Brave Girl Eating_ A Family's Struggle With Anorexia Part 4

This book is not like those despairing memoirs I couldn't read. It's written by the mother of a fourteen-year-old with anorexia, who was dismayed at the treatment options offered; she found another treatment, one I haven't heard of before. I read the whole book, sitting on the floor in the library, and by the time I'm done I have a glimmer of real hope for the first time.

That night I spend hours online, digging up everything I can find on family-based treatment for anorexia. FBT-or, as it's often known, the Maudsley approach-draws on the work of Salvador Minuchin, who more or less developed family therapy in Philadelphia in the mid-1970s. Minuchin discovered that when he treated anorexic teens with family therapy, about 86 percent recovered-a staggeringly high number, given that typical recovery rates were then (as now) closer to 30 or 40 percent. He reasoned that dysfunctional families must cause eating disorders, and much of his work thereafter focused on "fixing" family problems to help teens with eating disorders recover.

Around the same time that Minuchin was experimenting, three therapists at London's Maudsley Hospital-Gerald Russell, Ivan Eisler, and Christopher Dare-noticed how nurses on the hospital's inpatient unit were able to get anorexic patients to eat by sitting with them, rubbing their backs, talking kindly to them, encouraging them, often for hours. "They made it impossible for someone not to eat," recalls Daniel le Grange, director of the eating-disorders program at the University of Chicago Medical Center. "They were consistent and persistent." I called Le Grange after stumbling across information on an anorexia study at the University of Chicago, three hours away from us; treatment is free if you're enrolled in the study. Maybe Kitty will qualify.

Le Grange trained with Eisler and Dare at the Maudsley Hospital in the mid-1980s, and, along with Dr. James Lock of Stanford University, wrote the clinician's manual on FBT. Now he tells me that the Maudsley therapists also noticed that no matter how kind the nurses and doctors were, being hospitalized was traumatic for both teens and their families. "We were still inevitably giving parents the message, 'You've failed at something that most parents succeed at, which is to feed your kids,'" he says.

Patients at the Maudsley Hospital ate and gained weight. But once they went home, they invariably relapsed, because parents were traditionally told not to sit and eat with them. In fact, eating-disorders specialists often recommended (and many still do) "parentectomies," physical and emotional separation between parents and a child with anorexia. Parents are still advised by therapists like Dr. V. not to pressure their child to eat, not to talk about food, not to be the "food police," to find other subjects to discuss. They're told to b.u.t.t out, stand down, give their teenager s.p.a.ce and autonomy.

They're told, in essence, to watch their child starve to death.

Anorexia, parents are often told, isn't about food; it's about control. Their children need to feel that they're in control of their eating, or, more likely, their noneating. They'll eat when they're ready. They'll eat when the underlying issues that caused the anorexia in the first place have been resolved.

Except a lot of them die before that happens. If it ever does.

Like Salvador Minuchin, both Chris Dare and Ivan Eisler are family therapists. They believed from the start that families played a key role in the recovery process. Unlike Minuchin, they didn't a.s.sume that families therefore caused eating disorders. On the contrary. "[Dare and Eisler] always had the whole family present," explains Le Grange. "So there's the kid who has anorexia, but you also see the other two who are perfectly healthy. It's not that the parents don't know how to raise their kids and feed them; something just went awry with this one."

I think I understand what Le Grange is getting at. For the last two months Jamie and I have been trying to get Kitty to eat, mostly without success. The process has felt adversarial-us against the anorexia-rather than supportive, both because we've been told by therapists like Dr. V. that we're not supposed to get involved with Kitty's eating and because we feel like we screwed up in the first place. That sense of self-blame and disempowerment is part of what's preventing us from being effective. But what if we approach Kitty's eating from a different point of view? What if we, like the nurses at the Maudsley Hospital, make it impossible for her not to eat?

That was Dare and Eisler's idea. Patients in the hospital ate with the support and encouragement of nurses; teens at home could eat if their parents supported and encouraged them. Parents love their children, and they have an enormous stake in their child's recovery. No family's perfect. But maybe they don't need need to be perfect. Maybe they just need to be able to get the job done. to be perfect. Maybe they just need to be able to get the job done.

