Surviving an Eating Disorder: Strategies for Family and Friends Interview

Judith Brisman, PhD, CEDS, joined us for an interview on Surviving an Eating Disorder: Strategies for Family and Friends, which was written by Michele Siegel, PhD, Judith Brisman, PhD, CEDS, and Margot Weinshel, LCSW. What follows are our questions in italics and Dr. Brisman’s thoughtful responses.

Congratulations on your Fourth Revised Edition of Surviving an Eating Disorder: Strategies for Family and Friends! Your first edition was published in 1988 and one of the earlier books in the field. How do you feel about the progress we’ve made since then?

I think we all have come a long way– and we all still have alot to learn.

Surviving has followed the trajectory of the field.  In its first publication in 1988, the thinking in the field was that teenage and young adult patients with eating disorders needed to separate from their parents and learn to take hold of their own lives.  Thus the initial publication of the book advocated for parents to step back, encourage psychotherapy for their child and support the work of autonomy and independence, with the belief that disordered eating would abate as a result.

Boy were we wrong!  Over time, both from our own experience and the research of the Maudsley investigators in London, we realized that parents knew more about the kids than we did.  It became critical that parents  be center stage in any treatment  process.  Over time, the editions of Surviving have specifically questioned not IF, but HOW parents and significant others can be involved.

In this 4th edition, we spell out the Relationship Model—Parents as Partners. While the first line of action with anorexia is always for parents to attempt to re-feed their starving child, we have found that in many situations, direct re-feeding just isn’t tenable or doesn’t work.  In these cases, parental involvement is still critical but takes a different role.  Here, a team (usually consisting of a therapist, dietician, physician and sometimes a psychiatrist) sets the goals for weekly weight gain and health stabilization. The parents’ job may not be to literally feed their child (though they definitely need to work with the dietician to learn what needs to be plated at each meal). Their job is to work with the team weekly to set limits if the needed weight is not gained. These limits may involve stopping sports involvement, increasing meetings with the team, or ultimately establishing when and how a higher level of care will be insisted upon. Parents often need to be supported regarding how to specifically set up these limits. For example, they may be urged to contact residential programs and find out where and when there is availability. Their message to their child is that the limits WILL be adhered to—but it is up to the person struggling with food to eat or not eat. We have so often seen that when it is clear that being pulled out of school or activities is a reality, or when an appointment for a HLC (higher level of care) consultation is actually set up, the son or daughter is able to push through, despite not wanting to, and allow for the needed weight gain.

So, one big change is that families and significant others are worked with directly and ongoing throughout treatment.

The other change that has occurred over time, both in the field at large, as well as in our book is that for many years, we diid not recognize the need to consider a hugely diverse population of people struggling with food and body issues, other than white middle-class girls.  This edition of Surviving has changed language, clinical examples, and content to address the needs of those of all identities whom we all have sorely missed over the years. In the field at large, there is currently an in- depth awareness of and outreach to the populations we have missed.

Finally, it is only in recent years that we all have become aware of how pernicious diet culture has been and how dieting has, for so many, ended in the development of severe and ongoing eating disorders. This edition of Surviving advocates strongly that diets are harmful and should not be considered if someone is bingeing or in a large body. Over 90% of “dieters” gain back their original weight—and often more—after being on any kind of restricted food plan. Instead the focus is on self-care, attention to one’s internal and emotional life, awareness of hunger and fullness, and an appreciation of how stigmatization of size results in a child learning to hate themselves.

In this regard, the field in general, has made great strides. The Health at Every Size movement has urged professionals and laymen alike to consider their own prejudices and has pushed for a completely different awareness and clinical approach regarding body size and body hatred.  Similarly,  the field has made great progress in allowing for much more access to care for people of all sizes, socioeconomic levels (there are many free support groups and low cost programs available) and to attend to the diverse population of those with eating disorders who have been missed over the years.

That said, we still have so much to learn. The stats show that about a third of the anorexic population is not able to recover. Much more research is needed in that regard to question the physiological and psychological aspects of this disease.  Diet culture has ruined the lives of so many and influences treatment in still a majority of medical and clinical settings.  And, insurance companies still need to be taken to task for their ongoing oversight regarding coverage for the treatment of eating disorders.

We have come far.  We still have so much to change and to learn.

