December 12, 2011

A Guide for Families

by Dr Charles Fishman

Eating Disorders are not about food

People with eating disorders are generally referred to as sufferers or patients. There is another group that is suffering and that is their families.

The degree of helplessness that the families endure is profound. Sitting by at meals …as every morsel of food that passes through their anorectic family member’s lips, their spirits lift. The problem is that it was only a morsel. This can go on days, weeks, months, years, even decades. Or fearing, when she leaves the table after dinner to the bathroom, that she is purging.

This guide is for you, long suffering and patient families. On this page you will find a new perspective and tools to understand the disease that is practical. No psychobabble – just common sense and practical advice on how you can help.

The information in this guide is based on my clinical experience, the literature, and most importantly, on follow-ups of cases I have seen as far back as 25 years ago. Families like yours, who have being in the position of feeling– damned if they do and damned if they don’t. If you encourage eating, it becomes a power struggle, if you don’t there is a better chance that no food will be taken in that day. Or, knowing, when she flees to the toilet after a meal, that she is purging. Or will he ever stop gaining weight? What to do?

Hopefully this guide can offer concrete information, solutions and hope.

In Western culture, there is a value, especially for women, to be thin and there are many magazines that tout this idealised body configuration. Many people blame the fashion magazines for causing eating disorders. However, if magazines were to blame, eating disorders would not be so rare. There are millions of people who read the magazines, yet , for example, Anorexia Nervosa currently affects only 0.5% of the population. There must be other factors. In my clinical experience, the fundamental force behind eating disorders is poor relationships.

Eating disorders begin when a person does not feel good about themselves, or they feel that they need to lose weight. This is the voluntary part of the problem. The weight loss begins. As this progresses, the compulsion behind the weight loss strengthens and the person begins to get trapped in a cycle of disordered eating where they lose their free will. They are no longer in control of their eating. Voices begin to tell them that if they eat, then they are a bad person, someone who is un-loveable.

These voices apply in Anorexia Nervosa and Bulimia Nervosa. These increase the resistance towards taking or keeping calories. However, all eating disorders stem from conflict especially in relationships with the people who are closest to the sufferers.

What Family and Friends Can Do

There are a number of practical things that friends and family can do to support the recovery of an eating disorder in their loved one. These include:

1. Decrease the isolation of the person with an eating disorder.
Isolation makes eating disorders worse; therefore a central part of our model for this problem is to ensure that sufferers are not isolated. Friends and family are key to decreasing isolation.
2. Support the sufferer address conflict in their lives.
Family and friends need to be available to support the person with an eating disorder address the conflict in their lives. For example, a client in her early twenties was having trouble with her boss and her boss’s son. In the therapy session, her father volunteered to go with his daughter as she confronted the offending people at her work. In session it was made clear that freedom from the eating disorder comes as the young woman uses her own power to address and change the situation. However, the support of the father was invaluable.
On the website, there is a re-enactment of a therapy session with “Betsy”. Betsy is a young woman who has severe over eating. The weekend prior to the therapy session. she realised that she has been being sexually harassed. With the urging of her therapists, she called and confronted the man who was harrassing her, getting him to stop. Family and friends need to be there for women like Betsy as they seek to transform their troublesome relationship.