This perspective marked a paradigm s.h.i.+ft in the treatment of eating disorders. Historically, anorexia has been viewed as a biological "solution" to a psychological conflict: a teen starves herself in an attempt to resolve emotional issues, including loss, family conflict, fear of independence, and confusion about s.e.xuality. This case history, cited in 1984 by Pauline S. Powers, M.D., professor of psychiatry and behavioral medicine at the University of South Florida in Tampa, is pretty typical: Ms. E., age 21, could not choose a career, but thought she might become an airline stewardess. Her mother rejected this idea as "not good enough," and described the job as "only a waitress in the sky." This is an isolated example in a woman whose choices had been rejected as poor throughout her life. As a consequence, she felt empty and unable to direct her own life.*

I wonder if there's a mother anywhere in America who has actively supported every single one of her daughter's choices.

Or how about this case history, also cited by Powers: Laura is a 14-year-old girl.... Her father was a soft-spoken, highly successful lawyer. Her mother was a guilt-ridden woman with inflexible rules for her daughters and teenage son. She bitterly resented her role as a housewife and mother.... The family interaction patterns commonly described in anorexia nervosa were present. There was an absence of intergenerational boundaries (e.g. the father covertly sided with the patient against the mother) and there were rigid fixed patterns of interaction (e.g. attempts to change Laura's violin practice schedule met with overt resistance from the entire family). Enmeshment was present (e.g. when a cold remedy for Laura's sister was prescribed, the father dosed both daughters "to prevent" Laura from developing a cold) and there was a lack of conflict resolution (i.e. either emotionally charged topics were avoided or occasionally there were prolonged unresolved quarrels).*

More recently, here's what clinical psychologist Richard A. Gordon, author of Anorexia and Bulimia: Anatomy of a Social Epidemic, Anorexia and Bulimia: Anatomy of a Social Epidemic, has to say about eating disorders: has to say about eating disorders: Anorexics and bulimics draw upon the common cultural vocabulary of their time, through latching onto the contemporary mania about dieting, thinness, and food control that have become endemic to the advanced industrial societies. They utilize these cultural preoccupations as defenses that enable them to escape from-and achieve some sense of control over-unmanageable personal distress, most of which revolves around issues of ident.i.ty. [S]imilar to hysteria, anorexia and bulimia are socially patterned, the fas.h.i.+onable style of achieving specialness through deviance.

It's no wonder the clinical literature reflects this perspective, though, given that Hilde Bruch's book The Golden Cage The Golden Cage has been considered the definitive text on eating disorders since it was first published in 1978. Bruch, who was a professor of psychiatry at Baylor College of Medicine, described the typical anorexic as a sparrow in a golden cage, a child of privilege who seems to have everything but who deep down feels stifled by her parents' expectations and often unspoken demands, unable to express her feelings directly. The cla.s.sic anorexia patient, writes Bruch, "was not seen or acknowledged as an individual in her own right, but was valued mainly as someone who would make the life and experiences of the parents more satisfying and complete." Bruch describes families where "clinging attachment" and "a peculiarly intense sharing of ideas and feelings develop," where parents overdirect and overcontrol, pressuring the child to meet their expectations and heal their own emotional neediness. has been considered the definitive text on eating disorders since it was first published in 1978. Bruch, who was a professor of psychiatry at Baylor College of Medicine, described the typical anorexic as a sparrow in a golden cage, a child of privilege who seems to have everything but who deep down feels stifled by her parents' expectations and often unspoken demands, unable to express her feelings directly. The cla.s.sic anorexia patient, writes Bruch, "was not seen or acknowledged as an individual in her own right, but was valued mainly as someone who would make the life and experiences of the parents more satisfying and complete." Bruch describes families where "clinging attachment" and "a peculiarly intense sharing of ideas and feelings develop," where parents overdirect and overcontrol, pressuring the child to meet their expectations and heal their own emotional neediness.*

The more I read Bruch and Minuchin and others, the worse I feel. Le Grange helps me put things in perspective by pointing out that by the time a family comes in to therapy with an anorexic child, the usual family dynamics no longer apply: parents are anxious, the patient is irrational, the other children are traumatized. So what you see in family therapy for anorexia is not a family's typical modus operandi.

Once upon a time, and not all that long ago, our family ate together, talked and joked and kibitzed at the table. At this point, though, we probably look pretty d.a.m.n pathological. I think of our last month of family dinners: Jamie and I begging Kitty to eat. Tears and tension. Emma slouching lower and lower in her chair or bolting from the table. I wonder if we'll ever have a normal family dinner again. Or at least one that doesn't leave me shaking and sick to my stomach.

