Starving

He had no patience for psychology and was highly skeptical of an illness he had never heard of. I wondered if reaching out to him had been a mistake. The last thing I wanted himto do was call up his sister and admonish her to “just snap out of it.”

Sienna had managed to hide her illness for a long time but it had finally mushroomed out of control, putting an end to pretenses. She had been rushed to the emergency room at Hope Haven after collapsing in a gym. Doctors who evaluated her in the ER had her transferred to the Eating Disorders Unit, where her distraught parents gave their consent for the 16-year old to be treated.

As a treatment coordinator on the Addiction Unit, I generally have nothing to do with ED cases unless the patient also had an alcohol or substance abuse issue. But Sienna’s psychiatrist had decided he needed someone who spoke Hebrew on her treatment team. The family moved from Israel two years earlier, and while Sienna and her mother spoke English, her father still struggled with the language. Dr. Carroll had canvassed the hospital for a Hebrew-speaking therapist who could help out. After clearing things with my supervisor, he approached me directly.

He was a tall, thin, sixtyish-looking man with thinning hair and an unassuming manner. With his homespun look, he looked a bit out of place in an environment where doctors dress in flashy, expensive suits. “We’re not making progress in the therapy and I’m wondering if it might be due to the father not being sufficiently involved,” Dr. Carroll explained after briefing me. “He’s there with his wife and daughter at family sessions but takes a back seat. Could be the language barrier prevents him from fully participating. We need someone who can bridge that gap. Your supervisor offered to free you up if you’re willing to give us a few sessions this week… Does it sound like something you’d consider?”

Hearing the case was about a Jewish patient immediately aroused my interest. I was also intrigued by what I’d heard about this doctor’s success with anorexic adolescents. “I’m actually very interested in seeing your therapy in action,” I told him. “And congratulations on the amazing coverage in Medical Byways.”

Dr. Carroll had recently brought a burst of limelight to Hope Haven when a prominent medical journal showcased him in a feature story about eating disorders. The article highlighted a form of family-based therapy Dr. Carroll had instituted in the ED Unit that was showing promise with anorexic patients. Splashed over several pages, the article with his picture and a photo inset of the hospital adorned the wall in the main lobby under a glossy caption, “Hope Haven In The News.”

His approach to adolescent anorexia puts parents at the center of the recovery process, responsible for feeding their starving child and restoring her weight. This system was a departure from the prevailing belief that adolescents need autonomy over their bodies and can be empowered to achieve their own recovery.

“Parents have an inborn capacity to nurture their child; we just help them access an ability they already possess in order to restore their sick child’s weight,” he explained to me when we met in his office the next day. “An adolescent in the grip of anorexia is no different from a youngster with a raging fever who needs medication. As a parent, do you sit around and negotiate while the child is wasting away? Or do you feed your starving child?”

The treatment required the patient and his or her family to be fully enlightened about the ravages of anorexia and the dire fallout on the bones and vital organs. In graphic language, they learn that the disease, if unchecked, leads to stunted growth, osteoporosis, spinal fractures, heart and kidney failure – and ultimately, death.

“It scares the daylights out of people but there’s no other way to rally the family,” the doctor explained, noticing my expression. “And we depend on the family to be a bulwark of emotional support during the recovery process.” He went on to explain that anorexics are “remarkably inventive,” resorting to all kinds of schemes to avoid eating or to expel the food. “They can prove to you ten different ways the scale is wrong. Or they hide weights on their body so the scale gives a false reading. But we treat these schemes as part of the disease, coming from fear and anxiety, not expressions of the patient’s true character.”

In his office the next day as we discussed the upcoming family session, he gave me a thumbnail description of the parents, Ziva and Yosef Kesser, calling them an “odd couple” with different ethnic and educational backgrounds. The father was of Yemenite extraction, the mother was raised in Australia. They moved from Israel for economic reasons, he said. Ziva was a cosmetician and Yosef worked as an excavator. Ziva appeared to be the dominant force in the family. Husband and wife seemed equally concerned for their daughter, showing up on time to every session and heeding the guidance of Sienna’s treatment team.

