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June 20, 2011

Starvation Nation: Inside a Groundbreaking Eating Disorder Facility

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anorexia

Rachel, 25, at 61 pounds, after being admitted to the hospital in July 2010.

Photo Credit: Melissa Ann Pinney

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By sophomore year of high school, at 5'3", Rachel weighed 145 pounds. She'd quit student council — she'd been secretary of her freshman class — and was distant from friends. Afternoons were for her secret ritual, which she says she "looked forward to every day, all day." One afternoon at the end of her sophomore year, she was so ravenous driving home that she went too fast and got a speeding ticket.

During the fall of her junior year, Rachel stopped the bulimia but started restricting her calories again. Her weight plummeted, dropping steadily over the next few years. By December 2004, as an English major at the University of Colorado at Colorado Springs, she weighed just 82 pounds, although she was now 5'4". Her doctor, psychiatrist, and counselor checked her into treatment at the Eating Disorder Center of Denver (a different facility from the ERC). She left three months later and spent the spring recovering. In 2007, healthy, she started graduate school.

In the fall of 2008, Rachel, now 23, started teaching English at a high school near her parents' house. The new job took a serious toll on her eating habits: Constantly cold, she drank diet hot chocolate all day and wore stockings with leggings and pants pulled over them. Shocked by her relapse, her parents took her out of work. By Christmas, just 71 pounds, she looked gaunt and haunted, the thinnest she'd ever been. Somehow, she convinced her parents she was improving, but by June 2009, she still hadn't gained a pound. They checked her into the newly opened Eating Recovery Center that month; homesick and lonely, she cried to them every night on the phone.

The ERC, located on two floors of a hospital building in Denver, looks like an upscale ski lodge or dormitory. Patients chat by an open fireplace; bedrooms are full of picture collages and stuffed animals. But despite the spa-like bathrooms and wide-windowed conference rooms where therapy takes place, life here is regimented. Bedroom doors are locked so patients can't exercise in secret. Bathroom trips are made with staffers, who check toilets before flushing. Meals must be finished in 30 minutes, and nurses and therapists are constantly on the lookout for patients smearing butter under the table, casually patting napkins on top of their chicken to remove oil, dropping food stealthily on the floor, or even hiding yogurt in their ears or hair — "compensatory behaviors" patients use to get the food off their plates without eating it. (Anyone caught manhandling food like this has to make up the calories with Boost, an energy drink.) On the cafeteria wall, disordered behaviors and substitutes are clearly posted: "Use hands to eat a sandwich," not utensils; "use condiments in moderation." The goal? Relearn to eat.

On a winter day, 12 ERC patients gather for a community meeting. At these sessions, with therapists present, the group checks in with one another, sharing concerns with their own behavior or issues they've noticed. Ranging in age from 19 to over 50, the women look like college students during finals, wearing stylish leggings or sweats, shearling boots, fleeces, and T-shirts. (Both overly baggy clothes and tight garments are discouraged.) One woman has a feeding tube taped to her cheek; another holds a stuffed bear. Going around the circle, they share their "successes" — one accidentally put on mismatched socks that morning but didn't change them, despite feeling insecure about it — and "accountabilities." A blonde 35-year-old says her upcoming release is making her anxious, and she fears taking it out on her food, mixing inappropriately or cutting or chewing too much. Another woman asks how they can help her manage that at lunch. She asks for subtle reminders, like eye contact or a nudge. She also asks the other women not to go through the box of thin clothes she's throwing out ("sick" clothes in ERC lingo). She doesn't say why, but it's obvious: If anyone else could fit into the clothes she can't wear anymore, it would be extremely traumatic.

In a "values" group meeting later on, patients are asked to divide a pie chart according to how much time they spend thinking about their eating disorder. One girl, her brown hair in a ponytail, says just 16 percent of her circle is free for other activities. "We experience happiness when we align our lives with our values," a therapist says. "How can we make your true values take up the whole pie?" Many patients are so consumed with thoughts of staying thin that even the simplest activities become a sinister means of losing weight. Bermudez remembers spotting a patient in a Target parking lot; he'd just had a serious discussion with her about her high risk for bone fractures. At Target on a supervised ERC outing, she was turning cartwheels around the parking lot for surreptitious exercise. "She came up, and we met face to face," says Bermudez. "I couldn't believe it."

One of ERC's boldest moves has been creating a brand-new therapeutic framework, the "pillars of recovery," which highlights patients' personal ideals — relationships, faith, learning — and recovery principles, like "mindsight" (the ability to analyze your own thoughts). The change-based psychotherapy doctors have used for years forces patients to disown the anxiety that causes their disorders; the new approach helps them accept and manage it, a revolutionary idea in the stagnant world of eating-disorder treatment.

