May 19, 2021 • 45 mins
Anorexia has the highest mortality rate of all mental disorders. Without treatment, up to 20% of people with serious eating disorders die. But people with anorexia do not want to change. They don’t want help. They don’t want to eat. So, how do you change the behaviour of a person who does not want any help? Well, let’s find out in this episode of What Monkeys Do.
In this episode, I speak with Mette Bentz, a psychologist and PhD, who works in the child and adolescent mental health centre in the capital region of Denmark. She is a specialist in the treatment of anorexia. She will help us understand the severity of the illness, what to look for and how we treat it best.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Morten Andersen (00:05):
Hello, and welcome to What Monkeys Do. My
name is Morten Kamp Andersen.
And this is a podcast about whatit takes to make a change and
make it stick.
This podcast is about change.
And the changes we've talkedabout so far have been changes
that we have decided ourselvesthat we've taken upon ourselves
(00:29):
to do or are okay with. Butthere are also changes that we
go through which we have notchosen ourselves, a messy
divorce may not be our choice,our partner simply left us or at
work, the company isrestructuring and your job role
changes, and you don't like it,but you have to embrace it.
Those are changes that you havehave to go through, but you may
(00:52):
not want to. And then we have acompletely separate category.
This is where people are doingsomething towards themselves,
which ultimately may cost themtheir lives. And the people
standing next to them have nochoice but to force them to
change. Now this could be anaddiction, like alcohol or
(01:13):
drugs, or how they eat. Anorexiais in that category. It is a
really serious mental illness.
In fact, it has the highestmortality rate of any mental
disorder. Without treatment, upto 20% of people with serious
(01:33):
eating disorders die. But peoplewith anorexia don't want to
change. They don't want help.
They don't want to eat. So howdo you change the behavior of a
person who really do not wantany help? Well, let's find out
in this episode of What MonkeysDo. My guest today is a
psychologist and PhD. She worksin the child and adolescent
(01:56):
mental health center in thecapital region of Denmark. She
is a specialist in the treatmentof anorexia. Welcome to you,
Mette Bentz.
Mette Bentz (02:08):
Thank you very much more than I'm glad to be here.
Morten Andersen (02:11):
Yeah, I'm really looking forward to this.
So in this episode, we'll talkabout how to recover from
anorexia nervosa or justanorexia for short, how to help
a person who do not want help.
But before we begin, can youtell us a little bit about you
and how you came to work withanorexia?
Mette Bentz (02:29):
Yes, I certainly can. Well, actually, I started
out as a nurse, a registerednurse that figured out I wanted
to work more specifically inthis psychological and
psychiatric era. So I went backto university and studied some
work. Before going into thefield of eating disorders, I
(02:49):
work in other areas withchildren and adolescents with
different kinds of challenges.
And I got interested in howimportant it was to work with
the important people around theyoung person. And I actually
developed quite, almost for howimportant those people are. And
maybe they can do more for theyoung person, I choose what I
(03:10):
can say or do as a psychologist.
So I really got interested intoworking with those around the
one but the challenge, then Iwanted to gain some experience
in psychiatry, and I actuallywasn't focused on eating
disorders at all. But well, Iwas lucky to get a position in
the the section for eatingdisorders. And here I am still
(03:34):
after 14 years.
Morten Andersen (03:36):
Wow. So let's try to start off with trying to
understand anorexia better, Iguess it can be sometimes
difficult to know if somebodyhas anorexia standing next to
them. So what are some of thesymptoms to look for, in another
person, if that person hasanorexia, not
Mette Bentz (03:52):
The main symptoms and those that constitute the
diagnosis. First of all,foremost that you avoid eating
sufficient amount of food, youhave a restrictive eating
pattern, we sometimes call it sosimply avoiding food that can
maintain or make your body gainweight, then, of course, that
(04:15):
will entail a significant weightloss. So the significant weight
loss is also part of the thediagnosis, the part that
actually makes it so serious.
And then there is also a morepsychological aspect pertaining
to this. The disturbed bodyimage or the disturbed
experience of your own body, thefact that you can feel fat while
(04:38):
you're in my ciated, or the factthat you can compare yourself to
everybody in the classroom anddraw the conclusion that you're
the biggest person there eventhough it's not a physical
reality, all these aspects of adisturbed body image. So those
are the main categories thenalso, of course, the
malnutrition will impact Thebody's way of functioning, which
(05:00):
specifically the hormonalsystem. So worth the rest, or
puberty development will perhapsgo into a pause, girls will lose
their menstruation if theystarted menstruation. So those
are signs that the body isshutting down because there's
not sufficient nutrition. Andthen, of course, there's a lot
(05:20):
of other symptoms following thefact that you need nutrition
that are more nonspecific, likeyou lose your temper easily, you
get sad or anxious that you usenot to be and you get pale and
tired and you feel cold all thetime have no energy, you don't
remember what teachers said inschool and all those nonspecific
symptoms that simply follows thefact that you're not getting
(05:44):
enough nutrition.
Morten Andersen (05:48):
And I guess many people have tried to go on
a diet. So try to restricteating, I guess, many people
look at other people and feelfatter than they actually are, I
guess there must be a line whenwe call it normal focus on
weight. And where we say this isactually an issue, is there a
BMI index level? Or is therecertain body functions that
(06:11):
stopped to work? Or what? Whenis it anorexia, and when is it
just being too focused on ourown weight?
Mette Bentz (06:18):
That depends a little bit actually. But in the
ICD 10 diagnosis system that wework with in Denmark, it states
that if you lost 15% of yourexpected body weight, so let's
kind of BMI limit. But probablythat will soften up in the
upcoming revision, because youcan have lost 12% of your body
(06:41):
weight and be severely ill. Sowe'll go with significant weight
loss with some kind of impact onthe bodily functions. Yeah.
Morten Andersen (06:49):
Okay. So losing a lot of weight, till a level
where I'd actually may even hurtyou having a distorted body
image. And I also know that, orI've researched that many girls,
they will try to get a certainweight level, but then they will
level that down and level thatdown all the way. So they can't
(07:10):
actually even stop themselvesand saying, so when I get to
this amount of kilos, then I'llbe satisfied. It's actually a
virtuous negative circle, isthat correct?
Mette Bentz (07:19):
That is very much growing. And maybe that's part
of what makes it so difficultthat you can start with a quiet
down, simple weight loss that'snot dangerous in anyways, it's
very innocent in a way, but thenit triggers something that
starts a maintaining cycle thatdrove me further and further
(07:40):
down in it, and makes itimpossible for you with your own
wills power to, so to speak,lift yourself up with your
bootstraps and get out of itagain.
Morten Andersen (07:49):
I said girls, but as I understand it, most
people who are suffering fromanorexia I actually women, I
think it's something like 90%women and 10% men. I don't know
if that's correct. But why is itmostly women?
Mette Bentz (08:02):
I don't know.
Really, because since we don'tquite know the reasons or the
what causes and reaction. It'salso difficult to say, why does
it cause it more in girls? Weknow that genetic and biological
factors play a role incausation. And therefore it's,
it's reasonable to think thatthere's something in girls, the
genetic makeup of girls thatmakes them more vulnerable,
(08:24):
then, of course, also, it'sthere have been a lot of
theories put forward regardingour cultural influence, where
the values of self control andthe bear values of good
appearances, that we tend to sethigher standards in those values
regarding girls than boys. Ithink that's in a way it's
changing in these years. Somaybe we will get to see more
(08:48):
increasing number of boys in thefuture? No,
Morten Andersen (08:53):
I think I read that up to 50 to 80% of the
causes seem to be genetic. Sothere's been twin studies where
basically, we've been trying tofigure out how much of this is
genetic and how much is not. Butyou said, We don't really know
where the causes of anorexia is,how far are we in understanding
why why people develop anorexia.
Mette Bentz (09:16):
Not that far, actually. I'm afraid. You're
right, the fact that we knowthat genetics play a role. I
guess we didn't know that somedecades ago. But we also know
that the genetics are very, it'sa very complex, it's more of a
widespread pattern of changes inthe gene area rather than one
(09:37):
specific gene. And it may notnot even be a specific gene
pattern for anorexia but morefor vulnerability for a range of
different things. I know thatthere was working in those areas
or looking for the genetic,genetic aspects of it. For
instance, the hormones thatregulate our our moods in our
(09:59):
Anxiety and our that that isclosely connected to how we
regulate our appetite, appetiteas well. So there's something
more a little bit morenonspecific there. But also we
know it's not 100%. So we knowthere must be something else,
which might be suicidal,cultural, probably is, as we
(10:21):
mentioned before, and there alsomight be some influence some
environmental influences thatare more personal. Like, for
instance, having been anoverweight child, being bullied,
perhaps having difficultyfinding friends or finding your
place in, among your peers, thatkind of stressors in life, there
(10:41):
seem to be a little more ofthat. But then again, that a lot
of young people experience thatwithout getting anorexia. So I
think what we know the most isthat it's multifactorial, which
in a way means that it'scomplicated. And there's many
paths.