According to her parents, Sienna was respectful and good natured. She had made a good adjustment to her new school, but the previous year she began to show alarming drops in weight and loss of interest in friends and social activities. She downplayed her parents’ concerns with one excuse after another. Only when she began having fainting spells and finally collapsed in a gym, did her parents learn the truth.

“We’ve had three family sessions. She seems to want to work with her parents but for some reason, it’s not moving as it should. She’s just treading water,” Dr. Carroll mused. “Meaning,” he looked up at me from behind his wire-rimmed glasses, “there’s been barely any weight gain. She’s five foot one and came in at 77 lbs. She’s still hovering just a bit above that point.”

“Is there some kind of power struggle going on? Could that explain her resistance?” I asked.
starving-3_03

“It’s a power struggle but not in the usual sense of a teenager resisting authority. It’s taking place inside Sienna herself – the destructive power of the eating disorder pitted against her desire to live. The illness distorts her thinking to an extent but she’s sane enough to understand she’s in serious danger. The love and support she’s been getting should have strengthened the part of her that wants to be well. We need to get to the bottom of why that’s not happening. ”

I tried to picture the scenario…. a teenager’s parents sitting on either side of her, coaxing her to eat, pleading, insisting… and the starving girl pretending to eat but not swallowing the food, hiding it in her napkin or pocket or whatever. I couldn’t process it. It was beyond comprehension. What would drive a person to behave this way? And how could I help, if the parents themselves couldn’t budge her?

“You’re probably wondering how you can be of help,” Dr. Carroll said, reading my mind. ”Well, I think it’s likely I’m missing important cues about the family dynamics because of the language barrier with the father. I sense some tension between the parents but it seems to me their concern for the daughter overshadows that. At least that’s my impression. I’d like you to have a session with Sienna and then meet her parents. Maybe join us in a family therapy session. Whatever you can learn will be very helpful.”

Dr. Carroll handed me a folder with Sienna’s name at the top. “Is she an only child?” I asked.

“There’s a half-brother from her father’s first marriage. He’s about 15 years older than Sienna and lives in Israel. She’s quite fond of him and looks up to him. There was no talk of him flying here for a visit, though.” He sighed. “We have to work with what we have.”

I met Sienna in the lobby of the Eating Disorder Unit the next day, immediately noting the telltale signs of her illness… dry, lifeless hair… a too-thin face…bulky clothes masking her emaciated form. With her deep-set violet eyes and high cheekbones, she was still striking. Despite an overall sadness and apathy, I was struck by the flashes of humor and keen intelligence that animated her at moments.

Describing the daily routine at the hospital, she poked fun at what she called the patients’ shenanigans. “We get weighed twice a day and it’s like a game to see who can outwit whom. Will the staff win by getting honest readings on the scale? Or will we be able to somehow pull some stunt like drinking a ton of water right before we get weighed to pump up the number? We’re like naughty children playing this foolish game on the grown-ups.” She added softly, “But the joke is on us.”

I asked her about life before she was hospitalized. She said things had been rolling along fine until she started a diet that had “gone bad.” She was an A student and had friends, life at home was “pretty good” except that as an-almost only child, other than a brother in Israel much older than her, she was often lonely.

“Coming from Israel, was English hard for you to master?”

“Nope, my mother is originally from Australia and grew up in Europe. So I had a headstart with the English. And we spoke nothing but English for almost six months before coming here. My mother and I, I mean. ”

“Aha, that’s where your unusual accent is from. Are you comfortable in English? I can switch to Hebrew if you like.”

“I know…Dr. Carroll told me you speak Hebrew. But I’m cool with English.”

“I can see you are. Magniv,” I smiled, trying out my Israeli slang.

Her eyes flew open. “Magniv! I haven’t heard that word in so long.”

“Don’t you keep up with your friends in Israel?”

“Not much. I did in the beginning, when we first moved and I was so homesick.”

“You were 14, right? A very vulnerable time in a girl’s life…”

“I not only left my friends but my grandparents. I’d go there on Shabbat and they always saved me some special dishes… jachnoon … kubaneh… Do you know what that is? Teimani foods served on Shabbat. We’re not religious but my grandparents are. They’re very old and don’t hear well so we can’t even talk on the phone.”

