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Francie
Hi All,
My d asked for and entered partial hospitalization treatment in late February after discharging herself from college. She had been binging and purging nearly every meal by that time, and had been for awhile (not sure if weeks or months). Treatment was 5 days a week for about 6 hours/day. She was able to stop b/p for as long as a three week period during this time.

After these successes, my d was stepped down to IOP level a few weeks ago (about 15 hours/week) and her clinician has been reminding us of the countdown of insurance-covered days left in treatment. My d has about two to three weeks left of IOP treatment.

My d has begun b/p again. 4 times over the last 8 days, and it has caused her to miss treatment days. We are taking steps to abort or diminish the amount of time she b/p's. (taking her to the ER, taking away the car, removing food from the house, making her pay for food she wasted). We have never been able to abort a b/p attempt, but we have been able to diminish the amount of time she spends on it.

While we brought up our concern that she's being stepped down too soon, as evidenced by a resumption of b/p symptoms, her clinician warned us of the possibility that our d would become 'treatment dependent' if she stayed around too long in treatment.

Is this 'treatment dependency' a real thing to be worried about? I found this link: https://psychcentral.com/disorders/dependent-personality-disorder/treatment/

As we face stopping IOP treatment in 2 or 3 weeks we have choices. We can go ahead and try to insist insurance give her more days, as we've engaged the assistance of the state health care advocate's help. Or, we can agree with the clinician that our d has become 'treatment dependent', and cut her off to sink or swim with her outpatient team. 

To make matters worse, the outpatient therapist she likes and has been seeing on and off for about 1 1/2 years is leaving the state in a week. Ugh. 

I appreciate any insight you can share about the reality, or concern about 'treatment dependency'.

XO


Francie

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melstevUK
Hi Francie,

I am sorry for what you are going through, it is such a long and tough journey.  I have had a look at the article linked and I would tend to take the clinician's comments with the proverbial pinch of salt.  

"Psychiatrists and physicians should be aware that individuals with dependent personality disorder will often present with a number of physical or somatic complaints."

Firstly, I don't think it is appropriate to diagnose any kind of treatment dependency or personality disorder when there is an active eating disorder involved, and also while your d is still well under the age of 25 or over.

I think she manages better either IP or in an outpatient setting because the structure and supervision ensures that she does not have the opportunity to binge or purge.  In her head I am sure that she will be desperate to b/p but there are others around and in charge to stop this happening.

To me it appears to be that the illness still has her in its grip - understandably because overcoming it takes time.

Also, it is unlikely that she will go from a high level of b/p occurrences to nothing, just because she has had a period of treatment.  I really don't have a lot of experience of b/p type an but I suspect that, while your d is still underweight and there (to my knowledge) has not been any major attempt to get her weight up she remains stuck in this limbo.

I understand your anxieties and reservations that the therapist your d relates to is leaving - because it feels like another hurdle to cross.

So I guess it is a case of regrouping and thinking of where you go from here.  I can imagine how very tired you are of it all.

Where is d at with plans for her future?  Does she want to return to college?  Does she still do some part time work?  I would tend to focus on her life outside the eating disorder again to see what she feels she can do right now, and fit treatment around that.
Given that the length of the IOP days was reduced and she was informed that treatment would end soon - to me it appears that the anxiety around this has led to an increase in her b/p symptoms.  So is it a confidence issue, that she fears being left on her own without support?  This is quite different to being treatment dependent; it relates more to not being able to fight the compulsion on her own.  It is not as if she is choosing to be ill or as if the symptoms are somatic.  She is ill, with an illness that takes a lot of effort and support to get over.   Ultimately she will have to learn at some stage to manage anxiety in different ways - but in the longer term I think this will be hard to achieve while she is still underweight because of the anorexia diagnosis.  Weight gain and adequate nutrition still need to be given attention - but are any of the clinicians involved seeing this as part of the picture?  

I don't know if my comments have helped or have made you feel worse - I certainly hope that this is not the case.  Keep looking forward, you are doing everything right in terms of intervening and responding and it would appear that your d is accepting of this.  That in itself is a huge positive.

