Family on the Front Line
Excerpt from The Parent's Guide to Eating Disorders
by Marcia Herrin, EdD, MPH, RD and Nancy Matsumoto
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How Families Can Help
The approach that I use in my practice of treating childhood eating disorders is to have parents highly involved in treatment, along with the pediatrician and psychologist who work closely with me. I consider hospitalization a last resort when all else has failed.
What I see most often is parents who want to help but have no idea how to do so, and children who want to give up their eating disorder but are equally mystified as to how to go about it. I warn parents that while they must be prepared for recovery to take months of hard work, success is likely if they take the following suggestions and guidelines to heart.
Stop Blaming, Move Beyond Anger
Despite the trend among therapists to blame parents less for their children's eating disorders, in most cases, parents do blame themselves for the problem. They worry that they have been too strict or not strict enough, too critical or too lax, too inattentive or too smothering.
Our advice is that rather than focusing on what you as parents have done wrong—an unproductive pursuit that ignores the complex tangle of genetic and environmental factors behind most eating disorders—let's talk about what you can do right. What can you do to help your child recover or protect your child from engaging in an eating disorder at all? If you focus on blaming yourselves or each other for things you have done in the past, you will have neither the spirit nor the energy to make positive changes in the present.
Your focus as parents should not be, "What did we do to cause the eating disorder?" but instead, "What are the factors that are perpetuating it, and how can we change or eliminate them?"
It is important to remember that your child has not chosen to have an eating disorder, even though they may have set the stage for it by dieting. Remembering this will help you to focus less on blaming yourself or the child for bringing on a seemingly frivolous disease (eating disorders are far from that), and help you to concentrate your energy on quickly attacking the disorder and turning it around.
You also need to move beyond the anger and exasperation that accompany blame. There is evidence that families in which parents make critical?comments to their child during recovery have a reduced chance that recovery will occur. Supportive, noncritical parenting is a key factor in turning around an eating disorder.
Establish a United Front
As parents, you will be more effective at helping your child overcome an eating disorder if you have worked through conflict, poor communication, and any inconsistencies between yourselves. If you are divorced, separated, or struggling in your marriage, this may be difficult. Sometimes the best strategy in such situations is to put your own problems on hold and focus on your child's eating disorder first. As your child's disorder begins to improve, you can begin to address your own marital problems. This is not impossible; I have seen parents who have worked well together in dealing with an eating-disordered child, despite their own marital problems.
As you work out a plan for solving the eating disorder, you may have to inform relatives or close friends so that they do not undo your hard work with a thoughtless comment or action.
The Role of Siblings in Recovery
In families held hostage by an eating disorder, sibling relationships can either be a negative influence on the eating-disordered child or a positive one. With a little guidance from you, your non-eating-disordered child can serve as a powerful ally.
My patient Susan's older brother, Rob, believed that if Susan just went on a diet and exercised, she would lose the weight she had gained from her bulimia. Every time Rob delivered his "lecture," Susan felt devastated because those strategies were the very behaviors that triggered her eating disorder in the first place. Rob's mother had to intervene and told him, "Stop. It is not okay to talk to Susan about these things. We are working on reversing her disorder in the most effective way possible, and your comments are not helping. It will take time. What you need to do is just love and appreciate Susan as she is and keep quiet about her weight and appearance." Parents have to be particularly firm about sibling comments. It must be made absolutely clear that siblings are never ever allowed to tease a sibling about their weight. (See pp. 201–02 in Chapter 10 for more on the Maudsley approach and siblings' role in combating an eating disorder, and p. 97 in this chapter for more on protecting siblings from a family member's eating disorder.)
Don't Forget to Take Care of Yourselves
If you are depressed, exhausted, or feel guilty, you may not be the best parent to help your child recover. I know parents who have developed an effective "tag-team" approach in such situations. After a month of being on the front lines feeding her anorexic daughter, Jeri was feeling completely worn out and demoralized, as well as guilty that her daughter, Kia, was not making more progress. Jeri and her husband, James, decided that James would take over supervising Kia's eating, at least at dinnertime. Kia told me that though she loved her mom and felt she really understood her food issues, her dad's matter-of-fact approach was refreshing. "Dad doesn't take it personally like Mom does when I struggle," Kia told me.
