8. Helping Children and Young People with Eating Problems and Disorders
The desire to feed others is primal. It is one of the most important ways we can show we care. It is also an incredibly important part of daily life. Whether taking others for lunch or dinner, celebrating birthdays and special holidays, giving sweets and chocolates as gifts, food surrounds us. We do not just eat and feed others because of hunger, food provides pleasure. Eating food, preparing food, cooking food, even growing food, all have social dimensions. Within different faiths, food also marks important events, Christmas, Hanukkah, New Year, Eid, Divali, Valentine’s Day, Easter, Mother’s Day, or Father’s Day, and many others, every celebration seems to include food.
But food is also essential to our survival. At its most basic, without proper nutrition, we get ill and die. When we have children, our first instinct is to feed them. When we feed our children, it makes us happy and fulfilled. If food is scarce, it is common for parents to feed their children over themselves. When food is in abundance, parents are likely to indulge their children with their favourite foods. It is the most basic way of nurturing another being.
When we begin to notice our child is not eating as they should, we question why. Babies may be lactose intolerant, unable to digest particular foods, or unable to tolerate particular textures, fussy eaters could have neurodevelopmental difficulties. As parents, we take note of likes and dislikes and can be alert to changes in eating habits. So, whilst losing appetite could be a sign of a physical illness, or a virus, or intense sadness rather than a problem with eating itself, we are aware that over eating can also be a sign of a physiological problem. Changes in eating can invoke a powerful emotional response in parents and they can often seek help to determine what is wrong.
For parents too there can also be a sense of social shame when a child is not eating as we think they should. We are judged if our child is too thin or too fat, too fussy or perceived as greedy. We want to be seen as good parents, so if we feel judged by others, it can also have a profound effect on how we feel as parents. Complicating the matter is the way in which this may be differently perceived in different cultures, and parents will employ various strategies in order to get the child to eat what they believe to be the correct diet. Parents may first ask for advice from immediate family, grandparents, friends, neighbours, then Health Visitors, doctors and other professionals in attempts to address the eating problems in their child.
It is so important to be aware of the differing emotions in parents and how long they have been battling with these feelings when they come to us for help. It is also vital to understand that the child or young person may have been experiencing internal and external angst for quite some time too. Therefore, the family that you see in front of you initially, when they are at crisis point, will most likely not be an accurate reflection of how they were prior to the difficulties they are currently experiencing.
8.2 A Skills-Based Approach to Assessment
This chapter is the only one which looks at a single issue, rather than taking a broader view of applying skills, and it will do that by looking at a series of case studies as a way of demonstrating HOW skills are applied in this difficult treatment setting, as well as highlighting the process used to apply those skills, which draw from a range of different theoretical approaches, but apply the techniques using what we have seen to be nursing approaches. Although this chapter concentrates on eating disorders, it does not set out the very important guidelines used in the formal treatment of anorexia, bulimia and other eating problems. Other books have done that well (McDougall et al. 2017) and it is particularly important that nurses and others are aware of the importance of physical healthcare alongside psychological care in the treatment of eating problems, which have the highest mortality rate amongst children and young people’s mental health issues (Smink et al. 2012). NICE guidelines in the UK (NICE 2017), for example, set out the latest thinking on treating these issues, and the well-regarded MARSIPAN (RCPsych 2014) document is also vital. Recently, in the UK additional funding has focused on the Maudsley guidelines (Eisler et al. 2016) as a framework for treatment within the English specialist services, which have received additional funding and training. All of these documents will tell you WHAT to do, we are concentrating on HOW to make these strategies and guidelines effective by using nursing skills to engage children, young people and families.
The guidelines quoted above all stress the need for assessors to undertake the task of assessing thoroughly, sensitively and with compassion. Because of the many possible reasons for eating difficulties and disorders, a detailed developmental assessment is usually necessary. Assessors should use and encourage curiosity in family members during this process. We need to explain exactly why the assessment is essential in getting to understand the experience of the entire family and that during the process young people and their carers may discover some lovely things about themselves and how others see them. We also need to let them know that at any time, if they disagree with what someone else has said, they can interrupt and provide their version. This is so everyone feels that their opinion is valued and that they are respected in the process, but may not be something that families are used to doing. Systemic and family therapies stress the need for curiosity to be used in this way to gently elicit information in an acceptable manner rather than using a more formal developmental history taking approach, which can appear to be a box-ticking exercise (i.e. DAWBA 2012). Likewise, it is important that an assessment is structured to gather information without being too overwhelming (Wright and Leahey 2013).