Eisler and his colleagues understood the way family dynamics change when a child has anorexia. In the early 1980s, they developed a set of protocols for weekly family therapy that put parents in charge of their anorexic child's eating, making them, in effect, the food police. Their findings echoed Minuchin's: 90 percent of the adolescents treated with FBT were still doing well five years later, compared with 36 percent of the teens who got individual therapy. (A later Canadian study shows that "involving adolescents' parents in treatment might be necessary, particularly for adolescents who describe the greatest resistance to treatment.... Adolescents who perceived their relations.h.i.+p with their parents more positively also reported greater motivation to change their eating disorder.")*

That number-90 percent-is the one that catches my eye. It represents the best news I've gotten since Kitty was diagnosed. Why wouldn't wouldn't we try a treatment with such a high recovery rate-especially if the alternative is treatment with only a one in three chance for full recovery? we try a treatment with such a high recovery rate-especially if the alternative is treatment with only a one in three chance for full recovery?

And there's another reason to try it: chronic anorexia is notoriously tough to treat. Years of malnutrition, restricting, and altered social interactions set up a potent and self-reinforcing pattern that becomes part of an adult's ident.i.ty and physiology. After five or ten or fifteen years of anorexia, recovery is far less likely.

All the more reason to take this on aggressively and fast. If we can help Kitty recover now, while she's still a teenager, while she hasn't been sick for very long, her chances are way better.

We can do this, I know we can-if Jamie gets behind it too. One of the key criteria for the success of FBT is that parents present a united front. Consistency and persistence, as Le Grange told me. That makes sense; all child-rearing efforts, whether they involve potty training or curfew setting or eating disorders, require that parents be on the same page. I know from our experiences so far how hard it is to keep at Kitty to eat another bite, have another sip, finish the milk shake or pasta or cheese. You feel like you're torturing your child by pus.h.i.+ng, pressing, insisting. And you are, in the short term. But the long-term stakes are so high. It seems to me a fair trade-off: X number of days, weeks, months of h.e.l.l, in exchange for a lifetime of recovery. I know what I want to do. What we need to do.

For the next several days, Jamie and I talk and argue and grieve together. "I can't understand it," he says, over and over. "Why won't she just eat?" I can't understand it either. But my gut tells me that we're asking the wrong question. The question isn't why why but but what: what: What do we do now? What do we do now?

What it boils down to is that we have three choices: Send Kitty away. Keep doing what we're doing. Or try some version of FBT, the Maudsley approach.

In the end the decision is easy.

The next morning I call Dr. Beth and Ms. Susan and tell them our plan to begin family-based treatment with Kitty. Ms. Susan has heard of FBT and thinks it could be a good option for Kitty because she's young and hasn't been sick for long. (How long is call Dr. Beth and Ms. Susan and tell them our plan to begin family-based treatment with Kitty. Ms. Susan has heard of FBT and thinks it could be a good option for Kitty because she's young and hasn't been sick for long. (How long is long, long, I wonder? Because I feel as though Kitty's already been sick a long time. Too long.) Dr. Beth has never heard of it but promises to do some reading and call me. I wonder? Because I feel as though Kitty's already been sick a long time. Too long.) Dr. Beth has never heard of it but promises to do some reading and call me.

FBT comprises three phases: Phase 1 is weight restoration, Phase 2 is returning control over eating to the adolescent, and Phase 3 is resuming normal adolescent development. Phase 2 seems a long way off; there's no way we're letting Kitty control her eating anytime soon. I have no idea what "resuming normal adolescent development" means, and frankly, at the moment, I don't care. We are solidly in Phase 1.

Kitty has lost only six or seven pounds since June, but it's painfully clear that she'll need to gain a lot more than that to recover. Dr. Beth graphs Kitty's height and weight from birth, plotting her natural growth curve, and gives us a number to start with: twenty-five pounds. That's how much Kitty needs to gain, at least for now.

