F.E.A.S.T's Around The Dinner Table forum

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tp7
Hello,

       My 13D just started a PHP that focuses in anxiety and OCD in addition to ED.  Since she came out of IP in early March we managed to get her WR at home but her anxiety has skyrocketed and she hasn't been able to go to school, change her clothes, see her friends or be out in public much.  She has also become extremely defiant in just about every aspect of life other than food.

When my D got out of IP she flat out refused to eat.  Our approach from that time on has been "If you don't want to eat then we'll stay at the table until you do.  If it takes all day then go ahead, I've got all day".  She is pretty darn stubborn and she seriously pushed back at the beginning.  The first meal took 6 hours and the second meal took 5 hours, but she has been able to finish most meals since then in a reasonable amount of time. We have also been working through fear foods by telling her that not eating them wasn't an option, even if it took all day.We haven't missed a single meal or snack since March because we've repeatedly told her that we will stay with her until she's done, even if it takes all day.  And we also tell her that if she doesn't eat we'll then send her back to IP.  
   
Fear of those two things alone seem to have given her motivation to eat.  Meanwhile everything else in her life has seemed to fall apart, but at least we felt like we had the eating part more or less down in terms of enforcement.  The reason we enrolled her in the PHP program was to help her get a handle of her crippling anxiety.  

So we're two weeks into it, and the staff from the program started getting into a methodology disagreement with me in front of my D.  They did it in a nice way but still, they should not be having these discussions in front of her!  😡😡😡They claim to focus more on "creating a positive relationship with food", so in essence more "encouragement" rather than "blackmail" (as my daughter calls it).  We were discussing eating pizza, which is a fear food for my D but which she has successfully eaten several times since she came out of IP. Does she like to eat it? No.  Does it make her nervous? Yes.  But our approach has been to not budge and not negotiate and just sit at the table until D eats it.  Granted, last week she suddenly flipped at the pizza restaurant and ran into the bathroom to hide. Getting her out of the bathroom resulted in a ton of drama and unpleasantness all around.  But she did eat the pizza in the end (through tears).

The approach from the PHP program is to just give a supplement if they don't want to eat it, while gradually increasing the amount of supplements until they're having more intake in supplements than the original meal would have been.  This is supposed to create a natural motivator for choosing the meal instead.  So we have gone from not having had a single supplement in months, to suddenly having supplements right and left while at PHP.  And then the staff from the program started telling me in front of my D that they wouldn't recommend sitting in front of dinner for hours if she doesn't want to eat something but rather to just give a supplement if something is too difficult to eat. 

Oh my D pounced on that opportunity!! She has spent the last 3 hours going on non-stop about how allowing her once in a while to have a supplement at home would help her be more motivated to tackle fear foods.  According to her she would feel like she it's an option that she could use if she is having an extremely hard time with a particular food without fear of "being sent away".  She claims that fear of "being sent away" (to IP) is making her anxiety worse and not giving her the right type of motivation.  She's now basically asking for the right to have a supplement at home about once a week if she finds a food item too difficult to eat.  

On the one hand, I feel like the goal is to no longer have any supplements and we were already there and now we're taking a step back and this is just her ED talking.  On the other hand though, maybe the people at the PHP have a point about trying a "positive" motivator.  I was with her when she was given a piece of bacon. She initially said that she wanted a supplement instead, but when she realized that she would need to drink an entire cup of supplement she decided to eat the bacon without a fuss.  So maybe this approach does work?

Either way I now feel pretty undermined by the people at PHP (I will have a serious word with them on Monday about this) and I'm not sure of whether to say yes or no to the request for a weekly supplement option. Any advice?

Thank you!

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Foodsupport_AUS
It sounds like you have done an amazing job getting those meals in over the last 4 months or so. Has she gained weight as well? At 13 she should be gaining consistently, there is no true goal weight, and if not that may be contributing to some of the persistent ED you are seeing. 

As for dealing with fear foods. There is no one way or right way to do this. 
I think it is important to acknowledge that your D is truly terrified of these foods, with all sorts of thoughts about what they may do to her. 

