The Documentary “Thin” and the Treatment Loophole

Thin

If you know eating disorders, then you know the 2006 HBO documentary Thin, by Lauren Greenfield.

The documentary follows four young women receiving treatment for anorexia and bulimia in a residential facility. Many of us with eating disorders know Thin for somewhat macabre reasons. Like other depictions of the illness (film, literature, or otherwise), the film served as a kind of “how to” guide, with little tips and tricks that hadn’t yet occurred to us.

(That is disturbing, I know — but keep in mind that we are talking about a mental illness here.)

I watched the film four or five years ago, although I don’t remember how I discovered it. I found it morbidly fascinating at the time — probably because it practically mirrored my own life, although I had yet to admit that to myself, let alone to anyone else.

I had no intention of watching the film ever again. I know myself — I am easily triggered by depictions of eating disorders.

But last week, I was browsing HBO Go for something to watch while my husband was working a night shift, and there it was.

I froze.

Do NOT watch it, Jo. This is a dumb idea. SO, so dumb.

And yet, I felt I had to watch it — but not to relive the experience of being sick with an eating disorder. Thin is set at The Renfrew Center of Florida (Coconut Creek). I went through inpatient treatment at The Renfrew Center of Philadelphia (Spring Lane). It can be difficult to reflect back, simply because it was such a painful period. But now I could watch it with eyes 18-months-removed from the experience. It seemed as good a moment as any to revisit that episode of my life.

So, while politely acknowledging the voice in my head urging me to shut it down, I clicked play.

Glamorizing? Hardly…

Amazingly, I was not “triggered” at all by Thin this time around. I was surprised by this not only because I have a very hard time seeing depictions of eating disorders, but also because the film has been criticized by some in the eating disorder community for creating an allure around eating disorders, perhaps even glamorizing them.

I know allure when it comes to this illness. Allure is that strange magnetic quality that keeps anorexia clinging to me like a stray piece of plastic wrap. It’s the thing that I can’t seem to reason, coax, or threaten away. So, believe me, if there were anything even the least bit “alluring” about these illnesses snuck into this film, I would be the first to pick up on it.

I was not allured. Fascinated, yes, but not allured. It was just too real. Every detail — the cups used at meals, the 5 (for us, 4) AM weights and vitals, the team meetings, the nutritional supplements, the needles and tubes and wheelchairs, the boredom, the landline telephones, the community meetings, the feelings-sharing, the counselors who looked to be fresh out of college…

And the food — oh my god, the food. So much food. Too much food. I felt I wouldn’t make it another day having to eat like I was eating. I was making up for lost time, though. I had to repay my body all that I’d stolen over the years. Organs that needed fat, hair that had to grow back, a pulse that needed to jump back to life.

I watched the girls in the film doing all these things in treatment and that pulse of mine got even quicker. I was not allured. I was horrified.

Obviously, I can’t generalize what I’m saying to all people in recovery. In fact, I don’t recommend trying this out. But what I can say is that it afforded me an insight that I’ve been struggling to reach on my own. It showed me in no uncertain terms the abject misery that is an eating disorder. The girls in the film were not promising young women with dreams and goals and passions. They were ghosts. And I used to walk among them.

The Treatment Center Loophole

And now the more controversial (but I hope not ungracious) part of this post…

The film does not paint a pretty picture of Renfrew. It makes the treatment seem demeaning, the staff disdainful and condescending, and the atmosphere infantilizing.

Let me say this first — I feel immense gratitude for that place. Renfrew saved my life. To this day, the therapist I had in the NYC day program remains one of the most influential people in my recovery process (together with my outpatient therapist, of course, who has been in this with me for two and a half years now).

Moreover, it took me well over a year to finally write about this topic, because I am not trying to be critical of Renfrew, nor am I implying that it is a bad treatment center. In the last 30 years (it was the first residential facility in the country, by the way) it has helped thousands of women recover from eating disorders, trauma, and other issues. Many of us would not be here today without Renfrew.

But Renfrew is not without its shortcomings — and I believe these are the same shortcomings that belong to many large treatment facilities that are responsible for the lives and wellbeing of hundreds, even thousands of patients. One in particular is the “treatment loophole” that we see the Polly fall through in Thin, and that I saw swallow some of my own friends in treatment. I hit it too, in fact — this loophole was the back door through which I ultimately had to leave Renfrew.