In true FBT, I read, a therapist meets weekly with a family, supporting them as they figure out how to get their child to eat. The therapist doesn't tell tell the parents how to do this but rather the parents how to do this but rather empowers empowers them to find strategies that work. I think back over the last few months of family dinners, remembering one in particular, a week or so before Kitty's official diagnosis, during the time I knew something was wrong but didn't yet understand what. We had company-my mother-in-law was visiting, along with my best friend from college and her young daughter-and we'd gone out to a restaurant, seven of us sitting at a round table. We had to send the waiter away three times because Kitty was negotiating, in a tone of rising hysteria, what she would order. The menu was full of dishes she had once loved: mussels in b.u.t.tery broth, spaghetti carbonara, salmon in creamy dill sauce. She wanted a salad with grilled chicken, dressing on the side. I looked at my emaciated daughter, the flat hollows under her eyes, the protruding k.n.o.bs of her shoulder bones. I looked across the table at friends and family who had traveled thousands of miles to see us, whose eyes reflected their concern and bewilderment even as they pretended not to hear our agitated whispers. If we'd been alone, I probably would have let her order the salad, thinking them to find strategies that work. I think back over the last few months of family dinners, remembering one in particular, a week or so before Kitty's official diagnosis, during the time I knew something was wrong but didn't yet understand what. We had company-my mother-in-law was visiting, along with my best friend from college and her young daughter-and we'd gone out to a restaurant, seven of us sitting at a round table. We had to send the waiter away three times because Kitty was negotiating, in a tone of rising hysteria, what she would order. The menu was full of dishes she had once loved: mussels in b.u.t.tery broth, spaghetti carbonara, salmon in creamy dill sauce. She wanted a salad with grilled chicken, dressing on the side. I looked at my emaciated daughter, the flat hollows under her eyes, the protruding k.n.o.bs of her shoulder bones. I looked across the table at friends and family who had traveled thousands of miles to see us, whose eyes reflected their concern and bewilderment even as they pretended not to hear our agitated whispers. If we'd been alone, I probably would have let her order the salad, thinking At least she's eating something At least she's eating something. But in front of the people who knew us best in the world, I felt sudden shame. Kitty was too thin; we knew it, they could see it. We weren't doing our job as parents, Jamie and I. We were failing our daughter.

And so we argued, behind our menus: You love mussels-order that! Or the carbonara. Remember how much you used to love carbonara? You love mussels-order that! Or the carbonara. Remember how much you used to love carbonara? The more we pushed, the more frantic Kitty became, and the more determined I felt that she would order something reasonable and eat it. Now I was embarra.s.sed about the scene we were making too. The more we pushed, the more frantic Kitty became, and the more determined I felt that she would order something reasonable and eat it. Now I was embarra.s.sed about the scene we were making too.

Finally Jamie put his hand on my wrist. He's more private than I; his tolerance for public scenes is low. He shook his head. I knew what he meant. What did it matter, really, what Kitty ordered? We both knew the problem went far beyond one dinner.

And so she ordered the salad, and pushed it around her plate, while the rest of us, as if to compensate, ate heartily, sopping up sauce with slabs of Italian bread, forcing the conversation away from the drama we couldn't talk about. It was as if my daughter's ghost sat at that table, untouchable and alone, watching through an impenetrable scrim. We drove home that night in despairing silence. Another meal-or, rather, another no-meal. Another turn of the screw pulling Kitty's skin tight across her sharpening bones. Another twist of the knife that now sawed away at my heart, night and day.

And now, I think, what next? I'd give anything to avoid another dinner like that. We've been failing with Kitty for weeks. How will things be different? How will we get Kitty to eat? I want someone to tell me exactly what to do.

We have no FBT therapist, because there are none in our small midwestern city. But we do have Ms. Susan and Dr. Beth. And we also have something no one else in the world has: we love Kitty best. No one else in the world can possibly want her to get better as much as we do. No one else loves her as fiercely, as nonjudgmentally, as unconditionally as we do.

And so we make a plan, Jamie and I. We'll take charge of Kitty's eating. We'll serve her breakfast, lunch, snack, dinner, and snack, starting at about fifteen hundred calories a day, and we'll b.u.mp up the calories by three hundred every couple of days, until she's getting enough. Until she starts to gain weight. Even though I have no idea how, exactly, we're going to pull this off, how tomorrow will be different from yesterday, I feel an immense relief at the thought of starting over. These weeks of wondering and worrying and feeling helpless, of feeling stalled and in limbo, have taken a toll on all of us-Jamie, Emma, and me. Now, however hard it is, we'll be doing doing something. something.