Hugs.  Thinking of you.
Believe you can and you're halfway there.
Theodore Roosevelt.
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Foodsupport_AUS
I am also very wary of labelling a young adult or anyone as dependent on treatment. I am not even completely sure it is a thing. I would read this as she needs the treatment because at the moment she feels unable to do it for herself. By all means slowly encourage her to do so but when she fails she isn't doing it because she just wants to rely on her treatment team, she fails because she is not ready. 

My D at one stage talked about how she ended up in hospital so many times. She in fact hated hospital and still has nightmares and flash backs to some events that happened when she was there. They she had numerous NG tubes, she was restricted to two rooms, with what I feel were unreasonably strict rules regarding watching television or doing quiet activities. 
She said that she hated the staff there but she also knew they could put down a tube if she couldn't eat whereas I could not. She wanted to hate them for this and not me. Realistically she needed the impossibility of getting away from eating. At home she just sat, she would and did sit all day.

This is not treatment dependence. This is needing more care until she can do it on her own. To even suggest your D would want to do this indefinitely seems silly. She may be capable of doing things more independently but it would seem to me that she is still too frightened to do without those firm boundaries. 


D diagnosed restrictive AN June 2010 age 13. Mostly recovered 10 years later.  Treatment: multiple hospitalisations and individual and family therapy.
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Torie
Foodsupport_AUS wrote:
I am also very wary of labelling a young adult or anyone as dependent on treatment. I am not even completely sure it is a thing. 


That's what I was thinking - labeling someone as treatment dependant strikes me as a really weird thing to say.  Really weird.  I mean, isn't anyone who requires treatment, "treatment dependent"?  (Diabetics and cancer patients included.)  The alternative would seem to be stopping treatment while she is still very unwell.  NOT a good option, in my book.  Personally, I would fight to keep her in treatment, but perhaps in a different facility.  Doesn't she still need to regain weight? 

I'm a little confused about the b/p interventions.  To my mind, the "bingeing" is not nearly the problem so much as the purging.  Is it possible to prevent the purging? 

It is so hard.  I'm sorry you're having to take on the medical profession on top of tackling ED.  Ugh.  Hang in there. xx

-Torie




"We are angels of hope, of healing, and of light. Darkness flees from us." -YP 
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Kali
Francie,

My daughter has been in one or another form of treatment for 3 1/2 years. Does that mean she is treatment dependent? No. It means she has a life threatening illness which is difficult to treat. Nobody would ever say that about someone who had cancer or diabetes or heart disease or any other illness which required monitoring on an ongoing basis.

There is often a resurgence of symptoms when someone steps down in care and if so, IMO, treatment or the situation at home needs to be adjusted and it sounds as though you are taking steps to try and address that.

Sorry this has been going on so long...you are a true warrior. I am glad to hear she had a period where the b/p was diminished...if she did it before she can do it again. What was working for her during that period? Also I'm glad to hear she asked for treatment herself. How does she feel now about continuing?

warmly,

Kali



 




Food=Love
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mjkz
Francie my daughter has been in some form of treatment for over 15 years. She still sees a therapist twice a week but she has a life, is out there functioning and holding her own.  I think it is a small price to pay to see where she is right now.  Do I think she is treatment dependent?  No.  I think she has had some really bad knocks in life and genetic predisposition to a severe eating disorder and treatment resistant depression.  I'm for whatever keeps her moving forward, happy, and healthy.
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Torie
mjkz wrote:
Francie my daughter has been in some form of treatment for over 15 years....  Do I think she is treatment dependent?  No. 


True enough, but.  The real question, I think, is:  Would she be in a better place if she had been labeled "in danger of becoming treatment dependent" and thus booted out of treatment 13 years ago?

Heck no.

Still shaking my head. xx

-Torie
"We are angels of hope, of healing, and of light. Darkness flees from us." -YP 
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Francie
"Where is d at with plans for her future?  Does she want to return to college?  Does she still do some part time work?" Hi Melstev, she does have plans to return to the commuter college this fall with a fulltime schedule. but I am not sure I'm comfortable with that. She'd be away from monitoring for so long I would be concerned she'd throw away her lunches (as she did last year). But at the same time, boredom is a huge trigger for her!! She is still at her part time job, about 12 - 16 hours/week.

