Book Review: Brave Girl Eating by Harriet Brown

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Family based treatment/ Maudsley approach:….0…1c.1.64.serp..8.32.2428.0..0j35i39k1j0i131k1j0i20k1.lb4H6kNOu7c

I just finished an absolutely amazing memoir about how anorexia touched one family and a mother who would not give up until she found the right care for her daughter.

Harriet Brown is a journalist. She has a journalist’s clear eye for detail and conviction and passion to explore all sides of a story with scientific research. When her 13 year old daughter Kitty, suddenly develops anorexia, Harriet is in denial at first. Kitty is intelligent. She wrote a paper about eating disorders once. She is someone who usually bounces back from the down times in life. Their family is not one where her parents are critical of her, in fact she places very high expectations on herself. At first her mom thinks it’s a phase she’s going through. But as the weeks go by and she continues to lose weight and restrict to a dangerous level there’s no denying anymore. Particularly after a terrible trip to the hospital where Kitty is in the ICU for three days.

At that point Harriet takes time off work a and combines her talents in journalism with her feerce devotion to her child to take this head on. She quickly discovers that the popular treatments/ research on eating disorders does not at all fit her family. She does have a sister with bulimia. She herself has dealt with panic disorder. So there is some genetic predisposition but not a huge amount. The main research focuses on the typical family that they say “creates” an eating disorder. A family where the child is put under overwhelming amounts of pressure to do well in all areas of life. Where all emotions are denied and expression not encouraged. Usually the mother is extremely emotionally dominating and the father is passive. The child develops the eating disorder to (broadly) control the one thing she can in a stifling and emotionally abusive environment, and as a way to escape growing up. As though her family is on the one hand extremely stifling, she is also then extremely dependent on them and sheltered. This creates mixed messages and the set up experts say for anorexia in particular.

Harriet says again and again that she would take any blame thrown her way if it meant Kitty could be free of her disorder. But she just doesn’t see the connections. And she doesn’t see that there’s anything different she can do with Kitty in relation to what is suggested. When she attempts this route, sees one therapist who tells her not to be “the food police,” attempts to have Kitty go to partial hospitalization, Kitty becomes even more anxious terrified of being away from her family. And it just makes Harriet feel worse.

From the start, the family is blessed with an amazing Pediatrician Dr. Beth. Dr. Beth is the one who first diagnosed Kitty. She gives the family a huge amount of hope from the start saying that one third of people with anorexia have a full recovery. She refers them to a psychiatrist that Harriet calls Dr. Newby, because she’s young I guess new to the field. Harriet and Kitty don’t particularly like her. She tries different antidepressants. Prescribes some PRN a anti anxiety meds which do sadly end up being used when her symptoms get out of control. Once they even try an antipsychotic used in eating disorder treatment. It’s the one med that seems to work however side-effects stop them from continuing it.

So meds aren’t helpful. Tradditional ways of therapy and beliefs about eating disorders aren’t helpful. Harriet’s husband Jamey and Emma, Kitty’s sister are left along with everyone else to struggle against what Harriet calls “the demon,” or “not kitty.” From the beginning she does an amazing job of vividly personifying and separating her daughter from the illness. Something I feel is vital for both those that suffer from any psychiatric illness, their loved ones and professionals. She refuses to believe that Kitty is “choosing” this disease, or that she just needs to “choose to eat” She stops yelling at her daughter trying to bribe her reasoning ETC. She realizes there is no reasoning with “not Kitty.”

One day she happens by the library and finds in new arrivals a book called Eating with your Anorexic. It describes a totally different approach to the treatment of eating disorders. Family Based Treatment, FBT, or the Maudsley Aproach. FBT does not blame the parents, or the child for the disorder. It does not focus on sending the child away or forcing them to do something that is neurologically imposible, which is to have insight into their disorder when they’re literally starving. FBT puts the focus on the parents taking control of the child’s eating. In a loving but firm way. It was discovered at Maudsley hospital, somewhere in the UK, that nurses who spent hours calmly insisting that the child eat, quietly talking to them and otherwise creating an environment where the task was nonnegotiable, saw results. Another psychologist developed the idea that doing this in the hospital is not enough. That parents need to do the treatment at home for it to be effective.

There are three stages: Weight restoration, giving control of eating back to the child, and the child resuming normal development/ life. This is just the thing that Harriet intuitively has been searching for. Something practical scientifically based and that focuses on the solution, on a purely physical level. Throughout the book Harriet adds to the story by detailing some very interesting research findings, around the neurobiology of starvation, and other physical biological processes. Basically saying that there is absolutely no way that someone can engage in productive therapy, or really do anything until they have their body back in balance. Their brain’s abilities are terribly compromised.