The initial assessment should provide lots of information. When asking parents about their own individual backgrounds, if there is genuine curiosity then supplementary questions, about how they met for example, can be taken positively and more information may be offered, often to the delight of the young person, who may not have heard these stories, and start to see their parents in a new light. However, if the parents are feeling particularly judged and appear suspicious, then it is best to avoid pursuing this angle, even if it is deemed important, until you have gained their trust. Questions about early development can be made fun. Rather than sticking to a simple set of questions about developmental milestones, you can ask what the young person was like as a very young child, what they liked and disliked, who their friends were, how they separated from their parents at nursery and school. These questions can more gently uncover any early signs of developmental delay, separation anxiety, personalities and childhood relationship difficulties.
Whether parents remain together or live separately and how this is managed is useful information. The nature of relationships with step-parents, half or step-siblings are also crucial to making sense of how the family functions. If the child or young person is adopted or fostered, then there may be less detailed information to work with. As long as we can glean as much as we can in a carefully considered manner which inspires trust and a sense of coming together for the same aim, that is the most important aspect in developing the basis of a therapeutic relationship. Whilst this is being done in a manner which aims to develop a therapeutic rapport, we may be told something that is worrying to us. Unless this requires immediate attention, such as hospitalisation or the removal of the young person to prevent imminent harm (under safeguarding or child protection rules), everything should be noted and any concerns should be voiced openly and options or ways forward discussed together with the family and young person respectfully.
Sometimes, following assessment, it becomes fairly clear what has happened and how it has happened. It is essential that we present this hypothesis to the young person and the family to see if it fits with their understanding of the difficulties. It may be that we have missed information, which leads us to rethink our ideas and come up with a new hypothesis, so checking is important, rather than assuming we know what is going on, a common failing with ‘experts’! If our ideas are validated then planning a way forward with everyone’s consent is of the utmost importance. Care plans can then be formulated together and further appointments made. Letting the family know exactly what they should expect of the service is not only good practice, but it also reminds the young person and family that they are not alone and will receive the support they require.
Communication with the GP is essential and another key component of any care plan. We are always going to be part of a wider healthcare (and often social care) team, so clear communication about who is performing what role within the team is essential. Practitioners need to know that checks and tests have ruled out physical health causes and routine blood tests may be necessary because restricted diets can deprive the body of important nutrients, and bingeing and purging can interfere with the balance of electrolytes in the body. Assuming that someone else is doing this can have tragic consequences, so make sure that communication is good, and let the young person and family know that you are talking with other parts of the wider team.
With younger children, it is possible that sadness, bereavement, bullying and insecurities within the family have precipitated the eating problems. It makes sense therefore to address these difficulties with the family and the social systems that surround them. A parent becoming unemployed, money being tight, or welfare benefits being withdrawn can also cause a sensitive child to react to the tension in the home by reducing their food intake. Parental mental or physical ill-health can also cause stress and pressure within the home and lessen the appetites of young people through stress and worry, which is why in-depth thorough assessments can be vital. These are sensitive issues, which need to be approached through an angle that is empathic and non-judgmental.
Sometimes, what begins as an eating problem can turn quite quickly into a disorder. Once the initial assessment has been completed, it is important to remember that all assessments are ongoing and with each subsequent session, more information may come to light as the family and young person feels safer and more able to trust the practitioners. Some sessions may be undertaken with the young person by themselves or just with the parents or caregivers.
8.3 Anorexia Nervosa
There are many theories about anorexia nervosa—remember that ‘anorexia’ on its own can be used to describe not eating for other reasons, the ‘nervosa’ describes the psychological element. The commonly accepted medical model tends to focus on identifying potential causes, and, depending on assessment outcomes, developing treatment plans to address those causes and any subsequent effects accordingly. Theories of aetiology, the potential causes, range from ‘flawed’ parenting, family mental health, bereavement, an overly strict, rigid or pressured home environment, childhood trauma or abuse (see Rikani et al. 2013). Clinicians, under this model, are encouraged to explore environmental reasons for the anorexia, which can lead very quickly and unwittingly into parents and carers feeling blamed for the illness in the child. This has the potential to cause further rifts in family relationships and can in itself hinder treatment and damage already fragile relationships.