“How sad for both of you. They must miss you so much! Do they have other children and grandchildren in Israel?”
starving-2_03
“Only my brother Noam and his family. I miss them more and more. I used to see them every couple of months when they came to visit my grandparents. We’re like… we’re very close.” Her voice caught in her throat.

“It must have been so painful to be torn away from those you were so close to.”

“It’s not supposed to be permanent, but who knows?” she said disconsolately. “They said that two years ago.”

“Are you in touch with Noam?”

“He doesn’t know I’m in the hospital. I don’t want him to know.”

“But — wouldn’t he want to know something like this?”

She was silent.

“You know, you’ve had more drama in your life than most kids your age… Were you overwhelmed trying to navigate a new society and a new social circle at such a young age?”

“At first it was exciting. I’m good at making friends. We had a big, beautiful house. I got a whole new wardrobe. I even got a new name.”

“You mean a nickname?”

“No, a totally new name. You know any Israelis named Sienna?”

“No. But I know Israelis are great at inventing names.”

“Where do you think I got it from?”

“No idea. Some celebrity?”

“Think. What Israeli name sounds like Sienna?”

Nothing remotely similar came to mind.

“Give up?” she teased. “Well, it’s Tziona.”

“Tziona!” I laughed. “Of course. They’re so similar, you almost don’t have to get used to anything. That was probably the easiest part of adjusting to America.

“There’s an actress by that name. And it’s easier for Americans to pronounce.”

“I can hear that… Was it hard to fit in with kids from different races and different colors in public school?”

“Pretty weird, at first. But I realized something. No one fits in, you know that? Everyone just pretends to.”

“Here in America, you mean?”

“Yeah. In Israel people really care about things. They don’t just pretend.”

“Israel is a more serious culture,” I said. “But they know how to have fun there, too.”

“I used to know how to have fun… It just doesn’t interest me anymore.”

“When did the bubble burst, before you started dieting? Or after, when it “went bad”?

“It wasn’t a bubble bursting. More like a slow… whuddya callit …when fireworks die out…?”

“Slow fizzle, you mean?” I offered.

“Yeah… whatever.” She wrapped her arms around her knees and rested her head on them. She looked so desolate. I wondered what was going through her mind.

“Sienna, can I ask you a question?” I asked. “You threw out a comment before, “the joke’s on us,” meaning the games the girls play to keep their true weight from showing up on the scale. As if there’s both a little girl and an adult side by side inside you… The little girl who’s acting naughty and the adult trying to keep her in line?”

“Acting naughty… or nuts? They didn’t put me in a locked-down unit for being naughty.”

“You’re right. We’re talking about an illness, there’s no question about that. My question is–”

“Thank you for saying that illness straight out. My parents are scared to death of that word. My mom especially.”

“What about your father?”

“He’s more… I don’t know. More on my wavelength.”

“Speaking of your father, he’d go back to Israel tomorrow if he could, right?”

“How do you know that?”

“Just a hunch. You said he’s on your wavelength. And it’s written all over you that libi b’mizrach…your heart is in the East.”

She looked past me, out the window where snowflakes were decorating the window in the waning light. “You got that right,” she said softly. She paused. “So what was your question? I think I cut you off before.”

She certainly was on her toes. Did she actually want me to probe?

“Well, your doctor said your weight is about the same as it was when you were first admitted and he doesn’t understand why. I’m going to ask you to dig deep into yourself to answer this, Sienna… Think about the little girl and the grown up we spoke of before…Why is the little girl inside you still calling the shots? What does she really want?”

She turned her head from me. When she looked up after a long while, her eyes were brimming with tears. “If I knew I would tell you,” she said bleakly.

I drove home that evening trying to make sense of the Kesser’s history. The family had moved to America “for economic reasons,” Dr. Carroll has said. And Sienna mentioned that her parents had to get themselves “out of debt.” But moving from Israel meant abandoning the father’s elderly parents who had no other children nearby – not something a close-knit Sephardic family would normally do. What drove that decision? Was it serious financial trouble? Health reasons? Some kind of family feud?

