Interview with Esther Herman, clinical social worker and head of Mayanei Hayeshua’s Eating Disorders Clinic
South African-born Professor Rael Strous, Medical Director and head psychiatrist of the hospital’s newly-opened Mental Health Centre, says that no community—including the orthodox community—is immune to the mental health challenges of the wider society.
“A society in denial about mental health issues will ultimately pay a high price in terms of social ills and community dysfunction. Israel needs a mental health centre that caters to the religious community, since we know that up to 70% of that community refuse to go to a secular mental health facility. Cultural sensitivity for religious patients is a major priority, and we are determined to eradicate the emotional fragility that once plagued religious families around mental health issues. This is reflected in our stated goal to integrate each and every patient back into their family and community.”
Within the psychiatric department, a special unit was established to address one of the invisible epidemics of modern life that is just as pervasive in the charedi community as it is elsewhere: eating disorders.
We spoke to Esther Herman, head of Mayanei Hayeshua’s Eating Disorders Clinic, about the causes, warning signs, and treatment available.
A: No one knows exactly what causes eating disorders, but a growing consensus suggests that these disorders are rooted in a mix of biological, psychological, and sociocultural factors. An exaggerated need for control is often part of the picture. A distorted body perception can convince sufferers that no matter how thin they are, they can only become beautiful if they become even thinner. This takes over a person’s life, with the obsessive management of appearance and weight counting more than their own health.
A: It typically begins as teens—girls and boys—struggle with their self-image. During the adolescent years, there is a strong need for social acceptance, and it is only natural for teens to want to be seen as attractive. Teenage girls in particular can sometimes spend hours in front of the mirror, studying their face and their body. When this spirals out of control, it can become deadly. Eating disorders usually involve abnormal eating habits that negatively affect a person’s mental and physical health. The most common of all the known eating disorders is anorexia nervosa, which manifests as a distorted negative self-perception of being fat and unattractive. As a result, the person literally starves herself or himself in order to lose the perceived “extra” weight. Other forms of eating disorders include bulimia, which involves binging on food and then forced vomiting; and excessive or compulsive eating.
A: The lives of teenage girls from religious families are largely governed by strict school rules, stern parental decisions and social pressure. These girls may reach a point where what they put into their bodies feels like the only way they can exert any control over their lives. Many used to think that it was only girls in the secular world, constantly exposed to media and advertising, who formed an impossible ideal for appearance. Unfortunately, the religious community is not immune to eating disorders, even though religious girls have little exposure to media and advertising. Some young women are encouraged to start dieting before they begin the shidduch process, and they cannot stop dieting even when they have reached their target weight.
A: Surprisingly, it is family members who often unknowingly encourage the phenomenon by placing excessive focus on being ‘healthy,’ ‘thin,’ ‘beautiful,’ and ‘ready for shidduchim.’ For example, the mother of one patient used to give her daughter money for every kilogram she lost. That daughter is now anorexic. In extreme circumstances, families that place too much emphasis on healthy foods can cause an extreme reaction. Teenage children avoid eating altogether, thus preventing the intake of vital nutrients. Kids with self-esteem issues, with a tendency towards perfectionism, and who grow up in very critical environments, are more likely to develop anorexia.
A: With proper treatment, the answer is yes. Of course, it would help if we could point to one specific cause. One reason that the disorder can be hard to treat is that is so difficult to obtain compliance. There is an urgent need for more facilities to treat eating disorders. Experts estimate that around 50,000 girls and boys in Israel suffer from anorexia. It is well documented that anorexia is a serious psychiatric illness with a mortality rate of up to 20%. Last year, Mayanei Hayeshua opened a brand new multi-disciplinary Mental Health Wing, incorporating an outpatient clinic specialising in eating disorders. We are actively planning to expand the clinic into a full-fledged Eating Disorders Department that will include a number of inpatient beds and a full Day Care programme, so we can really tend to our patients on an intensive 24/7 basis.
A: Our treatment techniques include behavioural models offering incentives for cooperation and disincentives for lack of compliance. We have a multi-disciplinary team of professionals: psychiatrists, psychologists, social workers, dieticians, cognitive-behavioural therapists, and parental counsellors. We subject young women who are hospitalised for treatment of anorexia to a very strict programme designed to save their lives. We also administer an educational programme that helps keep the girls part of their community. We are one of a very few hospitals in Israel that specialises in treating eating disorders.
A: Eating disorders can often go undetected until they are quite advanced. This is both because the patient (and often the family) is inherently in denial that there’s anything wrong, and because patients make great efforts to hide their illness. Some young women with eating disorders are not necessarily alarmingly thin. The problem is not their objective weight. The problem is that it can be so difficult to spot the symptoms. The most obvious signs are an unending diet, obsessive restriction in calorie intake, and complete avoidance of carbs or fats.
A: There can be. Some young people develop an attitude toward eating that might be described as religious: assigning moral or spiritual virtue to avoiding unhealthy or calorie-dense foods, or food in general. The person’s sense of self-value revolves around eating or avoiding eating, and around losing or gaining weight. Food becomes an obsession, both in thought and in action. Patients can develop rituals around preparing food, serving food to others, collecting recipes, eating according to self-made sets of rules and avoiding eating in front of other people.
A: Starvation begins to affect a person’s physical health. Usually, the family physician will refer a patient to us based on physiological symptoms: weakness, unexplained fainting spells, quickened pulse, hair loss, complaints of feeling cold, tingling in the extremities, stomach-aches, or menstrual irregularities. The patient often does not make a connection between these symptoms and malnutrition. It can be even more difficult to identify the disorder with boys, since society rarely makes the connection between independent and self-sufficient teens and a mental disorder. But it is not only physical symptoms that raise the alarm. Patients are referred to us because of emotional symptoms. A teacher or counsellor may report that the girl is isolating herself, suffers from mood swings or shows no interest in social activities.
A: An eating disorder is essentially a struggle over the life of someone whose distorted thinking prevents them from understanding how much harm they are causing to themselves. Even patients who understand how serious their situation is and who want to be healed, find it hard to break their obsessive patterns of behaviour. Many of the patients who arrive at Mayanei Hayeshua are in an advanced stage of the illness. Their desire to continue losing weight is paramount. When we have no choice, and we assess that the patient’s life is in danger, forced hospitalisation can sometimes be the only solution.
A: Our policy is—wherever possible—to actively involve parents in the healing process, at all levels, psychiatric, physical and spiritual. It is helpful that in the religious community, children tend to defer to the authority of their parents, who also provide the necessary support and encouragement. We are seeing phenomenal success specifically when we can work with the parents. Similarly, we experience excellent cooperation with schools. One of our 7th grade patients goes to the teacher’s room every day at the 12 o’clock recess and drinks her nutrient formula in front of the teacher. At Mayanei Hayeshua, we are not just reactive. We proactively organize outreach lectures and educational programs for worried parents in order to raise public awareness, to help families watch for tell-tale signs and to send out the message that anorexia is treatable.