A Parable for Staying the Course in Treatment

Have you ever heard of the ancient Chinese book called the I Ching, also known as The Book of Changes? If you were young during the 60’s and 70’s, I bet you have, otherwise, probably not. Sources of inspiration, when doing really complex and challenging things, such as re-feeding a sick child who resists and resents your efforts, can come from unexpected places. For me, this week, that source of reflection was the I-Ching, as I remembered a story in it about a fox.

Wikipedia says: “The I Ching also known as Classic of Changes or Book of Changes, is an ancient Chinese divination text and the oldest of the Chinese Classics. Possessing a history of more than two and a half millennia of commentary and interpretation, the I Ching is an influential text read throughout the world, providing inspiration to the worlds of religion, psychoanalysis, business, literature, and art.”

The wisdom of the I Ching was consulted by tossing a series of sticks or (later) coins whose shape, created by their fall on the ground, correlated with specific combinations of six straight or broken lines. Each of these “hexagrams”, which are catalogued in the I Ching, referenced a parable. The parable-image I am writing about today is number 64 called “the little fox: before completion”.

Treatment of a young person with an eating disorder is not easy. Treatment needs to be planned, consistent and seen through to the end. It is exhausting. It can be demoralizing. It is necessary.

I have now treated thousands of pediatric patients with eating disorders. I have begun to feel that I know how this particular human condition behaves: how it robs, how it tortures, how it deceives and endangers. When our team engages alongside the child’s parents in battle against the illness, against the wasting, trying to wrest a child from its grasp, everyone is energized, even when they are scared.  Lines are drawn, plans are made. And if you think that re-feeding a reluctant, angry and frightened child is easy… well, then you’ve never tried it! There will be no thanks. You will have to fight your ground every step of the way, but take heart: things will get better. Your child will get better!

It is precisely when things get better, though, that the eating disorder engages you in its final deception. Weary, you begin to ask “are we done yet?” And the understandable desire to “be done” takes us to a place where we lose sight of the actual end game: “state not weight”. Rather than any particular weight, the state of good health is the goal: well-nourished, medically restored, back in school, socially engaged and happily active.  

Sometimes these things follow on naturally from full weight restoration, but — as many parents can tell you — sometimes they do not. Psychological recovery (which you will not achieve without weight restoration) is as important as physical recovery, and not always does improvement in physical appearance denote healing of the heart!

The desire to be done, to “just go back to normal”, has caused a problem for many, many families who — convinced “it will be ok” — have ended treatment a bit too early, a bit prematurely and then been stung by the rapidity of relapse.

Ironically, insurance companies, once bastions of misinformation about the (non)importance of weight restoration to recovery, now lean heavily on programs and on parents to “be done with treatment” once the weight comes back, once they’ve “gained enough”. At that point they frequently refuse to authorize care. Never mind the child’s psychological devastation; they “weigh enough”.

I watch that temptation to end treatment just a little too soon. I sympathize with the parental exhaustion, the yearning for normalcy and yes, the wishful thinking. Yet it is still my job to warn against it, no matter how unpopular the view.

And I think about the parable in the I Ching of the little fox. Listen: “Before ending: success, if you work hard for it. The little fox tries to cross the frozen river, but gets its tail wet before it can finish crossing the ice. No goal is favorable now, if you seek only the easy way. The fox crossing the frozen river must be cautious (this is an old Chinese proverb).  If he tries to rush to the end he will fall into the water. Our affairs cannot be rushed to completion.”

Thank you, little three thousand-year-old fox.