We interviewed Maria Ganci and Dr. Linsey Atkins about their book Unpack Your Eating Disorder: The Journey to Recovery for Adolescents in Treatment for Anorexia Nervosa and Atypical Anorexia Nervosa. What follows are our questions in italics and their thoughtful responses.
In your book, Unpack Your Eating Disorder: The Journey to Recovery for Adolescents in Treatment for Anorexia Nervosa and Atypical Anorexia Nervosa, you explain various risk factors. How does this knowledge provide a useful starting place for adolescents diagnosed with Anorexia Nervosa or Atypical Anorexia Nervosa?
We find that looking at risk factors is important in two ways. Firstly, it is a very effective starting point and helps the clinician to introduce the concept of an eating disorder in a less confrontational way. Talking about the various risk factors and which may or may not apply to them allows the adolescents to open up and explore their situation without feeling negative about themselves. Adolescents can then begin to identify what is happening to them and understand that they are in fact suffering from anorexia.
Secondly, discussing risk factors assists in the externalization of anorexia which is an extremely important part of treatment. Understanding that anorexia is not who they are but is instead an illness that has taken over some of their thinking processes is critical for the adolescent to stand up to AN and take action to recover. We have found that adolescents respond well to the analogy used in the book that compares AN to catching a cold. A cold is a viral invasion which even though is part of you is still separate from you, even though you experience all the symptoms like coughing, sneezing and feeling unwell. When we recover from a cold we function just as we did prior to getting infected, which is the same with anorexia.
You chose to speak in a wonderfully respectful manner to adolescents. Please elaborate on the importance of addressing their competence.
The vast majority of adolescents we see seeking treatment for anorexia are intelligent, thoughtful, and very caring young people. Throughout the book we strive to reinforce this positive message, as one of the ways anorexia keeps a hold on these wonderful young people is to make them believe they are worthless and unable to defend themselves. This positive message is a key part of the treatment as well. Helping adolescents discover their inner strengths and resources and how they can tap into them to build up their sense of self is crucial to wrestling back control from anorexia. Only then can they recover.
Skills to manage challenges like meal-related distress, riding emotional waves, and purging behaviors are available to your readers. What led you to write about “managing” challenges vs. “eliminating” them?
Eliminating challenges is definitely something to aspire to, however, we have found that talking in this way can be interpreted by an adolescent with anorexia as a threat to their sense of self, especially in the early stages of treatment. Added to this is the strong link between certain personality traits and eating disorders such as perfectionism and trait anxiety which are difficult to change and near impossible to eliminate. Therefore, the approach we take is to work with the adolescent to understand what influences their behavior and reflect on how their traits may be misused in the service of anorexia rather than used for their true benefit. Our aim is to manage the challenges first until the adolescent gains this insight after which is much easier for them to desire elimination.
Your section on turning personality traits into inner resources is packed with power for personal growth. Please share an example.
A previous patient of ours was an adolescent who had anorexia and struggled with obsessionality. She reported being obsessed about weight and calories and could not stop herself from continually thinking about it, especially at meal times. This was when she felt most overwhelmed and obsessed on working out the calorie content of the food and its impact on her weight. As part of her treatment we did the following:
- Discussed the pros and cons of obsessionality as a personality trait and emphasized that it is how you use this trait that matters.
- Investigated how AN was using the personality trait destructively.
This helped her understand that the trait was being used against her.
- Questioned how the obsessionality impacted her recovery goals and went against her values. We then asked her if she wanted to continue doing this to herself in order to help her commit to change.
- Worked together on practical strategies she could use to manage the obsessionality during meal times and the difficult time period after meals. This focus was on the more realistic aim of management rather than elimination.
- Practised re-channeling her obsessionality to more productive activities and to develop mastery in using this trait to achieve her goals rather than in the service of anorexia.
How do you define psychological recovery in the context of anorexia?
We define psychological recovery as the normalization of eating patterns as well as having the capacity to manage the thought processes that define anorexia with adaptive strategies rather than maladaptive strategies used when an adolescent has anorexia.
We talk about anorexia being a psychological illness with severe medical complications which means that we should not just focus on physical recovery. If we address only the physical recovery we have reverted back to the old medical model of treatment. We believe that adolescents with anorexia are able to benefit from psychological work as many underweight adolescents suffering from anorexia are psychologically capable and are achieving high academic standards or excelling in their hobbies. It is a ‘starved’ brain that cannot respond to psychological input and thinking is dependent on the amount of daily fuel supplied to the brain. If parents are re-feeding their adolescent appropriately, then they can benefit from psychological work.
Please comment on the value of appreciating one’s emotions in eating disorder recovery and in life.
Emotional competence is an important component of an adolescent’s interactions and connections with others. Without it, an adolescent can feel isolated and rejected. For those with anorexia, this is especially relevant as research has shown that they are less able to identify their own emotions as well as the emotions of others. They have also been shown to be more likely to experience emotional under or over regulation. For this reason, we have focused on emotions as a key part to building up the sense of self and learning how to rally against anorexia.
Throughout your book, you offer journal exercises. Your goal?
It has been our experience that many adolescents struggle to initially engage in journaling. Facing a blank page and expressing oneself emotionally can be very daunting. We believe that this is due to their desire for structure, certainty and having an avoidant coping style. To overcome this problem, we have developed our own journal called Letting Go of ED – Embracing Me that is semi-structured, easy to work with, and less demanding. We do however have some adolescents who take to journaling very easily. They seem to enjoy the self-reflective component and are motivated by the challenge of re-wiring their brain that we reference throughout the book.
About the authors:
Maria Ganci is a Registered Clinical Mental Health Social Worker and Child and Adolescent Psychoanalytical Psychotherapist. Maria has over thirty years’ experience working with families, children, and adolescents in Mental Health Services. She has devoted the past fifteen years solely to treating children and adolescents with eating disorders. Maria is the Co-Director of APT Therapeutic Solutions Pty. Ltd. and runs a successful private practice providing training, supervision, and consultation both nationally and internationally in the treatment of eating disorders. Maria has worked under the auspices of Dr. Ann Moye, Michigan, USA, for the past five years to further develop and deliver Adolescent & Parent Treatment (APT). She is the author of Survive FBT, a manual that supports parents through Family-Based Treatment, which has been translated into Japanese and Swedish.
Dr. Linsey Atkins is a Registered Clinical Psychologist with fifteen years of experience providing child, adolescent, parent, and family therapy for eating disorders. Linsey has specialized in evidence-based treatment approaches and runs a successful clinical and supervision-based private practice in Melbourne, Australia. Linsey has worked under the auspices of Dr. Ann Moye, Michigan, USA for the past five years to further develop and deliver Adolescent & Parent Treatment (APT) training nationally and internationally. She is a Co-Director of Adolescent & Parent Treatment Solutions Pty. Ltd., an online service that provides treatment resources, training, supervision, and consultation in Adolescent & Parent Treatment for eating disorders. Linsey has published articles on adolescent eating disorders as well as delivered lectures and presented workshops at national and international conferences.