Morten Andersen (10:56):
And and even though we know that, let's say
50 60% is genetic, we haven'tfound the actual genes yet. It
hasn't either we can point to asingle gene or, you know, a
multiple of genes and say, ifyou have them, then you're very
likely. So it's still verynonspecific. I read that in the
US is estimated that 9% of allwomen will suffer from anorexia
during their lifetime. That's ahuge number. So are there more
(11:20):
people suffering from anorexiatoday than there has been in the
past?
Mette Bentz (11:24):
It is right. If you're looking at the Danish
numbers, the the number of youngpersons receiving an anorexia
diagnosis in child andadolescent mental health care in
Denmark have been growing, butso has the number of all other
kinds of diagnosis that you canget within child and adolescent
mental health care. And thenumbers for anorexia has not
(11:45):
been growing more than the restof them, actually, some
diagnosis have been explodingquite a lot more than the number
for anorexia. So maybe there'smore, or maybe there's more
illness, more generallyspeaking, or maybe the threshold
for getting help or getting adiagnosis have been lowered,
(12:07):
maybe there's less stigma, maybeadults around the young people
are more aware that they need toseek help. So all these factors
may account for the fact that wediagnosed more.
Morten Andersen (12:16):
Okay. And I guess one of the things that has
changed over the last Say, say10 years is the advent of social
media. And from my ownperspective, I would think that
that would have that would maketwo changes. One is obviously
that you are more exposed topeople from all over the world.
So when I grew up, I couldcompare myself to the people in
(12:39):
my class and the class nextdoor, but that was literally it.
Now I can compare myself with,you know, hundreds of 1000s of
people who most of them arephotoshopping themselves on
social media. So as I wasresearching for this, I found a
number of YouTube channels wherethey're actually girls who were
encouraging other girls tobehave in ways that would make
(13:01):
you lose weight a lot that wouldlead to anorexia. So people will
also giving each other advice onsocial media how to lose weight.
So I guess social media canreally make you know, people who
are vulnerable, easier to becomeill with anorexia,
Mette Bentz (13:19):
and social media, you can choose to follow only
those that are thinner thanyourself. And social media is
very adept in promotingunhealthy or unrealistic body
image ideas. You can furnishPhotoshop, everything Of course,
you can get a positive response,you can feel you're part of a
community that promotes how tobe anorexic or how to cheat your
(13:43):
parents or your therapist andall all these kind of tips and
tricks. You can find them onlineif you want to.
Morten Andersen (13:50):
I have a young daughter, she's using TikTok and
I was just looking at what it isthat and most of the girls that
she's following, at least arevery thin and very beautiful.
And I can understand why sittingin your bedroom, looking at
those you feel that you areinadequate, or you want to look
like that and you will dowhatever it takes, you know, you
(14:12):
can start on some innocentbehavior like exercising more or
you know, losing some weightbecause you want to look like
that person on TikTok, but thenit evolves into becoming a
mental illness. Is that right?
Mette Bentz (14:24):
Yes. And perhaps that makes it a bit difficult
for parents and friends toreally know when, when is it too
much? Because it's it's healthyto exercise but when exercises
controlling you when you arefeeling really bad with
yourself, if if you hurt yourleg and you couldn't go the one
go running, if you have to do itevery day, even if your grandma
(14:46):
has birthday, all those kinds ofsigns that this is taking over
your life and ruining otheraspects of your life. It's a
gradual process, difficult tosay when is it too much but The
fact that it's ruining yourhealth or your psychosocial
life, that's definitely anindicator that this is too much,
(15:07):
and it's out of your owncontrol.
Morten Andersen (15:09):
So anorexia is essentially a mental illness.
And some of the signs are thatyou have significant weight
loss, the weight loss can be somuch that a significant part of
your body may not function.
Well. You are preoccupied withfood, you think about food all
the time, and you compare yourown body to other people's body.
And you may not even have theright vision of image of how
(15:31):
your body is you feel you'refat, but you're actually quite
thin. But anorexia is verydangerous, because it is it has
a high mortality rate. And thatis because if you continue to
lose weight, you will actuallydie. Or you may die because you
have some other disorders aswell. Because as I understand
(15:51):
it, there are some commonbi-disorders as well. Can you
can you tell us what, whatpeople or girls often with
anorexia they also suffer from?
Mette Bentz (16:03):
Yes, well, actually, I think you will find
that almost all otherpsychiatric diagnosis have
elevated frequencies in apopulation that are suffering
from anorexia. But when you seeyoung persons that I do then
with that would be primarily Ithink, what we see most of the
anxiety disorders and autismspectrum conditions, but it
(16:27):
might be anything else. And inthe adult populations, for
instance, you'll see a highernumber of personality disorders.
Morten Andersen (16:34):
Okay, so it's not just anorexia that this
person is battling with, it'salso maybe anxiety or depression
or autistic spectrum disordersor any other personality
disorders. Interesting. Okay, sothat was a lot about what
anorexia is, I think the thereally interesting thing is also
how do we help people withanorexia? But first, let's have
(16:57):
a break.
So now we understand anorexiabetter. The question is, how do
we treat anorexia? I know thatyou're primarily work with
something called Family BasedTreatment? Can you tell us what
(17:18):
that is, and how a typicaltreatment course is.
Mette Bentz (17:21):
So a family based treatment is family therapy
format, where you engage thewhole family, and especially the
parents, to help the youngperson suffering from anorexia
to start doing what she feelsthe most, which is eating,
sufficient for waking. So it's,it follows techniques and
(17:42):
interventions from other formatsfor family therapy, but focus in
them specifically on goingagainst the symptoms of
anorexia. And specifically inthe beginning to start with
nutrition, nutrition. So it'sbuilt in three phases, such just
a way to have things in orderdoesn't have to be three. But in
(18:06):
the beginning, we focus on thesomatic, the physical security,
to the parents take overresponsibility for the child's
eating, and helps the child eatenough for restoring a healthy
body, then we go into phase twothat are more focused on
(18:27):
gradually handing overresponsibility for eating to the
young person, himself orherself, in an age appropriate
level, of course. So in phaseone, you may say that parents
take away some autonomy from theyoung person. And then in phase
two, they need to work withgiving it back to the young
(18:47):
person in a manner so that thatit's not giving back to
anorexia, but giving back to thehealthy part of the youngster.
And I think some of the thingsthat surprises people is that we
need to focus on eating andweight gain, firstly, because
it's so difficult, so why, whygo head on to the most the thing
that your child fears the most.
And also, many people willthink, well, it's not about food
(19:12):
and must be about somethingelse. So why not focus on
something else, and then maybeit becomes easier to eat? Yes.
And while it is probably right,that there might be something
else, then it doesn't make iteasier to eat. And the longer
time a young person isunderweight, the more self
maintaining it gets. So theprognosis will be better if we
(19:32):
can help parents help theirchild gain weight as fast as
possible.
Morten Andersen (19:39):
So if that person is also suffering from
anxiety, what do you essentiallysaying is in phase number one,
we'll focus on getting theweight up to normal because the
person cannot function properlybefore we get that. Now, I said
in the beginning that when we'redealing with people who have
anorexia, they don't want tochange they don't want to eat so
(20:00):
You're saying that well, theparents you have to make the
person eat? And on the otherhand, I suppose the girls don't
want to eat? How do you solvethat problem?
Mette Bentz (20:13):
Yes, well, first of all, I maybe I would like to
nuance a little bit. So thatwell, it's more than might be a
part of the illness, that youdon't really appreciate how
serious the disorder is, or youdoesn't really recognize the
rational arguments, becausethere's something else that have
taken over your your train ofthought. So it's part of the
(20:35):
illness is what we might callambivalence, that in a way, you
want to listen to your parentsand you want to live a normal
life and then another part ofyou are terribly feared that
that will imply that you will bethe fattest person ever, and
look like the Michelin Man orwhatever. So for some, it's
(20:56):
difficult to recognize that it'sactually a serious as it is, and
then again, for others, they doappreciate that this is
difficult, and this is out ofout of my control, but they are
so afraid to confront it, thatthey cannot muster the ability
to do it on their own. Sothere's many different nuances
to it, rather than just theydon't want to change, I think
(21:19):
part of them wants to change.
Morten Andersen (21:20):
So if you have a girl who have, you know, over,
I don't know how long beeneating, I don't know, 500
calories been lying to yourparents got into your her mind
that she is really fat. And theworst thing that can happen is
that she will eat. Now you'retelling her parents? Well, you
have to make sure that she eats,I don't know, three 4000
(21:42):
calories a day. And it's reallyimportant. If she does not then
she could end up dying. How doesthe parents do that? I mean, how
do you help them do that?