So with her husband on board they start the process of refeeding. They become experts in nutrition and calories. It starts in the summer. They put breakfast, morning snack, lunch, dinner and bedtime snack in front of Kitty. And wait. And watch as “not Kitty” attacks Kitty and do everything they can to help Kitty win. It’s heartbreaking to hear of Harriet’s descriptions of her daughter trying to get through each meal. Dealing with physical pain, huge amounts of anxiety and rages. She tries to physically hurt herself and Jamey must restrain her. She verbally puts herself down for hours. She sobs and has panic attacks. There is no reasoning with “not Kitty” and often no getting Kitty back in control. They had to learn to just wait it out.

They have weekly weigh ins with Dr. Beth. Dr. Beth also will spend a couple of hours for some appointments and in her own way acts as a therapist to the family, or at least emotional support consultant. They also do find a therapist they call Ms. Susan. She builds a good relationship with Kitty and her parents and has the hopeful practical approach that fits with FBT. Unfortunately there are no FBT trained therapists in the area. But Harriet later consults with the director of an eating disorders FBT program and strongly advocates for the training and spread of FBT to this day as does Kitty.

Through it all they have other battles. One is of course the insurance company. Harriet describes the ins and outs of literally having to beg for extra sessions. And the huge incredibly alarming disparity between physical health and mental health. How Kitty’s ICU stay was basically covered, yet getting weekly therapy, and psychiatry visits is almost imposible beyond the allotted amount of money per year. Which is incredibly limited and that they unknowlingly wasted some of with the first bad therapist. The most telling incident on just how cruel the system is is when she describes putting together a huge amount of documents and being given ten minutes to present her case at the insurance company. She does so. They seem to at least look thoughtful. The next day she receives a denial letter. Judging by the time the letter was sent plus the time when the meeting was she figured that the letter had likely been written if not sent before she actually made her case.

She often said she was lucky to have a job where she had the extra financial resources to cover care. Not a ton of resources but more than many many families. A continued advocacy effort for her continues to be around access to mental healthcare that is actually compassionate and treats people like people and not just a number or too much money spent.

The refeeding process has it’s ups and downs. At times Kitty seems to be getting better. They come up with an abbreviated school day around her meals at home. She is starting to hang out with people, guys who don’t focus on body image or food in the way girls do. She connects more with her sister and there are more glimpses of happiness. But then there are the back slides the times not Kitty comes out in full force.

And the most frustrating thing ends up being the lack of weight gain even with calorie intake that can’t go any higher. It turns out that there is documented research around metabolism that everyone has a set metabolism a rate in which they process calories that basically can not be changed. So the theory of forcing oneself to lose or gain weight by some kind of fixed schedule is not physically possible. Especially for a developing teenager. So her target weight keeps changing. By the end of the book they still hadn’t reached it. As time passes Kitty becomes more insightful around her eating disorder. More willing to articulate her feelings about it and is able to do more in the way of therapy. But not before starvation was stopped. Harriet also discovered that long after that initial year of refeeding, if she restricted even a little, didn’t get a full day’s calories, her mood would have a sharp downturn.

Basically as much as Harriet, and the family wanted to turn their backs on “the demon” forever and not to be one of those families where the person is always trying to “manage” their disorder, they come to accept that it will have to be managed. There will be times that Kitty loses the ability to manage her own weight. And her mom is committed to being there no matter what. Learning when to step back and let Kitty have her independence and control of food, and when to stand up to “not Kitty” as she tries to resurface and take her child away. She won’t let that happen again.

She mentions at the end of the book a public service add on mental illness that only ran for a few days. It was a series of ransom notes stating things like “We have your daughter. We make her throw up every night. There’s nothing you can do.” The same was written to personify, anxiety, depression, and other illnesses. She believes the uproar, which caused the removal of the PSA was due to people wanting so much to feel in control of these terrible things that were stealing their children’s minds and their lives. But the thing is They, the illnesses, outside of anyone’s control, were stealing their lives. It isn’t the person’s fault. It isn’t the parents fault. They need professionals who in their hearts understand this. Who are willing and able to stand with the family against whatever it is and fight until it’s gone, or at least too afraid to come back in full force. It reminded me of a powerful therapy session where I was told I was being “mugged by my emotions.” It was true. I had no idea how to deal with my feelings. They came out of nowhere and attacked me. I had no idea what was ok to feel so assumed anything but neutral or happy wasn’t and so again and again was vulnerable to them. I had nothing to fight with.

These are powerful and perspective changing metaphors in the world of mental healthcare. I feel the Maudsley approach should be included in the basic overview of eating disorder research and treatment. So that at the most basic level of understanding it’s there. As another lense on things. Are some people’s eating disorders caused by emotional trauma? Yes. Are some people dealing with a multitude of disorders to the point that you can’t tell what caused what? Yes! Is every family judgmental and unhealthy. No this book proves that. Harriet says in the end that she feels more families could do FBT . They just need confident professionals, and mentors who have been there. I wonder if or how this approach, nonjudgmental family based, could be transferred to the treatment of other disorders. I highly recommend this book packed with both extraordinary scientific information as well as an emotional raw and truly hopeful journey of recovery.


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