The next morning, as Emma sleeps late, Kitty comes downstairs to a bowl of cereal, milk, and some strawberries-a small breakfast by ordinary standards. But when she sees that the cereal is already in the bowl, that she doesn't get to measure it herself, her resistance begins.

"I could have done that," she says in a good-girl, wanting-to-be-helpful tone of voice. "You didn't have to."

I'm ready for this. "I don't mind," I say cheerily. "That's my my job. All job. All you you have to do is eat." I pull out the chair, gesturing grandly for her to sit down. I'm inhabiting my role-the happy, helpful mom-to the hilt. There's no such thing as overacting in this play. have to do is eat." I pull out the chair, gesturing grandly for her to sit down. I'm inhabiting my role-the happy, helpful mom-to the hilt. There's no such thing as overacting in this play.

Kitty grips the seat back, her knuckles white with effort. "I don't feel like cereal today," she says. "I was really looking forward to some cottage cheese."

"Oh, I'm sorry," I say. "I finished the cottage cheese yesterday." Actually the cottage cheese now resides at the bottom of a large garbage bag by the curb, along with twelve packages of ramen noodles, a frozen loaf of reduced-fat bread, two bottles of nonfat salad dressing, two bottles of low-fat salad dressing, a bag of pretzels, six cartons of yogurt, and a bunch of grapes. Last night, when I couldn't sleep, I purged the kitchen of every nonfat, low-calorie diet food I could find. The grapes I regret, but they had to go; they were one of Kitty's lunchtime standbys.

We move into Act Two: bargaining. "I'll eat some of the cereal and all the strawberries," says Kitty. "I can't eat all that cereal today. I'll eat more tomorrow. I promise."

I muster a sympathetic look. "I know it's hard for you to eat," I say. "But this is your breakfast today. Please sit down."

Kitty's eyes gleam suddenly. The good-girl facade is slipping. I brace myself for Act Three: refusal.

"I don't want cereal," she says mutinously. "I want cottage cheese."

I think back to all the times over the last few months I've rushed to the store to get Kitty cottage cheese or yogurt or grapes-"safe" foods, foods she feels comfortable eating. Of course she expects me to do it again; why wouldn't she?

"This is your breakfast today," I repeat. "Please sit down and start eating."

She sits down, to my surprise, and peers into the bowl. Act Four begins: distraction. "It's all soggy now," she complains. "I can't eat this."

The cereal can't be that soggy; it's only been out for a minute or two. I go to the cupboard, pour another bowl of cereal about the same size, and place it on the table in front of Kitty. I get out the milk, which she tries to take from me. "I'll pour," I say brightly, staying in character.

"You gave me more this time," she says in alarm.

"I gave you exactly the same amount," I lie. I have no idea how the bowls compare. I may be new at the refeeding process, but I've been a parent long enough to have mastered the art of authoritative p.r.o.nouncements.

Kitty picks up the spoon and dips it into the cereal here and there, inspecting each flake as if she's looking for contamination.

"Please eat before this bowl gets soggy too," I say.

Kitty puts down her spoon and looks up at me. Act Five: pathos. "I'm trying," she says in a pitiful voice. "It's hard, Mommy!" Tears well up in her large brown eyes.

I want more than anything to put my arms around her and say, Never mind, Kitty. You don't have to do it; I know it's too hard. Never mind, Kitty. You don't have to do it; I know it's too hard. But she does have to. And I have to help her do it. Even if it means being tough. But she does have to. And I have to help her do it. Even if it means being tough.

I play my trump card, the one Jamie and Dr. Beth and I agreed on when Kitty came home from the ICU. "OK," I say. "Go on upstairs and pack your bag."

"What?"

"We have to go back to the hospital for a feeding tube if you can't eat," I say matter-of-factly.

I've heard of kids with anorexia who don't mind feeding tubes. Who ask for them. I'm counting on Kitty's fear of the hospital and the feeding tube, but I'm aware that this delicate interaction could go either way.

In the silence that follows I watch a range of feelings pa.s.s across her face: Her fear of the tube and the hospital. Her wish to please me. Her true terror of the food that's been set before her. And under it all, the deep and powerful hunger she doesn't recognize but that I can't help seeing in her eyes, in the tremor of her hands, in the birdlike hunch of her bony shoulders.

