Here is a final note for now on the issue of parental involvement with eating disorders. Previous blogs have brought up thoughts, questions, disagreements and clarifications. I am grateful for that and would encourage all of you to read through online responses to the earlier blogs. In them, alot of important information abounds.
First, as for the research cited in my last blogs, there was alot of confusion regarding what I meant. When I cited Minuchin, for example, as "proving" that parents caused eating disorders, that was because he said that he observed anorexic families as being overly enmeshed, with no boundaries and poor communication. He was quite famous for those observations, and that's a big part of where parent "blame" began. But his research was terribly flawed, and I was trying to say that we cannot look to his findings to prove anything.
Of critical importance, I want to underline the fact that I don't think families always cause eating disorders. When I say not "always," what I mean is that there indeed are families in which there is emotional turmoil or neglect. Here, kids will cling to whatever they can to get by -- and yes, in these cases, cutting, drinking, binging and sometimes starving are all symptoms used to cope. Thus, in some families, there is such stress that many symptoms develop in the kids -- eating disorders among them -- as means of dealing with intolerable feelings. Yet even in these cases, with anorexia, re-feeding is the first line of intervention, whether it is by the family, professionals or an intensive care inpatient facility.
For many, many other kids, however, there is a genetic predisposition that our fertile cultural terrain allows to explode into the mess of a severe eating disorder. For anorexia in particular, this means there is a gene that tilts the person toward obsessive, perfectionistic behavior -- a gene that would likely not be activated if the culture didn't demand bodily perfection, change and a sense that "winner takes all." In our demanding and bodily obsessed culture, however, this gene lights up like wildfire, and serious eating disorders can be set into play. This has nothing to do with family dynamics and can erupt in any family environment.
With anorexia, re-feeding has to be the treatment of choice. Where I differ from some readers is that I believe just how that re-feeding occurs can be different depending upon the needs of each family. Right now I have two older teenagers, restricting anorexics, with whom the nutritionist and doctor set up food plans and minimal weight gain needed per week. I work directly with the parents to help them set limits regarding what activities will be lost (treatment at home instead of a hospital, camp, sports, etc.) if the teens don't meet their weight gain each week.The parents don't directly feed the kid, but they are intimately involved in the treatment process. I do ongoing work with the parents (and, in other cases, with the kids) to see what is getting in the way of keeping to the treatment and food plans.
Alternately, I have two other cases with younger anorexics in which the parents and I are working together in a direct re-feeding kind of manner in which the eating is non-negotiable: the parents either feed the daughter directly or monitor every bite.
In all cases right now, the work tumbles back and forth, and there are many chaotic, difficult moments, but for now, all the kids (despite different approaches to the actual re-feeding) are moving forward and gaining weight. Some parents can't afford to stay home and sit with their child 24/7, but others can't afford not to.
So I try to work with the resources and wishes of the parents and give them different options, and I firmly believe (and have seen, many times over) that different options can work well with different families.
I hope we all continue to think hard about these issues and allow for ongoing questions to evolve. I am grateful for the people at FEAST, who have allowed me to more clearly put into words the thoughts I have on this issue, and to the Maudsley researchers, without whom I wouldn't have even known to try to get parents to re-feed their kids. (Go here for information on the FEAST November conference, where these ideas can be discussed openly -- and off-cyberspace!)
I'll be writing more soon in other arenas, but for now, let's all keep thinking and questioning what works -- and why.