3. Believe in your family member and create a climate of possibility.
It is imperative for both the family and the person with the eating disorder to believe that change is possible, and to work together to create it.
For example, the video on the website of “Joy”, a woman who suffered from Bulimia Nervosa for 15 years. During her eating disorder she abused drugs, became a prostitute, and was severely suicidal. She came to therapy with her husband, and originally they both believed that this was an incurable problem. However, she did overcome it, and as she talks about in the video, it was her family and friends who were invaluable in her treatment. They created an environment of believing in her, and made her believe that she, like everyone else, had more functional facets that could be expressed.
4. Parents need to be involved in the treatment of Anorexia Nervosa.
In my book ‘Enduring Change in Eating Disorders’, I did follow-up with patients for as long as 20 years, all outpatient clients. For 85% of these clients, the former patients were symptomatic and doing well in their lives at follow-up.
When was was the patient not doing well? When the professions and the family were not working together.
The family needs to see to it that there is a coordinated system of care for your afflicted family member. When there was not a positive outcome, the family and the different treatment professionals were not organised or did not communicate with one another. Good results come from an integrated system of treatment.
But you ask, isn’t this the job of the professionals? Indeed, it is, but the family needs to be there to advocate for their suffering family member. Not only be an informed consumer, but be an active consumer who actively sees to it that the treatment is working well.
What is important is that parents are proactive consumers of care for their suffering family member. Insist that the treatment involves the family. In this model, the family is the resource for creating the transformation.
On this website there are many points and suggestions that families can extrapolate to better support your family member who is going through this.
5. Decrease the stress in the life of the family member suffering from an eating disorder.
Very importantly, what makes eating disorders worse is stress. For everyone, especially children, stress arises when parents are fighting, especially through their child. In a divorced situation, you need to ask yourself do you hate your ex-spouse more than you love your child. You need to realise that you need to be there for your child: It is not about your issues, nor is it about your issues with your ex-partner, it is about being there for your child who has a potentially fatal disease. Anorexia is the most fatal of all psychiatric diseases. Be sure not to fight thought your young person.
On this website, is a video of “Allie”. She does not have an eating disorder. We include this because of her family situation—she is caught in the middle between her mother and step-father. When young people have eating disorders, this Triangulation between parents makes the eating disorder much worse.
Also, on the website, is an interview with “Bonny”. Her family treatment for her anorexia nervosa was 4 months in duration. This segment is a 20 year follow-up.
6. Set clear, respectful boundaries.
Another crucial issue that the parents can be sensitive to and can help their suffering family member is with boundaries. Boundary violations can profoundly exacerbate the eating disorder. Parents can see to it that boundaries in the family are respectful and developmentally appropriate.
7. Find new ways to deal with conflict.
Conflict is one way of transforming malfunctioning systems. The family needs to create a context where conflict is safely addressed. It is an area that many families need to learn. I have had many family clients who say to me that they have a perfect family and that they never fight. This is a warning sign to me. It is important to be able to express your opinion and/or dissatisfaction, even though this can create some discord. New communication to deal appropriately with these conflicts is important.
8. Don’t be blackmailed by the eating disorder.
There are numerous families who are so afraid of the eating disorder that they do not address conflict. Instead they allow their family member to continue with their life in the same manner that has lead to the eating disorder. One client of mine with severe bulimia was living alone in an isolated environment. However, her family was so afraid that they would make the disorder worse that they financially supported her to live in this isolated fashion, and watched as the eating disorder slowly became worse. While addressing the eating disorder may be difficult, it is imperative if change is to occur.
9. Believe that these difficulties are treatable, especially with your help.
Parents need to believe that these problems are treatable. Parents also need to realise that they must help their suffering family member. The family is the greatest resource to recovery. While I am not ignoring the value of professionals who should be consulted, it is the friends and family who are the crucial element in facilitating recovery.

We welcome families and friends with suggestions and reflections to this document.

One Response to “A Guide for Families”

  1. Reina Marica Arias says:

    I have learned a lot from this article. Thank you.

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Book: Enduring Changes in Eating Disorders

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Endorsements from Clients

  • Hello Charles! I am unsure if you will even remember who I am haha, but this is [name withheld] – I saw you in (I think) 2017 with anorexia.

  • My wife and I felt quite emotional last Monday after our short Zoom session. All three of us hugged. It felt like the end of a relatively short but profoundly enriching journey with you which started in June at your home office on Waiheke Island.

  • Dear Dr Fishman Thank you so much for this website. I have a long history of swinging between bulimia and compulsive over-eating. I am currently a compulsive over-eater.