I remember Sarah, the girl who talked to my neighbor and me, and imagine Kitty's angel and devil, locked in a fierce and vicious fight. They roll on the ground, their claws raking my daughter's skin, their fangs slas.h.i.+ng, shrieking and bellowing in my daughter's ear. She can't look away, she can't not hear them, and in my pity and horror and love all I can do is make myself as powerful as I know how and stand beside her, touch her, be present with her suffering.

Kitty picks up the spoon, loads a tiny bite of cereal into its silver bowl, and lifts it toward her mouth. The spoon shakes in her hand, and a flake falls off. She lowers the spoon, carefully scoops up the fallen flake, and lifts it once more. Go on, Go on, I think. I think. Keep going. Keep going.

And she does.

Breakfast takes a full hour. Afterward, Kitty writhes on the living room couch, crying, berating herself on and on for eating the whole bowl. I'm both encouraged and disturbed by the fact that her inner monologue is now made manifest. I sit with her, stroke her hair, and talk, words spilling out of me without thought or pause: I love you, you're my girl, you had no choice, I made you eat the cereal. I love you, you're my girl, you had no choice, I made you eat the cereal. At this last her head comes up, and I catch a glimpse, the first in weeks, of the child I've known and loved for fourteen years. The real Kitty, whose look of sly but innocent mischief used to make me laugh, whose wide-set, velvety brown eyes popped open at birth as if she couldn't wait to be part of the world. For a while as an infant the only way she could fall asleep was if Jamie held her along his arm, facedown, and whizzed her around. She never wanted to sleep; she never wanted to miss a thing. At this last her head comes up, and I catch a glimpse, the first in weeks, of the child I've known and loved for fourteen years. The real Kitty, whose look of sly but innocent mischief used to make me laugh, whose wide-set, velvety brown eyes popped open at birth as if she couldn't wait to be part of the world. For a while as an infant the only way she could fall asleep was if Jamie held her along his arm, facedown, and whizzed her around. She never wanted to sleep; she never wanted to miss a thing.

I think of everything she's missing now: friends, sports, sleepovers-the ordinary pleasures of a fourteen-year-old girl. I think of everything she'll miss if she doesn't recover: Love. Friends.h.i.+p. Meaningful work. Her whole life, really. The life she's meant to lead. The life she deserves.

We sit together on the couch until Kitty falls asleep, exhausted, and then I slip away to the kitchen to start making lunch.

We start on a Monday in early August, just over a month after Kitty's diagnosis. For the first three days I call in sick to work-it's not a lie; I do feel sick-and we spend virtually every waking moment taking on anorexia. I cook and Jamie sits with Kitty. I sit with Kitty and Jamie takes Emma to a movie, away from the anxiety (ours and Kitty's) that saturates the air. Breakfast blends into lunch, lunch into afternoon snack, snack into dinner and bedtime snack. Three meals and two snacks, and each one takes at least an hour. In hospitals and residential clinics, patients with anorexia have to finish eating within a set amount of time-half an hour, usually. As long as Kitty's eating, I don't see the point in making an arbitrary limit. That would just put more pressure on her, and there's enough already. Monday in early August, just over a month after Kitty's diagnosis. For the first three days I call in sick to work-it's not a lie; I do feel sick-and we spend virtually every waking moment taking on anorexia. I cook and Jamie sits with Kitty. I sit with Kitty and Jamie takes Emma to a movie, away from the anxiety (ours and Kitty's) that saturates the air. Breakfast blends into lunch, lunch into afternoon snack, snack into dinner and bedtime snack. Three meals and two snacks, and each one takes at least an hour. In hospitals and residential clinics, patients with anorexia have to finish eating within a set amount of time-half an hour, usually. As long as Kitty's eating, I don't see the point in making an arbitrary limit. That would just put more pressure on her, and there's enough already.

Sometimes we sit there for an hour and Kitty still doesn't finish. If she's eaten at least part of it, we give her a bottle of Ensure Plus to make up the calories.

On Day Three I take Kitty to the pediatrician's office for her weekly appointment. She has eaten everything we've put in front of her-not easily, not happily, not quickly. But she's eaten. Dr. Beth, as usual, greets Kitty warmly, touching her lightly on the shoulder, and Kitty offers a rare smile back, a tight little moue that brings tears to my eyes, for the dissonance between this and her old smile, wide and direct and full of joy. Her eyes full of light. One day, I swear, I'll see that light again.

