Treatment options in Israel

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Choosing a treatment team for your child is a high pressure task because so much is riding on it. Time is of the essence; so while you should make sure to give the matter due diligence, try to make appointments and come to a decision as quickly as possible.

In general, there are two different options. One is to find a treatment center which has all of the treatment that your daughter will need in one place; dietician, therapist, psychiatrist, etc. The obvious and strong advantage to this is easy and open communication between the professionals who are treating your daughter and a multidisciplinary approach. The second option is find a dietician, a therapist, a psychiatrist, etc. and have them each treat your daughter separately. If you go with the separate approach, make sure that each treatment provider is willing to work together with the other members of your daughter’s treatment team. This requires more time and effort, but without collaboration I am not sure how effective the treatment can possibly be.

If you are going with the ”all in one place” approach, there are several options–kuppot cholim (health funds) have eating disorder clinics. Ask your pediatrician or family doctor about referring you to one of these clinics. Generally, the patient sees a dietician and a therapist once a week and the parents are mandated to see a different therapist once a week. There is a psychiatrist who works there as well if meds are needed. The therapists talk to each other and relay information back and forth, but in my experience, there is no family based approach and the parents are kept out of the loop to a large degree. Some hospitals have outpatient programs which are similar in structure and function to the kuppot cholim and some hospitals have day programs where the kids come after school and stay for the afternoon. There are supervised meals and each child has a treatment team (therapist, dietician, psychiatrist), though from what I understand they do not get treatment every day. The supervised eating is helpful for working parents. I know that you have to pay a small fee for treatment through the kuppat holim eating disorders clinic but it’s not a lot of money, especially compared to private treatment. I am not sure about whether there is any payment involved through the hospital day centers; but if there is, it’s probably nominal.

If your daughter needs more intensive treatment than what the health care system can offer you, private treatment may be necessary. Shahaf in Tel Aviv is an amazing treatment center and offers a true multidisciplinary approach with a multitude of therapy options (psychotherapy, art therapy, family therapy, psychodrama, etc.). It’s super expensive, but the treatment is exceptional in every way.

You need to take into consideration the degree of your daughter’s illness. Once a week outpatient treatment works for girls who are diagnosed before the eating disorder has the opportunity to take hold; when the illness is easier to manage. Hospital day centers provide more extensive care, but take into account that they are not eating disorder specific and your daughter will be hanging out with kids who have various mental issues. They are all receiving treatment, and many of these kids are extremely nice, but it’s a consideration. It’s a supervised place to hang out and there is a staff to supervise mealtimes, but it’s not a treatment center in that there is a ton of treatment. If your daughter is severely restricting and has developed a more militant attachment to her eating disorder, you may need more intensive, private treatment.

If you have specific questions, feel free to email me at parentinganorexia@gmail.com.

 

When do you hospitalize your child?

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When should your child be hospitalized? Of course since this is my blog, it’s just my non-medical opinion, but I have been around the block a time or two (or six). These are what I would consider general guidelines:

1. When there is an obvious medical condition such as a critically low BMI, irratic heart rate, dizziness/fainting, outright refusal to eat, or any other symptom that requires immediate medical attention and supervision.

2. When you have already gone the outpatient route and received a high level of care and nothing is working; your child is continuing to lose weight at an alarming rate and the eating disorder is getting more entrenched in her.

3. When your daughter’s treatment team recommends hospitalization because they can no longer take responsibility for her health and they feel that she needs a hospital setting.

4. When the eating disorder is taking over and harming your family. At a certain point, no matter how much you love your sick child, you come to the realization that you cannot sacrifice yourself/your spouse/your other children to the anorexia; the burden of the illness becomes too great for the family to bear. There is no shame in this–when you are in over your head and your child needs more help than you can give her in a home setting, it’s time for hospitalization.

5. If you cannot supervise your daughter’s eating and you cannot find someone who can do this and she is losing weight rapidly because she needs supervised meals and you cannot afford or find an outpatient clinic that can help you with meal supervision, you may need to consider hospitalization.

6. If you get to the point where your home is toxic for your daughter or your daughter is toxic for your home, hospitalization may be an answer.

And one more thing–don’t use hospitalization as a threat to try to get your daughter to gain weight unless you are going to follow through and hospitalize her if her condition does not improve or worsens. If you threaten, you have to follow through.

 

What I took away from my daughter’s hospitalization

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My daughter was hospitalized for about 7 months. During that time, we really floundered as parents. It was a very strange situation to be in; we were parents of a child who really didn’t belong to us in many ways. We were told when we could visit her/when we could bring her home for a visit and for how long we could keep her, we weren’t allowed to participate in decisions made on her behalf, we were forced to abide by the hospital’s rules, etc. It was not a positive experience for us, and if I could do it all over again I would do it differently. But I definitely learned a lot along the way.

No matter what, you are always the parent of your child and (provided that you are a good parent) anyone who tries to distance you from your child is quite possibly harming her. Parents need to be active participants in their child’s recovery. The first therapist that we were assigned to at the hospital was unintuitive and trained to work according to only one method, self psychology, which was the blanket method of the unit that my daughter was in. Personally, I define self psychology as “blame the parents” because effectively, according to my understanding from reading about self psychology, that’s what it is. My personal opinion is that it’s a harmful method to use in treating kids with eating disorders. It doesn’t take into account any genetic, biological, or non parental factors, it just kind of assumes that somewhere along the way, you messed up your kid. That’s not to say that somewhere along the way I did not mess up my kid, but I don’t think that should be the automatic starting point. So make sure to ask all hospitals that you are looking into (before you have your daughter admitted) which methods of treatment they subscribe to and do your research to understand how they will be treating your child on the psychological and behavioral end. Make sure that their methods appeal to your intuition and that they are not rigid in their philosophies; eating disorder treatment is not one size fits all. I can’t say this enough times–bad therapy is harmful. If something about your child’s treatment makes you uncomfortable or doubtful, don’t hesitate to respectfully challenge authority–just because someone has an MD, PHD, MSW, RN, or any other alphabet soup combination after their name does not mean that they should be blindly trusted to make decisions on behalf of your child. The less they want parents to be involved, the more cause there is for concern.