On an impulse, right before saying goodbye to Sienna, I urged her to let me call her brother, Noam. “I don’t want him to think I’m a nutcase,” she protested.

“If he was in trouble, wouldn’t you want to know?” I asked. She relented and gave me his number.

Now I was questioning whether I should in fact reach out to him. He might have some of the answers we were seeking to explain Sienna’s deep resistance to healing. Yet from my meeting with the parents earlier in the day, it was clear that Ziva and Noam did not get along, and that Ziva preferred not to have him involved. Who was I to mix in?

I found myself reliving the conversation. Yosef had turned on her impatiently when she rejected my suggestion to bring Noam into the picture. “Maspik! This is her brother who loves her! When will you realize this is not about you, it’s about Tziona and what’s good for her?” His wife threw him a withering look and he glared back at her.

They were indeed an odd couple. Ziva was sophisticated and impeccably dressed. She carried herself with an air of propriety and class. I placed her in her late fifties, quite a bit older than her husband. With his broken English, distinct Sephardi look and Israeli bluntness, Yosef seemed to come from another world.

When Ziva stepped out of the room for a few moments, I asked him what his real reason was for leaving Israel and moving to America. “I did it to please my wife,” he said bluntly. “She needed a higher standard of living. I regret it. I left my elderly parents. Tziona got sick. She would not be sick today if we had stayed in Israel.”

“Why do you think that?”

“To tear a sensitive child away from everyone and everything she loves? It was a mistake. I should have been wiser. And stronger.”

“Is there any chance of moving back to Israel in the near future?”

“I’ll do what I have to do,” he said evenly. “Enough is enough.”

•••

In Dr. Carroll’s office the next day, I described my meeting with the Kessers, watching his eyebrows shoot up as I described the sudden fireworks at the end. He questioned me intently about every nuance.

“Do you realize the significance of what you just told me?” he asked abruptly.

“You mean that Yosef blames Sienna’s sickness on the move to America?”

“That’s one thing. But just as significant, we learned that his relationship with his wife seems to be unraveling over a very burning issue – guilt. I wasn’t at all aware of that.”

“How is that going to impact Sienna?” I asked.

“Well, it’s bound to force some kind of change in their lives. You know, I’ve seen sickness draw some families closer and drive others apart,” he reflected. “I’ve been working with the assumption that Sienna’s sickness was bringing her parents closer together. What you’ve just told me though, is making me rethink that. It seems her illness is actually putting a great deal of weight on a very weak link in that relationship.”

“Yosef’s guilt?”

He nodded. “Guilt over the harm he believes he caused Sienna by putting his wife first. And guilt over leaving his elderly parents.”

“But if she starts to recover… couldn’t that turn things around for them?

“She’s not likely to recover as long as she imagines she’s saving her parents’ marriage by remaining sick. She’s also saving herself because a child’s sense of security is terribly threatened by a parental breakup.”

“Do we actually know that she’s aware of the trouble between her parents? She gave me no indication of that.”

“Even from behind doors, a girl this sensitive is picking something up and feeling very scared… So Mom and Dad are now united for her sake. All she has to do to keep that “togetherness” going is stay sick. That is the real reason there’s been no weight gain. Do you see what I mean?”

The tightening in my stomach told me he was right.

“How can we free Sienna from feeling responsible for her parents’ marriage?” I asked. Dr. Carroll looked as stymied as I felt.

What a bizarre mess this was. “Do we have anything to lose by calling her brother?” I queried.

“No, go ahead. Might as well try that. This situation needs a game-changer.”

You mean a miracle, I thought.

•••

Noam gave me a cool reception and I had mixed feelings talking to him. He sounded very concerned about Sienna but highly skeptical when I described the symptoms of anorexia, an illness he had never heard of. He had “no patience for psychology,” he said. I wondered if reaching out to him had been a mistake. The last thing I wanted him to do was call up Sienna and admonish her to “just snap out of it.”

“What is this, some kind of hunger strike?” he demanded. “Tziona’s not the type to be rebellious.”

“It’s not a hunger strike and no, she’s not rebellious. She’s frightened and confused. It started out as a diet that snowballed out of control. It’s an illness. There’s a ward in the hospital where she’s staying that is full of patients with an eating disorder similar to hers.”

