-year-old daughter has anorexia nervosa. Last year she was hospitalized for bradycardia, stabilized, and sent home with a high-calorie diet plan which she immediately refused. Since then, she spent 60 days in a residential treatment center and achieved a healthy weight before discharge. She came home and resumed school, but has relapsed (I use that term loosely, as she was never really in recovery, only playing the game in order to come home.) As of this week has lost 20 pounds. She is severely restricting her food intake and has had to spend 5 days in our local hospital for severe dehydration and malnutrition.
My question is, how do I get her to allow me to prepare food for her and get her to eat it? Her therapist wants me to take control of her meals, but she doesn't allow me to prepare her food at home. She will only eat at restaurants where she knows the calories in the specific meals. I'm at a loss as to how to even begin this process. I am growing more and more frantic every day.
Peter Doyle, PhD responds:
I’m sorry to hear this has already been a long and frustrating ordeal for your family as you’ve all tried to get this eating disorder out of your daughter’s life. It is not unusual to experience strides in the structure of an inpatient or residential setting and then have difficulty translating those gains into life back at home. Your question of how to help your daughter to eat at home is at the heart of family-based treatment. Every family approaches this challenge in a slightly different way, but all the families I’ve worked with had to first overcome the sometimes difficult challenge of viewing their son or daughter’s decisions about food, eating, and exercise as decisions within the purview of parents. In the midst of an eating disorder, your daughter does not make decisions about food alone. She struggles to make choices with the constant presence and destructive influence of the eating disorder. You have seen what kinds of choices the eating disorder will make.
In your question, you ask about her allowing you to prepare food. The question the eating disorder doesn’t want you to ask is: why do I need permission to prepare my daughter food? We would not ask permission of our children to remove illicit drugs from their room or to stop them engaging in some other self-destructive behavior. Eating disorders often feel different in this way, however, and many parents struggle to give themselves permission to intervene as aggressively as they would like. There are a number of different strategies and contingencies that parents can use to help their child with an eating disorder to eat. Depending on the degree of resistance, these strategies can take many forms. Some families see stall tactics, so meals become hours long. Other families see food fly across the room, so more food is prepared. Still other see attempts at subtle bargaining, so expectations are reiterated over and over. All have the same underlying message: eating in a healthy way is the top priority and is not negotiable. This need not be done in a draconian manner and in fact should be done in a firm but supportive way. After all, you are not punishing your child by insisting on healthy eating. You are merely setting limits and not allowing self-destructive behavior. A mental health professional trained in family-based treatment can help you find your own strategies and tactics for executing these strategies.