Coming to terms with the unhealthy side of exercise as the parent of an eating disordered child

One of the most challenging issues faced by all eating disorder providers is that of compulsive and compensatory exercise. Compensatory exercise is where one feels compelled to “exercise food off” even after eating small amounts. Compulsive exercise is less conscious than that, more …well, a compulsion. In children it often looks like they are “jumping out of their skin” with movements they cannot control.

The struggle to understand how strong the urge to exercise can be

Learning to balance “energy in and energy out” in growing children is something we go over everyday here in treatment. But it is hard for the kids to understand and accept, and hard for some parents too. Certain parents have no trouble with the metaphor of an “injured athlete” who must rest in order to be able to return to full performance, or a broken bone that must be immobilized to heal”, but others identify strongly with an athletic child’s deep urge to exercise to “feel better” or “tame anxiety”, even when it is suppressing their menstrual cycle and impeding recovery. The concept that there can be such as thing as “pathological exercise” is as difficult to accept as the concept of pathological love.

It can be equally hard for parents to accept that their normally “obedient” or “rule following” child will do things behind their backs and even lie about it. “I’d notice if she was exercising,” they say. “There must be some other reason she’s not gaining weight.

Privately our patients speak clearly, even eloquently, about their inability to contain their anxiety and the fact that exercise helps them control it, however temporarily. But how can we convey this to parents in a way that they can believe it really pertains to their own child?

A case in point

The other day a mother handed me a letter from her child whom we have been treating for a while. This girl is the beloved daughter of her Mom and Dad and I pretty much love her to death as well. Anyone would. Prior to her illness she was social, engaging, funny and active in several sports. Moving felt good to her and she was good at it. Like her Dad.

Then she developed severe anorexia nervosa and sought treatment at Kartini Clinic where we began the long road of weight restoration. Despite huge amounts of food, though, her weight gain was stalled and it had been puzzling us for weeks. We suspected that she exercised secretly, but couldn’t prove it. Her mother was at a loss. Her dad admitted he struggled to entertain the idea of life without constant exercise himself. How could he advise her?

Then this letter.

This visibly nervous young girl slipped a handwritten note into her mother’s pocket one day. Kids in her family have a tradition of slipping notes into their mother’s pocket without speaking when speaking is hard. Later she and her parents generously allowed me to share her note. They hope that her words can help other parents understand what some of our children are up against.

Dearest mother

…[a very sweet preamble in which she apologizes for not being able to say the words in person] — Well I might as well just say it—I have been secretly exercising in the study. It has been going on for basically the whole time I have been here. There were many moments when I was going to tell you, but then was stopped by ED…I am sorry and hope you are not angry with me…I want to get better and stop and that is why I am telling you. I hope people in the clinic are not mad at me and rather see this as a step in the right direction, that I am asking for help. I don’t really know what to do… I didn’t want to exercise but I just had to, it was my disorder. I’m scared to stop exercising but I know it is what I need to do and I don’t want to do it anymore ( I never did)… it’s not just in the study though, it’s whenever I’m left alone in my room. Or even in the shower. That’s why I didn’t shower for so long, not fully because of my body, but because I didn’t want to have to exercise. Also, I wake up in the middle of the night and will do some. Not like a work-out, just like some squats. I don’t know what to do about these two things. Just know that I am so ashamed of this and just feel horrible about myself. I wish I didn’t do this and you didn’t have to deal with it. Also know that this gives me huge anxiety giving you this and my eating disorder is mad at me for giving it to you… I just know that I need and want to stop and need your support doing so.”

For my part, I’m just glad she wrote the note, but especially glad that her mom is the kind of mom with a pocket a child feels safe slipping a hand into when words fail.

Now we can move forward.