When dealing with anxiety and approaching fears there is the concept known as flooding: https://en.wikipedia.org/wiki/Flooding_(psychology)
This is what you are currently doing with your D. I

The team at PHP is offering an option which allows her a choice between two fears: higher calories in a supplement or the feared food (flooding). 

There is a third option of working with exposure therapies - and that is to look at graded exposures - making a list of least feared foods to most feared foods and slowly working your way up. Depending on the level of fear you can do with things like touching, small bites, part portions and full portions. 

This is called graded exposure and is also a very valid treatment for fears and phobias. It can also sometimes be used with something called systematic desensitization where calming exercises are used at the same time to help calm things further. 

I agree with you that the PHP 's approach is not well done at all but given your D appears to be increasingly distressed and on edge it may be more appropriate to seek an approach that is not leaving her feeling that way. Perhaps graded exposure may be a better path for you?

D diagnosed restrictive AN June 2010 age 13. Initially weight restored 2012. Relapse and continuously edging towards recovery. Treatment: multiple hospitalisations and individual and family therapy.
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ValentinaGermania
"When my D got out of IP she flat out refused to eat.  Our approach from that time on has been "If you don't want to eat then we'll stay at the table until you do.  If it takes all day then go ahead, I've got all day".  She is pretty darn stubborn and she seriously pushed back at the beginning.  The first meal took 6 hours and the second meal took 5 hours, but she has been able to finish most meals since then in a reasonable amount of time. We have also been working through fear foods by telling her that not eating them wasn't an option, even if it took all day.We haven't missed a single meal or snack since March because we've repeatedly told her that we will stay with her until she's done, even if it takes all day.  And we also tell her that if she doesn't eat we'll then send her back to IP. "

I think you have done amazingly well with that approach and it seems to work. Whatever is needed to get the food in is o.k. It is very much the same what we did 2 years ago. Congratulations on getting her WR!
What you did is make not eating impossible and that is the right approach. And that refusing to eat means IP in consequence is true and not blackmailing. ED feels blackmailed for sure as this means a very good incentive to eat and your d can tell ED "I must eat or I will be send IP again". We did the same and I remember I only once needed to ask my d to pack her bag to go back to hospital. Many months later she told me that this was the best thing I could do in that tricky situation then because she could tell ED that it was not her choice to eat.

"The approach from the PHP program is to just give a supplement if they don't want to eat it, while gradually increasing the amount of supplements until they're having more intake in supplements than the original meal would have been.  This is supposed to create a natural motivator for choosing the meal instead.  So we have gone from not having had a single supplement in months, to suddenly having supplements right and left while at PHP.  And then the staff from the program started telling me in front of my D that they wouldn't recommend sitting in front of dinner for hours if she doesn't want to eat something but rather to just give a supplement if something is too difficult to eat."

I think a supplement should be the last option and not an excuse for not eating. Normal food is always better than a supplement. With that approach you might get to drinking only supplements and refuse all food within the next time. A supplement is last option and not a daily alternative.
If you offer a supplement it gives ED a choice. And I fear your d will need to fight at every meal against ED that wants to have the supplement.

"I was with her when she was given a piece of bacon. She initially said that she wanted a supplement instead, but when she realized that she would need to drink an entire cup of supplement she decided to eat the bacon without a fuss.  So maybe this approach does work?"

If that approach works it would be easy to avoid daily supplements as you can always have the normal food option more attractive as the supplement. I would be careful with new ED rules like "once a week I am allowed a supplement" as this will increase to twice a week, once a day...you get what I mean. YOU should decide to give that supplement if needed and not ED should decide that he wants a supplement.

How many fear food is left there? If it is just a few, what about a laddering approach as Foodsupport suggested? We had fear food day once a week (Sunday here) and we served one fear food from the list each Sunday and after some weeks let d decide what was served next week (and it was her way to tell us what she would like to eat but AN does not allow).
Keep feeding. There is light at the end of the tunnel.
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tp7

Foodsupport_AUS and Tina72, 

Thanks so much for your thorough and informative replies, these are really helpful. 

