Dr. Lock: We have no clearly effective treatments for anorexia nervosa once it becomes a chronic disorder. We can help with symptoms, and we can improve some aspects of quality of life. But it remains the most lethal psychiatric disorder with the possible exception of substance abuse. It has been extraordinarily under-researched. One of the reasons is that there has been a longstanding belief that it is a disorder of choice, that people choose not to eat so it is not a legitimate psychiatric disorder.
TCPR: Yes, parents are often perplexed about why their kids have the condition. What do you say when the parent is asking us, “Why is my daughter not eating? Wouldn’t everything be better if she could just start eating? What is wrong with her?”
Dr. Lock: I say “No one knows what is causing this disorder.” And I also say it is not a matter of choice. It starts off very innocently, but it becomes a pretty fixed and obsessional set of beliefs and behaviors much like OCD. Usually what the family is wanting to know is, “Did we cause this?” Parents often feel that they cause many things and, unfortunately, psychiatry has a history of blaming families for various conditions. We no longer blame autism on “refrigerator mothers” or schizophrenia on double-binding mothers, but we once did, and anorexia has been laid at the feet of families for a very long time without any evidence to support that perspective.
TCPR: We are going to discuss some of your work with family therapy, but before we get to that, what’s the bottom line on medications for anorexia? Have we decided that medications just do not work for the condition?
Dr. Lock: We have found no systematic evidence that any medication yet tried is effective. However, because anorexia also leads to or is associated with anxiety disorders and depression, medications can be used to treat those conditions. For anorexia itself no known medications have been shown to be effective in any systematic studies of any scale. One of the reasons for this may be that people with anorexia don’t want to take the medicine. They often don’t agree they need treatment of any type and especially taking medication that may cause weight gain, is anathema to these patients.
TCPR: Tell us about family therapy for anorexia.
Dr. Lock: The cornerstone of the approach is a belief that families can learn to do the very things that happen on an inpatient service for weight restoration at home. When you hospitalize people with anorexia, you will see the patients get their weight up; then you discharge them and watch in the next two months all that weight disappear, and you know that the behaviors they mastered in the hospital weren’t generalizable. In contrast, in the family environment and home environment the patients learn how to manage their illness in the same place where they live and work, and so those behaviors then can be maintained and changed.
TCPR: How do you begin the treatment?
Dr. Lock: The treatment begins by meeting with the family members who live in the home. Session one is all about helping address the family’s sense of powerlessness; its sense of anxiety about the fact that their child is so ill that they could go to the hospital and perhaps die; and that the efforts to date that they’ve made have not been able to reverse the behaviors. The therapist joins with the family in this dilemma and facilitates first of all the notion that they are not to blame for the illness; that parents are indeed the best resource to help their son or daughter; and that they need to take responsibility for making sure that their child is able to move forward and gain weight. And the therapist then says “We will begin that process right away with a meal, and I want you to bring a meal next week that you think will help your son or daughter begin to gain weight.”
TCPR: So the family meal is the second session?
Dr. Lock: Yes, the family sits down together and the therapist is attentive to what the parents brought. Regardless of what the family meal is in terms of the food, it is an opportunity for the therapist to see what the family is doing; learn what their thinking is; see if the parents can agree and work together to change behaviors, just like you would with any behavioral problem with a child. Usually the family makes a set of decisions by the end of that meal about how they are going to proceed. They learn that if left on its own the behaviors are going to re-instill themselves, and so the family develops a plan for a week or two of pretty intensive monitoring and making sure that their son and daughter eats and doesn’t exercise.
TCPR: So basically, the family is playing a role similar to staff at an eating disorders facility.
Dr. Lock: Yes, they are creating in their own house a behavioral milieu which will not allow the behaviors of anorexia nervosa to manifest themselves consistently. This is not necessarily a new thing—families have always tried to help to support the treatment after discharge from hospitals. But they didn’t know what they should do; they felt they were punishing their child; their child threw fits or was tearful. They didn’t have the support of an expert therapist to help them weather that storm and face down those behaviors consistently. The therapist helps them create a very clear plan of action as opposed to on-the-fly kinds of decision making, which can undermine behavioral change. This treatment with the family continues for several weeks like this. Eventually, the child can go back to school for half a day or sometimes a full day—if the parents are able to go to school and eat with them. And in successful cases, they are able to make weight gains of a pound or two per week over the ensuing six to eight weeks.