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Eating Disorders: The Journal of
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The Venus Fly Trap and the Land
Mine: Novel Tools for Eating Disorder
Treatment
a
a
Laura L. Hill & Marjorie M. Scott
a
The Center for Balanced Living, Columbus, Ohio, USA
Published online: 26 May 2015.
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To cite this article: Laura L. Hill & Marjorie M. Scott (2015): The Venus Fly Trap and the Land Mine:
Novel Tools for Eating Disorder Treatment, Eating Disorders: The Journal of Treatment & Prevention,
DOI: 10.1080/10640266.2015.1044353
To link to this article: http://dx.doi.org/10.1080/10640266.2015.1044353
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Eating Disorders, 00:1–6, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1064-0266 print/1532-530X online
DOI: 10.1080/10640266.2015.1044353
HOW I PRACTICE
The Venus Fly Trap and the Land Mine: Novel
Tools for Eating Disorder Treatment
LAURA L. HILL and MARJORIE M. SCOTT
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The Center for Balanced Living, Columbus, Ohio, USA
INTRODUCTION
In the last decade, genetic and neurobiological research has increased our
understanding of eating disorders (ED), allowing us to view these illnesses
from the inside out, and pointing toward a new paradigm for treatment
(Frank, 2015). We now know that there are altered brain responses which
fire differently in persons with eating disorders compared to those who do
not have eating disorders (Kaye, Fudge, & Paulus, 2009).
Genetic research helps explain why some people have a higher vulnerability in developing ED over others, while neurobiological studies indicate
how the gene expression plays out in brain response (Steiger, Labonté,
Groleau, Turecki, & Israel, 2013). As we increase our understanding of
ED through the lenses of functional magnetic resonance imagery (fMRI)
and positron emission tomography (PET) studies, a new model emerges
that describes nature/nurture influences on ED, and lays a foundation and
framework for new ED treatment tools.
Neurobiological research describes where and how ED symptoms occur
in the brain. At our ED Center, nearly every patient and family member
report that upon learning these neurobiological findings, they feel less guilt
and increased relief that there is a biological explanation to this illness. It is
as important for families to learn this as it is ED patients, because whenever
possible the family plays a central role in supporting their loved ones and
can be a vital part of the solution, instead of the problem.
Address correspondence to Laura L. Hill, The Center for Balanced Living,
8001 Ravines Edge Court, Suite 201, Columbus, OH 43235, USA. E-mail: laura.hill@
thecenterforbalancedliving.org
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L. L. Hill and M. M. Scott
Metaphors are a wonderful tool to simplify complex topics, while simultaneously having the capacity to introduce novelty and hope to a painful
experience. Consider the Venus flytrap. It is a carnivorous flower that has
teeth-like projections on the top and bottom petals. When a fly is drawn
to the flower and walks into the depths of its petals, the flower closes and
devours the fly.
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NATURE/NURTURE MODEL
The Venus flytrap is a metaphor for the nature/nurture influences on
ED. The “teeth” on the bottom petal represent genetic traits that trigger
neurobiological alterations, increasing one’s vulnerability to develop an ED.
Each tooth is a different trait such as: perfectionism, avoidance or inhibition
anxiety, obsessionality, impulsivity, and competiveness (Kaye, Wierenga,
Bailer, Simmons, & Bischoff-Grethe, 2013).
Each tooth on the top petal is an environmental/social influence such as:
“be thin,” “eat only ‘healthy’ foods,” “be the thinnest,” “eat less than everyone
else,” or “exercise more than others.” The diet is the fly. As the fly lands on
a petal of the Venus flytrap and walks into the flower, the flytrap closes, thus
capturing the fly and consuming it. So too, as a diet becomes more restrictive,
the body becomes increasingly strained from too little energy intake, causing
self-destructive behavioral responses.
If there are several ED genetic traits or “teeth” in place, dietary restriction
triggers identified genes to “turn on,” creating a new level of brain and hormonal responses, “entrapping” thoughts and behaviors, and devouring the
body (Klump et al., 2010). As the Venus flytrap closes, a diagnosable eating
disorder has developed. The person is “locked” into destructive perceptions
of body image, feelings, and actions that confine daily life.
On the other hand, if the Venus flytrap had missing genetic or environmental “teeth,” the fly could maneuver its way out. In like manner, for those
who have fewer genetic precursors, or are not exposed to as many environmental triggers that encourage the diet to increase, the person is freer to
step away from the diet. The question becomes: how can those who have
been caught in the flytrap and held by a wall of genetic and environmental
teeth, get out? How does this metaphoric nature/nurture model inform new
treatment?