Jeri, who was truly exhausted, benefited from seeing a counselor herself, who helped her sort out her feelings and develop a more productive outlook.
Establish a Collaborative, Not Conflictive Relationship with Your Child
Once you have achieved a more positive frame of mind, you can turn to figuring out how you can collaborate with your child to devise an effective recovery plan. Parents can usually be most helpful at mealtimes at home. Is your child eating? Missing meals? Purging after them? (See Chapters 10 and 11 for methods of monitoring these issues in a productive way for more on the Maudsley approach and Parent-Assisted Meals and Snacks [PAMS].)
I have found that when I ask an eating-disordered child what her parents can do to help out, she often has definite ideas. She may suggest that they keep certain foods in or out of the house, fix her plate at dinner, ask if she is hungry when she reaches for thirds, or limit the amount of television she can watch if lack of exercise is a problem. What always surprises me is that even very independent children, when asked in a nonconfrontational way how parents can be helpful, can come up with practical and innovative methods.
I find that some children or adolescents initially insist they can solve their problems with little parental involvement. Although parents may be skeptical, I encourage them to give their child a chance to do this. Be ready, however, to step in if your child is not successful, without saying, "I told you so."
Collaborate, Don't Collude: You As Parents Are Ultimately in Charge
While we have emphasized the collaborative nature of the ideal recovery, this is different from colluding with your child to keep the disorder going. It is important that as parents, you are in charge of eating and food issues in the home. If you have not been before, you need to be in charge now. You should still take into account your child's likes, dislikes, even fears; but make it clear that you are ultimately in control of buying and preparing food.
The story of one of my patients, Marcy, illustrates what can happen when parents let a child's eating disorder dictate food choices. Marcy's eating disorder is one of the most medically serious types: anorexia complicated by bingeing and purging. Her agreement with her parents was that she would eat only food that she purchased with her father. At first, she chose only healthy foods. As her eating disorder progressed, however, Marcy began buying more and more bread and gallons of ice cream to binge on. Her father had by then become so intimidated by the eating disorder, and so afraid his daughter wouldn't eat enough if he tried to restrict her purchases, that he looked the other way week after week as her shopping basket overflowed. Meanwhile, Marcy's purging increased, leaving her malnourished, worn out, and guilt-ridden by the endless cycle of bingeing and purging.
Marcy refused to let any other family member touch or eat the food she bought. Before she began working with me, Marcy's family had let her disorder get so out of hand that they had rented a separate apartment for Marcy and her father. The family's hope was that, isolated from the rest of the family, Marcy and her father could focus on her eating problems and bring them under control. Instead, the apartment became a storehouse for binge foods and virtually a private setting in which Marcy could binge, purge, and overexercise.
I advised Marcy's family to give up the apartment and get her room ready at home. Her parents began to insist that she eat with the family, allowing her some choice in what she ate, as long as she had a balanced meal. An eating disorder as serious as Marcy's can take years to overcome, but she is slowly making progress with substantial professional help.
One caveat about establishing control: When it is necessary for you as parents to get involved in and even control your child's food intake, it is important that you take care that the controlling does not extend to other areas of your child's life, such as friends, clothes, and after-school activities.?By interfering in those areas, you leave your child no room for self-expression or independence. Any credibility that you had in the area of food monitoring will be shattered as your child grows resentful and more rebellious at what she perceives as a gross breach of reasonable boundaries. She may, in fact, even turn with a vengeance to her disorder, in part, because she knows this is one way to really "get" to you, her parents.
Remember, the reason you have taken over food decisions is that the eating disorder has temporarily rendered your child incompetent in this aspect of her life, not in every aspect.
Having given you advice on one way to avoid eliciting a rebellious reaction from your child, I must now tell you that some amount of rebellion is almost inevitable. As you work on these concrete goals and actions, all designed to bring about a speedy recovery, it is important to remember that you are dealing with a child or an adolescent, which means that rebellion and testing limits is normal. Most children express their natural rebellion toward parents because they are handy. Although it is hard, I constantly remind parents that they need to remember this, and to separate their child's natural rebelliousness from the eating-disordered behaviors that they are trying to eradicate. You should be quite surprised if your child does not rebel and resist your attempts to turn the eating disorder around.
