So, you are about to do the first session with your son or daughter, and you don't know what to expect; or, you just finished it, and have no idea what just happened! ;) I thought my best approach would be to kind of walk through what is typically addressed Day 1.
My first job, even though I'm a psychologist, is to assess your child's physical state. I might do weird things like take his/her pulse, and I will annoyingly grill you on your child's most recent vitals, labs, etc. As I have explained before, I have a bit of an odd job, given my training. I'm trained in talk therapy, right? But, in eating disorder treatment, what comes first is physiology. So whereas you come in potentially expecting me to to dig into your child's thoughts and emotions, this is not going to be the priority at this stage, and hopefully this post will help explain why.
Eating disorders, especially those that have resulted in weight loss, are brain AND body disorders. Weight loss and/or starvation (you can have either or both), impact their brain heavily. It changes the way your child thinks, and the way he/she behaves. You have likely noticed they have become more anxious, more depressed, more obsessed (particularly on food and weight, of course), and they explode in anger like they never have before. There's a good reason for this. In short, the part of the brain that is impacted is the frontal lobe; that is the part of the brain that is responsible for rational thinking, impulse control and decision-making. I think it always helps a bit when I say it's the part of the brain impacted by substance use also. We expect somewhat chaotic, irrational behavior from those using drugs, but we don't expect it from the overly compliant kids/teens that end up with EDs. So, it is helpful to realize that that part of the brain is "hijacked." And therefore, our primary job is to repair that part of the brain.
In addition, what we know about kids and teens is that they tend to get sick very quickly, and they tend to recover very quickly. In all my years of doing this, I have rarely had to refer an adult for admission for medical monitoring. In kids and teens, this is more common. One of the tricks with kids and teens is that we have to look not only at the amount of weight lost, but also the amount of weight they should have gained during the time of their ED, but didn't. I realize that didn't make complete sense. Basically, kids and younger teens are supposed to be gaining weight all the time. So, when they lose weight, say 10 pounds, they not only "lost weight" but also "failed to gain." So, let's say they lost weight on the scale in six months; but, during that six months, they were also supposed to gain 5# naturally. So, at the time of the assessment, they have actually "lost" 15 pounds. Adults only have to look at weight loss, as they don't have the "failure to gain" variable.
In either case, the weight loss impacts the frontal lobe, and so we sees the symptoms I listed above. And, those exact symptoms, and the brain impairment, make it so insight-oriented therapy is not really possible at this stage. Emotions other than anger and fear are often shut down. The primary answer you hear to most questions is "I don't know." And often they don't know; their brains need healing.
And that means weight gain. Many therapists want to avoid talking about weight gain, because it upsets the client. And it does, very much. But, I approach working with teens by respecting their intelligence and their ability to understand science. I separate them from their eating disorder, and what i have found over the years is that, yes, the eating disorder has a meltdown about hearing about weight gain, but your smart child can understand why the brain needs to be repaired. Admittedly, they would prefer their brain could repair without weight gain, but sadly, I'm a therapist, not a magician. ;) So, we are left with weight gain as the cure.
So, initially, you will find this talk therapist mostly asking about medical indicators, and also asking the same questions the dietitian asks; what does food intake look like, what does energy expenditure look like, etc. And then I'll start to explain what I explain here in this post, and more. The goal is for both patient and parents to understand where we start, what the focus must be, and it gives me a sense of how willing the kid/teen is to consider engaging in treatment at home. I will often explain that there are two paths to treatment: one is treatment at home, with parents providing the structure, and the other is treatment in a treatment center, with the treatment providing structure. Kids/teens (and adults with EDs) like to make up path #3, which is something, "I'm fine, I"ll do what I want." Um, no. That's a mythical path; one of the two actual paths must be chosen.
The main task for parents and teens leaving that first session is this: 1) contact providers you have been referred to to create a full treatment team, getting in as soon as possible, 2) follow dietary recommendations, starting immediately (willingness to do so helps determine which of the two paths we will end up on), 3) separate the patient from the ED (asking parents and teen both to get mad at the ED while making it clear there is no anger toward the patient him/herself), and 4) for parents, begin to learn about Family Based Treatment, from the resources provided in my previous post.
That's kinda it. That's really all we can do in that first hour, unless there's a need for a medical intervention immediately. I know it's hard to walk out not having all the answers from any of us on the treatment team, but trust that those answers will come and you will make your way through this, one day at a time.
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