I first wanted to mention how much it means to feel supported by you.  I'm always more than open to discussing different approaches to solving a problem in private with health professionals, but when staff at the PHP started saying things like "Well, our approach is different" in front of my daughter I felt really undermined.  She hadn't ever questioned our approach until now, and she's of course pushing back hard and saying things like "They're the professionals so why aren't you doing what they say?".  We've fought so HARD to get her back to eating and I refuse to take a step back.  

This particular PHP focuses on tackling all aspects of an ED including the anxiety and (in some cases) the OCD that come along.  They do it through exposure therapy.  My D hasn't completely rebelled against this approach, which we've taken as a good sign given that she has refused absolutely everything else like medication, and she gives her regular ED therapist the silent treatment every time.  I think that part of the reason she's open to it is because the initial exposures seem so non-threatening and also because these are suggested by someone other than mom or dad.  However the way this program tackles meals and snacks seems to me much more relaxed than how we've been doing it at home.  And now I'm afraid that the ED will take this as an opportunity.  

Yet given how on edge my D has been, maybe a more gradual exposure to fear foods might be worth a try. We've been trying the flooding approach that Foodsupport_AUS describes above, and while it has worked in terms of getting my D to eat, she has become so oppositional that we've become stuck in every other aspect of life.   

We sat down with our D this morning and told her that we would be willing to agree to give a supplement for at most half of the not eaten fear-food and at most once every two weeks.  This would be only as a trial, and the amount of supplement will have to be more calories than the amount of the original food item.  We told her that we reserve the right to go back to our original approach at any time if we don't see any progress being made.  By progress we mean that we should in theory go back to no supplements after some time because fear foods continue to be tackled successfully.  Tina72, I think you're right that we run the risk of my D simply taking that opportunity to start asking for supplements more often, so my H and I decided that asking for more supplements would be an outright sign that it's not working out.

We'll see how it goes, thank you both for wonderful support!

TP7



 

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kazi67
Hi tp7
just thought I’d add and you may have already tried this 
when we first started to take our d out to restaurants/cafe etc
we would google the menu and see what they had on offer so my d would have an idea of what she could order and this helped with her anxiety 
also in the beginning we would take a lunch box with a “safe” meal (more so if we were going to a friends BBQ or family luncheon type of thing)
if she didn’t feel comfortable with what was there we would simply heat up her “lunch” that we brought 
also when it was family/friends I would make a phone call beforehand to explain the situation and ask that please no comments to be  made 
this worked for us, just thought I’d share 
x
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tp7
Thanks kazi67 -  Having a backup lunch in tricky situations is a good idea.  At the restaurant we were caught off guard because my D knew the menu and had already eaten there many times before. So we thought that it would be one of the easier places to go to.  However what we're learning is that being able to get through a tough meal one time doesn't necessarily guarantee success the next time around.  I think that your idea about having a "Plan B" in these tricky situations sounds great.  
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ValentinaGermania
"However what we're learning is that being able to get through a tough meal one time doesn't necessarily guarantee success the next time around."

That was same here. And I can add that when I THOUGHT a fear food would get hard it often went better than expected and when I thought it would be easy we often had a completely meltdown about it. Eyes closed and go through it was the best advice.
Keep feeding. There is light at the end of the tunnel.
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tp7
Thanks Tina72!  I'm glad to know that it's not so uncommon to have setbacks with things that we thought we had already overcome.  
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ValentinaGermania
tp7 wrote:
Thanks Tina72!  I'm glad to know that it's not so uncommon to have setbacks with things that we thought we had already overcome.  


Like when you start feeding a baby after breast feeding they must eat something about 20 times until it is normal again for their brains. It is like a stroke patient that needs to learn everything again from the start. The first time you introduce something again it is completely new to the brain. After you did it a few times there is a thin new wire in the brain. With every time you serve this again this wire gets thicker and thicker until it is stabil again.
Therefor it is important to serve a fear food a lot of times again with short time in between so the brain learns that this is normal again.
Keep feeding. There is light at the end of the tunnel.
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