Brave Girl Eating (17 page)

I know that time is a long way off. I know the trouble is still now and the happy ending is yet to come. Earlier today I saw my doctor for a physical. When she walked into the room, I surprised both of us by bursting into tears. It felt good to cry; these days I am mostly numb and disconnected. I can't afford to feel pain because once it starts it might never stop, and then what good would I be to anyone? There will be plenty of time to process all this later. After Kitty's recovered.
When,
not
if
.

In fairy tales there is often a cleansing ritual, a symbolic expunging of dangerous magic. I want there to be a ritual for us. I want to walk through the house with a bundle of burning sage, a braided candle, a stick of incense. I want to wipe away the confusion and misery and suffering. But for rituals to work, you have to believe in them. And I don't. I believe in the marriage between the mind and the body, thought and feeling. I believe in the body's need to be
nourished and the mind's ambivalence about doing it. I can't afford to feel powerless and helpless; that's a luxury, that kind of thinking, and it won't help Kitty one bit.

That night I sit with Kitty as she gets ready for sleep. Six months ago she would say goodnight and close her door, and that was that. Since the anorexia, we've resurrected our old bedtime routines. Now she lies on her stomach and hikes up her pajama top, and I put my hand against her back. I can still see the knotted rope of her spine, but now the vertebrae are covered with smooth flesh. Three months ago, I hated feeling the rude skeleton protruding through her icy skin. The claws of her hands. Touching her left me bruised and anxious.

With the tip of my index finger I trace letters against the warm skin of her back: I. L. O. V. E. Y. O. U. We started this ritual when she was learning to read, when putting letters together into words was a magic act she never tired of.

After a while I get up. “Don't go,” says Kitty. “Don't leave me all alone.”

“I won't,” I say, easing myself down on the bed again. “You know I won't.”

 

By the third week
of September, Kitty's weight has plateaued. Jamie and I confer with Ms. Susan and raise her calories to thirty-five hundred a day. That's a lot of food.

Eating large amounts upsets Kitty's stomach—eating any amount seems to upset her stomach, actually—so we try to reduce the volume and make sure everything she eats is calorie efficient. Our kitchen becomes High-Calorie Central; Paula Deen is my new literary muse. We go through so many sticks of butter that I dream
about unwrapping them in my sleep, peeling back the translucent paper, dropping them one by one into an enormous metal bowl.

Which leaves Kitty with a meal plan something like this:

One of the challenges in refeeding Kitty is the fact that she feels no hunger. So she says, and I believe it. It's still there—coming out in her continuous and obsessive thoughts about food, her need to plan every bite—but her brain and her body have become disconnected when it comes to eating, which makes sense in a way. If starvation is a function of, say, famine or war, if there's no food available, then constant hunger pangs would be a pointless torment. Loss of appetite, in that case, is both a blessing and a self-defense mechanism.

Hunger is a function of a complex set of chemical interactions we don't yet understand, involving hormones like ghrelin, which is produced in the stomach and makes its way to the brain, rising before a meal to trigger eating. People with acute anorexia have high
levels of ghrelin. Another hormone connected with hunger is leptin, made by fat cells, which tells the brain you've eaten enough, shutting down hunger. People who have lost weight have low levels of leptin, which pushes them to eat more.

We need hunger in the same way we need pain: a stimulus that makes us behave in ways that preserve ourselves and our species. Without hunger, eating is a chore dictated by the clock, a literally unpalatable task to check off a list. Eating without hunger can feel punitive, the introduction of foreign matter into a body that does not welcome it. It's easy to forget to eat without the relentless goad of stomach pangs, when food doesn't look or smell good.