What is the loophole? This loophole appears when the staff and therapists become too tangled in policies and procedures to notice the patients slipping through. It is the gap between stringent adherence to rules and a respect for the complex human being whom these rules are meant to serve.

In Polly’s case, this meant getting kicked out of the facility after a few minor (at least to me they seemed minor) infractions, such as getting a tattoo while out on pass and smoking in her bathroom. Infractions, for sure — but serious enough to warrant expulsion? To be the deciding factor in a matter of life and death?

Polly relapsed shortly after her discharge, and she passed away in 2008.

Of course, who knows whether a different ending to this particular inpatient stay would have made a difference for Polly in the end. Hindsight is 20/20. What I do know is that when you are cut loose by a group of people in whom you’ve placed your fragile trust — and who assure you that you aren’t alone in this battle — it’s pretty damaging. It feels like abandonment. It carries the unspoken message that you are beyond help.

I know nothing about Polly’s situation beyond her portrayal in Thin. But I did see friends of mine get prematurely discharged from treatment. As we all know, treatment facilities operate on different levels of care — residential, partial hospitalization, intensive outpatient, and outpatient — depending on the severity of the illness.

Often — very often, actually — patients struggle at the level they’re on. (E.g., not gaining weight quickly enough, or overall symptoms being too severe.) In these cases, we would receive a warning or two (three, if you were lucky) that if you didn’t improve, you would have to be moved to the next higher level of care.

That makes sense. The problem is that many patients cannot move to higher levels of care for logistical reasons (the most common of which is that insurance will not cover them). And yet, for whatever reason, that rarely factors in to the decision. If a patient is too sick for a particular level of care, then she has to leave. If she can’t find a way to that higher level of care, she’s given a list of referrals to support groups (and it’s her responsibility to contact them).

Perhaps this move is supposed to be a hint of “healthy” intimidation, a lesson in how much responsibility one must take for her own recovery. Perhaps it is born of the legal implications if a center were to remain responsible for a high-risk patient. I don’t know. I’m not a clinician, and I don’t know how to run a treatment center. But personally, I find it baffling that this situation can happen at all, to say nothing of the frequency at which I saw it happen. I understand that rules, policies, and procedures are in place to keep patients safe. But what about factoring context into a patient’s treatment? Why is it okay to discharge a sick patient to no care whatsoever (because if she’s too sick for PHP, she certainly won’t be allowed into IOP) simply because she is not well enough for one level and doesn’t have the means to go to the higher level?

Through the loophole

My Renfrew journey ended in a similar fashion. I discharged from the intensive outpatient program in June of 2014. At that point, I had been in treatment for six solid months. In the weeks before my discharge, I began to struggle a lot. I’d found it difficult to adjust to the IOP program and to being back at work. But mostly, I was simply worn out — treatment fatigue, through and through.

I told my IOP therapist that I was beginning to think that the program was no longer helping me, and wondered whether I should just discharge to outpatient treatment. I had said this believing it would open a discussion, but apparently my therapist agreed wholeheartedly. I was discharged within a week.

Within two months, I’d relapsed. I called my IOP therapist and asked if I could return to treatment. Now that I’d spent some time away, I said, I felt that I would be able to put renewed energy and effort into the recovery process.

The response was a strictly-business email saying that, given my reasons for discharge in June, it would not be appropriate to readmit to Renfrew at that time.

I panicked. I called and begged them to reconsider. Then I called and begged for recommendations to a program that would take me. But the decision was final and that was the end of it. I was no longer within the purview of their care.

Ultimately, this rejection was the proverbial blessing in disguise. I admitted instead to Monte Nido, and, twice now, I’ve had remarkably helpful experiences there. Their philosophy of full recovery was water for my parched spirit. I’ve felt continually supported by the EDTNY community and know that I will always be welcomed back if ever I need the support.

So, in the end, I’m grateful that the Renfrew snafu occurred. But it took a long time to accept what happened and to work through the abandonment and trust issues that it aggravated in me. To me, what that rejection meant was that I am, in fact, alone in this fight. It meant that I would be supported and encouraged only to the extent that I do things the way I’m told to do them. It meant that I was beyond their help.

I have to wonder whether Polly, too, took in these subtle messages.

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