People ask me what are my sessions are like and how long it takes to get a result. Well, it depends. Here is a vignette of a three-session case that took two months from beginning to end.
Setting the stage
A father called about his 14-year-old daughter. His first stated concern was maybe his daughter had a sensory issue in her mouth. After his description, my thought was that this child might need a feeding therapist to mediate sensory issues. Father did not want a feeding therapist. He said he was not clear. The real issue, he thought, was that his daughter did not eat vegetables. I told dad that it would be a healthier practice if his daughter, Mary (not her real name), ate vegetables. Vegetables have a bitter taste, I told him, that some people simply do not like. Some of these flavors come from sulfur compounds. These compounds prevent cancer and other illnesses. Sulfur compounds, such as isothiocyanates in broccoli, are health powerhouses that taste bad to some people. I wondered, if there was an eating disorder or another problem that, for some reason, could not be disclosed over the phone. We made an appointment.
Act One: Getting to Know You
Mother and Father came along with 14-year-old Mary. You could feel their mutual affection. Once we settled in, Mom and Mary sat close together holding hands with their feet touching each other. The young lady had beautiful features, skin and long, healthy hair. Her goal, she said, was to look like her other, equally pretty, female friends. She stood up and showed me photos of her apparently slimmer friends on her smart phone. They seemed to have healthy weights for their heights. Mary was not concerned about vegetables, it seemed. To meet her appearance goal, she wanted to lose weight. She also told me that she liked my striped socks. The socks, she said, showed that I had personality. We connected. To level the playing field, I restated to Mother and Mary what I told Dad about bitterness and vegetables. Meanwhile, I forgot that this was June: beach season’s beginning. A healthy 14-year-old girl might have concerns about her appearance in swimwear. Despite Mary’s concerns about her appearance, a local male heart throb, she told us, had asked her out.
Mary ate dairy, meat, carbs, fruit, as well as junk food snacks. Her parents ate vegetables so there was modeling. She did like edamame, young, fresh and bland soybeans frequently served salted in their pods. The parents were both at an appropriate weight. Mom was well toned from routine workouts.
I kept looking for hints of a feeding disorder. None appeared. Mom and Dad stuck to the vegetable story. I still suspected some problem. When a person avoids an entire category of foods, they can be classified as a problem eater. Another strategy, though, is to avoid giving a problem a name. Providing a name for problems creates a fixed notion in some people. Clinicians who avoid labeling prefer to look for ways to change things. Dad, in his attempt to change Mary, once tried to bribe Mary with an iPhone if she ate some vegetables. She tried some and regurgitated. Her parents became upset. In my view, her response to the bribe could be seen in a positive light. I told the family that Mary was in touch with her body. The fancy phone could not subvert Mary’s connection to her body. People with eating disorders have lost touch with their body, hunger and satiety. Here was more of evidence that I did not have to suspect a feeding disorder.
The two main reasons to eat vegetables, I told the family, are antioxidants and phytochemicals. Antioxidants give fruits and vegetables their colors. Simple nutrition advice is to eat a rainbow of colors. Following that advice helps us obtain all kinds of antioxidants. Vegetables, however, are especially notable for potent phytochemicals, such as the sulfur compounds that make foods like broccoli nutrition powerhouses. Mary consumed plenty of antioxidants in fruit. She was not getting all the phytochemicals found in vegetables. Broccoli, is a member of the family of cruciferous vegetables that include brussels sprouts, cabbages, cauliflower, collards, kale, mustard greens, and watercress. For those of you who also do not like vegetables but like mustard, mustard seeds like their greens, also contain isothiocyanates which give mustard its tasty bite.
For the first session, I brought along bottles of commercial, iced green tea. One made with hibiscus and one green chai latte. Green tea is rich in catechins, phytochemicals that protect the heart and lung. Chai teas are made with herbs and spices such as turmeric, which is another phytochemical star due to its anti-inflammatory power. Mary took some tentative sips. After seeing that she sort of liked the green teas, I learned that Mary was willing to try and could try a vegetable product without revulsion. Taking the matter one step further, I informed the family that tea is a kind of vegetable soup. This soup of steeped leaves is so special, we gave it a special name: Tea.