And hunger does more than just get us to the table. It determines, in part, how we metabolize what we eat. In the late 1970s, Swedish researchers fed two groups of women—one Swedish and one Thai—a spicy Thai meal. The Swedish women absorbed only about half as much iron from the meal as the Thai women. When the meal was mushed up and served as a paste, the Thai women absorbed 70 percent less iron than they had before—from the same food.
^*

The researchers concluded that when we eat a meal that's unfamiliar or unappetizing, we don't get as much nutrition out of it as we otherwise might. Why? Because some of the digestive and metabolic processes don't take place in the gut. The smells, looks, and sensory gestalt of a meal we're looking forward to trigger a series of processes in the brain, which in turn tells the salivary glands to kick into high gear, producing more saliva, and the stomach to secrete more gastric juices, both of which help digest the food.

Maybe this explains, in part, why it's so hard for Kitty to gain
weight. Maybe refeeding is not just a matter of calories in, calories out; maybe the anticipation and experience of eating helps determine how much of the meal Kitty's body hangs on to. In which case this process is going to take a long time.

Physically, Kitty is making progress. Slow progress, but still. Mentally—that's another story. At Dr. Newbie's urging we start her on Zyprexa, a new-generation antipsychotic, and after two days she perks up, acting like herself again, with a certain alertness and outward-looking perspective that's been gone for months. She says she feels better too, that she still has all the anorexia thoughts but the guilt isn't as strong. Unfortunately, she develops a side effect called akathisia—jitteriness, agitation, and anxiety—and Dr. Newbie says we have to take her off the Zyprexa, that the anxiety will intensify to unbearable levels. When I tell Kitty, she protests, “But it makes the voice get quieter.” The voice in her head, she means. The voice of the demon.

I'm frustrated enough to cry. This is the only medical intervention that's helped Kitty at all, and now she can't take it. No shortcuts; we'll have to do this the hard way.

When I look back even a month, though, I see how far Kitty's come. Dr. Beth agrees. At our weekly appointment, Kitty asks when she can stop trying to gain weight and go on a maintenance diet, and Dr. Beth says, “Now!” When she heads down the hall to get something, I follow her out.

“I thought Kitty had to gain another ten pounds or so to reach her target weight,” I say.

“I think she can gain weight more slowly now,” says Dr. Beth. “Maybe a quarter pound a week.”

A quarter pound a week? I think about how long it took to get Kitty started gaining weight. I don't understand why Dr. Beth
wants us to slow down now that she's actually got some momentum. Why go back to prolonging the misery?

“I've seen people overshoot their goal, and that wouldn't be good,” she explains.

I want to ask, “Why not?” But I'm conscious, suddenly, of the fact that I weigh thirty pounds more than the charts say I should.
Self
-conscious. I don't want to hear Dr. Beth say, “Because I don't want her to be fat like you.”

To be fair, I have no idea if that's what she's thinking. What
I'm
thinking is, Wouldn't it be better for Kitty to be a little “over”—whatever that means—than to chance falling down the rabbit hole again? We know the risks of her weighing too little; what, exactly, are the risks of her weighing five pounds “extra”?

I don't say any of this, partly because I feel such self-consciousness. Instead, I tell Dr. Beth that I think Kitty heard the words “You don't have to gain
any
more weight” and ask her to clarify. When we go back into the room, Dr. Beth tells Kitty she can up her activity level a bit and stay at the same calorie count. “So your weight gain will slow down,” she says. This is still a mixed message; for the last month we've been telling Kitty that she's going to feel better when she's gained enough weight, that our goal is to get her there as quickly as is practical and possible. We've told her to hang on, that things are going to get better. Now she's hearing, more or less, this is it. This is as good as it's going to get. I see the ambivalence on her face: the anorexia thinks this is fabulous news—you can stay thin! The part of Kitty that's not thinking like an anorexic is not so sure this is a good idea.

I'm with her.

This will happen again and again over the course of the next seven months: not just Dr. Beth but Dr. Newbie and every doc
tor we see will be quick to tell Kitty that she can back off, not gain any more weight, based on the numbers on the chart. No one asks whether she still has anorexic thoughts and feelings. No one asks
us
what her behavior's like, how hard it is for her to eat. They tell her she's fine when we can see clearly that she's not.