Psychotropic medications could “soften” the inside tissue of flytrap
petals, just as they impact neurochemical receptors allowing the person with
ED to have more cognitive and emotional strength to push harder from the
inside to lift the petal and fly away (Peterson & Mitchell, 1999). While some
medications may hold promise, they are not currently effective as stand-alone
treatments for most patients. The patient pushing alone with medication is
usually not enough to force the flytrap to release the fly. The environmental
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How I Practice
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and genetic teeth hold too much power without equal or increased force
countering the teeth-like hold. Since there is no proven device or mechanism to open the flytrap currently, it must be opened manually. “We” need
to push and pull from the outside of the flytrap to “pry open the petals,”
while the patient pushes from the “inside.”
The “we” is key in ED treatment. The ED treatment team needs to
actively broaden its forces. It is usually not enough for a clinician to treat
ED patients solo and assume the Venus flytrap will open with ease. Even a
multidisciplinary treatment team is sometimes not enough. Whenever possible, the “we” needs to include the family, so as to have the team pushing
from the outside while the medication and patient with a detailed meal plan
push from the inside in a combined effort to pry open the flower together.
In order to keep the patient from becoming exhausted or wanting to
give up, we need to be more specific, directed, and detailed. The patient
cannot see the larger picture when entrapped, nor identify where to push,
how much, and when. The family and treatment team can do for their loved
one what the patient cannot do for him/herself. We need to push, pull,
and maneuver in coordination with the patient to help him/her squeeze
through or bend the “teeth” or pry open the petal to crawl out. Otherwise,
the patient becomes discouraged or upset and the family steps back. In most
cases, the family members appreciate detailed ED information and desire
neurobiological tools to help inform their actions.
THE LAND MINE ACTIVITY: NEUROBIOLOGICALLY INFORMED
TREATMENT TOOL
New neurobiological treatment tools are needed for clinicians, families, and
patients to use in the process of recovery. The tools should help the family
and patient more fully understand how the brain responds when one develops an ED and when one is trying to escape its entrapment. Brain circuitry
responses have been identified and inform us of pathways that are underand over-firing compared to those without ED (Wagner et al., 2010), providing the team (clinical, dietary, medical, family, patient) with opportunities to
develop creative methods to pry open the Venus flytrap and maneuver out
together.
Hunger and fullness signals in the insula appear to be under-firing or
not firing at all as the illness progresses (Kaye et al., 2013). The person
with an ED comes to the table with low to no insular signals which provide
interoceptive awareness of hunger and fullness, and at times taste. There
appear to be reduced signals of pleasure from eating for those with anorexia
nervosa (AN), and the same after the first few bites for those who binge eat
(Stice, Yokum, Blum, Bohon, 2010; Wagner et al., 2010). It could be said
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L. L. Hill and M. M. Scott
that a person with ED is “blind” to eating due to reduced activity in these
specified brain areas.
How can a person approach a meal if these basic sensations are not
firing well enough to know what, how much, and when to eat? In addition,
it appears that thoughts become a loud, noisy, chaotic cacophony of indecision: “Should I eat this?” “What do I do?” “Eat it all?” “Vomit later!” The
metaphor rises again to serve as a heuristic tool for action to help patients
and their families explore ways to compensate for areas of brain “blindness”
in ED. Our group has developed a new tool with input from ED patients,
families, and other support people called the “Land Mine Activity.”
This tool can be administered with a group of ED patients and is best
experienced with both patients and their families or other support people.
The families experience what it is like to move through and complete a meal,
while blindly walking through a field of eating disorder “land mines.” To
begin, the patient is asked to stand on one side of the room. The opposite
side is identified as the completion of an unplanned meal. The patient is
then asked to share with the group the thoughts, feelings, and ED urges that
typically get in the way of completing the meal. Peers and family members
in the group are assigned to be the voices of the identified thoughts and
feelings.
The patient is told to close her/his eyes, to mimic areas of brain blindness while walking through the field. The patient is informed that all the
“noise” or thoughts/feelings about the meal and body size are going to
be yelled continuously as s/he walks forward. After the patient’s eyes are
closed, but before s/he begins to walk, objects are placed on the floor randomly (books, balls, any object in the room that could be stepped on). If the
patient steps on, or touches, one of these land mines, all noise ceases and the
patient steps back five steps. The reversal in steps represents acting on an ED
behavior; and the quiet represents the relief from the mental noise. As the
patient begins walking forward through the field of land mines again, the
mental noise begins again. The goal is to get through the field of land mines
while ED noise is being shouted. Patients win the game if and when they
navigate through the field of land mines, meaning they complete the meal.