When your child resists help, she is not deliberately being difficult; it is her fears that are causing her to act this way. The eating disorder has served as a coping mechanism, and you are threatening to take it away, which is a frightening prospect.
I try to help parents reframe their understanding of their child's resistance to change and rebelliousness, to see that it originates from their child's fears. Most parents find it easier to feel empathy for a child who is fearful than for a child who is rebellious. Addressing the fear rather than the rebellion can positively change the dynamic between you and your child, making you more clearly an ally of your child's rather than an enemy.
If you have agreed on a specific plan of action and your child strays from it, it is wrong to conclude that the child is disobedient. It means that the eating disorder is very strong. It may mean that the food or exercise plan you have agreed on is beyond what your child is capable of at this point, or that you need to be more involved. (See Chapters 14, 15, and 16 for more on these plans and Chapter 10 for more on the Maudsley approach.) If a second attempt at a renegotiated plan fails, you may want to reassess the situation and add professional help.
When parents take on the role of monitoring a child's eating, it is important to try to be flexible in your thinking about what "healthy food" is. I find that most people are far too rigid in what they find acceptable and what they find unacceptable. (See Chapter 8 for more on how parents can improve their family's approach to food.)
It is especially important to be flexible in the area of fears that your child may have about specific nutrients and foods. The most common example is fear of high-fat or high-calorie foods. Here, it is important not to be too rigid, but to realize that your goal, at first, is to get your child to eat, not to quibble about the quality of the foods she eats. I often see parents who squander valuable negotiating capital by insisting, for instance, that their underweight child drink whole milk instead of skim milk. The frequent consequence is that the child refuses to drink any milk at all, thereby, missing out on the calcium, protein, and other vitamins and minerals found in any kind of milk. Or the child will drink the whole milk but feel misunderstood and bullied into doing something she doesn't want to do. A similar dilemma occurs when a child chooses diet sodas over regular sodas. Since skim milk and diet sodas are widely consumed by people without eating disorders, it usually is not productive to ban these products from a child's diet unless she grossly overconsumes these foods and is not making progress in her recovery. (For a fuller discussion of diet sodas, see pp. 251–52.)
My patient Cecilia is one example of an anorexic whose extreme overconsumption of a diet product makes her an exception to the rule of flexibility. Cecilia was compulsively drinking six liters of Diet Coke per day and refusing to eat when her parents first called me. Her doctor was concerned about the stress that such an overconsumption of cold liquid placed on her already weakened body and worried that it would reduce her low body temperature to even more dangerous levels. Cecilia didn't feel hungry with so much fluid running through her body, which made changing her eating habits all the more difficult. The caffeine also gave her a manic sort of energy that ideally would have come in a more productive form from the consumption of calories.
My advice to parents, in other words, is to let your child have as much control as possible within the framework of the regular and healthy eating that you are trying to establish. Another example of this flexibility is not to insist that your child eat steak, but to insist that he have some protein for dinner. What kind will it be? The family is eating steak, but there is cheese and cottage cheese in the refrigerator, and tuna can easily be provided. It is important that you don't do too much catering, but that you provide food that meets your child's needs, and which he feels able to eat.
While some flexibility in thinking is necessary, you can also ask more of your child as his recovery progresses. At the beginning, it is more important that he eats enough rather than what or where he eats. While your child may begin his recovery refusing any higher-fat foods, your eventual goal should be to help him achieve a confident, no-fuss approach to eating that includes a variety of foods, from high fat to low fat.
With bulimic children, parents need to keep an open mind about what foods are "acceptable" for the recovering child. Bonnie, who developed bulimia after a summer at sleep-away camp, liked having a donut and a cup of hot chocolate after school. Although Laura, Bonnie's mother, would have preferred Bonnie eat a healthier snack, she knew that if Bonnie had to sneak her donut and hot chocolate, she would be more likely to eat two or three, or even more donuts, and overdo it on the hot chocolate as well. Laura decided to allow this snack for now and slowly encourage Bonnie to switch to more nutritious choices.
