Investigations

Spoon-feeding anorexics
For the parents of a teenager with anorexia nervosa-an eating disorder that strikes 1 to 2 percent of American women and has one of the highest death rates of any mental-health condition-being told to have a family picnic can seem like strange counsel.

No carefree Sunday outing, this family meal takes place on a small table in the office of Daniel le Grange, assistant professor of psychiatry at Chicago's Pritzker School of Medicine. All family members, including siblings, must attend. The parents are told to bring ordinary food to help their daughter-in almost all cases the anorexic is female-regain weight.

Daniel le Grange sits at the picnic table for anorexic girls' families, whose mealtime habits he scrutinizes. Photo by Dan Dry

Some families arrive with filling, high-fat dishes-nourishment the starving adolescent needs. Others bring sandwiches or take-out for themselves and for their daughter a separate, ultra low-cal meal-a sign that the parents "collude with the illness," le Grange says. Still others bring multicourse, gourmet feasts prepared by the anorexic girl, who refuses to eat.

Le Grange, who does not partake in the meal, asks about the food: where it was purchased, who prepared it, if it's the family's usual fare. At the same time he observes how they interact: does the mother urge her daughter to take one more bite, while the father takes his daughter's side? Does the son nag or inform on his sister? Afterward le Grange talks frankly with the family-including the anorexic-about what behaviors to change. His goal is to train the parents to act as a noncritical, sympathetic tag team whose task is to cajole the girl into eating enough high-calorie food to reverse her starvation. Siblings learn to offer moral support rather than act like small parents.

This method, called the "Maudsley approach" and pioneered by Christopher Dare and Ivan Eisler at the University of London's Maudsley Hospital, contradicts more than a century of thinking about the family's role in eating disorders. In 1873, when British physician Sir William Gull first named anorexia nervosa, he advised feeding patients regularly but warned that family members were "generally the worst attendants." French doctor Jean-Martin Charcot, who independently discovered anorexie hysterique the same year, went even further and suggested socially isolating patients. By the 1950s, toxic families-domineering mothers, overcritical fathers-were blamed entirely for the illness, a theory that sounds plausible but lacks clinical evidence: "We don't know what causes eating disorders," le Grange says.

While the Maudsley approach often is described as controversial, "most parents don't think it's controversial at all," notes le Grange, a South African who studied with Dare and Eisler while earning his Ph.D. in psychology at the University of London. "What we're telling them to do is what most parents do well-feed their children."

In academic circles, however, family-based therapy has been criticized for giving parents a license to control. "Nothing could be further from the truth," counters le Grange. "It's the eating disorder that controls the adolescent." For anorexics, eating is an ordeal: patients obsessively calculate and recalculate calories or refuse to eat unless food is arranged in a certain pattern. Parents can end this obsession by temporarily revoking their daughter's responsibility for choosing to eat. When she begins to gain weight she regains her ability to make healthy choices because, le Grange says, "obsessive thoughts and feelings are side effects of the starvation."

Compared to other treatments, care under the Maudsley approach is astonishingly brief: just 20 sessions over six months, with the family meal usually scheduled for the second session. In other meetings the family discusses the daughter's progress. Le Grange doesn't address body-image issues, he says, because the therapy works without it. Once the adolescent begins to gain weight, he argues, those issues disappear. At the end of the therapy he and the family talk about adolescent issues, reintegrating the patient into the world of normal adolescent socializing and concerns.

Recent evidence indicates that the approach works. A 1997 study by Eisler, Dare, le Grange, and others found that after five years, more than 80 percent of adolescent patients recovered completely with no further treatment. The key is to catch the illness early, le Grange says, when patients are in their teens and still live at home. "I use the analogy to cancer," he says. "It's like a tumor that's malignant, but it hasn't metastasized."

Le Grange, who joined the U of C in 1998, is one year into a five-year study funded by the National Institute of Mental Health to evaluate the Maudsley approach's effectiveness on 90 adolescents with bulimia nervosa, an eating disorder characterized by binging and purging. Because the desire to purge subsides after a few hours, the parents might watch a movie with their daughter after a meal or even accompany her to the bathroom-"just like nurses would in an in-patient unit," le Grange explains. "It may seem very intrusive, but the intervention has to be more powerful than the illness for it to have any effect."

Le Grange is adapting his treatment manual for family-based anorexia therapists (Guilford Press, 2001) into a parents' guide, If Your Child Has an Eating Disorder, to be published next year. He hopes it will replace books that rehash terrible advice, such as "don't talk about food."

"How can you not talk about food," he asks, "when your daughter is starving?"
- Carrie Golus, AB'91, AM'93