Nutritional stabilization, to normalize hormones, is also key. Meals are difficult here, and it's hard to reconcile the scene inside — women dropping bits of chicken on one another's chairs, or doing frenzied jumping jacks at night between nurse rounds — with the current public health obsession, obesity. According to the NIH, 97 million Americans are overweight or obese. "My patients are the casualties of the war on obesity," says Dr. Ken Weiner, founder of five treatment centers (including ERC), and Rachel's doctor. "Parents ask how to eating-disorder-proof a child: Never put your kid on a diet." Michelle Obama's crusade against childhood obesity and the addition of BMIs to report cards in some public schools make eating-disorder experts shudder. They believe the anti-fat campaign will trigger a whole new health crisis for the 11 million Americans who are anorexic or bulimic.

Doctors hope for a cure within 30 years — a custom drug or early gene intervention technique. Experiments comparing the brains of anorexic and nonanorexic subjects via MRI and PET technology are promising because they may reveal how anorexic brains really work. Until then, eating disorders' status as mental illnesses mean families struggling to pay for treatment — which can cost up to $1,000 a day — can take advantage of mental-health parity laws, expanded by President Obama to omit treatment limits for psychological diseases.

In November 2009, Rachel left ERC at 96 pounds. She'd hated the food — Italian paninis and Mandarin-orange salads — begging ERC's dietitian for chicken breasts with rice. Ecstatic to be free, "I assumed my weight would maintain itself," she says. For a while, it did. By January 2010, she was working as a substitute teacher at her mother's school and as a nanny for a local family. But by February, her psychiatrist and counselor were recommending she get help again. She'd lowered her daily calorie count to 600, and was chewing packs of gum and NutraSweet to blunt her hunger. After months of this, she was weak. Nausea and headaches kept her in bed until noon. Finally getting up, she'd rest after every movement: Stand up, rest. Put on socks, rest. She couldn't climb stairs, and was too tired to go to the park. Her charges played video games.

Though she continued to work as a nanny through June, she'd lie awake in bed and think about dying, imagining her mother finding her dead from a heart attack. In the nighttime silence, her mind raced. "I'd wonder, There's only five hours till morning — am I going to make it?" She didn't bother weighing herself and avoided mirrors, knowing she looked awful, but for doctor visits, she'd tie 10-pound ankle weights to each leg, under her pants, and chug water before getting on the scale. "I had an overwhelming sense of anxiety and fear," she says. "I didn't want to die, but I felt like I was almost there."

Finally, in July 2010 — one year ago — her psychiatrist called to say Rachel needed to go to the hospital. Now. So Linda took her to the doctor. As they walked to the waiting room from the parking garage, she noticed her daughter's strange gait and, frisking her, discovered the weights. "What are you doing?!" she asked, incredulous. "I was a basket case," says Linda now. "We thought she weighed 80 pounds — which was awful enough — but it was so much worse. I've learned crying doesn't help. You get numb instead." But when she sat down with Rachel's physician, the doctor herself was in tears. "She said, 'We're going to lose her,'" says Linda. Her daughter was just 61 pounds. Although Rachel barely spoke that afternoon, she was flooded with relief at the prospect of being hospitalized. Maybe now she wouldn't die.

By August, she'd gained 10 pounds in the hospital and returned to the Eating Recovery Center — her third stint at treatment, the second there, in 15 years. Forced to eat 3,600 calories a day, she was constantly tempted to cut back. But, having come so close to death, she had new motivation. "I reminded myself every day why I was there — my family, my future," she says. In December 2010, at 96 pounds, she left.

Today, 26 years old, Rachel weighs 105 pounds (her goal is 115), and says she is optimistic about the future. She's renewing her teaching license and dating a young Army officer, Chris, whom she met through church friends. Before they go out, she checks the restaurant website for healthy options. When she was served Thai food with beef, noodles, and peanut sauce — three of her scariest foods — at his friends' house for dinner recently, she ate a normal serving, using ERC skills. "I just looked at the worst-case scenario: I'd gain a pound. And that's not that big a deal. I could always lose it." No one there realized what a triumph it was for her (Chris knows only the basics about her disorder), but "it was just another dinner for them, and it felt good to have it be another dinner for me, too," she says.

Despite her new outlook, Rachel has some regrets. She knows her eating has disconnected her from the people around her, and physically, "I wonder if I'd be more intelligent, or taller, if I hadn't restricted during my pivotal growth years," she says. She takes several vitamins and supplements to improve her bone density, plus Wellbutrin (an antidepressant) and Cymbalta, to combat anxiety and depression. She sees a counselor weekly and a psychiatrist monthly. Hardest of all, however, has been letting a central part of her identity go. "The feeling other people get from doing a good job at work, or raising kids who are productive in society, or planting a garden and seeing it bloom — that's the feeling I get from losing weight," she says. "Life moves slower, and I feel like I'm doing the right thing. After all, this is what every American desires to do. And I can do it."


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