Up to 50 per cent of women suffering from an eating disorder will at some point have to be hospitalised. As many as 20 per cent of them eventually die from their illness. Joyce Ross goes behind the scenes at a Florida treatment centre.
Picture Editor Duane Ashurst
The manor house at Renfrew’s Philadelphia facility.
Skin sisters: Tracey Rauh (left), 34, was anorexic for 18 years before contacting the Renfrew Centre. Anne Walsh (right) 25, has suffered from eating disorders since she was 17.
Last August Tracey Rauh, 34, passed out in the women's locker room of the local YMCA after a swim with her 12‑year‑old daughter. She woke up a few seconds later on the wet tiles, alone and terrified. "It was the first time I thought I could die from what I was doing to myself," she says.
At 5'6", Rauh, a newspaper editor in New Hampshire, weighed 88 pounds. She admits that her behaviour had become extreme. "I was paranoid," she says. "I even thought about writing to the company that made my toothpaste to see how many calories it contained."
Rauh has anorexia nervosa. She had been hospitalized four times before near her home in York, Maine, for her eating disorder. But this time, desperate for a treatment that would end her 18 years of starvation, she called the Renfrew Centre in Coconut Creek, Florida.
The day before she left home, Rauh biked 30 miles and began taking laxatives. "It was like, I'm not going in at 6st 3lb," she says. "I knew I could drop 5lb more." Though covered by a sleeping bag and two blankets in the car, she shivered as her family drove her to the airport. It was 26 degrees outside. "I ate nothing on the plane," she remembers. On August 14 she checked into Renfrew weighing just over 6st.
Nothing to lose: the day before her treatment began, Tracey Rauh cycled 30 miles and then took laxatives –“I knew I could drop 5lb more.”
Until just over a decade ago, the only inpatient treatment available for severe cases of anorexia or bulimia was in locked psychiatric facilities, where women were strictly monitored, often forcibly fed, and even given shock treatments. The Renfrew Center in Philadelphia, which opened in 1985, was the first residential treatment centre for women with eating disorders. The Coconut Creek location was opened five years later.
We try to normalize a woman's eating and behavioural patterns," explains Lynn Siegel, a psychologist and the co‑clinical director of the centre in Philadelphia. "But we don't believe in punishing the patients if they don't eat."
It's unsettling at first to look at these women, to reconcile their vulnerable, almost girlish features with the ravages of the disorder. Most are dressed in shorts and T‑shirts and appear to be in their 20s, but they move with none of the energy one expects to find in young women. Their faces are pale, slender, and sensitive; their bodies, frail skeletons of bulging bones and withered flesh.
A woman who weighs only 5st 6lb may be in grave medical danger. She has usually stopped menstruating; she may have damaged her reproductive system and increased her risk of endometrial cancer. Some, like Rauh, develop osteoporosis, and for those with bulimia, years of purging can do permanent damage to the oesophagus. As 25‑year‑old patient Anne Walsh says "When the body loses potassium and calories, it starts eating at the bone. The last thing it will go after is your heart."
Everything to gain: patients at Renfrew often choose to have a blind weigh-in treatment.
A patient's day usually begins around 6 A.M. with a weigh‑in call. "I hate waking up for it," says Chris, a 27‑year‑old fabric stylist who chose not to give her last name. After years of dieting too intensely, drinking too much, and clinging to a dead‑end relationship, Chris tried to gain control by not eating. At Renfrew she didn't want to know how much she weighed (5ft 4in tall, she was admitted at just over 7st). "My therapist suggested blind weigh‑ins at first," she says, "so I looked away from the scale."
The atmosphere at breakfast, where Chris goes after weigh‑in, is equally tense. The women look anxious as they reluctantly gather their silverware and confront the day's menu, sometimes tearfully. Chris was too distracted to eat during her first week in treatment, so she focused compulsively on other people. Some ate only with their fingers, crumbling bread into hundreds of pieces, or mixed everything on their plate into mush. Chris began with tiny portions of food, using a very small fork to feed herself. Finally she gravitated toward a group of teenagers, "a strong table, really serious about eating everything. The girls said, 'Eat the food; it will make you feel better."