We know that many parents and carers of young people who develop anorexia are high achievers (Halse et al. 2007). Many are perfectionists, middle class, often in high profile jobs. Do they put pressure on the young people in their care or do the young people feel that they have to live up to what they perceive to be parental expectations, or are they actually just very much like their parents, with a similarly driven personality themselves? To avoid this trap of blaming either parents or child, which can lead to a very negative reaction and disengagement from therapy, relationships need to be explored in depth. Whilst the guidelines we have talked about discuss the importance of a family history and understanding of family interactions, it is important to be clear with the parents or carers, and with the child and young person why so much emphasis is being put on this aspect. The medical model of finding a cause and then treating it is very familiar to anyone who has had contact with healthcare professionals, it is the dominant way of thinking, but no-one likes to think that THEY are the cause of someone else’s distress or illness. In working with young people and their families, parents may therefore blame themselves or each other, consciously or subconsciously, and they will be searching for answers, wondering what they have done wrong. Because of this dominant way of thinking about illness, they are likely to be believing that if they can put their finger on the trigger, then they can help to make their child better. Any added inference of blame by professionals will therefore only add to their sense of shame.
The young person can, and often does, also feel guilt. They may feel guilty for putting their parents through emotional turmoil whilst also feeling driven to continue along their path because no one understands what they are going through. They can become secretive, hiding their eating habits and weight loss from those around them and also hiding their thoughts, feelings and fears. Ironically, this often compounds the problem, so when the extent of weight loss is discovered the parents feel even more guilty for not having noticed.
By the time young people are referred to specialist mental health services, parents have already realised there is a problem that they feel helpless to solve. They can feel confused and frustrated. They may well be asking themselves why is this happening to my child? Why won’t my child eat their favourite foods anymore? Why are they throwing their lunch away? Why are they now insistent on eliminating certain foods from their diet? Why has my carefree child turned into a silent stranger? Often, young people cannot answer their parents’ questions. They can be just as confused about what is happening to them as everyone else. They do not understand either, yet feel compelled to continue on their path regardless. Getting a young person who is experiencing this for the first time to explain themselves to a stranger when they cannot even explain it to themselves is incredibly difficult.
This is why we felt that in order to provide the best service possible to the young people and families that we were working with, we really needed to find a better way to understand what this particular set of young people were going through. What had distorted their thinking patterns so much and sent them on a path of self-destruction? In our search for understanding, we came across a book written by Peggy Claude-Pierre: ‘The Secret Language of Eating Disorders’ (1997), which gave us new insights to so many of our questions. Peggy, a parent herself and a psychologist, had begun to notice the signs that other parents had spoken about, in her eldest daughter. These manifested in changes in mood, changes in behaviour, changes in eating patterns, making up excuses not to eat with the family, becoming withdrawn and secretive and hiding her weight loss under baggy clothes. As a parent, she took her daughter to see specialists, where a diagnosis of anorexia nervosa was made.
In her book, Peggy wrote about feeling blamed for her daughter’s illness. She described the intensive assessments and evaluations by professionals searching for a cause and the impact that had on her entire being as a parent. The main conclusion of the professionals was that other than refeeding, there was little else that could be done. Her daughter was described was manipulative by some healthcare professionals, whilst others assumed there had been sexual abuse in her earlier years and another group said it was a fear of growing up into a young woman that was the cause. Peggy knew her daughter well. She knew that she was unusually sensitive to, and aware of others’ needs, and attended to them diligently. She wrote about her determination as a parent not to give up. She described her need, as a psychologist herself, to really understand what had happened to her daughter and find a way to help her. It was Peggy’s close relationship with her daughter that not only enabled her to ask, with genuine curiosity, what she was thinking and feeling? It was the love and trust between them that allowed her daughter to answer openly and honestly. Her daughter told her that there seemed to be a voice in her head that was much louder than her own and even though she knew it made no logical sense, she felt compelled to obey it. The fact that her daughter had always been very logical confused Peggy and they began to explore these alternative thoughts together. One day, whilst driving in the car together, her daughter told her: “… you see these traffic lights? I know they are on green but my head is telling me that for me, they are on red. It is as though I am not allowed to go through even though others can.” (ibid page 13).