"is it a confidence issue, that she fears being left on her own without support?" The clinician seems to think so. My H and I do, too.   

"Weight gain and adequate nutrition still need to be given attention - but are any of the clinicians involved seeing this as part of the picture?"
 Hi Torie, She has gained about 9 lbs, and she is involved with a dietician and I am home most all the time so I can see what she's eating. She still doesn't let me plate or even prepare her own food most of the time. Some days she eats well, some days she restricts and eats smaller portions. She sometimes will add to a meal if I suggest she add a protein drink, or another addition to her meal. 

"To my mind, the "bingeing" is not nearly the problem so much as the purging.  Is it possible to prevent the purging?" Unfortunately, we have not been able to prevent the purging once she's binged, but we have been able to lessen the time she spends on it. And a binge for her doesn't need to be a whole lot of food, just more than she thinks she should have. We just have to be diligent and watchful when she eats. What seems to work is more frequent, smaller meals. 


"I am glad to hear she had a period where the b/p was diminished...if she did it before she can do it again. What was working for her during that period? Hi Kali, She was on Naltrexone for about a month so I'm thinking that's what helped. But it is risky for her to go on it again as she has liver damage. Also I'm glad to hear she asked for treatment herself. How does she feel now about continuing?" She is still okay with continuing.

Thank you everyone. We'll try to get her to continue with treatment as long as is possible. And I am blessed that I work out of my home in a very part time job so I can be home a lot.

At this next family meeting with the T, my d wants to develop a contract with us so she can go back to school this fall, but I am not in favor of what she's voiced so far: if she purges 1 x a week she can go back part time. If she purges 1x every 2 weeks, she can go back full time.

I am thinking the purging has to stop. Period. Then she can go back to school. And, holding her back from school is problematic also because as I've stated above, boredom/a day spent at home with nothing to do is a very strong trigger for ED behaviors. 

In Jan/Feb, when I was fully hands-off and following the Al-Anon program (let her suffer the consequences of her actions) the constant purging was frightening to witness, but she did on her own come up with the plan to leave school and start treatment. 

Maybe if I let her go back to school and not hold her back there's a chance she just might get angry enough at the ED if it messes up yet another semester, which it will if it continues. She is a chemistry major and has signed up to take Organic Chemistry and Calculus 2 and two easy electives. Pre-ED she had the brains to take those demanding classes, and she complains if classes are too easy.

Does that idea sound too crazy/risky? No purging, continued weight gain and meal compliance, and she has the freedom to go back to school?

XO

Francie

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Kali
Hi Francie,

I like this contract better:

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No purging, continued weight gain and meal compliance, and she has the freedom to go back to school.


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She still doesn't let me plate or even prepare her own food most of the time.


Can part of her meal compliance be that she eats what others prepare sometimes (in this case you or her dad) Which is a normal way to eat at home. For example, my 22 year old son who does not have an ED eats what I offer him when he is home and although he does take some food himself, he also eats what has been prepared.

Than this one:

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At this next family meeting with the T, my d wants to develop a contract with us so she can go back to school this fall, but I am not in favor of what she's voiced so far: if she purges 1 x a week she can go back part time. If she purges 1x every 2 weeks, she can go back full time. 


It sounds as though she is asking for permission to purge and go back to college and that you are not in agreement with this. That seems wise.

Kali


Food=Love
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Francie
Thank you, Kali. If she can't stop purging, then she's not ready for school. Period.

She is in such a better place than she was a few months ago. I don't want to withhold school, but I can't agree to a minimized purge schedule as part of a contract. It would be like giving permission to purge, as you point out. And if I give her ED an inch, I know it won't be long before it will consume her again.

She will eat some meals I prepare. We often eat salads for dinner in the summer. She will eat a dinner salad I prepare. I add cheeses, olives, nuts, protein. She adds her own dressing but it is an ordinary dressing with fats. It is not the ideal recovery meal, but she will eat salads gladly and it's not a food she'll purge.

Knowing my daughter, she will be one who will have to recover slowly. She was that way with a lot of things growing up: was nearly 4 when she mastered toileting, same for sleeping in a bed, and took nearly two years driving with me in the car before she got her license to drive on her own. Perhaps it is part of her perfectionistic tendencies. She wants to feel she has a mastery of something before she can 'fly solo'.