Once more I think of Daniel le Grange's comment about how anorexia seems to infect everyone around the sufferer too. And I can't help but wonder how much the current angst about obesity and the general culture of fatphobia affects doctors' attitudes. Still, we're lucky to have our treatment team, even if I don't agree with everything they recommend. Today, for instance, toward the end of this appointment, Kitty asks if she can fast on Yom Kippur, two weeks away. I hold my breath, wondering what Dr. Beth will say.

What she says is just right: “That would not be a good idea for you, Kitty.”

“But all my friends will fast, and I'll feel awful if I don't,” says Kitty. “How about if I just eat lightly?”

“Nope,” says Dr. Beth. Thank God.

In the end, the nagging sense of unease I have about Kitty's target weight is resolved in the best possible way: she begins to grow. By the end of September she's half an inch taller, which means her target weight goes up too. For the moment, anyway, we're back to straightforward refeeding. Spare no calories. Full steam ahead.

Every family deals with
anorexia in its own way, just as each family deals with—well—everything in its own way. One of the long-standing arguments for the screwed-up-psychodynamics theory is that by the time families get to treatment with an anorexic teen, they tend to look rather similar: resistant child, angry/worried/overwrought parents. Lots of tension, especially around meals.
Lots of frustration expressed on all sides, especially around meals and eating. Lots of criticism, also related to food and eating.

But this homogeneity is superficial. There's no better way to see what a family's really made of than to go through the process of refeeding. Anorexia and its horrors can highlight every little crack in the mirror of a family's self-image; it can also take a hammer and smash the whole thing to bits.

In their 1994 book
Helping Families Cope with Mental Illness,
psychiatrist Harriet P. Lefley and professor of social work Mona Wasow write:

I cringe at the label mental illness. Yet there's truth here. Janet Treasure, a psychiatrist at the Maudsley Hospital in London who
specializes in treating eating disorders, says that caring for a child with anorexia is just as stressful as caring for a child with schizophrenia or other serious psychiatric disorders.

I believe it. Taking care of Kitty has been the hardest thing our family has ever gone through. Harder than both girls' colicky infancies. Harder than my bout with postpartum depression after Emma was born. Harder than surviving the ups and downs of the freelance world, or the week Emma spent in the hospital with Kawasaki disease.

It's harder because the range of emotions is so much greater, and because the literal exigencies of this process are so complex. There's the denial at the start, followed by dawning comprehension, shock, and horror. There's shame and self-blame, guilt and doubt. There's anger and frustration. And then there's the sheer exhaustion, physical and emotional, of battling a force you can't physically touch and don't understand.

I know families who put a child into residential care because they need a break, and I don't think badly of them for it. “For a year and a half, anorexia consumed our whole family,” one mother tells me. “We had a bit of breathing room when she was away. Time to think.” I can't imagine sending Kitty away and being able to relax. But I also can't imagine dealing with the demon every day for a year and a half.

And then again, the fallout isn't entirely negative. There's a growing movement toward involving families more in the mental health treatment for their children, whether they're dealing with bipolar disorder, eating disorders, depression, or autism. The days of experts “fixing” a child—or attempting to “fix” the child—are over. This isn't to say that families should go it alone without professional help. But part of the pleasure as well as the burden of being a parent
is engaging with your kids, no matter what's going on with them. Caring for Kitty now—despite the demon—feels more satisfying than watching her starve and not being able to do anything about it.

The events of the last few months have taught me a lot about our family's strengths and weaknesses. On the plus side, we've practiced attachment parenting from the start, and both Kitty and Emma seem to trust us. In times of trouble, they tend to turn toward the family rather than away. We know them, and each other, pretty well. We're a communicative family, and I think we do OK at expressing feelings and listening to one another. That was one of Hilde Bruch's critiques of “anorexigenic” families, families that produce (in her view) children who must resort to anorexia in order to express themselves. Bruch believed that families like ours shut down their children's true feelings and engender a kind of intimacy based on falseness and superficiality.