We discussed trying dark chocolate, which contains flavonoids, linked to improved blood pressure, cholesterol balance and insulin activity. Mary was concerned about chocolate causing pimples. I reminded her of her conditioning and weight goals. She countered with the family’s plans to visit the M&M store in nearby Times Square after the session. Weight loss was not too high on the agenda. I had more evidence that she was not obsessed.
The family was given homework to try more black, green and herb teas and to enroll in a local gym. Mary agreed that if she toned up she would reach her appearance goals though her weight would remain the same. She agreed with the toning effect of exercise and agreed to join a local gym. Mom consented to accompany her.
Act II: Revelations two weeks later
Additional evidence of a willing and supported teen came at the second visit when the family reported on their homework. The M&M store visit was switched to a store that sold dark chocolate powder. Mary said the cocoa powder may have given her that pimple on her upper lip, though much evidence says there is no reason for her thought. I kept the research to the side for the moment. We can live without chocolate. Bravery is an essential, and I wanted to promote that virtue. Mary had gone to a tea shop and purchased 5 kinds of tea. She also enrolled at a local gym with her friends and completed a few days of workouts. I passed out some informed, popular articles on how some fruits and vegetables share antioxidants such as anthocyanins make the blue and purple in berries, red cabbage and onions. “Perfect bathroom reading” remarked Dad. He was relieved, looking back, to get the facts in writing.
The second visit was notable for two revelations. First was the announcement that Mary had hemolytic anemia, a potentially fatal auto-immune disease. Hemolytic anemia has no nutritional triggers. Possibly, this fear of a life-threatening uncontrollable event was replaced by an apparently controllable nutritional concern.1 Possible, too, that this deeper, hidden worry was behind the second revelation. Later on, Father blurted out, “You mean there is nothing wrong with my daughter?” “Yes.” I said, “there is nothing wrong with your daughter.” I reiterated in each session that adolescence is a time of change. Mary will likely go through many personality and taste changes as she matures. The element of flux, rather than fixity, entered the sessions continuing the theme of non-diagnosis.
Scientists have examined the dislike of bitter foods. Taste scientists opine that dislike of bitter flavors may have been a protective mechanism from an evolutionary perspective. Many toxins have bitter flavors. Two taste researchers recently concluded that for some people distaste for bitterness is related to a combination of genes and a person’s age. Adolescents who dislike bitter flavors go through a taste change in their early twenties.2 Inborn and social factors play a role in the acceptance of bitterness according to scientists. “Children’s heightened preference for sweet and dislike of bitter, though often detrimental in the modern food environment, reflects their basic biology.”
Act Three: Growing Up and Saying Goodbye
The final and third visit focused on vegetables, physical growth and a third revelation.
Mary’s diet lacked cruciferous vegetables, the ones rich in sulfur compounds. Since Mary and I had a good relationship based on a shared taste in socks, acceptance and trying new foods, I brought two new foods to try: (1) a commercial juice made with fruit and vegetables and (2) a very small plastic container of alfalfa sprouts. The commercial fruit and vegetable drink contained kale and its first ingredient was sweet potato juice. After the initial sips there was no gagging or revulsion. Unlike tea in the first encounter, which was sipped slowly, the entire 12 ounces was consumed rapidly except for a little taste shared with Father. I suggested that when Mary was with her friends, she could order a similar drink in a juice bar or purchase the juice she just enjoyed. In this way, Mary could slowly learn to tolerate more vegetable flavors in the worlds of her friends and family. Eating vegetables could begin to be a pleasant experience.
Drinking tea, they told me, had become a game, itself a kind of therapy. At home, they offered each other “vegetable soup” instead of calling the drink tea. Teacups became a small servings of vegetables with love as enshrined in the Book of Proverbs (15:17, NIV): “Better a small serving of vegetables with love than a fattened calf with hatred.” Teas and juices became a way Mary could share vegetables with her family and friends. Mary’s bitter stressor transmuted into a warm connector. Our work in the office could radiate to Mary’s volitional world.