“Why didn’t my father tell me about this? Why is a therapist calling me? Selicha, I’m just trying to understand what’s going on.”

I couldn’t tell him his step-mother didn’t want him in the picture. “Maybe he didn’t want to worry you. Tziona gave me your phone number.”

“Miskeinah… She should never have left Israel. My father regrets it very much. But Ziva gave him no peace. I’m sure she doesn’t want me to know about Tziona. She knows how much I was against them moving. I offered to have Tziona live with me. It was flat-out no.”

“Is that offer still good?”

“Of course it is. Bring her today!”

“Well, let’s see what happens… In the meantime, I think Tziona will be thrilled to hear from you. She misses you terribly.”

“Poor thing. They stuck in her in a school with goyim and who knows what else. Selicha,” he caught himself. You are Yehudiya, kein?”

“Yes, of course.”

“Well, Geveret, call it what you want but if someone is miserable and cries out but no one hears, maybe starving herself is the only way to get people to listen.”

He was pretty sharp, this brash Israeli who didn’t believe in psychology.

A couple of days later, I escorted Sienna to my office in another wing of the hospital. She had finally gained a few ounces, and being allowed to leave the locked Eating Disorder Unit for the first time was her reward.

Fifteen minutes into our session, there was a brisk knock on the door and in walked a tall, broad-shouldered man with a navy windbreaker and a kipah seruga. Sienna gasped. She flew into his arms, crying, “Noam! Ani lo maminah!”

He laughed, relishing her happiness. “Tziona! Let me see how tall you’ve grown.” She was weeping with emotion and he held her until she calmed down. They started talking at the same time and broke off, laughing. “So you haven’t changed at all, still interrupting your elders!” he teased.

“This is Raquel, my therapist,” Sienna said, gesturing to me as she wiped her tears. “This is my brother, Noam. Can you believe it? He came from Israel!”

“Shalom uvracha,” he flashed me a wink. I was so thrilled to see him I didn’t know what to do with myself. I couldn’t leave them alone as it was against regulations to leave Sienna unsupervised by hospital staff. “Just ignore me,” I told them. “I have to stay here but I have plenty to keep me busy.”

The two withdrew to a corner of my office where Sienna sank down onto a sofa. “I brought you a present from Shuli and Moshe,” Noam said, withdrawing something from his wallet and sitting beside her. It looked like kids’ drawings and letters along with some photographs. Sienna read the letters and examined the pictures, commenting on them animatedly. The conversation soon turned serious and I caught a bit of it, enough to know that Noam was urging his sister to come back to Israel and live with his family. She wanted to “desperately,” she said, but was afraid of what her mother would say.

“Nothing to be afraid of, Tziona. We’re going to straighten everything out. I talked to Abba already. First, you need to get better. It might take some time but we can do it together. You have to destroy what is destroying you, metuka…” He withdrew a chocolate candy bar from his pocket, unwrapped it, broke off a couple of pieces and handed her one. He popped a piece into his mouth. Go ahead, neshama,” he urged. After hesitating, she chewed and swallowed it.

“Good?” he asked. She nodded. He handed her another piece, praising her for being brave. In seconds, they had finished the whole thing. Noam kept talking to her, making her laugh as they munched on the chocolate together. He took out a small package from his windbreaker pocket. “Chemda baked these for you,” he said. Whatever it was disappeared in seconds.

“Do you sit around and negotiate while the child is wasting away? Or do you feed your starving child?” Dr. Carroll had summed up his treatment. Recovery from an eating disorder is a long journey, he stressed, paved with continuous battle against a tenacious illness. Sienna’s parents had diligently followed his guidelines but their unhappiness frightened Sienna, making her think she could buy their security and hers by staying ill.

But it would be different with Noam. He had appeared in a deceptively normal way, as miracles often do, unheralded and unexpected. Without baggage, training or agenda. With nothing in his pockets but a handful of chocolate and cookies. And the immeasurable power of love.

•••

All names and identifying information regarding patients, family members, hospital staff and facilities have been changed.