Please tell us how you’ve used your experience with patients to develop this book.

Patients have taught us much more than any training programs have! For example, early on, a young recently married woman struggling with bulimia made a contract with her husband. They agreed  that she would tell him each night whether she had “been good” (her words) or not that day. For a week or so, that really helped her stop the binge/purge cycle.  But soon thereafter, she abashedly admitted that she had started to feel so controlled that even though her husband was doing what she had asked, she found herself secretly bingeing in the bathroom and vomiting when she showered.  We stopped that agreement right away and changed it so that she could call her husband (IF she wanted to) and just let him know she was going through a hard moment. That encouraged open communication about difficult feelings instead of control over the eating behaviors.

Another young man actually was our inspiration to write Surviving. Before the first edition of the book, early in the 1980’s, he had called us from JFK airport. He was flying to LA, ring in hand, about to ask his girlfriend to marry him. “But she is bulimic,” he told us. “Should I tell her she has to stop throwing up or I won’t marry her?”  Michele Siegel and I had been getting calls like this every day.  Parents would ask, “Should we move our refrigerator to the backyard to keep our daughter from bingeing?” Friends would call and want to know what to say to another friend whom they knew was starving. This was in the days before email or the internet.  We were constantly explaining that communication, compassion, and understanding would be much more effective than just attempts at control.

It was Michele’s idea to put into writing what we were saying over the phone or in consultations. As a result, Surviving was born. Over the years, our work with families has made it clear that there are always too many concerns and questions to keep significant others out of the treatment arena. They taught us well how to get them best involved.

What are some of the psychological aspects of eating disorders?

There is not a person in the world who doesn’t have psychological issues! That’s important to think about because of course anyone with an eating disorder would also have their own idiosyncratic set of psychological issues. Usually what we see though is difficulty knowing or expressing one’s feelings—the eating behaviors become ways of expressing sadness, anger, fear…or even extreme joy. Also, people who struggle with eating disorders may have a hard time knowing just who they are.  They often get lost in other peoples’ experiences of them. A compliment from a partner can determine whether they feel good about themselves or not.  A good review, a good grade—a “good” number on the scale can all be ways of assessing who someone is. A confident sense of one’s self can either be lost or never develop—thus, the culture’s messages regarding what someone should look like have more power than they would for someone who felt more sure of themself.  Often the eating disorder is the only way the person feels they have control. Despite the obvious harm, restriction, bingeing or purging might be the only way for someone to feel that they are doing what they want to do. 

While there is no question that both physiological and cultural factors influence the development of eating disorders, it is critical that the eating issues are not just seen as problems with food and weight. In Surviving, we highlight the many possible psychological issues that may well be present and might  be getting in the way of recovery. It is an important time to get to know who the person is and how they feel beyond just the needed focus on food and weight.

The role of the family has shifted over the past few decades. How would you like to see families support their loved ones for recovery?

As indicated above, when a child is in treatment for an eating disorder, the question must be not IF the family is involved but HOW. If a team is involved, the dietician works with the parents to spell out the details of what is needed for each meal.  And the parents need to know, week to week, how to address the inevitable questions that arise.  Should a mom answer if the daughter asks if she looks fat?  Should parents comment if food isn’t eaten?  What should parents do if they continue to find traces of vomit in the toilet—even if their child is in treatment for bulimia? Surviving answers many of these questions but the overall message is that the family needs someone on the team to be in touch with ongoing. Questions arise as to how this is done.  Often the individual therapist should see the parents with (or if the kid insists) without the child present. Or if a family therapist is in the picture, ongoing communication has to take place amongst all of the professionals so the parents know what helps and what doesn’t.

In general, some messages for the families are the following-

Eating disorders are NOT just about food—they are also about feelings and the family needs to look at how feelings are dealt with in the family. This is a big focus in Surviving—whenever someone is suffering from any disorder, be it anorexia or even cancer, it is an opportunity to question how emotions are expressed (or stultified) in the family. Often, disordered eating is a means of expressing internal experiences that have no other way of being dealt with (anger, grief, shame, trauma).  No matter the disorder, this is a time to pay attention to communication and emotional expression. It is an opportunity to question what else might be needed for each person in the family. 