Mette Bentz (21:52):
When we are talking about children and young
persons, I think we benefit fromthe fact that they are under
age, and they are in their careof their their parents. That is,
of course a judicial issue. Butit's so much more than that.
It's also a psychological issuethat kids develop and grow in
their sense of self and how theyare in the world. getting
(22:14):
support from parents parents arethe attachment figure we might
we call it in psychology, theyare the ones that you look to
for comfort or guidance orsupport when things are
difficult. So in a way, webenefit from the pet, the fact
that most of these young kidscoming to treatment, have
(22:35):
attachment figures, that istypically mom and dad that deep
down, they have a feeling thatokay, they they look out for me
are they actually in they haveknown in the past what was right
and good for me, and they willcare for me. So even though they
will, they will say I don't wantto eat, we we kind of benefit
from the fact that they haveattachment figures that they can
(22:56):
rely on. And they have some kindof basic trust towards the
parents. So when parents in aconsistent, warm empathic way,
keep on insisting You have toeat this, I know you're afraid,
this is what you need, trust me,you have to eat, so on so forth,
then actually that creates astrong framework, a
(23:16):
psychological and socialframework that makes it likely
for the kid to let the voice ofmom and dad in a way speak
louder than the voice ofanorexia in her in her head. So
I know that it can feel likeyou're actually forcing your
child to eat, I think the termforce would fit better in what
we do with house in hospital.
But at home, it's not forcingit's creating a framework so
(23:39):
strong that it's very muchlikely that the kid will will
follow in and try to work withyou, at least some of the time.
And as they gradually gainweight, then their mind becomes
a little better. And they canbetter work with the rationality
of sites and see several sitesof things and all that.
Morten Andersen (24:00):
How important is it that the child understands
that he or she has a problemthat they recognize it as a
problem? How important is thatfor the treatment and success of
the treatment?
Mette Bentz (24:11):
for young people who have mums and dads to him to
engage in treatment, they dothis, it's not necessary. It's
more necessary that mom and dadknow that there is a dangerous
issue here threateningthreatening my child's health,
and he's not able to deal withit on her own. A bit like if she
was starting using drugs tomanage stresses in school, I
(24:34):
think most parents also wouldinterfere and say, Well, I
sympathize with how you feelschool is stressful. But this is
not how you're you're notallowed to solve it this way.
I've tried to help you anotherway. So I think it's in a way
it's in line with parentsintervening when a child has
endangering his or her life oror development.
Morten Andersen (24:56):
It reminds me a little bit of when you make an
intervention for somebody who isan adult alcoholic, to maybe go
into rehab. And what you oftendo is you make an intervention
in that person's house. So yougather friends and family to
call them and say, I think youhave a problem I think you
should go to, to rehab. And hereit's also attachment figures in
a sense, where you trust thatperson, and you may not have a
(25:18):
personal insight that that isactually I am at that level of
addiction. But if those peopletell me that I have a problem, I
will do it because I trust them.
I guess it has the samedynamics.
Mette Bentz (25:31):
I think you're absolutely right. And it often
struck me and touches me thehow, in the very first family
session, often it seems new tothe young person to actually
hear this joint narrative of thewhole family on how this has
been coming into the family lifeand his affecting has been
affecting everybody in thefamily and actually being, you
(25:52):
know, forced in a way to hearhow mom and dad and siblings are
actually very worried for them.
It's kind of an eye opener thatreally touches them, which is a
very touching moment to witnessactually.
Morten Andersen (26:04):
Yes. So if we think about how can you help a
person who do who do not want tochange how you can help a person
change? Well, one of the firstthings you can actually do is
you can, if you are anattachment figure, a good friend
or somebody who that persontrust, you can actually have an
honest conversation with thatperson about this is where I see
you are at and that may spurthat person into may not have a
(26:30):
full awareness of one's ownsituation, but at least have a
trust in I need to do something,as I understand it, you're
working on a research projectwhere you're looking at the
effectiveness of family basedtreatment, can you tell us a
little bit about what what thefindings are or what we know
about the effectiveness offamily based treatment,
Mette Bentz (26:47):
we investigated how the family based treatment work
or what outcomes it produces,when you use it in a government
funded service, as we have inDenmark, compared to the the
research settings abroad, wherethe randomized control studies
are made, it compares very well.
And within 12 months, 57% ofyoung persons with anorexia
(27:09):
nervosa will have fulfilledtreatment, going through all the
phases and does not need anymore treatment for the eating
disorder. That may not be sothat every single one of them
are totally out of every symptomfor eating disorders. So that's
one of the other findings thatmany more of those than the 57%
(27:31):
are actually weight restored,which is not well, it's not no
surprise, because parents arereally, really effective in this
department. But some will beweight recovered, but still have
some thoughts and feelingsaround food that are difficult
and maybe require extra supportfrom parents for a longer time
period. And I think, actually,that's one of the benefits of
(27:55):
having the family involved,involved, that they can actually
continue the support aftertreatment has ended here, yet,
but the main finding is that wewe help a good proportion of
young persons, then the nextpart of the study is what we
actually made it for it was toto say okay, so this proportion
(28:16):
that does not gain benefit willfrom family based treatment. Who
are they? What characterizesthem? How can we identify them?
And how early in treatment?
might we be able to identifythem? Because that would be the
starting point of well,improving treatment?
Morten Andersen (28:35):
Yes? And what are some of the things that we
can say, must be in place? Solet's say that you have a father
and mother and an a sibling, andthe father is working a lot and
therefore not really present? Soit's really on the mother to do
it? Is will that still beworking? Or does it need to be
the whole family workingtogether on this? Does it matter
(28:57):
if the family is is a divorcedfamily? There's socio economic
reasons. I mean, is thereanything we know that is better
for a recovery in a family basedtherapy,
Mette Bentz (29:08):
we do know that when parents are aligned, it
works better. It doesn't have tobe that they both do equally in
the same or take charge of theequal numbers of meals. But they
can be aligned in many differentways. As long as they are
creating, in a way a joint frontthat the kid and anorexia knows
(29:31):
that there's no way I can dividethem and have that feel sorry
for me because mom wants me toeat this and all that. So as
long as parents are aligned,then there are many different
ways that they can share, sharethe work between them, but it's
it's really stressful to do soif the dad works a lot and mom
(29:52):
is doing it all alone. I wouldstill talk with this, this
couple of parents that theymight want to rearrange that for
me. Get rid of time because it'sit's very stressful and mom will
need some, some timeouts. Andshe needs to be relieved. Okay,
so parents aligned, that'simportant. Yes. And also that
parents are willing to enableto, you know, stand forward as
(30:17):
authority figure for the childand say, right now, this point
of time in your life, I knowbetter, huh? My theory, I may
not be right. But I have afeeling that for Danish parents
that is particularly difficult,or maybe for North European
parents, because we valueindependence and autonomy very
(30:38):
much. And parents really feelthat they are being a tyrant, if
they say you have to do this, oryou cannot do that.
Morten Andersen (30:45):
Yes. So I can see if you have a 17 year old or
18 year old daughter who's who'salmost about to move out of the
house and you have spent someyears trying to encourage her to
be independent and makedecisions herself and you've
stepped back from from manydecisions. Now you have to go in
(31:06):
and really take charge and say,I control a large portion of
your decisions around food, butalso what you do in terms of
activities in your spare time,everything exercise you're not
allowed to exercise have for awhile, and things like that,
that that will be a completereversal of how they have had a
relationship for the last 567years.
Mette Bentz (31:27):
Yes, and it gets more and more difficult the
older the child gets. And we cansee that in effectiveness
studies actually, that theyounger the patient is when we
start a family based treatment,the better is the outcome. But
still, this stands from parentswho need to be able to do that.
And I think actually, that alsorequires that parents can do
(31:48):
this shift of thinking that thisis care. It's not only control,
it's not primarily control, it'sprimarily taking care and taking
adult responsibility. So if youcannot make that transition,
then you will feel that like theworst parent in the world. And
you would feel that my childwill never speak to me again.
(32:08):
And she will never love meanymore. And all the worst
things that we fear as parents,yes. Okay, so there's a few
things I need to also say. So wealso know that blaming and, you
know, reproaching, saying, seewhat you're doing to the family,
see how difficult you're doing,you're making me feel putting
(32:29):
blame on the person withanorexia, it's understandable,
and very much so but it doesn'thelp it more works against
treatment. So it's veryimportant to separate the young
person from the illness, so thatthe young person can, you know,
feel the empathy for herstruggling, while parents are
(32:50):
still taking a stance towardsanorexia, I think those are the
main factors ingredients thatneeds to be in place for
family-based treatment to work,
Morten Andersen (33:01):
okay, so, parents needs to be aligned,
they must be willing to takeownership, so to speak of the
cure of their teenage daughter,and then trying not to blame. So
and I guess in order not toblame, you have to see this as
almost as an illness taken overa child. So it is not separate
(33:22):
the the child from the illness,so to speak. So it is the
illness that you do not like andnot the child.