Next, I passed out a set of growth charts to Mary and her dad. Mom was home that day. Mary’s weight was in the healthy range at about the 75th percentile for weight, and height. The charts revealed that Mary’s weight and height were at the 50th percentile when she was she was 10 and had shot up to the 75th when she was 12, a big jump. I wondered whether Mary had not quite adjusted to the change. I wondered if growing up and out was part of what was going on with her concern with her weight. She was getting tall like her father. Mother is really short. Accepting the father, a man and tall, and leaving the mother, short but still in the world of competing/joining with women. This type of concern that goes into the realm of psychoanalysis and is out of my domain. Yet, I still wondered about Mary concerns over her appearance and being liked by her girlfriends. Meanwhile, another local heart throb had asked her out.
We discussed trying cocoa powder again. Mary accepted an “and relationship” for her pimple and the eating of the dark chocolate powder rather than a causal relationship for that pimple on her upper lip. Meaning, that, perhaps, the pimple on her lip appeared, maybe, as coincidence with her first trying of cocoa powder. Yes, Mary had legitimate concerns about acne and concerns with her health. She could equally entertain a new kind of thought based on our trust in each other. Mary had also slacked off on the gym visits. Another sign she was not obsessing over her appearance, another sign of an eating disorder. We all smiled and shrugged.
Finally, I wanted to test how far we had progressed. I presented the alfalfa sprouts along with the fact that they were homegrown. Alfalfa sprouts are about one inch and a quarter long, fairly bland with two tiny green leaves. The sprouts contain phytoestrogens linked to cardio-protective and anticancer effects. Also in the sprouts are saponins, linked to improved ratios of “good” HDL cholesterol to “bad” LDL cholesterol. Saponins possess bitter and soapy flavors that repel insect pests. The saponin’s flavors are pretty much washed away in the sprouting process but might be apparent to someone sensitive to bitter flavors. To serve the sprouts, I brought along a small, flat bowl, the kind used for soy sauce in sushi bars as well as chopsticks.
Mary did not know how to use the chopsticks I also brought along. I brought the sticks in case touching the sprouts, the sensory delay raised by Father, existed for Mary. This was unlikely to exist because she ate fruit. We all ate some sprouts with our fingers, an impromptu “little kid” activity. Sprouts were new to Dad and Mary. They tried something new together, another connector. Mary tried one, then two. I ate some as well. We shared a meal of vegetables with no gagging or no vomiting.
My intention in bringing the small plate and little sprouts was to emphasize the smallness of the food. Looking back, I realized the session was about size and growing. Like Mary, sprouts are still growing, young plants. Before we began vegetables loomed large. Now Mary held the vegetable instead of the vegetable holding her and her family. Vegetables could now appear smaller.
Then, Father produced a third revelation: He did not like onions and garlic, other strong-tasting sulfur compound foods, until he finished adolescence. Maybe Mary’s dislike was the kind of genetic trait taste researchers discovered. Mary’s genes that could cause a fatal incident in her blood also united father and daughter. Biology, a source of fear, was also, in part, a connector. Fighting and fear were replaced by experimentation, jokes, knowledge and possibilities. Mary had sources of vegetables in her diet, and deeper connections. Doors for more experiences were open.
Dad declared our sessions over on the third visit. It would have been nice to have one more visit. We could have tried a small salad or one of Mother’s meat and broccoli dishes from her native Philippines. As we said our good-byes, I inadvertently continued the growing-up theme. “You are really tall,” I unconsciously uttered for my final words as our eyes met. Mary was sprouting. We had all worked together to find a way to minimize stress in the family and maximize Mary’s health in tune with her strengths.
1. Wedge M. In The Therapist’s Mirror: Reality in the Making. New York and London: W. W. Norton & Company; 1996.
2. Mennella JA, Bobowski NK. The sweetness and bitterness of childhood: Insights from basic research on taste preferences. Physiol Behav. May 20 2015.