Harriet Brown's Brave Girl Eating tells the story of the family-based therapy that helped her daughter out of anorexia. We spoke to Brown about why such therapy isn't more widespread, and about how her daughter's illness affected their whole family.
Brown's daughter, called Kitty in the book, developed anorexia at 14 and relapsed at 18. Both times, Brown and her family used family-based treatment, also called FBT or the Maudsley approach, rather than traditional psychotherapy or inpatient treatment. FBT, in which parents take charge of an anorexic patient's eating and offer love and support while still making sure she (or he) gets enough food to restore much-needed weight, flies in the face of the old orthodoxy that eating disorders are caused by family problems and only a "parentectomy" can solve them. But Brown writes that in one study "90% of the adolescents treated with FBT were still doing well five years later, compared with 36% of the teens who got individual therapy." Still, there was no FBT therapist in the Browns' town when Kitty got sick, and Brown mentioned to me that though many of Kitty's friends suffered from eating disorders at some point, none of them received family-based treatment. So why hasn't the approach caught on?
Brown explains that many clinicians still approach eating disorders as essentially a problem of nurture: "if a kid has problems, it has to be something in their upbringing. It probably came from some family psychodynamic." This may change as the biological bases for a whole host of mental issues, including addiction, come to the fore, but Brown says there's another obstacle to widespread FBT as well:
[T]he sort of "dirty little secret" of treatment in the field is that a reasonably high percentage of people who treat eating disorders have had them themselves, and a lot of them never really fully recovered. And so I think that if you got sick, you were sick for 10 years, or 15 years or whatever, and then you got better, but maybe not all the way better, [...] you are used to thinking about your illness in terms of psychodynamics. You know, "I had a wretched mother, and an absent father, and this happened to me when I was a child." You know, that's your personal narrative, and I think that it's human nature to impose that on the world.
Family-based therapy is far from easy — Brown recounts multiple scenes of Kitty screaming at her parents, her teenage rebellion mixed with the terrifying voice of her illness. In an especially heart-wrenching moment, Kitty tells her mom, "I'm afraid I'm going to be built like you!" Brown says, "It's really painful to have your kid say that, even if you understand where she's coming from, even if I know that her thinking is distorted." She says her daughter's illness "has caused me to struggle more at times" with body image. But none of this has shaken Brown's commitment to helping Kitty, to telling and showing her, "I love you, and I'm not going to let you starve."
Despite their media coverage in the last few years, eating disorders are still poorly understood. In a post for Psychology Today, Brown writes about the misconception that we can tell by looking whether someone is healthy:
Part of the issue is that we are, all of us, used to looking at bodies-especially the bodies of women-through the distorting lens of our culture's emphasis on the unattainable thin ideal. When your eyes are accustomed to seeing images of young women who are five-eleven and weigh 110 pounds, it's hard not to see everyone else as "not that skinny." When you're used to seeing protruding hipbones and images where every lump, bump, and wrinkle has been Photoshopped out, it can be hard to recognize when someone's too thin.
It can also be hard to recognize why. Of her goals for the book, Brown says,
[W]hat I really want people to understand is the essential nature of an eating disorder. I want them to know that it's not a choice. It's not something that people choose, and it's not something that they can choose to recover from in any kind of casual way. [...] I called the book Brave Girl Eating because I want people to know that someone who has anorexia or bulimia, you know, they go through hell and they have to be extremely courageous, not just, like, occasionally, but all day, every day, but for as long as they're sick.
And, she says, "I want them to know that families are part of the solution."