Robyn DiDonato, a petite 31‑year‑old with dark brown hair who came in weighing 5st 8lb, initially sought out the most severely ill patients. "I used to sit with the thinnest anorexic in the dining room," she says. "This woman was incredibly smart, she had gone to Yale, and she weighed around 4st 6lb. I idolized her but feared her. To me, she stood for death and put some fear in me, like, 'You could end up like this."
Because those at extremely low weights may not be able to tolerate much solid food, Tracey Rauh began her treatment at Renfrew with small portions of vegetables and melon and Ensure Plus, a calorie‑and‑vitamin‑packed liquid supplement. She remembers her first glass: "I was in a room with a therapist and some other patients. Some of us were crying. I had a panic attack. I didn't want to take it. But I did."
Dying to be thin: Anne Walsh used to survive for weeks at a time on slices of lemon.
As a woman's metabolism increases from its slower starvation level, her nutritionist will suggest that she eat more. "In order to gain 1 to 2 pounds of weight per week," says Karin Sargrad, a Renfrew nutritionist, "a woman may need 2,500 to 4,000 calories a day. When you have a woman who is going from 300 to 4,000 calories, it can be shocking."
"Your body changes very quickly," Rauh says. "It's like a speeded‑up puberty ‑suddenly you have hips again."
To help patients deal with depressive reactions and feelings of utter helplessness ‑particularly the sense that gaining weight amounts to losing control‑ Renfrew offers individual and group therapy daily from 8 A.M. to 9 P.M. For the most part, when the women aren't eating, they're in therapy. The sessions target issues like sexuality, relationships, substance abuse, and others problem areas common to women who have eating disorders. “I was put with a group of women who really understood my background," says Rauh, who was sexually abused as a child. At Renfrew, she finally met others like herself. A 1993 Renfrew study found that 61 percent of its anorexic and bulimic patients had been sexually abused before the age of 19.
In a session on body image last fall, Anne Walsh, who at 17 had sometimes lived for weeks on slices of lemon, was startled when her therapist traced the outline of her body with a marker. It was dramatically thinner than the one Walsh had drawn herself, just minutes earlier.
Rauh also had no idea how emaciated she appeared to others. "Once," she says, "I was waiting in line in a restaurant and looked across the room at a woman. I thought, She must be anorexic. And then I realized that I was looking in a mirror. That's the only time I've ever seen what I looked like."
Some patients are surprised that they are allowed to exercise‑albeit with restrictions‑while in treatment. "I ran two miles three times a week after I'd gained a certain amount of weight," Rauh says. Psychologist Lynn Siegel emphasizes that a patient is given permission to exercise only after careful evaluation of her weight, vital signs, and nutritional intake, and that ‑ in Philadelphia at least ‑ women are given a choice of a 15‑minute walk or a Stretch and Tone class.
The usual stay at Renfrew is two weeks, followed by graduated levels of outpatient treatment. According to the American Anorexia/Bulimia Association, an estimated 6 percent of American women now have eating disorders. Research done by Timothy Walsh, a professor of psychiatry and the director of the New York State Psychiatric Institute's Eating Disorder Research Unit in New York City, says that 30 to 50 percent of anorexic women will go in and out of hospitals and treatment centres, perhaps making slow, limited gains. Between 10 to 20 percent of the women who are hospitalized will die.
And some, like Robyn DiDonato, will live normal lives again. DiDonato had suffered from anorexia for almost five years before she had treatment, but she left Renfrew in 1989 "with ammunition," she says. "A meal plan." She also sees a therapist once a week and attends a 12‑step group for people with eating disorders. Her weight has been stable at 7st 9lb. "Food will always be a discomfort for me," she says. "But it doesn't pose the same threat that it used to."
Body conscious: in an exercise that highlights startling misconceptions of self-image, patients sketch an outline of their body, then compare it with the genuine article drawn for them.
Rauh, who left Renfrew last fall after putting on 21 pounds, says, "Leaving was like losing an arm. I was so scared and depressed." She is continuing her therapy and is struggling to stabilize her weight. "I've lapsed a bit," she says. "I'm 7st 9lb. And I know every calorie I ate three days ago. But that doesn't stop me from eating them." When Rauh hears that anorexic voice, "You're fat, you're fat, you're fat," she still falls back on a Renfrew technique. "I write down the bad voice on one side of a piece of paper," she says. "On the other, I write down good thoughts. It helps me to see what's happening."