But not today. When Kitty steps backward onto the scale, wearing a paper gown, I'm horrified to see that she's lost a half pound. How is that possible? I know Kitty's been eating. I've seen it with my own eyes. And I know she's not purging, because either Jamie or I stays with her for an hour after each meal or snack.

As Kitty gets dressed, Dr. Beth motions me out into the hall, where she explains that during starvation, the body's metabolism slows down, trying to conserve energy. It becomes superefficient, wringing every drop of energy out of each calorie that comes its way. When the food intake increases, the metabolism revs up, way up, in response. It becomes less efficient, spending more calories than before for the same activities. That's what's happening to Kitty right now. "It can take a lot of calories to get weight gain going," says Dr. Beth.

Over the next few months we will learn just how many calories it takes-at least twice as much as the average teenage girl eats. Unfortunately, Kitty's psychiatrist, Dr. Newbie, doesn't seem to understand the vicissitudes of metabolism. At our visit to her the next day, she takes me aside to say that if Kitty loses any more weight-even a quarter pound-she'll have to hospitalize her. "Her heart could be in danger," she tells me.

I try to explain what Dr. Beth explained to me. "Kitty's eating now," I tell Dr. Newbie. "If you put her in the hospital, we'll lose momentum."

But Dr. Newbie stands firm. It would be too dangerous, she says; Kitty's heart needs to be monitored if she loses any more weight.

We don't tell Kitty. And that night we b.u.mp her daily calories up to eighteen hundred. Kitty complains that her stomach hurts, she's bloated, she can't physically eat this much, her stomach will explode. I'm torn. I know she's eating more than she has in a long while, but she's gotten here slowly, and eighteen hundred calories doesn't seem like that much. Dr. Beth says to keep going, so we do. We try putting a heating pad on Kitty's stomach after each meal, but it doesn't seem to help. Other tactics work better. We watch a lot more TV than we ever have before because Kitty says it's easier to eat while she's watching. And after a meal, TV or movies or books on tape help distract her from the guilt of having eaten.

I expect this influx of calories to produce, if not a miracle, then at least a quick change. And we do see changes. Kitty's eyes don't look quite as sunken; her skin is a little pinker. She gets mad at me one day, and I'm thrilled; until now, she's had neither the confidence nor the energy for anger.

But she's still anxious about eating. Anxious Anxious doesn't begin to cover it, actually. Kitty's obsessed with food-how many calories it has, how I've prepared it, how it's arranged on the plate. Before each meal she gathers a veritable a.r.s.enal of silverware: her baby spoon, its looping silver handle tarnished; an odd hors d'oeuvre fork, half the size of a regular fork; a child-size b.u.t.ter knife. After she eats, especially at night, she berates herself for hours. "I'm so fat, Mommy," she sobs. "I feel so guilty for eating." She often cries herself to sleep, with Jamie or me sitting beside her, rubbing her back the way we did when she was a baby. doesn't begin to cover it, actually. Kitty's obsessed with food-how many calories it has, how I've prepared it, how it's arranged on the plate. Before each meal she gathers a veritable a.r.s.enal of silverware: her baby spoon, its looping silver handle tarnished; an odd hors d'oeuvre fork, half the size of a regular fork; a child-size b.u.t.ter knife. After she eats, especially at night, she berates herself for hours. "I'm so fat, Mommy," she sobs. "I feel so guilty for eating." She often cries herself to sleep, with Jamie or me sitting beside her, rubbing her back the way we did when she was a baby.

And in many ways what we're doing feels like taking care of an infant: We feed her, many times a day. One of us must always be with her. We spend a fair amount of time comforting and entertaining her. She's even dragged her mattress into our room, positioning it on the floor beside our bed because, she says, she sleeps better when we're close. That suits me, too; I need to know that she's not doing a thousand sit-ups in her room in the middle of the night.

In our culture, children are supposed to grow up in as many ways as possible, as early as possible. We expect them to sleep on their own, feed and toilet themselves, tie their own shoes, and make their own peanut b.u.t.ter sandwiches as soon as they're physically able. If they don't, we think there's something wrong with them. We make no allowances for children who need to go slower or stay closer; instead, we pathologize them and accuse their families of unhealthy enmeshment. I'm sure that sometimes too much closeness can be unhealthy. But sometimes a helping hand is just a helping hand, and not a symptom of parental neglect or developmental delay.

