When Bad Things Happen to Good Parents
By Judith Brisman, PhD
I think one of the hardest things parents face when a son or daughter struggles with an eating disorder is the question of whether they have failed at their job. Parents endlessly apologize in overt or even nuanced ways for being who they are. “I exercise,” they tell me. “I value good health.” “I eat.” “I drink.” “I’ve been home too much.” “I’ve been home too little.” The question of “what I did wrong” abounds.
As Dr. Ed Levenson has aptly noted, “Most parents act badly in good faith. They are doing their best.”
It remains unclear to me why some kids develop eating disorders and some kids remain unscathed. I’ve worked with some of the most caring, thoughtful, attentive parents with whom, no matter what we do, no matter how hard we try to intervene, we end up watching, bewildered, as their kid tumbles into hell. With many families, there is not any given factor that makes it clear why this kid, in this family, needs so much help.
No question, oftentimes parents have grown up in tormented situations where emotions are intense or hidden, where tragedy has struck, and where the parents themselves have scrambled to survive. In these cases, parents may need help learning how to recognize and effectively communicate their own needs. Substances or food may be turned to as a way of dealing with stress or relationship difficulties. Parents may have learned nothing else. It may be clear that no one in the family is easily able to openly voice one’s experience. In such cases, it makes sense that disordered eating can develop as a way to give voice to what is going on inside.
But look at any family closely, and there are always questions about communication and boundaries. There are always difficulties balancing one’s own needs with those of others. As my wise younger brother says, “No one gets you more mad than your own kids.” True enough. We’ve all been there. Who wants to be defined by those moments?
When bad things happen in any family, how do we avoid blame and use the crisis as an opportunity to see what can be changed now? An eating disorder, or any family crisis for that matter, is oddly an opportunity. We take our cars in for checkups every year. Yet, how often do we take our families in to see what is working and what is not? In most families, the answer is never—until something goes wrong. Something going wrong can be a gift of sorts to stop short and listen. What does each person in the family really need now?
The question is not what everyone did wrong, but what everyone can do now to best set the stage for recovery—for the person in trouble—and also for the family itself.
In recent years, families and clinicians alike have been challenged as to what “setting that stage for recovery” can look like. Family-based therapists have urged parents to intervene directly and refeed their starving anorexic child. That’s what allows for recovery, they have insisted. This thinking has brought needed and seismic changes to the field. It has allowed parents to come center stage regarding the recovery of their son or daughter. We now all know that parents have to be actively involved in the treatment process when their child is suffering with an eating disorder.
But direct intervention by parents does not always work. A family I once saw heroically tried to feed their starving 15-year-old daughter. The kid stonewalled both parents. Mealtimes spilled over with anxiety and rage. No matter what the parents did, their daughter thwarted them. “I know parents aren’t supposed to be blamed,” the mom told me, “but do you know what a failure I feel like when I can’t even put this treatment into play?”
With this kind of challenge as a base, all of us in the field, clinicians, researchers, and parents alike, are continuing to question what works—and when.
One of the ways I like to think about the treatment of eating disorders is that it really is a caricatured version of child-rearing itself. There needs to be an ongoing—and ever-changing—balance between limit setting (and the guiding safety of structure) and freedom (and with it, the ability for a growing child or teen to face failure and mistakes).
In this spirit, one direction I always consider, when direct refeeding or intervention with eating doesn’t work, is to engage parents in setting limits that are determined by a treatment team. When working with an anorexic teen or young adult, this may mean that a physician determines whether outpatient work can be done and what measures (i.e., weight, hormonal changes, etc.) are needed to re-establish health. Weight gain is determined and a dietitian is engaged to help set up a meal plan and to carry out weekly weigh-ins. A goal of a pound increase a week is typically set. A therapist is involved as the lead facilitator, engaging both the patient and the family to question what gets in the way week to week. The parents’ job is not to directly feed their son or daughter, but to determine consequences if treatment isn’t complied with. Thus, not gaining the needed weekly weight could result in school sports stopping or an outing with friends being canceled (not as punishment, but to ensure meal compliance). Parents hold a tremendous amount of leverage with kids. The question is how to use it effectively. If weight isn’t gained, or if meals aren’t eaten, a higher level of care has to be considered. The work is jagged, with weight often fluctuating up and down. We look for a general upward trend.