Rauh's body, however, may never fully recover. "My knees are so bad from the osteoporosis," she says. "But there's deeper damage, with myself, my family, and my job. I missed my child's first day of school. That's permanent."
Now that Chris is on her own, she starts her day with the same breakfast she ate at Renfrew: an English muffin, a teaspoon of peanut butter, a banana, and some orange juice or fruit. "It centres me," she says. She also keeps in touch with a dozen women from the centre, women whose stories she knows almost as well as her own.
"Once, in a group meeting," Chris says, "a friend of mine at Renfrew who weighed 5st 3lb and had terrible medical problems heard me say that I couldn't even win at anorexia, that I never got thin enough. And she said, 'This isn't winning, Chris. This isn't winning."
The first swallows: patients at Renfrew slowly get to grips with a “regular” diet.
On the menu: the Renfrew Center’s dos and don’ts list.
The will to win
One woman’s account of how she overcame her battle with food. It's been eight years since I was hospitalised with bulimia and anorexia. Some of the women I was treated with are now dead, others are still in and out of treatment. If someone had asked me when I weighed 6st 8lb or was popping one of the 40 laxatives a day whether I’d ever have a life that wasn’t ruled by food, I would have said no.
I was hospitalised at the beginning of my senior year of high school. My bingeing had become so bad that I would leave class in the middle of an exam to eat. Once home (both of my parents worked), I'd wolf down cartons of ice cream, kilos of cheese, entire quiches, and whole boxes of cereal. I would allow myself only an hour to eat so that the food would not begin to be digested. Then I'd drink a bottle of emetic and throw up. Afterward, I'd take laxatives to remove whatever the emetic had left behind.
During the anorexic phase of my illness, I saw vomiting as a dirty habit and imagined that I was attaining a purer state of mind by fasting and dropping to the floor for 500 sit‑ups each time I was alone. The feel of my rumbling stomach was like a drug high.
When I began bingeing again, I put on weight, and my parents heaved sighs of relief. They had no idea what I was doing. When I got to the stage where I was bingeing seven times a day, I finally chose to go into hospital.
The bulimics there sometimes had black gaps in their months, or their teeth were yellow and rotting from stomach acid. The anorexics looked like walking skeletons. One woman had been a nuclear physicist. Down to 4st 6lb, she would weep over the food she was forced to eat and would make ten trips to the microwave per meal, always moving to burn calories.
Calories were strictly counted, and nurses locked bathroom doors to keep women from purging. Exercise was banned, and on walks in the hospital grounds you were chaperoned until you had earned enough "points" to stroll alone.
I needed this intense schedule. I needed to be taken out of my routine of self‑destruction. But the hospital is only temporary. I was in for more than six weeks before the insurance ran out. My doctor said, "You'll either make it or you won't."
They don't just leave you. There is aftercare. I saw my psychiatrist every two weeks in his office. I vividly remember my first trip to the supermarket after getting out. I wheeled my trolley up and down the aisles, each a sea of endless possibilities of what to avoid or indulge in. I ended up buying one 2lb tub of vanilla yogurt and fleeing like a criminal.
I was not, by any means, instantly cured, and initially I lost a good deal of weight. I still binged, although sporadically, and I still made myself throw up. But I began to see what triggered these episodes. Stressful family arguments, college applications, anything dealing with impending adulthood sent me to the refrigerator.
It is never simply over. But at some point, though I'm not sure exactly when, I made a choice to get better.
I can't remember the last time I made myself throw up. Though my friends assure me that I am still thin, once in a while I look in the mirror and hear the sick voice tell me, "You've sure got a set of thighs." But I don't diet. It’s like smoking cigarettes; just one, at night, with a drink, and you end up buying 20 the next day.
I eat what I want now, even chocolate‑chip cookies. I am not a do‑gooder like some of the recovered people I know. When I go out to eat and see a woman at the table next to me picking at her salad, her collarbones sticking out, I am not filled with sympathy. I do have the urge to shake her because I believe, if she could only see a sliver of light in the dark room I know she lives in, she could recover. But I don't. It has to be her choice.