Mette Bentz (33:29):
Exactly, that's very important that you need to
continue saying that to yourselfuntil the child again and again.
Morten Andersen (33:36):
Okay, so and and the reason why family-based
treatment works so well is thatit is it is going on in her
environment, so to speak. Forinstance, if we look at the
success of of getting people offdrugs, so people go into rehab.
Now one of the things that isdifficult for that person is
that going back into the sameenvironment, will actually make
(33:58):
it more likely that that persongoes back into the addiction
because you've not changedanything about the environment.
Now, this is actually thereverse here, you keeping the
person in the environment wherein her room where she was
learning the tricks of losingweight without parents knowing
it and so on. That almost seemscounterintuitive. Why Why does
(34:19):
that work so well here?
Mette Bentz (34:20):
Well, I think actually, it may be so well so
effective, because you actuallylearn new habits and new skills
in overcoming somethingdifficult in your, your everyday
home and with your closestothers. Because before family
based treatment, the primary thetreatment to go to was to put
(34:41):
kids into hospital for a longduration of time away from
families. And it was evencustomary to say that parents
you would be disturbingtreatment so you're allowed to
one short visit a week and oneletter a week or something like
that. So we actually did theopposite in the older days. And
while that can also be effectivein gaining weight, then we have
(35:06):
exactly the same problem, as youmentioned with addictions that
when you go back home, it's verydifficult to generalize what you
have experienced in hospital anduse it back home. And especially
when you're doing it as a youngperson on your own, and your
parents have not been part ofthat journey. So I think that
the fact that your parents ispart of the journey, and you are
exposed to new eating habits inyour own home, and you can much
(35:29):
sooner return to seeing friendsand going to school and having
the joys of everyday life thatactually should motivate you to
get out of anorexia, you caneasily get in contact with that.
Morten Andersen (35:42):
That's really, really interesting, what you're
saying there that what actuallyworks is that you teach a person
new habits in their oldenvironment, and therefore, that
will actually sustain it more.
So you're breaking old habitsand inserting new habits, so to
speak, in the same environment,and that is why it is effective.
That's really interesting.
(36:12):
Great, well, so far, we'vetalked about anorexia and the
treatment of anorexia. And I'dlike to see what we can learn
from the treatment of anorexiaand how we can apply it to other
changes. And I actually thinkthat you have said a number of
things which are, which arereally interesting, the last
thing we just talked about,which is that keeping people in
their environment where theydevelop the addiction, so to
(36:34):
speak. I don't think anorexia isan addiction, but but it
actually not quite. But but butyou keep it in that environment.
And then you teach them newhabits, that's a really
interesting thing. Have we seenthat work in in addiction as
well,
Mette Bentz (36:52):
in addiction, I actually don't know much about
treatment of addiction. When youtreat kids with anxiety
disorders, we know that it'svery important that exposure,
the gradual exposure andresponse prevention can be done
in a way that can be transferredto your everyday life and
preferably actually be done athome as well. So often you teach
(37:12):
parents the skills also ofexposure and response
prevention, when you're insidein kids. So I think it probably
covers a lot of other areas aswell, I guess, but I wouldn't be
sure.
Morten Andersen (37:26):
Now, in a previous episode, I spoke with a
Judy Grisel and Judy Griselwas, well, it's a fantastic
story. So she started off as aas a as an addict, and then
became a drug addict, and thenwas a homeless person and lived
on the streets. And then shemade a change. And she became
she went back to universitybecame a professor neuroscience
(37:48):
and wanted to figure out, whatis it in our brains that make us
prone to addiction? And duringthe interview, I asked her, so
how could you go from beingaddicted to drug to go to
university? What was what wasthe trigger there? And she
actually said that what wasimportant for her was that she
was replacing her addiction witha new, healthy goal. So she
(38:13):
wanted to find out, why is itthat we became become addicted,
and she went for that, I justwonder whether you've seen that
work in your practice as well,where you have girls who have
been obsessed with their bodyand obsessed with looking maybe
like a particular person orobsessed with reaching a
particular goal, whetherreplacing that goal and having a
(38:39):
focus on that, which is a morehealthy goal, whether that will
help in in a situation likethat.
Mette Bentz (38:45):
It doesn't specifically ring a bell, I
think, because actually, what Ithink more often is that it
seems effective when the youngpersons are able to kind of
broaden out a little bit not sofocused on one simple thing, but
be a little bit more toleranttowards how things can be not so
(39:09):
simple and more nuanced and notblack and white. So to let go of
the need, that everythingshouldn't be actually securely
predictably unequivocably inorder for you to feel
comfortable to actually be ableto feel comfortable even though
you even though you don't knowexactly what you're going to do
(39:31):
the whole day or what you'regoing to eat or who you're going
to meet. You know, to be moretolerable towards the general
unpredictability of life thatseems very helpful. But mostly,
I think for most youngteenagers, the fact that they
actually have the experiencethat anorexia took away from
them for a while, the connectionwith peers and going to school
(39:53):
and meeting up with friends. Soactually getting back to that
creates a strong motor which isvery very wonderful to see that,
okay, they actually want theirlife more than they want
direction now,
Morten Andersen (40:06):
letting go of control, so to speak, and also
not seeing things black andwhite is actually something that
will help people get get rid ofanorexia. I think the last thing
you've also mentioned a numberof times is having support from
people around you that you trusta lot. Now, obviously, many
(40:27):
teenagers, even though there areconflicts between parents and
them, they still trust theirparents to do the right thing
for them. I guess, some may nothave family close by, but or
could be in a situation wherethey are not there to support
you. But having people who dolove you a will, that you trust
(40:48):
will do the best for you. Havingthem to support you is actually
a major benefit for making achange is,
Mette Bentz (40:56):
I think it's the most powerful ingredient in
life, to have support because Imean, all of us meet challenges
that we cannot cope with alone.
So the experience that you giveyour child, if you help your
child through anorexia or anyother disease, the experience
that you can get help fromothers. And you don't have to
cope with everything alone. Ithink that's such an important
(41:17):
lesson. And maybe actually,another lesson I think the
parents have so powerfullyhelped their child learn is that
you need to be able to separatesubjective and objective reality
that your feelings is not alwaysthe same as reality, and that
you can feel fat without beingso just like you can feel alone
(41:37):
while people are still reachingout for you. So the ability to
separate what you feel in thehere and now in what is in
reality, it's a it's animportant important lesson that
I see parents again and again,teach their child while they are
helping them to eat.
Morten Andersen (41:56):
Fantastic. I must admit that researching for
this, I was surprised about howmany people suffer from
anorexia, I was very surprisedabout how lethal it is house,
how serious it really is. Butalso reading through the
treatment of it. I was surprisedabout how difficult it is to
treat. And I think it'stherefore an excellent case to
(42:21):
think about how do you helppeople who do not want help,
because it is very important,they do get help. And it's
really hard to actually treat.
But I think your lessons aboutsome of the things that you've
mentioned about what actuallyworks. So using people, family
who can help, because peopletrust the girls trust them that
actually is really importantthat you do it in their own
(42:43):
environment and change importantmindset and behaviors and habits
in their own environmentactually is really good. And
then what you said about makingsure that we should get away
from the black andwhite-thinking and have a more
sort of nuanced thinking and notmaking not confusing objective
reality with subjective realityalso is really important. Thanks
(43:04):
a lot. I think we learned a lotabout change and a lot about how
to help people, especially withwith anorexia, I want to say
thank you, to you, Mette, for afantastic interview. I really
appreciate your time.
Mette Bentz (43:17):
Thank you for putting into awareness this very
important topic was a pleasure.
Morten Andersen (43:22):
Thanks a lot.
What a great interview withMette. I took three things away
from the conversation. One, wecan help people change even if
they really don't want tochange. People with anorexia are
suffering from significantweight loss. And if they are not
(43:46):
helped, they will continue tolose weight until they can no
longer function. It is a seriousmental illness. But it is
possible to help them even ifthey at first do not want to be
changed. If they do notrecognize that they have a
problem. Even if they shout outloud that they will rather die
than eat. Two (44:06):
We can learn three things from family based
treatment and apply to otherchanges. We can learn that
having support from people wholoves you, and who you trust.
That helps a lot. In the case ofmany people with anorexia, this
is the parents but it's actuallytrue for all. We can also learn
(44:29):
that teaching new habits in theexisting environment helps a
lot. treating the person in ahospital and then to be sent
home afterwards does not givethe same outcome. better treat
the same environment that themental illness or addiction or
bad habit occurred. And finally,let go of the black and white
(44:50):
thinking and separate objectiveand subjective reality. Feelings
are not reality. That also helpsPoint number three, we do not
need to know why somethinghappens to change it. We know
very little about the causes ofanorexia, the exact role of
genetics, the exact role of theenvironment and which factors
(45:14):
are important. But we do know alot about how to help the
individual. And maybe there is alesson there. We don't have to
know everything about whysomething happens in order to
change it. anorexia is a lethalmental illness and Mary's work
is important. How can we treatyoung girls who are losing
(45:34):
weight to the point of killingthemselves who really don't want
to change? So thanks a lot forthat work Mette. Until next
time, take care
Hello, and welcome to What Monkeys Do. My
name is Morten Kamp Andersen.