The interesting part is that so very often, kids don’t comply until the moment they realize their parents really mean business. I’ve seen kids do nothing until it’s clear that they really will be pulled from the hockey team. Or they don’t take treatment seriously until an actual residential facility has been called and an intake has been set up.
Let me be clear that when a kid is not able to rally, even with these limits, it indeed may mean that he or she needs more support and potentially a higher level of care. But so often the problem is that the child tells the parents that they are making things worse—and the parents back off. Parents need to stay engaged, steady with limits, and prepared to keep the consequences. The support of the team with the parents at these points is usually invaluable because these are the times when kids will insist that the parents have caused the crises with food, that the parents are to blame—and that if Mom and Dad don’t back off, it all will get worse.
Of course, here, too, is where it all gets so very tricky, because our goal is not just to get kids to eat. Our goal is to grow them up.
And, indeed, as kids grow up, they present us with so many challenges. They drink, spend too much money, engage in scary sexual situations—and, of course, they eat too little or they eat too much. In the process of any treatment, the goal is not just to stop the behavior. The goal is to get the kid on board to question what he or she wants to do about his or her life.
In all of these arenas, as parents grapple with this ongoing task of balancing control with allowing for independence, two directions remain in play.
The first: Don’t stop talking to your kid. You’ll be met with rolled eyes or snide comments, but don’t back off. Ask what works, what doesn’t. Explain why you are setting the limits you set; listen to the inevitable “better idea” that he or she has. Consider your child’s thoughts when setting goals and limits, but don’t lose your own voice when doing so. Growing up means the ability to be close enough to have two people in the room at once—with two ideas, goals, and differing thoughts. But if limits can’t be changed, allow your daughter or son a voice through his or her feelings. Often the best thing you can do is just listen to why your child is angry, frustrated, sad (that he or she hates you for setting limits, for not allowing the school trip, for not letting up, and feels alone, not supported). This doesn’t mean you have to change anything. Just listen and really try to hear what is said, negotiating if you can, staying steady if you can’t. Listening, understanding—but not acting—may be one of the hardest things you do. You don’t want to give your child the message that anger or sadness needs to be fixed or taken away. These feelings are part of who he or she is. Being able to have feelings and not make them go away (by eating or not eating) is a critical part of recovery.
And second, in this spirit, pay attention to the strengths that may be obscured by someone’s struggle with food. A dad recently spoke of his son’s unbelievable ability (as an Ivy League college student) to not pay attention to information. “He is enraging!” he told me. “He never pays attention. He knows nothing about what is going on in the world. I think he thinks I’m talking about a lost cousin when we talk about Hillary and Bernie. He’s a valued player on the football team and he gets good grades. But how can he miss such basic information? Sometimes I think he actually is pretty dumb.” But this is a kid who has great friends, has obviously managed his way through team sports and college. “I wonder what he IS paying attention to?” I asked. “He must be thinking about something.” As we got to know more, it became clear that this is a kid who is thinking about people, not facts. He is worried about his troubled friend. He is mindful of who is holding court in a group setting. He was hardly paying attention to nothing—in the social arena, he was more skilled than most; he was hardly dumb.
In the face of a family crisis, much gets lost. It is a time when the whole family is entangled in blame and bad feelings. What someone is doing wrong shadows strengths, spirit, and attempts to survive.
If an eating disorder has erupted in your family, take a moment of silence and deep breaths, and ask the question: Who are you appreciating—and why? Where are you able to hold firm to with limits? Where do you cave—and again, why?
The work in a family is not just to get someone to eat—or not to eat. The work is to consider what needs changing in addition to the eating.
Crisis is opportunity. You’re hurting. You are scared. You worry what you did wrong. Don’t go this alone—get any support you need, because you will need to hold on tight and have a place for your own feelings. But at the same time, how can you also embrace courage, look closely at your family, and allow for the tune-up all of us rarely consider?
An eating disorder can be an odd blessing in disguise. Use it well.
About the author:
Dr. Judith Brisman is Founding Director of the Eating Disorder Resource Center in Manhattan. She is co-author of Surviving an Eating Disorder: Strategies for Family and Friends, is an associate editor of Contemporary Psychoanalysis and is on the editorial board of the journal Eating Disorders. She is a member of the teaching faculty of the William Alanson White Institute and she maintains a private practice in New York City.
Dr. Brisman is known internationally as among the first in her field to develop a treatment program for bulimic patients. She has published and lectured extensively regarding the interpersonal treatment of eating disorders.