Over this period of time, Peggy found that it was the distorted thoughts that were fuelling the anorexia. Her once confident daughter had begun to doubt everything. She had became so indecisive she could no longer make everyday small decisions and needed enormous amounts of reassurance. They discussed this loud voice in her daughters head which Peggy named ‘Confirmed Negative Condition’ (CNC). In a joint attempt to separate CNC from her daughter, they began to explore everything the voice was saying. Her daughter was then able to use her mother’s strength as her own by sharing exactly what the voice was saying to her when it was saying it. It was a punishing voice, an insulting voice which questioned everything she did. Nothing was right. The voice became louder and more punitive. In order to eat even small amounts of food which she knew, logically, could not sustain her, she was forced to negotiate by agreeing to exercise or skip another meal. The voice also told her she was unlovable, ugly, fat and stupid. This voice was unrelenting but by agreeing to join forces with her mother, she was able to allow a more gentle and compassionate voice to slowly begin to fight the CNC.
We read about this journey towards recovery and through it we gained some insight into the minds of those suffering with anorexia, the answers to many of our questions and a compassionate and respectful way to work with and to successfully treat this disorder. We were inspired by the fact that not only did Peggy successfully treat her daughter, she then went on to set up her own clinic and residential home for those who had battled the disorder in vain for years yet were able to recover under her care. The people she treated described these unrelenting voices in their heads, voices telling them they were undeserving, unworthy of a place in this world, unlovable and despicable, the voice generated self-hatred in them. They truly believed that death through starvation was the only course left for them. Peggy’s book gave us so much insight into the mind of anorexia, it provided us with the tools we felt we needed to fine tune our treatment approach.
The CNCs that Peggy referred to were already well known to us through other ways of conceptualising them, as ‘internal voices’, or negative automatic thoughts (NATS) which are well described in the Cognitive Behavioural Therapy literature (i.e. Kinsella and Garland 2008). Importantly, Peggy’s book does not describe the ‘voice of anorexia’, as we came to think of it, as being an external voice, which is more characteristic of psychosis. NATS are already well understood as a driver in depression and a maintainer in Obsessive Compulsive Disorders (OCD). In these circumstances, our usual self-chastising internal voice becomes louder, more punitive and self-deprecating in depression, or more and more demanding in OCD. This causes us to believe what it is telling us regardless of how illogical it may appear to the outside observer. We decided to call this ‘the voice of anorexia’ because it serves to distance the voice inside the mind from the behaviour of the sufferer. Peggy used the negative thinking versus the positive thinking technique called externalisation in systemic psychotherapy (Boston 2000) which distances the behaviours and compulsion from blame. She described feeding the positive and starving the negative as a powerful treatment tool.
We realised that we had to keep in mind the description of how all of the assessments made Peggy feel and how she described parents feeling tortured by the misplaced belief that they are the cause of their child’s condition (ibid page 7). We decided that above all, we would centre our assessments around curiosity, adopt a non-blaming stance with understanding and would respond sensitively with compassion, gentleness and respect. The following case examples will describe in some detail how we were then able to enact this approach to developing therapeutic relationships with the children, young people and families, and (usually) use this approach to facilitate their recovery.
Case Example One: Annie
The first young person who was referred to us following our exploration of anorexic thinking and the impact this illness has on all family members was Annie aged 11 years old. An only child, she attended the first appointment with her mother and father. We explained the assessment process to them and said we would try to make it less boring than it sounded. Annie was pre-pubescent and in her final year of junior school, and both parents were educated middle class professionals. Annie was a meticulous child, very obedient, studious and serious. She preferred not to speak much in that first session but instead opted for her mother to speak on her behalf. We reassured her that this would be fine but just asked her to speak out if her mother got anything wrong. All her developmental milestones had been reached and in fact Annie had been quite advanced in many milestones, crawling, walking, language development and fine motor skills were all acquired earlier than usual. Annie’s mother was a teacher and had taken time off to spend the first few years of Annie’s life at home with her. Her father travelled frequently for business so her mother undertook the majority of the parenting.
