The process of treatment begins at the first moment of contact. Because such contact usually comes by phone, treatment can start before the doctor and the patient have even met face-to-face.

As a doctor, I try to plant the seeds of success during those first, critical moments. If I create an atmosphere of trust, of caring, then there’s hope. If my tone is judgmental or threatening, then the process may be doomed.

The next step is to meet with those involved. If the patient herself asked for help, then the first appointment is with her; when the parents make the call, I may ask to see them first. In other cases it may be best to see everyone at the same time.

The initial evaluation may take one or more meetings. However, if the situation is life-threatening and the patient needs to be hospitalized, I don’t wait.

Every situation is different. If in your search for help you don’t feel the caregiver is responding to your needs, discuss the problem with him or her. If you are still not satisfied, keep looking.

The Initial Assessment

I perform a complete assessment of the problem before the patient and I agree on a plan for treatment. Too many professionals say, in effect, “Welcome to our facility, here’s how we’ll treat you, now tell me all about your problem.”

Typically I start by asking, “How may I help?” Patients often seem surprised that I play the role, not of adversary, but of collaborator on a joint project-as indeed I am.

The patient’s initial response is most revealing.

“You can’t help me. My parents are the ones with the problem.” This comment is typical of anorexics, who feel they aren’t sick at all and have come just to get people “off their backs.”

“My father called me fat, so I started losing weight.” People with low self-esteem are very sensitive to such remarks. One fifteen-year-old patient, inspired by the Olympics, demonstrated a gift for gymnastics. When her coach said she might do better if she “lost a little weight,” she began to diet. Unfortunately, she focused on weight loss at the expense of everything else. If starvation had been an Olympic event, she would have qualified for a medal.

“/ look in the mirror and I get scared. I want to find some peace inside.” Some patients know they are hurting themselves and want help in stopping. Especially in anorexia, the more distress the patient feels, the more motivated she is to get treatment.

Follow the Leader

In conversation I follow my patient’s lead. Following someone’s concerns, hopes, and resistances is more productive than a mechanical, by-the-numbers interrogation.

Sometimes when I ask, “How can I help?” she replies, “You can’t help. I don’t want to be here.” I may then say, “Well, someone is concerned enough to insist that you come here. Maybe we need to look at what’s going on in your life that makes you feel you need to starve yourself almost to the point of death.” Or she may say, “I don’t think you can help-nothing has worked so far.” I might then ask, “What have you previously tried?” and explore why other efforts have failed. And because words mean different things to different people, I would explore what she means by certain terms. Does “desperate,” for example, mean “confused” or “suicidal”?

Many times, the most telling clues come from something a patient avoids saying, or hesitates over. If a patient tells me something is none of my business, I’ll respect that. But later, when we’ve established a higher level of trust, I may ask again.

Trust is crucial. It takes time to build trust, to demonstrate concern and show that my intention is to heal, not to harm. When I show a patient that I accept her feelings as valid-although I don’t necessarily accept her way of dealing with those feelings-I send the message that the patient herself is worthwhile.


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