Eating disorders

A word about parents in the treatment of childhood eating disorders

By Abigail H. Natenshon, MA, LCSW, GCFP

Though ideally positioned to prevent problems and intercede, when it comes to eating disorders, it is safe to assume that in many cases, parents are often the last to know that their child is struggling. By virtue of living alongside their sick child, despite their comfort level or personal preference, parents have little choice but to become meaningfully involved. The question is, what will be the quality of that participation?

The answer lies in the guidance they receive about effective intervention from health professionals. Parent and child both seek the same end—to see the child happy, healthy and fulfilled. Parents need to determine how best to support the child towards this common goal. It is for the child?s therapist to offer parents the opportunity make their involvement constructive, effecting change positively and facilitating the intrinsically difficult task of recovery. Offering support that feels welcome and enriching is a continuously changing and challenging process as children make their way throughout the various stages of recovery.

Parents need to be present in their child's life.

Parents are in the best position to become diagnosticians. Eating disorders are diseases that appear around the kitchen table or in the family bathroom more often than they do in the doctor's or therapist's office. Lab tests show nothing of eating disorders until their lattermost stages. It is parents who observe their child being the last to show up at the dinner table, and the first to leave. It is parents who watch as the child pushes food around the plate or picks at it, rather than eating it. It is parents who are on the front lines when it comes to experiencing the child's depression and irritability, particularly around mealtime. They experience their child avoiding celebrations and withdrawing from family gatherings, and finding a myriad of good excuses for missing meals (they ate with their friends, they will find the remnants of vomit on the sink, the tub, and the toilet and observe rapid weight fluctuations in their child in many instances.

The recovery process too, happens at home, under parents noses, particularly in this day of managed care, where limited insurance coverage translates to a limited number of treatment sessions with health professionals. Hospital inpatient programs have become almost non-existent. A psychotherapy session lasts for 45 minutes a week; the child spends the bulk of their remaining recovery time at home. It is for parents to get with the program. Like it or not, parents are implicated and involved by virtue of physical proximity, if not emotional connection. It is the quality of that emotional connection that can contribute significantly to the nature and rate of the child's recovery.

It is an ironic turn of events that in a majority of cases, there is an inverse correlation between the importance of the role that parents play, and the parent's lack of entitlement and confidence in fulfilling that role.

The parents' dilemma

In all too many cases, parents

• are afraid to intervene with their child for fear of being intrusive and overly controlling
• believe they are the cause of their child's problem and that by becoming involved, they would only make matters worse
• are reluctant to interfere with the child's privacy and budding independence
• are afraid to incur their child's wrath, causing possible rejection
• mistakenly believe that what their child eats is none of their business. The opposite is true. The malnourished child with a malnourished brain is incapable of accurate self-perception, sound judgment and self-care. This child needs her parents now more than ever.

• Harbor their own personal issues around food and eating.

  Sheila is a 43-year-old mother of five, who admitted that her life is spent thinking about food and her inability to feel safe around it. She came to treatment as a result of her teenage daughter first beginning to experiment with symptoms of anorexia. Sheila "respects" her child's "control" over food, particularly because she doesn't feel she has that control herself. To this mother, it does not seem right to offer guidance to her child about healthy eating when she is so confused about what it is herself; because thoughts and words about food and eating come from "a part of her that is sick and obsessive", by offering her child guidance from that place within herself, she fears she will be inflicting her own problems. In addition, she is concerned that her own painful secrets will emerge and her secret life will be uncovered.

Complicating matters for parents are common misconceptions among therapists and health professional that seriously hamper the child?s and parents healing. Health practitioners treating eating disorders too frequently mistakenly believe that:

Overly controlling parents do cause eating disorders as so the goal for treatment is to perform a "parentectomy".

Teenagers best achieve separation and individuation from their parents through "geographical" separation if you will, by creating artificial barriers. In actual fact, there is no better way to help a child separate from parents than to encourage healthy bonding through communication.

Ethical and professional practice in the treatment of the individual child should exclude parents from the child's psychotherapy. The belief here is that the child in therapy deserves privacy. And of course this is true. As a psychotherapist, I too, am a fierce protector of the patient?s rights; confidentiality issues are real and legitimate. I believe however, that confidentiality breaches, boundary crossing and manipulations can be avoided unconditionally when families can be brought together to communicate their concerns in the family therapy milieu. Privacy and confidentiality issues all become non-issues when brought above board, when all relevant parties hear the same things at the same time and are offered the opportunity to respond. Family sessions may be diagnostic, ongoing or ad hoc; in all instances, they are healing for everyone involved.

Research that has come out of the Maudsley Hospital in London, England has proven that family therapy in fact offers the greatest opportunity for successful recovery with children living at home who have suffered from anorexic for three years or less.

I believe that parents must remain advocates for their children, not in the sense of taking control over their child's life, but by taking charge in those instances where the child has lost the capacity to care for herself, and only until such time as the is child is capable of resuming responsible self-care. This means that the strongest and most substantive presence for the parent needs to be at the start of treatment, until such time as the child has become personally engaged and invested in the treatment and recovery processes. Whereas support may take the form of providing and sharing meals and in some instances monitoring whether they get eaten, at another time in the child's treatment it may be seen in the parent allowing the child to independently determine her food choices and to simply trust that the child's relationship with food has become fully responsible.

One mother, early in her daughter's treatment for anorexia, left her work every day at lunchtime to go to her daughter's school and eat lunch together with her in the cafeteria. The external structure she provided was necessary to reinforce the child's lack of internal regulation at this point early on in the girl's treatment. As the child progressed in her treatment, her mother's advocacy changed in nature; she would show her support by simply having nutritiously dense lunch foods in the house for her daughter to use in making her own lunches, by trusting that her daughter would prepare a healthful lunch for herself, that she would remember to bring it to school, and that once there, she would take responsibility to eat it, consistently and fully. The "proof of the pudding, here, would be in the eating"—in other words, the only external monitoring required at this point would occur when the child stepped onto the scale periodically, either in her doctor's or nutritionist's office. The number would need to indicate that the weight was either stable or in a direction towards weight gain, not loss.