Our technique of allowing the mother to speak on Annie’s behalf, with the understanding that Annie would interrupt if mother got some things wrong, worked well. Annie began to interrupt her mother more and more often, and as she felt more confident to communicate with us, she divulged more information. She had delighted at hearing how she was as a baby and toddler, and when her mother talked of Annie’s struggles separating at nursery, Annie said it was because she preferred being with her mummy to being with strangers and other small children. We then asked each family member to tell us about a special memory they had of Annie growing up. Annie talked about a wonderful holiday they had taken together. Mother and father joined in, providing their own memories of that particular holiday a couple of years beforehand. They laughed together and when we asked what was their favourite food memory, each gave us different accounts while they enjoyed remembering together. We explored other current aspects of daily living. There was no bullying, and Annie maintained close friendships with her peer group. There had been no family bereavements, and Annie had close relationships with grandparents on both sides. She was doing well at school and seeing friends outside of school. Annie had always been a fussy eater but when we broached the subject of eating, we were met with initial silence from Annie and both her parents, in contrast to their previous discussion of less difficult matters. As a way of overcoming this sudden silence we asked if it was OK to read out the referral letter from the GP, and told them we needed them to let us know if the GP had got anything wrong.
The GP’s referral letter indicated that mother had become concerned because her fussy child had become more and more fussy over the past few months. Annie had begun to restrict her diet and no longer wanted to eat what had used to be her favourite foods in the evenings and at weekends. Her portions became smaller and smaller and she was visibly losing weight. Mother had phoned school and she discovered Annie had begun to throw her lunches away. Annie was clearly embarrassed by this and had retreated back into her uncommunicative self. She had sunk back into her chair and looked smaller somehow. We gently explained why we needed food to eat and that we were there to help her get back to how she used to be. We related this back to how they had told us she had been on the holiday. Her mother then talked about this happy go lucky child who loved to do so much with her had become withdrawn and had lost her sparkle and how she had been wondering whether Annie was becoming depressed. Annie’s father, who had said very little up to this point, suddenly spoke up. He said there was ‘an elephant in the room’ that no one was talking about. We asked him what he meant and he said that Annie’s mother had been bulimic for years so it was not surprising to him that this had caused Annie to develop her own eating disorder.
The atmosphere in the room changed again. Annie’s mother seemed compelled to discuss her own relationship with food and how she would eat normally with everyone else for a month or 2 followed by a month where she survived purely on slimming shakes in order to stay within a particular weight range. She looked visibly deflated and it seemed that the blame and guilt in the room were both very powerful emotions. We could see from Annie’s face that she had heard this many times before and she herself felt guilty for hearing her mother being blamed. We suggested that it would be a really good idea if we saw the parents alone for the next session because it seemed they had things to discuss that were not necessarily directly linked to the difficulties their daughter was experiencing but could possibly have an impact on her treatment.
Both parents welcomed the opportunity to talk about this particular issue and Annie seemed pleased and relieved that they were going to do so. We asked permission to weigh her so we could get an accurate view of her struggles. Her Body Mass Index (BMI) was 15.1 We then asked Annie if she felt able to complete a food diary over the next fortnight so we could see what she was eating. We also asked her to note how easy or difficult it was for her at each meal and reassured her that our aim was to help her get back to the young person she was on the holiday that she remembered so fondly. And prior to organising further appointments, we asked each one individually how the experience of that first appointment had been for them. This may seem like a minor aspect of the first appointment but in doing so we are reinforcing our commitment to the family. It reminds each family member that we are listening and are respecting and valuing each voice.
Relating this back to our new way of thinking we reflected that we could have heard the words ‘bulimic mother’ and decided that we had found the cause and gone down the route of suggesting mother get her own help. Instead, we decided to acknowledge that mother was bulimic, acknowledge that there were parental rifts because of this and the connection to their daughters eating difficulties and to acknowledge that this was affecting their daughter’s emotional wellbeing. We decided more information was needed and parents would benefit from a discussion without the presence of their daughter.