And this is a podcast about whatit takes to make a change and
make it stick.
This podcast is about change.
And the changes we've talkedabout so far have been changes
that we have decided ourselvesthat we've taken upon ourselves
(00:29):
to do or are okay with. Butthere are also changes that we
go through which we have notchosen ourselves, a messy
divorce may not be our choice,our partner simply left us or at
work, the company isrestructuring and your job role
changes, and you don't like it,but you have to embrace it.
Those are changes that you havehave to go through, but you may
(00:52):
not want to. And then we have acompletely separate category.
This is where people are doingsomething towards themselves,
which ultimately may cost themtheir lives. And the people
standing next to them have nochoice but to force them to
change. Now this could be anaddiction, like alcohol or
(01:13):
drugs, or how they eat. Anorexiais in that category. It is a
really serious mental illness.
In fact, it has the highestmortality rate of any mental
disorder. Without treatment, upto 20% of people with serious
(01:33):
eating disorders die. But peoplewith anorexia don't want to
change. They don't want help.
They don't want to eat. So howdo you change the behavior of a
person who really do not wantany help? Well, let's find out
in this episode of What MonkeysDo. My guest today is a
psychologist and PhD. She worksin the child and adolescent
(01:56):
mental health center in thecapital region of Denmark. She
is a specialist in the treatmentof anorexia. Welcome to you,
Mette Bentz.
Mette Bentz (02:08):
Thank you very much more than I'm glad to be here.
Morten Andersen (02:11):
Yeah, I'm really looking forward to this.
So in this episode, we'll talkabout how to recover from
anorexia nervosa or justanorexia for short, how to help
a person who do not want help.
But before we begin, can youtell us a little bit about you
and how you came to work withanorexia?
Mette Bentz (02:29):
Yes, I certainly can. Well, actually, I started
out as a nurse, a registerednurse that figured out I wanted
to work more specifically inthis psychological and
psychiatric era. So I went backto university and studied some
work. Before going into thefield of eating disorders, I
(02:49):
work in other areas withchildren and adolescents with
different kinds of challenges.
And I got interested in howimportant it was to work with
the important people around theyoung person. And I actually
developed quite, almost for howimportant those people are. And
maybe they can do more for theyoung person, I choose what I
(03:10):
can say or do as a psychologist.
So I really got interested intoworking with those around the
one but the challenge, then Iwanted to gain some experience
in psychiatry, and I actuallywasn't focused on eating
disorders at all. But well, Iwas lucky to get a position in
the the section for eatingdisorders. And here I am still
(03:34):
after 14 years.
Morten Andersen (03:36):
Wow. So let's try to start off with trying to
understand anorexia better, Iguess it can be sometimes
difficult to know if somebodyhas anorexia standing next to
them. So what are some of thesymptoms to look for, in another
person, if that person hasanorexia, not
Mette Bentz (03:52):
The main symptoms and those that constitute the
diagnosis. First of all,foremost that you avoid eating
sufficient amount of food, youhave a restrictive eating
pattern, we sometimes call it sosimply avoiding food that can
maintain or make your body gainweight, then, of course, that
(04:15):
will entail a significant weightloss. So the significant weight
loss is also part of the thediagnosis, the part that
actually makes it so serious.
And then there is also a morepsychological aspect pertaining
to this. The disturbed bodyimage or the disturbed
experience of your own body, thefact that you can feel fat while
(04:38):
you're in my ciated, or the factthat you can compare yourself to
everybody in the classroom anddraw the conclusion that you're
the biggest person there eventhough it's not a physical
reality, all these aspects of adisturbed body image. So those
are the main categories thenalso, of course, the
malnutrition will impact Thebody's way of functioning, which
(05:00):
specifically the hormonalsystem. So worth the rest, or
puberty development will perhapsgo into a pause, girls will lose
their menstruation if theystarted menstruation. So those
are signs that the body isshutting down because there's
not sufficient nutrition. Andthen, of course, there's a lot
(05:20):
of other symptoms following thefact that you need nutrition
that are more nonspecific, likeyou lose your temper easily, you
get sad or anxious that you usenot to be and you get pale and
tired and you feel cold all thetime have no energy, you don't
remember what teachers said inschool and all those nonspecific
symptoms that simply follows thefact that you're not getting
(05:44):
enough nutrition.
Morten Andersen (05:48):
And I guess many people have tried to go on
a diet. So try to restricteating, I guess, many people
look at other people and feelfatter than they actually are, I
guess there must be a line whenwe call it normal focus on
weight. And where we say this isactually an issue, is there a
BMI index level? Or is therecertain body functions that
(06:11):
stopped to work? Or what? Whenis it anorexia, and when is it
just being too focused on ourown weight?
Mette Bentz (06:18):
That depends a little bit actually. But in the
ICD 10 diagnosis system that wework with in Denmark, it states
that if you lost 15% of yourexpected body weight, so let's
kind of BMI limit. But probablythat will soften up in the
upcoming revision, because youcan have lost 12% of your body
(06:41):
weight and be severely ill. Sowe'll go with significant weight
loss with some kind of impact onthe bodily functions. Yeah.
Morten Andersen (06:49):
Okay. So losing a lot of weight, till a level
where I'd actually may even hurtyou having a distorted body
image. And I also know that, orI've researched that many girls,
they will try to get a certainweight level, but then they will
level that down and level thatdown all the way. So they can't
(07:10):
actually even stop themselvesand saying, so when I get to
this amount of kilos, then I'llbe satisfied. It's actually a
virtuous negative circle, isthat correct?
Mette Bentz (07:19):
That is very much growing. And maybe that's part
of what makes it so difficultthat you can start with a quiet
down, simple weight loss that'snot dangerous in anyways, it's
very innocent in a way, but thenit triggers something that
starts a maintaining cycle thatdrove me further and further
(07:40):
down in it, and makes itimpossible for you with your own
wills power to, so to speak,lift yourself up with your
bootstraps and get out of itagain.
Morten Andersen (07:49):
I said girls, but as I understand it, most
people who are suffering fromanorexia I actually women, I
think it's something like 90%women and 10% men. I don't know
if that's correct. But why is itmostly women?
Mette Bentz (08:02):
I don't know.
Really, because since we don'tquite know the reasons or the
what causes and reaction. It'salso difficult to say, why does
it cause it more in girls? Weknow that genetic and biological
factors play a role incausation. And therefore it's,
it's reasonable to think thatthere's something in girls, the
genetic makeup of girls thatmakes them more vulnerable,
(08:24):
then, of course, also, it'sthere have been a lot of
theories put forward regardingour cultural influence, where
the values of self control andthe bear values of good
appearances, that we tend to sethigher standards in those values
regarding girls than boys. Ithink that's in a way it's
changing in these years. Somaybe we will get to see more
(08:48):
increasing number of boys in thefuture? No,
Morten Andersen (08:53):
I think I read that up to 50 to 80% of the
causes seem to be genetic. Sothere's been twin studies where
basically, we've been trying tofigure out how much of this is
genetic and how much is not. Butyou said, We don't really know
where the causes of anorexia is,how far are we in understanding
why why people develop anorexia.
Mette Bentz (09:16):
Not that far, actually. I'm afraid. You're
right, the fact that we knowthat genetics play a role. I
guess we didn't know that somedecades ago. But we also know
that the genetics are very, it'sa very complex, it's more of a
widespread pattern of changes inthe gene area rather than one
(09:37):
specific gene. And it may notnot even be a specific gene
pattern for anorexia but morefor vulnerability for a range of
different things. I know thatthere was working in those areas
or looking for the genetic,genetic aspects of it. For
instance, the hormones thatregulate our our moods in our
(09:59):
Anxiety and our that that isclosely connected to how we
regulate our appetite, appetiteas well. So there's something
more a little bit morenonspecific there. But also we
know it's not 100%. So we knowthere must be something else,
which might be suicidal,cultural, probably is, as we
(10:21):
mentioned before, and there alsomight be some influence some
environmental influences thatare more personal. Like, for
instance, having been anoverweight child, being bullied,
perhaps having difficultyfinding friends or finding your
place in, among your peers, thatkind of stressors in life, there
(10:41):
seem to be a little more ofthat. But then again, that a lot
of young people experience thatwithout getting anorexia. So I
think what we know the most isthat it's multifactorial, which
in a way means that it'scomplicated. And there's many
paths.