Kitty's current regression, for instance, feels appropriate. She is fighting for her life-body and mind and soul. I think it's an excellent sign that she is letting us take care of her, however difficult it may be.

And it is-in fact, it's the hardest thing we've ever faced as a family. As the first official week of refeeding blends into the second, Jamie and I see more and more of the alternate personality I think of as the demon. I'm aware that this sounds strange; I know there's no literal devil inside Kitty, no supernatural force. But giving the illness a face other than hers helps me separate our daughter from the forces that torment her.

Day after day, we live under the tyranny of the scale. I'm almost as anxious as Kitty as her second weigh-in approaches. Please don't let her have lost weight, Please don't let her have lost weight, I think. To put her back in the hospital now would be to undo the painful, painstaking work of this last week. When Kitty steps on the scale at Dr. Beth's, I hold my breath. Which will it be-back home or to the hospital? I think. To put her back in the hospital now would be to undo the painful, painstaking work of this last week. When Kitty steps on the scale at Dr. Beth's, I hold my breath. Which will it be-back home or to the hospital?

"A quarter pound up," announces the nurse. "Good girl!" She smiles encouragingly at Kitty, makes a note in her chart, and whisks out of the room. I let out my breath in relief.

That's when all h.e.l.l breaks loose.

"I gained weight! Oh my G.o.d!" cries Kitty. She folds over on herself and begins a kind of moaning chant: I'm a fat pig, I'm gross and disgusting and lazy. Look what you're doing to me, you're making me fat. I should never have listened to you. I'm a fat pig, I'm gross and disgusting and lazy. Look what you're doing to me, you're making me fat. I should never have listened to you.

She lifts her head. Mascara streaks her sunken cheeks. "I'm never eating again," she hisses, and now it's the demon talking. "I won't let you make me fat."

I'm shocked to see the demon out in public. I can't think of what to do. So I don't think. I take Kitty's sharp chin in my hand and look into her dark eyes, which blaze with rage and, yes, fear. "I won't let you die," I say, slowly and loudly. "Do you hear me? I won't let you starve. I will keep you safe."

Tears squirt from Kitty's eyes; her mouth is open in a silent scream. But she's not really fighting me. I have to believe that somewhere inside, she can hear me.

I let go of her chin. She tucks her head down into the bony scaffolding of her arms and begins to cry, softly this time. The demon has receded. For now.

And that's how I come to understand the true nature of my daughter's prison. What we have to do to set her free.

We are walking a delicate line between truth and delusion, between confrontation and collusion, because our daughter is trapped between us and the demon. There are times when we have to face it down, in words and actions, take a public stand against anorexia. There are times when Kitty needs to hear us do that. But there are other times when the pain the demon inflicts on her will be too great to bear. I imagine the terror and agony she lives with and I want to scream. So sometimes we'll have to appease the demon with words, to spare Kitty.

Weighing in, for example. Kitty gets weighed in a hospital gown, standing backward on the scale, so she doesn't know the number. Now I ask the nurses who weigh her to refrain from any comment at all, explaining that if they tell her she's done a good job, she feels so guilty that it's hard for her to keep going. Best not to say anything at all, or show any emotion. We'll all try to be matter-of-fact, downplay the number on the scale, at least outwardly.

Yeah, right. I'm the least matter-of-fact person I know. Which is why it's all the more important to create a bland, superficial persona-The Mother-and stick with it. The Mother, I hope, will block the empathetic connection Kitty and I share. Kitty has to believe that I am calm and in control. She has to believe I can keep her safe. The Mother will speak in plat.i.tudes and generalizations, telling Kitty, for instance, "Everything will be all right. I promise." That's not a promise I would normally make, even before anorexia; and even if I did, Kitty would never buy it. But she has to buy it now. She has to trust me and Jamie to override the demon in her head. She has to trust us to be stronger than the demon, which hates every quarter pound she gains because it's one tiny step toward freedom. And somewhere inside, Kitty wants to be free. She's relying on Jamie and me to let her out of the prison she inhabits. I believe this, deeply, pa.s.sionately, truly.

We will make many mistakes. The trick will be to keep going.