Seeing the parents together was enlightening. Father initially presented as very angry and blaming. Mother talked about her guilt and began to cry, and then her husband, upon seeing this, softened in what he was saying. He had not realised how much she had been silently blaming herself. We took the time to discuss with both parents what we knew about eating disorders and bulimia, particularly the common need for control because the fear of being out of control was so strong. We talked about the belief that many bulimic people have that if their weight is not controlled, then nothing can be controlled and the result will be catastrophic. Father was both shocked and saddened that his wife had been going through this alone. She, in turn, said she felt so relieved that others could understand the emotions she was dealing with. We then went on to explain that although there are many theories about why someone begins to restrict their diet, a bulimic mother does not necessarily produce an anorexic daughter. That it is far more complicated than that. We discussed blame, guilt and shame and we really need to put those emotions aside and concentrate on helping their daughter. We reassured them that we were not blaming anyone and although motherly guilt is completely natural, that neither father nor mother should blame or feel guilty for their daughter’s illness. We also talked in depth about particular personalities. Intelligent, perfectionists, sensitive and caring personalities that seemed more likely to suffer from eating disorders. Father then talked about his wife and that they were all the things he loved about her. Both parents said that what we had talked about described their daughter perfectly. The session was ended very differently to how it had started. Allowing both parent to talk openly enabled them to discuss their emotions, us to share what we knew, and them to think together about eating disorders, it helped them to reach a shared understanding and went some way to lessen the burden of blame and guilt. In many ways we were following guidelines, exploring the family’s understanding of eating problems and providing psycho-education to help them better understand what their daughter (and in this case the mother) were going through, but the use of therapeutic relationship building had allowed us to follow this line of action actually much quicker than if we had followed a purely medical model by searching for a precipitating factor for the onset of Annie’s problems and then recommending that her mother seek her own help in the hope that Annie’s problems would resolve as a result of this.
The following session was a second family session. Annie had brought her food diary and said she had struggled a lot with it but she had tried her best. Parents were clearly acting together more as a couple and appeared much happier. They told us that the previous session had been extremely helpful for both of them. We discussed Annie’s struggles and applauded her efforts. We then began to talk about others with struggles with their eating and then explained what we referred to as ‘the voice of anorexia’. We discussed its punishing voice, how some have had to bargain with it and how it is illogical but compelling. We wondered whether she could relate to any of this. Annie then said that yes, she had the same voice. She said it made no sense but she had to follow its directions. We explained how the voice seems overwhelmingly powerful on its own, but when we employ the voices of our parents, it loses its power over us. We asked her if she could draw this ‘voice of anorexia’ so we could see how menacing it looked and asked her if she could enrol the help of her parents when the voice was telling her what she could and could not eat. We shared the words of the young woman with the traffic light analogy from Peggy Claude-Pierre’s book (ibid) and how her mother helped her to battle that voice with her own louder, more logical voice. We reflected that this was a voice of someone who loved her daughter at a time when her daughter was struggling to love herself. Both parents said they would be Annie’s external voice. We ended the session with another request for a food diary and a record of her ongoing struggles.
Annie returned the following week with an amazing drawing of the ‘voice of anorexia’. It was a cross between a devil and a monster, and was a very scary image. Rather than concentrating on the food diary, we spent time looking at the drawing together and exploring it’s meaning. Annie had clearly spent a great deal of time on this drawing and to her this was the demon that was fuelling the anorexia. We remarked on how frightening the drawing was, how wonderfully Annie had captured the essence of the demon and between us, therapists and parents, we all agreed that this was the stuff of nightmares which would have the same effect on us if it was attacking us. We were in fact normalising Annie’s behaviour and externalizing the compulsion. We were joining with her and acknowledging her fears. We were not dismissing her battles with anorexia, we were not suggesting that it was all irrational. This empathic and non-blaming approach was so important. What we had to do was to comfort her, join with her and above all, reassure her that she would no longer be expected to battle this monster alone. We photocopied the picture and put the copy on the wall during the session. We asked Annie where she would like the drawing to be put in the house. She suggested it would be best placed on the fridge in the kitchen. That way she would safest knowing that her parents would be constantly reminded what it was she was battling. It was then that we asked if we could see the food diary. She said it had been a little easier than before to fight the ‘voice of anorexia’. We asked what she felt had made it slightly easier. She told us it was knowing that she was not the only one with this voice, that others understood what she going through and drawing the demon helped her to visualise what she was fighting. Knowing she did not have to obey this demon had also helped. Prior to weighing her again, we asked what foods she had missed eating most. She said ice cream and Sunday roasts. After discussing her favourite flavours and the roast she missed the most, we ended the session suggesting if she thought about other foods she had missed, to tell her parents and perhaps they could go shopping together so she could choose herself.
Annie progressed quite quickly after this and returned to a more normal pattern of eating. Her age and developmental stage was a significant factor in her recovery, and she had quickly understood the externalization which enabled her to start to think differently about her eating. Trust and respect were vital in her recovery, but the way in which we had been able to work with the family to overcome the terrible silence that fell when we first talked about eating problems and addressed the ‘elephant in the room’ had been vital. By taking a non-judgemental and empathic stand we had developed a therapeutic relationship which then enabled parents to understand and support each other and Annie.