I'm ready to take the blame for anything I've done that might remotely have harmed either of my daughters. But on this point, I think Bruch was wrong. Both Kitty and Emma have been enthusiastically telling us how they feel and what they think from the time they learned to talk. For the most part, we've been listening. Not perfectly or all the time, but consistently and enough. More than many parents.

I sound defensive, I know. Like so many of my generation, I grew up in a household where children were supposed to be seen and not heard. My parents brushed off my feelings, telling me that if I just stopped thinking, everything would be all right. Maybe they didn't know what else to do; maybe that's what
their
parents had said to them. But I grew up determined to
listen
to my children, even if I didn't want to hear what they said.

Another of our family strengths is the fact that Jamie and I have
very different temperaments. I'm quick—sometimes too quick—to take action and rush to conclusions; he's a think-about-it-from-all-angles kind of guy. I'm loquacious; he's more reserved. I like to—
need
to—talk things through, while he's more private. He processes situations slowly; I tend to leap first, ask questions later. I'm empathetic, sometimes overly so, while he maintains more of an emotional distance. At times these differences have proved problematic for us as a couple. But they've made us more resilient and resourceful parents.

For instance, when we started this process of refeeding Kitty—only seven weeks ago?—I researched anorexia, came up with the plan to do family-based treatment, got things rolling. Jamie was slower to come to terms with what was happening. He got frustrated and angry more often than I did. “Why can't she just eat?” he would ask me in the privacy of our room. “I just can't understand this disease.” I didn't understand it either, but I didn't need to. I was focused on the next step, and the next. What did we have to do today? Tomorrow?

Now, however, we've switched roles. I'm the one who often loses patience first, who paces or frets when the demon emerges. I'm restless, always in motion; I clean and tidy obsessively and still have too much anxious energy at the end of the day. Jamie can sit with Kitty indefinitely as she weeps or rages. He's the calm and steady presence these days. On one of Kitty's bad nights not long ago, Jamie took her upstairs while I stood in the middle of the kitchen, overcome. I picked up a dirty plate, to load it into the dishwasher, and instead hurled it at the floor, where it smashed in a satisfying spray. It was so satisfying, in fact, that I broke three more. The only thing that stopped me was remembering that Kitty needs big plates. She'd freak out if I served her
food on small plates, because it would look like she was eating so much more.

Jamie would never have broken plates on the kitchen floor.

On the other hand, he's less assertive about what and how much Kitty eats. He's hesitant to push for more and often holds back instead of actually dishing out the food and requiring her to eat. The concept of counting calories in either direction is strange to him; that and his natural reticence make him hesitant to plunge in.

If Kitty gets well, all the struggles and suffering will have had a purpose, and the hardest thing we've ever done will also become the most important and most satisfying thing. And if Kitty doesn't get well?

I can't, I really can't imagine that.

 

One morning in early
October, when I collect the mail, I see an envelope from Kitty's school. I open it absently, thinking it's a progress report. Instead, Kitty's school picture stares up at me, taken the day she registered for school, nearly two months ago. It's shocking to come face-to-face once more with her huge, shadowed eyes, the exhaustion and despair written on her gaunt face. I slide the photo back into its envelope and bury it at the bottom of a dresser drawer. This is one school photo that's not going up on top of the piano.

But I'm also encouraged by this glimpse of how much progress Kitty's made in the last six weeks, progress it's hard to see on a day-to-day basis. Before anorexia, I tended to think about time in chunks—this week, this month, this season. This day. Now time has telescoped down into the intervals between Kitty's meals and snacks. Each takes on its own character and rituals. Midmorning snack, for instance, which these days often comprises several slices of toast with
cream cheese. Kitty arranges them on a large plate and methodically cuts them into squares with a knife and fork. She spears them, one at a time, and slowly chews them. It takes her twenty minutes to consume three slices of toast. Which feels like a long time when I'm sitting at the table with her, buttering my own toast (I've learned the best way to keep her eating is to eat along with her), but which is only half the time it took her to eat the same snack two weeks ago.

Progress. I'll take it.