Morten Andersen (10:56):
And and even though we know that, let's say
50 60% is genetic, we haven'tfound the actual genes yet. It
hasn't either we can point to asingle gene or, you know, a
multiple of genes and say, ifyou have them, then you're very
likely. So it's still verynonspecific. I read that in the
US is estimated that 9% of allwomen will suffer from anorexia
during their lifetime. That's ahuge number. So are there more
(11:20):
people suffering from anorexiatoday than there has been in the
past?
Mette Bentz (11:24):
It is right. If you're looking at the Danish
numbers, the the number of youngpersons receiving an anorexia
diagnosis in child andadolescent mental health care in
Denmark have been growing, butso has the number of all other
kinds of diagnosis that you canget within child and adolescent
mental health care. And thenumbers for anorexia has not
(11:45):
been growing more than the restof them, actually, some
diagnosis have been explodingquite a lot more than the number
for anorexia. So maybe there'smore, or maybe there's more
illness, more generallyspeaking, or maybe the threshold
for getting help or getting adiagnosis have been lowered,
(12:07):
maybe there's less stigma, maybeadults around the young people
are more aware that they need toseek help. So all these factors
may account for the fact that wediagnosed more.
Morten Andersen (12:16):
Okay. And I guess one of the things that has
changed over the last Say, say10 years is the advent of social
media. And from my ownperspective, I would think that
that would have that would maketwo changes. One is obviously
that you are more exposed topeople from all over the world.
So when I grew up, I couldcompare myself to the people in
(12:39):
my class and the class nextdoor, but that was literally it.
Now I can compare myself with,you know, hundreds of 1000s of
people who most of them arephotoshopping themselves on
social media. So as I wasresearching for this, I found a
number of YouTube channels wherethey're actually girls who were
encouraging other girls tobehave in ways that would make
(13:01):
you lose weight a lot that wouldlead to anorexia. So people will
also giving each other advice onsocial media how to lose weight.
So I guess social media canreally make you know, people who
are vulnerable, easier to becomeill with anorexia,
Mette Bentz (13:19):
and social media, you can choose to follow only
those that are thinner thanyourself. And social media is
very adept in promotingunhealthy or unrealistic body
image ideas. You can furnishPhotoshop, everything Of course,
you can get a positive response,you can feel you're part of a
community that promotes how tobe anorexic or how to cheat your
(13:43):
parents or your therapist andall all these kind of tips and
tricks. You can find them onlineif you want to.
Morten Andersen (13:50):
I have a young daughter, she's using TikTok and
I was just looking at what it isthat and most of the girls that
she's following, at least arevery thin and very beautiful.
And I can understand why sittingin your bedroom, looking at
those you feel that you areinadequate, or you want to look
like that and you will dowhatever it takes, you know, you
(14:12):
can start on some innocentbehavior like exercising more or
you know, losing some weightbecause you want to look like
that person on TikTok, but thenit evolves into becoming a
mental illness. Is that right?
Mette Bentz (14:24):
Yes. And perhaps that makes it a bit difficult
for parents and friends toreally know when, when is it too
much? Because it's it's healthyto exercise but when exercises
controlling you when you arefeeling really bad with
yourself, if if you hurt yourleg and you couldn't go the one
go running, if you have to do itevery day, even if your grandma
(14:46):
has birthday, all those kinds ofsigns that this is taking over
your life and ruining otheraspects of your life. It's a
gradual process, difficult tosay when is it too much but The
fact that it's ruining yourhealth or your psychosocial
life, that's definitely anindicator that this is too much,
(15:07):
and it's out of your owncontrol.
Morten Andersen (15:09):
So anorexia is essentially a mental illness.
And some of the signs are thatyou have significant weight
loss, the weight loss can be somuch that a significant part of
your body may not function.
Well. You are preoccupied withfood, you think about food all
the time, and you compare yourown body to other people's body.
And you may not even have theright vision of image of how
(15:31):
your body is you feel you'refat, but you're actually quite
thin. But anorexia is verydangerous, because it is it has
a high mortality rate. And thatis because if you continue to
lose weight, you will actuallydie. Or you may die because you
have some other disorders aswell. Because as I understand
(15:51):
it, there are some commonbi-disorders as well. Can you
can you tell us what, whatpeople or girls often with
anorexia they also suffer from?
Mette Bentz (16:03):
Yes, well, actually, I think you will find
that almost all otherpsychiatric diagnosis have
elevated frequencies in apopulation that are suffering
from anorexia. But when you seeyoung persons that I do then
with that would be primarily Ithink, what we see most of the
anxiety disorders and autismspectrum conditions, but it
(16:27):
might be anything else. And inthe adult populations, for
instance, you'll see a highernumber of personality disorders.
Morten Andersen (16:34):
Okay, so it's not just anorexia that this
person is battling with, it'salso maybe anxiety or depression
or autistic spectrum disordersor any other personality
disorders. Interesting. Okay, sothat was a lot about what
anorexia is, I think the thereally interesting thing is also
how do we help people withanorexia? But first, let's have
(16:57):
a break.
So now we understand anorexiabetter. The question is, how do
we treat anorexia? I know thatyou're primarily work with
something called Family BasedTreatment? Can you tell us what
(17:18):
that is, and how a typicaltreatment course is.
Mette Bentz (17:21):
So a family based treatment is family therapy
format, where you engage thewhole family, and especially the
parents, to help the youngperson suffering from anorexia
to start doing what she feelsthe most, which is eating,
sufficient for waking. So it's,it follows techniques and
(17:42):
interventions from other formatsfor family therapy, but focus in
them specifically on goingagainst the symptoms of
anorexia. And specifically inthe beginning to start with
nutrition, nutrition. So it'sbuilt in three phases, such just
a way to have things in orderdoesn't have to be three. But in
(18:06):
the beginning, we focus on thesomatic, the physical security,
to the parents take overresponsibility for the child's
eating, and helps the child eatenough for restoring a healthy
body, then we go into phase twothat are more focused on
(18:27):
gradually handing overresponsibility for eating to the
young person, himself orherself, in an age appropriate
level, of course. So in phaseone, you may say that parents
take away some autonomy from theyoung person. And then in phase
two, they need to work withgiving it back to the young
(18:47):
person in a manner so that thatit's not giving back to
anorexia, but giving back to thehealthy part of the youngster.
And I think some of the thingsthat surprises people is that we
need to focus on eating andweight gain, firstly, because
it's so difficult, so why, whygo head on to the most the thing
that your child fears the most.
And also, many people willthink, well, it's not about food
(19:12):
and must be about somethingelse. So why not focus on
something else, and then maybeit becomes easier to eat? Yes.
And while it is probably right,that there might be something
else, then it doesn't make iteasier to eat. And the longer
time a young person isunderweight, the more self
maintaining it gets. So theprognosis will be better if we
(19:32):
can help parents help theirchild gain weight as fast as
possible.
Morten Andersen (19:39):
So if that person is also suffering from
anxiety, what do you essentiallysaying is in phase number one,
we'll focus on getting theweight up to normal because the
person cannot function properlybefore we get that. Now, I said
in the beginning that when we'redealing with people who have
anorexia, they don't want tochange they don't want to eat so
(20:00):
You're saying that well, theparents you have to make the
person eat? And on the otherhand, I suppose the girls don't
want to eat? How do you solvethat problem?
Mette Bentz (20:13):
Yes, well, first of all, I maybe I would like to
nuance a little bit. So thatwell, it's more than might be a
part of the illness, that youdon't really appreciate how
serious the disorder is, or youdoesn't really recognize the
rational arguments, becausethere's something else that have
taken over your your train ofthought. So it's part of the
(20:35):
illness is what we might callambivalence, that in a way, you
want to listen to your parentsand you want to live a normal
life and then another part ofyou are terribly feared that
that will imply that you will bethe fattest person ever, and
look like the Michelin Man orwhatever. So for some, it's
(20:56):
difficult to recognize that it'sactually a serious as it is, and
then again, for others, they doappreciate that this is
difficult, and this is out ofout of my control, but they are
so afraid to confront it, thatthey cannot muster the ability
to do it on their own. Sothere's many different nuances
to it, rather than just theydon't want to change, I think
(21:19):
part of them wants to change.
Morten Andersen (21:20):
So if you have a girl who have, you know, over,
I don't know how long beeneating, I don't know, 500
calories been lying to yourparents got into your her mind
that she is really fat. And theworst thing that can happen is
that she will eat. Now you'retelling her parents? Well, you
have to make sure that she eats,I don't know, three 4000
(21:42):
calories a day. And it's reallyimportant. If she does not then
she could end up dying. How doesthe parents do that? I mean, how
do you help them do that?
Mette Bentz (21:52):
When we are talking about children and young
persons, I think we benefit fromthe fact that they are under
age, and they are in their careof their their parents. That is,
of course a judicial issue. Butit's so much more than that.