Progress in other areas, such as the settings in which your child is able to eat, should be similarly gradual. My patient Josie began to win her battle against anorexia by eating the meals her mother had prepared for her in the TV room. At the beginning of recovery, it is not uncommon for anorexic patients to feel hesitant to eat in front of others. Remembering early on the principle that eating enough was the goal, Josie's parents allowed her to eat where she chose. As she gained weight and felt better, they gently insisted that she eat one meal a day with the family, which she did. Over the course of a month, she went from eating no meals with her family to eating all of her meals with them.
Josie is an example of a child who made progress after a fairly simple change in her routine. If she had not improved, or if her recovery had stalled, we would have recommended adopting the Maudsley approach or Parent-Assisted Meals and Snacks (PAMS). (See Chapters 10 and 11 for more information.) The sooner the better, too, because the longer parents wait after anorexia becomes severe, the more entrenched the disorder can become.
Fight the Disorder, Not Your Child
If you find that it is difficult to be firm, remind yourself that you are not fighting your child, you are fighting the eating disorder. One technique, which may sound strange but is particularly helpful, is to think of the eating disorder as an outside force trying to lead the child astray, for example an evil twin.
Dashika, one of my patients, named her eating disorder "Ed." At first, I didn't get the connection. "Why Ed?" I asked her. Dashika replied, "Duh! Eating disorder—E D." She felt she could hear Ed whispering things in her ear that made her afraid to eat certain foods and even to binge. A good portion of Dashika's sessions were devoted to developing retorts she could use to put Ed in his place. Several years after this conversation with Dashika took place, my good friend Jenni Schaefer wrote an inspiring book called Life Without Ed: How One Woman Declared Independence from Her Eating Disorder and How You Can Too. I often give this book to patients.
The goal for children who take to personifying their eating disorder is to, first, understand what thoughts and behaviors originate from the evil twin. Next, they learn to counter these directives with healthier alternatives. Gillian's "evil twin" would tell her that she should never eat cheese because it was high in fat and would make her gain weight. She learned to respond, "But I know cheese is also high in protein and calcium." She knew she really had the upper hand when she could add, "And I know that some fat is good for me." The final step is for the child to evict the evil companion from her consciousness entirely.
It is also helpful to remember that as your child makes progress, control and management of eating should gradually be returned to her; this period of seemingly-harsh prohibitions will end as the disorder resolves.
Strive to Offer Compassion, Consistency, and Security
Research has shown that children who have formed secure attachments to their parents tend to show fewer weight concerns and a lower risk for eating disorders. In addition, children in families where parents behave consistently and are responsive to the child's needs have a lower risk.
While it is, of course, not possible for you to undo early parenting, you can use these findings as a guide for dealing with problems you may be having now. Responsive parenting means responding constructively and compassionately to the distress signals emanating from your eating-disordered child, not waving them off as idle complaints, or ignoring them and hoping that they will go away. Ideally, your children will come to view you as a safe haven or a secure base for helping them work through their problems.
Responsive parenting can also help in another important area: your child's self-esteem. While New Age concerns about self-esteem and "liking oneself" seem overworked and trite, it is something that is often overlooked when a child has an eating disorder. You can help by making it clear that you love your child and value her regardless of her achievements or performance. Parents cannot express their love and support too much. Don't be put off by your child's natural tendency to brush off your overtures; it is important that you express those emotions regardless of whether or not your child returns the affection.
As much as the eating disorder will seem to dominate your family life, it is important to keep your eyes on the bigger picture. Try to remember what your child was like before the eating disorder. What did you enjoy talking about? What was he interested in? Making an effort to engage your child around some of his interests and giving positive feedback for efforts in other areas can help him feel that you really care about him as a person, and counter the common feeling that he has been reduced to little more than his eating disorder. Acknowledge how hard your child is working at the challenge of overcoming his disorder, even though things may be at a very difficult stage at the moment.