Words can’t even begin to express how I feel about Dr. Jennifer Gaudiani. (And, I’m a writer!) Dr. G is the real deal: she is not only beyond knowledgeable about eating disorders, but she is also deeply passionate and caring. When I heard that she was writing a book, I was thrilled to endorse it. Thanks, Dr. G, for sharing an excerpt with us—and for donating signed copies of Sick Enough!
For a chance to win a signed book, see information at the bottom of this post. Be sure to check out SickEnough.com to learn more.
Why Medical Complications Matter in Eating Disorders
Despite… jaw-dropping statistics, the tragic and nearly universal reality for those with eating disorders is that they often believe they aren’t sick enough to warrant changing their behaviors or seeking help. This is true for patients who come to my outpatient clinic, and it was true for the patients I saw at ACUTE. Denial of disease severity is one of the hallmarks of these mental illnesses. Patients may think their bloodwork isn’t “that bad,” or their weight isn’t “that low,” or they may point to the fact that they are still high achievers in school or at work.
In writing this book, I hope to establish that anyone with an eating disorder is sick enough to seek help. If you have even one of the medical issues detailed in the book, you are sick enough. If you have never had an eating disorder, but you have a disordered relationship with food and your body, you are at risk for the medical problems I describe. Sometimes it takes medical truths, challenging the false narrative of “I’m just being healthy,” to make patients realize they are engaging in behaviors that are anything but healthy. Everyone has the potential for full recovery, and most medical problems will resolve with recovery.
Using metaphor and patient-centered language, Dr. Gaudiani aims to improve medical diagnosis and treatment, motivate recovery, and validate the lived experiences of individuals of all body shapes and sizes, while firmly rejecting dieting culture. One of Dr. Gaudiani’s most helpful metaphors is “The House on Fire.”
The House on Fire, a.k.a. Combatting “I’m Fine”
Very often, patients will try and convince me that they are actually fine. (I view the word “fine” as the four-letter f-word of our field.) They feel they are not sick enough for a higher level of care, to eat the full meal plan their dietitian has prescribed them, to warrant my concern, or to change anything they are doing in their disorder, etc. They say, “But Dr. G, I get a 4.0/I’m a star employee/I can still run every day/I’m a good mom/my potassium is normal/my weight is normal. I’m fine!” This line of reasoning can sound convincing.
An eating disorder will passionately defend itself. Like an abusive partner, it can push all other close connections away. When anything threatens it, it will lash out and become remarkably cruel to the person threatening it (the therapist, the parent, the partner) and even meaner to the patient. Eating disorders scathingly whisper that patients are nothing without their eating disorder.
What’s so hard about eating disorders is that patients retain their intellectual capacity and many aspects of their emotional capacity. We would never urge someone with schizophrenia, in the midst of a psychotic episode, “Use your inner wisdom here. Are there really little green men in the room?” The psychotic person can’t access the real world. The little green men are their reality.
We all have to keep in mind that for someone with anorexia nervosa, the beliefs that food and rest will cause devastating harm to their bodies, and their perception that their bodies are wretchedly inadequate and revolting, are their reality as well. And yet reminding patients to access their inner wisdom is a key element nearly every practitioner uses in their treatment of anorexia nervosa. Where the person with schizophrenia is fully incapacitated during a psychotic episode, the patient with anorexia nervosa can competently navigate the rest of the world, at least initially. This bizarre fact easily leads family members and friends to misjudge the severity and cruelty of this mental illness.
To combat the delusion that a patient is fine, I use a metaphorical story called “The House on Fire.” Imagine that a young woman is standing outside her burning house, and the fire department rushes up. The firefighter jumps out and says, “We’re here to put out your fire!” She says, “What fire?” He looks concerned and says, “Well, your fire. I smell the smoke. I feel the heat. I see the flames.” She smiles and says, “Oh no. If my house were on fire, it would be so hot that my sidewalk would be bubbling. And because my sidewalk isn’t bubbling, I couldn’t possibly have a house fire.” The firefighters understand her to be mentally ill, and they go put out her fire.
I go on to remind my patients that there is no single marker of illness that I look at to determine whether they are sick enough to proceed with recovery efforts. Saying, “My blood work is fine” is like saying, “My sidewalk’s not bubbling.” This is an extremely important point because someone who is fine can comfortably reject what all these people are telling them about how concerned they are and can proceed with restricting and exercising. The concept of “fine” stalls recoveries.
I try to introduce these concepts the first time I hear my patient trying to convince me how fine they are, so that the next time it happens, I can simply say in shorthand and with kindness, “House on fire.” I remind them of all the objective evidence of hibernation physiology they possess, medical signs that they aren’t fine at all.
Win a Signed Book! To enter to win a copy of Sick Enough, please post a comment below, answering: What can you do right now to choose recovery? Or, what can you do right now to support your loved one in recovery? (e.g., Call a friend for support.) Two winners will be randomly selected from all who comment.