Always use your parental intuition and don’t leave your child in a place that you feel is doing more damage than good. If you can’t sleep at night because you feel that your child is in danger, get up and start researching other options. Don’t be afraid to rock the boat or to make waves if you are convinced that your daughter is not receiving competent care, YOU are the parent. No one has your child’s interests at heart the way that you do. Find competent care, inpatient or otherwise–no matter where you live, it exists. Sometimes you have to look really hard to find it and most always you have to pay a lot to receive it, but what a difference it will make!

Signs of an eating disorder

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How can you tell if your child has an eating disorder? It’s as much about behavior as it is about weight. Here are some things to be on the lookout for–

1. Dieting–don’t let your child diet unless it’s warranted; and even then, it should be fully supervised by a dietician or a physician. If your child continues to lose weight after he/she reaches goal weight, don’t let it slide–take action.

2. Eating habits–a lot of this is gut instinct. Some of these behaviors are not necessarily indicative of a problem in one child and totally indicative in another. Use your instincts. If your child is restricting higher calorie foods that you know she likes, severely restricting calorie intake, only eating healthy foods, eating in a strange manner (cutting food into teeny pieces, not allowing the food to touch her lips, and taking a very long time to eat are some examples) or refusing to eat in front of others, pay more attention to the situation. If you suspect that something is going on, seek medical attention.

3. “I’ll eat later”– If your child keeps pushing off meals and promising to eat later but you never see her eat, don’t let this go. Insist that she eat at the proper times and in the proper amounts.

4. Excessive exercise–if your child is suddenly exercising at all hours of the day and night, start putting limits on exercise. If your child has a low BMI, exertion can be dangerous not to mention that it burns calories that your daughter can’t afford to burn. In this case, exercise should be totally forbidden until your daughter’s weight returns to a healthy range or allowed only under medical supervision.

5. Obsessing about weight–I admit that I am super sensitive since conversations about weight and calories are forbidden in our house, but it’s amazing to me how many normal conversations are about weight or food guilt (“I really shouldn’t eat that, do you know how many calories are in that dessert, I can’t believe that I just ate that”, etc.). If your child crosses a line and is constantly talking about how fat she is, how full she is, how disgusting she looks and you feel like it’s something more than teenage rhetoric, seek help.

6. Food diaries–if your child is recording everything that she eats and totalling her daily calorie count, this could be a sign that she has an eating disorder. If you find a food diary and the calorie count is really low (under 1000 calories), confront her immediately and seek help.

7. Body stance–this is pretty unscientific, but I have noticed that girls with an eating disorder have what I call an “anorexic stance”–they cross their arms over their stomach and are usually slightly hunched over. If you recognize this in your daughter, your radar should be up.

8. Always cold/wearing a jacket–girls with a low body weight are constantly cold and many times wear a jacket even when others are not cold at all. Again, this is not a sign in and of itself but paired with other signs can be cause for concern.

Bottom line–use your instincts, be aware of your child’s food intake, keep a strict eye on any changes in diet or behavior, and get help if you think that your child has a problem. The earlier you catch an eating disorder, the more likely it is that your child will recover.

Faulty wiring?

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I read an article a few years ago about alcoholism and it said that one out of every ten teens who sample alcohol will become addicted at some point in their lives. There is something in the way that their brain is wired that makes it impossible for them to resist alcohol. I can’t swear that the statistic is real, but I think that the same seems to be true with eating disorders. A class full of girls can go on a diet together; all but one will stop when they get to their target weight, and that one remaining girl won’t be able to stop losing weight even when she is way below her target weight because she is wired to become anorexic. One of my daughters dieted for about 8 months and as a result developed a healthy approach to eating and another one dieted for about 4 weeks and developed an eating disorder. A teen who never drinks a drop of alcohol has no chance of becoming an alcoholic even if s/he is predisposed toward it. There is no doubt in my mind that dieting is a trigger for eating disorders in those people who are wired to develop them. Maybe not in all people, but definitely in some. And dieting is part of the thin culture, and thin is in. I can’t say for sure that my daughter never would have developed an eating disorder if she hadn’t dieted, but I wish that I could go back in time and stop her before she started.

Baby steps

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When your child is sick, you want them to get better right now. And if not right now, then tomorrow. And if not tomorrow, then next week. Well, it doesn’t work that way with eating disorders. G-d knows I wish it did. The recovery process works in baby steps. Most of the time 1 step forward and 2 steps back. It’s a freaking roller coaster with ups and downs, and sometimes when you are down you can’t ever imagine that you can get back up again….but you do. You will. So put on those seat belts and settle in, because it is going to be a long ride filled with teeny tiny little steps of progress and not so teeny tiny setbacks. Savor those little steps of progress and accept that recovery will take as long as it takes. And meanwhile, don’t put your life on hold while you wait for your child’s recovery. Life is meant to be lived, even when things suck. Maybe especially when things suck.

Reaching out to other parents

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If you live in Israel and your child has been diagnosed with an eating disorder, maybe I can help you. I’m not a psychologist or a psychiatrist or a social worker or a nutritionist, I am just a mom who has been where you are now. I’m not really sure how I got into counseling other parents of anorexic kids, it just seems to have fallen into my lap. If you would like to talk things through with someone who understands what you are going through, send me mail at parentinganorexia@gmail.com.