Eating disorders

Important tips on dealing with parents and families of children in treatment for eating disorders: case studies

By Abigail H. Natenshon, MA, LCSW, GCFP

In preparing parents to become the most effective advocates for their eating disordered child, treating health professionals must:

1. Teach parents to become reality testers for their child.

   A father explains, "We are feeling very encouraged. K has put on 4 pounds in the past 6 weeks. All she needs now is about 3 more pounds and she'll be in the normal range."

   He had ceased to be concerned about his anorexic daughter because she had eaten enough to gain what he considered to be a substantive amount of weight. Being in a normal weight range, however, does mean that an anorexic individual has become normal, or is no longer sick. K is a severely anorexic 18-year-old who had been reluctant to let go of her disease. As she begins treatment, she considers it her "legal right" not to allow her parents to participate in her initial diagnostic sessions, though she left it to them to contact me to request bi-weekly, rather than weekly sessions, "in the interest of saving time" for her studies. For K, studying was a habit as compulsive as her restrictive eating behaviors.

   K had gained this weight through further compulsive requirements of herself fostered by the fear of having to leave school, not out of a relaxation of her fear of gaining weight. Furthermore, these parents needed to be more cautious than optimistic in light of the girls' reluctance to engage in the emotional aspects of eating disorder treatment. It was for them to remind K that what she has been able to accomplish to date is invaluable and commendable, that it will keep her body healthy while she recovers from the emotional aspects of her disease. Having made a great beginning in her recovery, she has accomplished a small sliver of an "upload" on the continuum line of eating disorder recover. Parents and child both need to be brought up to speed on the reality of the situation, to be disabused of the myths and misconceptions of so many of the principles of eating disorder recovery.

   It is critical for parents to remain reality testers for their children, even for those children who are hostile or reticent or ambivalent about embarking on the recovery process. In so doing, parents need coaching. There is no better coach for the parents than the therapist who is working with the child.

   In coaching these parents, I made it clear that there is no such thing as a weight that would liberate their daughter from the grips of her disease. Weight is simply not an issue when it comes to measuring recovery from anorexia. A person can be underweight and anorexic, normal weight and anorexic or overweight and anorexic. The rapid loss of weight for anorexics indicates that behaviors around eating are erratic and potentially dangerous. The process and dynamic around eating, which ultimately affects a person's weight, is what is significant; the introduction of healthy eating can stave off what might otherwise have become dire health problems for the anorexic individual. Eating, for the starving individual can preserve both life and life quality, can protect the brain's capacity to learn and the body's capacity to grow and mature.

   Weight restoration marks a person's ability to benefit most effectively from the therapy process. Weight restoration indicates that bone density will be maintained and the danger of dying is minimized. Recovery from an eating disorder lies in the person's thinking, way of life, freedom to eat without fear and guilt, capacity to live life fully and richly, solve problems effectively, make choices freely and moderate oneself. A body is not adequately fed and weight is not adequately restored until the female body has stored enough fat to sustain enough estrogen to support a monthly menstrual period, ultimately allowing the individual to bear children.

2. Teach parents to become limit setters, to create the "bottom line".

   Parent: "She isn't anorexic, of that I am sure. She eats. You know? She'll take an apple to school and will pick at dinner."

   E is a quirky, picky eater. A junior in high school, she has recently lost 20 pounds and is painfully thin. Her mother and sister both had been obese eight months before and had lost weight on a SlimFast diet. Unclear about a healthy approach to food herself, she wanted to know where to set limits for her daughter, where to express the concerns she felt, to say "Eat," when her daughter was unable to feed herself—especially when her daughter does eat some things and is not "totally starving". "Sometimes, to get her to eat, I'll say, 'Do it for me.'"

   The bottom line is what all people need to do to stay healthy. The human body must be fed and fueled in order to keep it alive and functioning. It needs to be fed nutritious food, on a regular basis in the form of meals. Meals should be varied and balanced and contain all of the food groups. Eating healthfully indicates that the person living inside that body cares enough about herself to stay alive and well and to be comfortable. How a person eats is an indicator of self-esteem and self-preservation.

   It is essential that parents are mindful of bare minimum self-care behaviors, and that they should expect and demand these behaviors from their child. Needless to say, parents need to role model healthy care taking of the self, making healthy eating a priority and demonstrating wise decisions about food and eating. When these signs are not apparent in the child, it is up to the parent to take charge, to expect and require food intake for their child's sustenance just as they would require insulin intake if their child were diabetic.

   Rules for self-care:

   1. The body is a machine that needs to be fueled in order to run properly and to keep it from breaking down. People need to eat three meals a day with snacks in between as optional. People get hungry and need sustenance approximately 6 times a day.
   2. People need to get a goodly number of hours of sleep every night in order for the brain to be alert and to function optimally.
   3. People need to tend to their daily hygiene, bathing, brushing teeth twice a day.
   4. People need to attend to the tasks that sustain them in the world; for parents, that means work and the financial support of the family. The work of the child is learning and education.

How to handle the rebuttal, "But you skip breakfast too."

It is important for parents to look seriously at their own issues with food, which will surely create the backdrop for their capacity to observe problems in their child and to respond to them appropriately. Parents, though not the cause of their child's eating disorder, have a great deal to do with the child's developing healthy or unhealthy attitudes about food and eating; unhealthy attitudes about food can ultimately translate into increasing the risk of a child developing an eating disorder. For their child's sake, but mainly for their own sake, parents too, need to recognize their issues about food and eating and confront them squarely and honestly. The parent who does not practice what he or she preaches is at a disadvantage in terms of legitimacy in asking the child to care for herself.

Parents need to learn eat breakfast as much as their child does. The benefits of sitting down at the breakfast table together to chat and share thoughts and concerns before everyone leaves for their day of school or work are immeasurable. This is a life lesson for the child that will benefit the parent equally.