But it is appropriate for us to set clear boundaries and absolutes, so, if she wants college that badly, she will put in a greater effort to stop the purging. She has about 5 weeks to go before the semester starts.

Francie

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Torie
Francie, I guess for me the question is: How many classes (if any) can be fit around the necessary supervision?  I always wanted my d to have as much life as she could, but supervision came first.  So she knew that in order to go away to university, she needed to be completely well, and otherwise she would be attending school locally.

I'm a little confused why she would be able to work a decent number of hours each week, but not attend commuter school part time. 

Just my two cents. xx

-Torie
"We are angels of hope, of healing, and of light. Darkness flees from us." -YP 
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Francie
Hi Torie, 

I'm a little confused why she would be able to work a decent number of hours each week, but not attend commuter school part time. 

For me it would be the combination of work AND school adding to unsupervised hours. She will not be giving up her job to go to school.

Francie

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mjkz
I know I couldn't support a contract that allowed purging once a week or once every two weeks.  I do think however that you need to put in clear consequences for purging and gradual set of consequences if it continues.  Reality is she is going to purge at times.  Even though I went with a zero tolerance contract, I knew she was going to slip up from time to time.  I would not do a contract with "if she purges once, she withdraws from school".  I would make there be consequences for purging and lost weight with perhaps a goal of if she gets up to purging once a week or twice then she starts dropping classes if that makes sense.  I went with black and white but had to realistically accept gray areas because if I didn't then I was just reinforcing that perfectionistic streak.
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Francie
Hi mjkz, your post is extremely helpful as black and white / all or nothing / perfectionistic thinking exists in her personality.


Thank you! You've given me lots to think about and have given me clarity as I start drafting my part of this contract. Thank you! XO

Francie

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mjkz
Happy to help Francie.  I just had an experience with my daughter purging while we were on vacation so this is particularly pertinent right now. 

She slips up so rarely now that all I ask of her is that she learn and process what led up to it and how to prevent it in the future.  I know she had some stressful things happen and I actually could see her slipping into binging mode but we were with a group and I couldn't really get her attention.  I followed her to the bathroom and could hear her purging.  I knocked on the door and asked her to come out and talk to me when she was done.  She was in tears over slipping up but looking back at it, she was able to pinpoint exactly when she got triggered and what happened.  We have a no purging at all rule but at the same time I do respect that she was able to work through what happened with me and we had a great rest of our vacation.  I know you and your daughter get there too.
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Francie
You are a true warrior, mjkz. You've been through so much with your d. I appreciate your story about the purging on vacation. It sounds like you did the best you could to best handle a bad situation (couldn't get her attention, were aware of what was happening, followed her, let it happen, and asked her to process it with you). From your description you were matter-of-fact but concerned. To me it is the perfect approach. Not judgemental, not emotional, but concerned and on top of it. 

Here at home both my h and I still get emotional when our d purges. We're working on it, though, as we know it doesn't help if we get angry and upset and frustrated. We will get there. Thanks again. XO

Francie

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Francie
Horrors! Hubby is fine with allowing purging in the contract and won't back down!! Back to square one. We'll have to rely on the wisdom of the therapist to get us through this one. 

Francie

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Foodsupport_AUS
Gah!! Send him this way and we will set him right!!!

Sorry it has to be so hard. 
D diagnosed restrictive AN June 2010 age 13. Mostly recovered 10 years later.  Treatment: multiple hospitalisations and individual and family therapy.
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Kali
Hi Francie,

When my h. and I don't agree about treatment, reminding him that our daughter has a life threatening illness and that she could die usually gets him back on board....after I start with that I then proceed to whatever plan for our d. I want him to support.

just a thought....


Kali
Food=Love
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mjkz
That's kind of like saying to an alcoholic I'll support you as long as you only get smashed one night a week or one every two weeks.  My daughter is anorexic and I'll support her as long as she only starves herself one day a week or one every two weeks.

Purging is a slippery slope so if you allow one, you will see more.  Maybe remind him of the money you lost the last time she went back and had to drop out.
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