Experimentation is necessary in this game, as in life. At first the “blind”
ED patient usually tries to walk through the field of land mines alone, only
to realize it is nearly impossible to get through the field or unplanned meal
unaided. After several tries, when the patient realizes s/he cannot do it alone,
s/he is asked, “What do you need to get through the land mine field?” S/he
almost unanimously chooses to seek support. This validates the central role
of the family in maneuvering around the land mines. The therapist instructs
the patient to specifically identify who s/he wants for support to get through
the field.
Once support is identified, the patient is asked to instruct the family
members, “What I need from you is . . .” ED patients report a range of needs,
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How I Practice
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from asking for words of encouragement as they walk, to asking family members to guide them with clear instructions around the land mines. Families
have responded by offering the requested methods of support, relieved to
know what their loved one wants and needs. Some family members have
tested additional creative responses such as holding their loved one’s arm
or stepping in front of the land mines themselves. One mother and father
actually picked their adult loved one up and carried her over the first few
mines.
After getting through the land mine field, reaching the goal of completing the meal, the patients and family members are asked to describe their
feelings and experience. The therapists draw upon their answers to identify
individualized actions that can be applied during meals at home that were
playfully experimented and acted out. The patients often realize that the key
is to keep going, to move forward, as awkward and difficult as it may be, in
order for them to push through the “teeth” of the illness.
It is recognized early in the game that stepping on land mines is
inevitable, just as an ED behavior is expressed when challenged with many
unknowns. In many ED cases, there appears to be no easy way out through
the hold by the genetic and environmental teeth alone. If possible, having
a united force with the family and clinical team results in greater power to
maneuver WITH the patient through the ED urges.
SUMMARY
In summary, a new paradigm is emerging that explores the nature/nurture
model of eating disorders. It acknowledges and actively applies new
neurobiological findings to transform treatment into individualized actions
that involve the patient, family, and the multidimensional treatment team.
Traits are constant throughout life, as are the teeth of the Venus flytrap.
Traits that have contributed to ED are not eliminated but transformed by
pushing and pulling them to bend and shift from self-destructive traits to
“teeth that bite into life activities,” in order to eventually engage in work and
a life with purpose beyond the ED.
Currently, it appears nothing less than active involvement of the family along with the patient and the treatment team, together pushing and
pulling through the teeth, will lead to eating disorder recovery. The Land
Mine Activity is an example of an experiential treatment tool founded on
concepts from neurobiological ED research. It provides an opportunity for
the patient to identify what is needed while the family can walk beside their
loved one in a playful game and explore how to maneuver around cognitive
and emotionally painful reactions to food, eating, and body shape. On a
larger scale, it is not just the patient and family that are transforming their
responses in this new treatment approach; the entire eating disorder field is
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L. L. Hill and M. M. Scott
transforming its overall paradigm as it integrates new neurobiological and
genetic findings into a more comprehensive and balanced approach to this
illness.
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REFERENCES
Frank, G. K. (April 2015). Recent advances in neuroimaging to model eating disorder neurobiology. Current Psychiatry Reports 17, 559. doi:10.1007/s11920-0150559-z
Kaye, W. H., Fudge, J., & Paulus, M. (2009). New insights into symptoms and
neurocircuit function of AN. Nature Reviews Neuroscience, 10, 573–584.
Kaye, W. H., Wierenga, C. E., Bailer, U. F., Simmons, A. N., & Bischoff-Grethe, A.
(2013). Nothing tastes as good as skinny feels: The neurobiology of anorexia
nervosa. Trends in Neurosciences, 36, 110–120.
Klump, K., Burt, S. A., Spanos, A., Mcgue, M., Lacono, W., & Wade, T. (2010).
Age differences in genetic and environmental influences on weight and shape,
International Journal of Eating Disorders 43, 679–688.
Peterson, C. B., & Mitchell, J. E. (1999). Psychosocial and pharmacological treatment of eating disorders: A review of research findings. Journal of Clinical
Psychology, 55, 685–697.
Steiger, H., Labonté, B., Groleau, P., Turecki, G., & Israel, M. (2013). Methylation of
the glucocorticoid receptor gene promoter in bulimic women: Associations with
borderline personality disorder, suicidality, and exposure to childhood abuse.
International Journal of Eating Disorders, 46, 246–255.
Stice, E., Yokum, S., Blum, K., & Bohon, C. (2010). Weight gain is associated with
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13105–13109.
Wagner, A., Aizenstein, H., Venkatraman, V. K., Bischoff-Grethe, A., Fudge, J., May,
J. C., . . . Kaye, W. H. (2010). Altered striatal response to reward in bulimia
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