Each day has its rhythms, too. Eating seems easiest early in the day for Kitty, both physically and mentally. As the afternoon wears on she complains of stomachaches, indigestion. She bargains and pleads. The demon is far more apt to make an appearance between, say, five o'clock and bedtime than earlier in the day.

She's particularly resistant to the daily milk shake, asking why she can't have a smoothie instead. “Peaches and yogurt sounds delicious,” she says, and I'm tempted, because it's such a pleasure to hear her say that any kind of food sounds delicious. But a peach smoothie is three hundred calories, tops, while a Häagen-Dazs milk shake is about a thousand. Kitty swears it's not the calories; she just prefers the taste of a smoothie, honest.

We tell her no, sorry, milk shakes are a must. I ask Dr. Beth to “prescribe” a daily milk shake, and that helps. A little.

For many kids, the descent into anorexia begins with restrictions that could be reasonable. Vegetarianism, for instance. I was a vegetarian for fifteen years; I'm certainly not wedded to the idea of eating meat. But I've heard too many stories about teens who go meatless (and often vegan) right as they're developing an eating disorder. Coincidence? I doubt it.

I'm convinced that Kitty's preference for smoothies over milk shakes comes from the anorexia, not from her natural tastes. But
when, exactly, did the shift begin? I think again of the sixth-grade “wellness” class that inspired her to cut out desserts. I bet other kids in that class cut back on sugar for a day or two, but Kitty's probably the only one who stuck to her resolution for weeks and weeks. Was that the beginning?

Years ago, Walter Kaye discovered lower-than-normal levels of the neuropeptide galanin in the brains of people who'd recovered from anorexia. Galanin is a kind of amino acid made by the brain, and its role is to stimulate an appetite for fat. Low levels of galanin likely lead to an aversion to eating fat. I wonder how long the subjects in his study had been recovered. Six months? A year? Ten years? I wonder if levels of galanin ever recover. Or is it possible that people who go on to develop anorexia make less galanin in their brains from the start?

Will Kitty's tastes change back, once she's recovered? Will she ever dig in to a plate of sesame chicken with the same innocent pleasure? Will the eating disorder rob her of her original appetites? Or is that loss part of growing up in this culture—acquiring guilt and anxiety over every bite we put into our mouths? So many women eat the way Kitty does, avoiding fat and calories; do they do it out of a wish to be thin, or true preference?

A few years ago, researchers identified a fat receptor protein known as CD36, found on the surface of human cells and throughout the body, including on the surface of the tongue. Recent research done by Nada Abumrad, a professor of medicine at Washington University School of Medicine in St. Louis, suggests that some people may naturally have higher levels of CD36, which may lead to a taste (and even a craving) for fat. Maybe people like Kitty who develop anorexia are born with lower levels of CD36. Maybe the disease process of anorexia alters levels of these fat re
ceptors. Or maybe anorexia masks Kitty's true tastes.

Whatever the cause, what I want to know is simple: Will she ever again eat the way she used to?

 

As October proceeds, Kitty
goes to school most days, if not eagerly then at least willingly. She spends part of her sessions alone with Ms. Susan. She seems livelier, more interested in the rest of the world. She still complains about stomach pain every time she eats. But she does eat everything we put in front of her.

One day she comes home from school with news: one of her friends is joining the school gymnastics team, and she wants to join too.

I love seeing her excited about something. One of anorexia's most devastating consequences is isolation. But gymnastics? Everything in me says no. Gymnastics was part of how Kitty got where she is now—the emphasis on form and line and how she looked in a leotard. The hours of strenuous practice. The constantly sprained ankles and pulled tendons. The stress of competing in meets.

And something more: my sense that the coaches, however pleasant, however good with the girls, saw them as gymnasts rather than children and teens. What I mean is that they saw them as interchangeable elements of the team rather than as whole people. There wasn't much warmth, despite the fact that most of the girls, including Kitty, spent ten or fifteen hours a week at the gym, spent years training, practicing, and competing.