It's also a psychological issuethat kids develop and grow in
their sense of self and how theyare in the world. getting
(22:14):
support from parents parents arethe attachment figure we might
we call it in psychology, theyare the ones that you look to
for comfort or guidance orsupport when things are
difficult. So in a way, webenefit from the pet, the fact
that most of these young kidscoming to treatment, have
(22:35):
attachment figures, that istypically mom and dad that deep
down, they have a feeling thatokay, they they look out for me
are they actually in they haveknown in the past what was right
and good for me, and they willcare for me. So even though they
will, they will say I don't wantto eat, we we kind of benefit
from the fact that they haveattachment figures that they can
(22:56):
rely on. And they have some kindof basic trust towards the
parents. So when parents in aconsistent, warm empathic way,
keep on insisting You have toeat this, I know you're afraid,
this is what you need, trust me,you have to eat, so on so forth,
then actually that creates astrong framework, a
(23:16):
psychological and socialframework that makes it likely
for the kid to let the voice ofmom and dad in a way speak
louder than the voice ofanorexia in her in her head. So
I know that it can feel likeyou're actually forcing your
child to eat, I think the termforce would fit better in what
we do with house in hospital.
But at home, it's not forcingit's creating a framework so
(23:39):
strong that it's very muchlikely that the kid will will
follow in and try to work withyou, at least some of the time.
And as they gradually gainweight, then their mind becomes
a little better. And they canbetter work with the rationality
of sites and see several sitesof things and all that.
Morten Andersen (24:00):
How important is it that the child understands
that he or she has a problemthat they recognize it as a
problem? How important is thatfor the treatment and success of
the treatment?
Mette Bentz (24:11):
for young people who have mums and dads to him to
engage in treatment, they dothis, it's not necessary. It's
more necessary that mom and dadknow that there is a dangerous
issue here threateningthreatening my child's health,
and he's not able to deal withit on her own. A bit like if she
was starting using drugs tomanage stresses in school, I
(24:34):
think most parents also wouldinterfere and say, Well, I
sympathize with how you feelschool is stressful. But this is
not how you're you're notallowed to solve it this way.
I've tried to help you anotherway. So I think it's in a way
it's in line with parentsintervening when a child has
endangering his or her life oror development.
Morten Andersen (24:56):
It reminds me a little bit of when you make an
intervention for somebody who isan adult alcoholic, to maybe go
into rehab. And what you oftendo is you make an intervention
in that person's house. So yougather friends and family to
call them and say, I think youhave a problem I think you
should go to, to rehab. And hereit's also attachment figures in
a sense, where you trust thatperson, and you may not have a
(25:18):
personal insight that that isactually I am at that level of
addiction. But if those peopletell me that I have a problem, I
will do it because I trust them.
I guess it has the samedynamics.
Mette Bentz (25:31):
I think you're absolutely right. And it often
struck me and touches me thehow, in the very first family
session, often it seems new tothe young person to actually
hear this joint narrative of thewhole family on how this has
been coming into the family lifeand his affecting has been
affecting everybody in thefamily and actually being, you
(25:52):
know, forced in a way to hearhow mom and dad and siblings are
actually very worried for them.
It's kind of an eye opener thatreally touches them, which is a
very touching moment to witnessactually.
Morten Andersen (26:04):
Yes. So if we think about how can you help a
person who do who do not want tochange how you can help a person
change? Well, one of the firstthings you can actually do is
you can, if you are anattachment figure, a good friend
or somebody who that persontrust, you can actually have an
honest conversation with thatperson about this is where I see
you are at and that may spurthat person into may not have a
(26:30):
full awareness of one's ownsituation, but at least have a
trust in I need to do something,as I understand it, you're
working on a research projectwhere you're looking at the
effectiveness of family basedtreatment, can you tell us a
little bit about what what thefindings are or what we know
about the effectiveness offamily based treatment,
Mette Bentz (26:47):
we investigated how the family based treatment work
or what outcomes it produces,when you use it in a government
funded service, as we have inDenmark, compared to the the
research settings abroad, wherethe randomized control studies
are made, it compares very well.
And within 12 months, 57% ofyoung persons with anorexia
(27:09):
nervosa will have fulfilledtreatment, going through all the
phases and does not need anymore treatment for the eating
disorder. That may not be sothat every single one of them
are totally out of every symptomfor eating disorders. So that's
one of the other findings thatmany more of those than the 57%
(27:31):
are actually weight restored,which is not well, it's not no
surprise, because parents arereally, really effective in this
department. But some will beweight recovered, but still have
some thoughts and feelingsaround food that are difficult
and maybe require extra supportfrom parents for a longer time
period. And I think, actually,that's one of the benefits of
(27:55):
having the family involved,involved, that they can actually
continue the support aftertreatment has ended here, yet,
but the main finding is that wewe help a good proportion of
young persons, then the nextpart of the study is what we
actually made it for it was toto say okay, so this proportion
(28:16):
that does not gain benefit willfrom family based treatment. Who
are they? What characterizesthem? How can we identify them?
And how early in treatment?
might we be able to identifythem? Because that would be the
starting point of well,improving treatment?
Morten Andersen (28:35):
Yes? And what are some of the things that we
can say, must be in place? Solet's say that you have a father
and mother and an a sibling, andthe father is working a lot and
therefore not really present? Soit's really on the mother to do
it? Is will that still beworking? Or does it need to be
the whole family workingtogether on this? Does it matter
(28:57):
if the family is is a divorcedfamily? There's socio economic
reasons. I mean, is thereanything we know that is better
for a recovery in a family basedtherapy,
Mette Bentz (29:08):
we do know that when parents are aligned, it
works better. It doesn't have tobe that they both do equally in
the same or take charge of theequal numbers of meals. But they
can be aligned in many differentways. As long as they are
creating, in a way a joint frontthat the kid and anorexia knows
(29:31):
that there's no way I can dividethem and have that feel sorry
for me because mom wants me toeat this and all that. So as
long as parents are aligned,then there are many different
ways that they can share, sharethe work between them, but it's
it's really stressful to do soif the dad works a lot and mom
(29:52):
is doing it all alone. I wouldstill talk with this, this
couple of parents that theymight want to rearrange that for
me. Get rid of time because it'sit's very stressful and mom will
need some, some timeouts. Andshe needs to be relieved. Okay,
so parents aligned, that'simportant. Yes. And also that
parents are willing to enableto, you know, stand forward as
(30:17):
authority figure for the childand say, right now, this point
of time in your life, I knowbetter, huh? My theory, I may
not be right. But I have afeeling that for Danish parents
that is particularly difficult,or maybe for North European
parents, because we valueindependence and autonomy very
(30:38):
much. And parents really feelthat they are being a tyrant, if
they say you have to do this, oryou cannot do that.
Morten Andersen (30:45):
Yes. So I can see if you have a 17 year old or
18 year old daughter who's who'salmost about to move out of the
house and you have spent someyears trying to encourage her to
be independent and makedecisions herself and you've
stepped back from from manydecisions. Now you have to go in
(31:06):
and really take charge and say,I control a large portion of
your decisions around food, butalso what you do in terms of
activities in your spare time,everything exercise you're not
allowed to exercise have for awhile, and things like that,
that that will be a completereversal of how they have had a
relationship for the last 567years.
Mette Bentz (31:27):
Yes, and it gets more and more difficult the
older the child gets. And we cansee that in effectiveness
studies actually, that theyounger the patient is when we
start a family based treatment,the better is the outcome. But
still, this stands from parentswho need to be able to do that.
And I think actually, that alsorequires that parents can do
(31:48):
this shift of thinking that thisis care. It's not only control,
it's not primarily control, it'sprimarily taking care and taking
adult responsibility. So if youcannot make that transition,
then you will feel that like theworst parent in the world. And
you would feel that my childwill never speak to me again.
(32:08):
And she will never love meanymore. And all the worst
things that we fear as parents,yes. Okay, so there's a few
things I need to also say. So wealso know that blaming and, you
know, reproaching, saying, seewhat you're doing to the family,
see how difficult you're doing,you're making me feel putting
(32:29):
blame on the person withanorexia, it's understandable,
and very much so but it doesn'thelp it more works against
treatment. So it's veryimportant to separate the young
person from the illness, so thatthe young person can, you know,
feel the empathy for herstruggling, while parents are
(32:50):
still taking a stance towardsanorexia, I think those are the
main factors ingredients thatneeds to be in place for
family-based treatment to work,
Morten Andersen (33:01):
okay, so, parents needs to be aligned,
they must be willing to takeownership, so to speak of the
cure of their teenage daughter,and then trying not to blame. So
and I guess in order not toblame, you have to see this as
almost as an illness taken overa child. So it is not separate
(33:22):
the the child from the illness,so to speak. So it is the
illness that you do not like andnot the child.
Mette Bentz (33:29):
Exactly, that's very important that you need to
continue saying that to yourselfuntil the child again and again.
Morten Andersen (33:36):
Okay, so and and the reason why family-based
treatment works so well is thatit is it is going on in her
environment, so to speak. Forinstance, if we look at the
success of of getting people offdrugs, so people go into rehab.