Families also need to notice food and body talk. How much fat-shaming is unwittingly done at the dinner table? How much do parents talk about needing to lose weight? How much emphasis is put on appearance? If all of the above were taken out of the mix, what WOULD the family be talking about? Make sure to STOP the body talk!

And remember, if someone is struggling with an eating disorder, that is just ONE part of who they are. What else is getting missed?  What is not emphasized in terms of their strengths, their resources? The co-author of Surviving, Michele Siegal, died tragically at the age of 39 of breast cancer. When she was sick, she often lamented that people were relating to her as a cancer patient, not just a person. Let Michele’s message be a warningno matter how sick someone is, they are still a person. Notice what has gotten lost or missed in your relationship with them.

What are the goals to keep in mind when confronting someone you care about who you believe has an eating disorder?

Be clear, direct, and as unemotional as you can be. Let the person know factually what you see (loss of weight, restriction, signs of vomit or packages of laxatives in the bathroom, missing food, etc). Let the person know how that affects you—if you are a parent, it may be that you are worried and feel you are responsible for making sure your child is safe and healthy. If you are a spouse or partner, it may be that you sense that something is wrong but feel like you and the person you love have become distant. If you are a roommate, it may be that your roommate is eating all your food. Try not to be blaming or angry. Just stay with your own experience. And then let the person know what you want them to do.  That may just be to talk to you about it. Or more urgently, if you are the parent and you think your child is in trouble, that may mean that you want to set up a professional consultation with a doctor or therapist who has expertise in eating disorders. Sometimes, you’ll be met with relief and an open conversation will ensue. More commonly though, expect the possibility of anger or denial. Stay steady, try not to counter emotions with other emotions. This can just be a start—maybe plan another time to continue speaking.

Or, if the situation is more urgent, get support from a professional or support group (FEAST-ed.org is a good support network) and get sound advice as to what needs to happen next. If you are worried, it is important not to go it alone.

You offer rules regarding problems with food. Rule #12 reads, “Do not anticipate someone else’s needs. Ask!” Your thoughts?

Family and friends regularly tell us that everything they are doing to try to help becomes a disaster! This often means trying to encourage someone to eat—or not to eat. If re-feeding your child is part of a thought out treatment plan, then you absolutely can’t listen to what your child says they need. You will need to tell them they have to eat even if they say it’s making things worse. You need to be the authority and make sure they eat what they need. 

In almost all other situations however, helping can hurt. “Try this—you’ll like it” is not going to help someone struggling with anorexia. Remember, anorexia is often about control. Telling someone what they like could feel controlling and will usually backfire.  Alternately, if the person you care about is struggling with bulimia or bingeing, saying something like “Remember, you are trying not to eat dessert,” will be shaming and won’t help. Ask the person you care about what they think you should do or say at moments they are worried. Remember, eating issues are about feelings as much as they are about food and body. Try to ask someone what they need or what they feel instead of assuming you know best.

In your last chapter, entitled “Wanting More:  Relating to the Person, Not the Eating Disorder,” you discuss “The Right to Grow Up.” Please tell us more.

When someone you love is in the depths of disordered eating, it’s hard to imagine that one of the goals is to encourage independence. But an important  part of recovery for anyone is to begin to have agency over one’s own life. If someone’s health is in trouble, no question medical stabilization is the first critical order of business.  But, as treatment continues, as long as someone is stable enough to be participating in outpatient treatment, a big part of the work is to also allow for the rights and responsibilities that are part of normal development.  For example, a teen who is engaging in restrictive, bingeing or bulimic behaviors will need to learn how to take care of the disordered eating.  But they will also need to learn how to negotiate the myriad of experiences that they will inevitably be exposed to—partying, socializing, dating, drinking. They also need to be given responsibilities around the house and with spending money. A crisis in any family—and an eating disorder can well be a crisis—can be an opportunity to pay attention to all the other areas in which any teen or young adult needs to grow. In fact, growing the healthier, social and more productive parts of one’s life often can be an anchor, reminding the person that there is much more to them than the protective, eating disordered part. This healthier part often is the anchor that allows for recovery.

About the author:

Judith Brisman, PhD, CEDS, was the Founding Director of the Eating Disorder Resource Center for over 35 years. She is co-author of the new 4th edition 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 of Eating Disorders.  She is a member of the teaching faculty at 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.

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