Now one of the things that isdifficult for that person is
that going back into the sameenvironment, will actually make
(33:58):
it more likely that that persongoes back into the addiction
because you've not changedanything about the environment.
Now, this is actually thereverse here, you keeping the
person in the environment wherein her room where she was
learning the tricks of losingweight without parents knowing
it and so on. That almost seemscounterintuitive. Why Why does
(34:19):
that work so well here?
Mette Bentz (34:20):
Well, I think actually, it may be so well so
effective, because you actuallylearn new habits and new skills
in overcoming somethingdifficult in your, your everyday
home and with your closestothers. Because before family
based treatment, the primary thetreatment to go to was to put
(34:41):
kids into hospital for a longduration of time away from
families. And it was evencustomary to say that parents
you would be disturbingtreatment so you're allowed to
one short visit a week and oneletter a week or something like
that. So we actually did theopposite in the older days. And
while that can also be effectivein gaining weight, then we have
(35:06):
exactly the same problem, as youmentioned with addictions that
when you go back home, it's verydifficult to generalize what you
have experienced in hospital anduse it back home. And especially
when you're doing it as a youngperson on your own, and your
parents have not been part ofthat journey. So I think that
the fact that your parents ispart of the journey, and you are
exposed to new eating habits inyour own home, and you can much
(35:29):
sooner return to seeing friendsand going to school and having
the joys of everyday life thatactually should motivate you to
get out of anorexia, you caneasily get in contact with that.
Morten Andersen (35:42):
That's really, really interesting, what you're
saying there that what actuallyworks is that you teach a person
new habits in their oldenvironment, and therefore, that
will actually sustain it more.
So you're breaking old habitsand inserting new habits, so to
speak, in the same environment,and that is why it is effective.
That's really interesting.
(36:12):
Great, well, so far, we'vetalked about anorexia and the
treatment of anorexia. And I'dlike to see what we can learn
from the treatment of anorexiaand how we can apply it to other
changes. And I actually thinkthat you have said a number of
things which are, which arereally interesting, the last
thing we just talked about,which is that keeping people in
their environment where theydevelop the addiction, so to
(36:34):
speak. I don't think anorexia isan addiction, but but it
actually not quite. But but butyou keep it in that environment.
And then you teach them newhabits, that's a really
interesting thing. Have we seenthat work in in addiction as
well,
Mette Bentz (36:52):
in addiction, I actually don't know much about
treatment of addiction. When youtreat kids with anxiety
disorders, we know that it'svery important that exposure,
the gradual exposure andresponse prevention can be done
in a way that can be transferredto your everyday life and
preferably actually be done athome as well. So often you teach
(37:12):
parents the skills also ofexposure and response
prevention, when you're insidein kids. So I think it probably
covers a lot of other areas aswell, I guess, but I wouldn't be
sure.
Morten Andersen (37:26):
Now, in a previous episode, I spoke with a
Judy Grisel and Judy Griselwas, well, it's a fantastic
story. So she started off as aas a as an addict, and then
became a drug addict, and thenwas a homeless person and lived
on the streets. And then shemade a change. And she became
she went back to universitybecame a professor neuroscience
(37:48):
and wanted to figure out, whatis it in our brains that make us
prone to addiction? And duringthe interview, I asked her, so
how could you go from beingaddicted to drug to go to
university? What was what wasthe trigger there? And she
actually said that what wasimportant for her was that she
was replacing her addiction witha new, healthy goal. So she
(38:13):
wanted to find out, why is itthat we became become addicted,
and she went for that, I justwonder whether you've seen that
work in your practice as well,where you have girls who have
been obsessed with their bodyand obsessed with looking maybe
like a particular person orobsessed with reaching a
particular goal, whetherreplacing that goal and having a
(38:39):
focus on that, which is a morehealthy goal, whether that will
help in in a situation likethat.
Mette Bentz (38:45):
It doesn't specifically ring a bell, I
think, because actually, what Ithink more often is that it
seems effective when the youngpersons are able to kind of
broaden out a little bit not sofocused on one simple thing, but
be a little bit more toleranttowards how things can be not so
(39:09):
simple and more nuanced and notblack and white. So to let go of
the need, that everythingshouldn't be actually securely
predictably unequivocably inorder for you to feel
comfortable to actually be ableto feel comfortable even though
you even though you don't knowexactly what you're going to do
(39:31):
the whole day or what you'regoing to eat or who you're going
to meet. You know, to be moretolerable towards the general
unpredictability of life thatseems very helpful. But mostly,
I think for most youngteenagers, the fact that they
actually have the experiencethat anorexia took away from
them for a while, the connectionwith peers and going to school
(39:53):
and meeting up with friends. Soactually getting back to that
creates a strong motor which isvery very wonderful to see that,
okay, they actually want theirlife more than they want
direction now,
Morten Andersen (40:06):
letting go of control, so to speak, and also
not seeing things black andwhite is actually something that
will help people get get rid ofanorexia. I think the last thing
you've also mentioned a numberof times is having support from
people around you that you trusta lot. Now, obviously, many
(40:27):
teenagers, even though there areconflicts between parents and
them, they still trust theirparents to do the right thing
for them. I guess, some may nothave family close by, but or
could be in a situation wherethey are not there to support
you. But having people who dolove you a will, that you trust
(40:48):
will do the best for you. Havingthem to support you is actually
a major benefit for making achange is,
Mette Bentz (40:56):
I think it's the most powerful ingredient in
life, to have support because Imean, all of us meet challenges
that we cannot cope with alone.
So the experience that you giveyour child, if you help your
child through anorexia or anyother disease, the experience
that you can get help fromothers. And you don't have to
cope with everything alone. Ithink that's such an important
(41:17):
lesson. And maybe actually,another lesson I think the
parents have so powerfullyhelped their child learn is that
you need to be able to separatesubjective and objective reality
that your feelings is not alwaysthe same as reality, and that
you can feel fat without beingso just like you can feel alone
(41:37):
while people are still reachingout for you. So the ability to
separate what you feel in thehere and now in what is in
reality, it's a it's animportant important lesson that
I see parents again and again,teach their child while they are
helping them to eat.
Morten Andersen (41:56):
Fantastic. I must admit that researching for
this, I was surprised about howmany people suffer from
anorexia, I was very surprisedabout how lethal it is house,
how serious it really is. Butalso reading through the
treatment of it. I was surprisedabout how difficult it is to
treat. And I think it'stherefore an excellent case to
(42:21):
think about how do you helppeople who do not want help,
because it is very important,they do get help. And it's
really hard to actually treat.
But I think your lessons aboutsome of the things that you've
mentioned about what actuallyworks. So using people, family
who can help, because peopletrust the girls trust them that
actually is really importantthat you do it in their own
(42:43):
environment and change importantmindset and behaviors and habits
in their own environmentactually is really good. And
then what you said about makingsure that we should get away
from the black andwhite-thinking and have a more
sort of nuanced thinking and notmaking not confusing objective
reality with subjective realityalso is really important. Thanks
(43:04):
a lot. I think we learned a lotabout change and a lot about how
to help people, especially withwith anorexia, I want to say
thank you, to you, Mette, for afantastic interview. I really
appreciate your time.
Mette Bentz (43:17):
Thank you for putting into awareness this very
important topic was a pleasure.
Morten Andersen (43:22):
Thanks a lot.
What a great interview withMette. I took three things away
from the conversation. One, wecan help people change even if
they really don't want tochange. People with anorexia are
suffering from significantweight loss. And if they are not
(43:46):
helped, they will continue tolose weight until they can no
longer function. It is a seriousmental illness. But it is
possible to help them even ifthey at first do not want to be
changed. If they do notrecognize that they have a
problem. Even if they shout outloud that they will rather die
than eat. Two (44:06):
We can learn three things from family based
treatment and apply to otherchanges. We can learn that
having support from people wholoves you, and who you trust.
That helps a lot. In the case ofmany people with anorexia, this
is the parents but it's actuallytrue for all. We can also learn
(44:29):
that teaching new habits in theexisting environment helps a
lot. treating the person in ahospital and then to be sent
home afterwards does not givethe same outcome. better treat
the same environment that themental illness or addiction or
bad habit occurred. And finally,let go of the black and white
(44:50):
thinking and separate objectiveand subjective reality. Feelings
are not reality. That also helpsPoint number three, we do not
need to know why somethinghappens to change it. We know
very little about the causes ofanorexia, the exact role of
genetics, the exact role of theenvironment and which factors
(45:14):
are important. But we do know alot about how to help the
individual. And maybe there is alesson there. We don't have to
know everything about whysomething happens in order to
change it. anorexia is a lethalmental illness and Mary's work
is important. How can we treatyoung girls who are losing
(45:34):
weight to the point of killingthemselves who really don't want
to change? So thanks a lot forthat work Mette. Until next
time, take care
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