Family Members of the Eating Disordered Patient

continued

Unrealistic expectations for achievement or independence also cause problems. Consciously or unconsciously children may get rewarded, particularly by their fathers, only for what they "do" as opposed to who they are. These children may learn to depend only on external rather than internal validation.

Children who get rewards for being self-sufficient or independent may feel afraid to ask for help or attention because they have always been praised for not needing it. These children often set their own high expectations. In our society, with the cultural standard of thinness, weight loss often becomes another perfectionistic pursuit, one more thing at which to be successful or "the best." Steven Levenkron's book, The Best Little Girl in the World, earned its title for this reason. Unfortunately, once successful at the dieting, it may be very hard to give it up. In our society, all individuals are praised by their peers and reinforced for an ability to diet. Once individuals feel so "in control," they may find they are unable to break the rules they set for themselves. The attention for being thin, even for being too thin, feels good, and too often people just do not want to give it up, at least not until they can replace it with something better.

Individuals with bulimia nervosa are usually trying to be overcontrolled with their food half the time, like anorexics, and the other half of the time they lose control and binge. Some individuals may place so many expectations on themselves to be successful and perfect at everything that their bulimic behaviors become the one area where they "go wild," "lose control," "rebel," "get away with something." The loss of control usually leads to shame and more self-imposed rules (i.e., purging or starving or other anorexic behaviors, thus starting the cycle over again).

There are several other ways in which I have seen faulty expectations contribute to the development of an eating disorder. The therapist needs to uncover these and work with the patient and the family to set realistic alternatives.

GOAL SETTING

Parents don't know what to expect from treatment or what they should be asking of their sons or daughters who are being treated. Therapists help families set realistic goals. For example, with underweight anorexics, the therapist helps the parents to expect that weight gain will take time, and when it begins, no more than a steady, slow weight gain of as little as one pound per week should be expected. In order to meet the weekly weight goal, parents (depending on the patient's age) are usually advised to provide various foods but avoid power struggles by leaving the issue of determining what and how much to eat up to the patient and therapist or dietitian. Setting goals in a family session helps guide parents in assisting their sons or daughters to meet weight goals while limiting the parents' intrusiveness and ineffective attempts to control food intake. An agreement will also need to be made regarding an appropriate, realistic response should lack of weight gain occur.

An example of goal setting for bulimia would be symptom reduction, as there may be an expectation on the part of the family that, since the patient is in treatment, she should be able to stop bingeing or purging right away. Another example would be setting goals for using alternative means of responding to stress and emotional upset (without resorting to bingeing and purging). Together the therapist and family help the patient discuss goals of eating when physically hungry and managing her diet appropriately to reduce episodes of weight gain and periods of anxiety leading to purging behavior.

For bulimics and binge eaters, a first goal may be to eliminate the goal of weight loss. Weight loss considerations should be set aside while trying to reduce binge eating behavior and purgings. It is difficult to focus on both tasks at once. I point this out to patients by asking them what they will do if they overeat; since when weight loss and overcoming bulimia are simultaneous goals. If stopping bulimia is a priority, you will deal with having eaten the food. If weight loss is a priority, chances are you will purge it.

The usual focus on the need to lose weight may be a big factor in sustaining the binge eating, since bingeing often precedes restrictive dieting. For a further discussion of this, refer to chapter 13, "Nutrition Education and Therapy."

ROLE OF THE PATIENT IN THE FAMILY

A family therapist learns to look for a reason or adaptive function that a certain "destructive" or "inappropriate" behavior serves in the family system. This "functional" behavior may be acted out on an unconscious level. Research on families of alcoholics or drug abusers have identified various roles that the children take on in order to cope. I will list these various roles below, as they can be applied to working with individuals with eating disorders.

Scapegoat. In the case of parental disharmony, the eating disorder may serve as a mechanism to focus the parents' attention onto the child with the eating disorder and away from their own problems. In this way the parents can actually work together on something, their son or daughter's eating disorder. This child is the scapegoat for the family pain and may often end up feeling hostile and aggressive, having learned to get attention negatively.

Often, as an eating disordered patient begins to get better, the relationship between her parents gets worse. When not sick herself, she ceases to provide her parents with a distraction from their own unhappy lives. This certainly must be pointed out, however carefully, and dealt with in therapy.

The Caretaker or Family Hero. This is the child who takes on too much responsibility and becomes the perfectionist and overachiever. As mentioned under the issue of parental expectations, this child puts the needs of others first. An anorexic is often the child who "never gave us any problems." "She was always so good, we never had to worry or concern ourselves about her."

There is a careful and gentle technique to uncovering and confronting these issues in a family. Yes, the parents need to see if their child has become the caretaker, but they need to know what to do about it and they need to not feel guilty about the past. In this case, they can learn to take more responsibility themselves. They also can learn to communicate better with and focus more attention on the child with the eating disorder, who has been virtually ignored because she was doing so well.

A caretaker often comes from a household that has a chaotic or weak parental system—the child becomes independent and assumes too much control and self-reliance before being mature enough to handle it. She is given, or takes out of necessity, too much responsibility. The eating disorder occurs as an extension of the child's self-imposed control system. Anorexia nervosa is the ultimate form of control; bulimia nervosa is a combination of overcontrol combined with a sort of loss of control, rebellion, or at least escape from it. A bulimic controls weight by purging; forcing oneself to purge is exerting control over the binge and the body.

The Lost Child. Sometimes there is no way to overcome a combative parent or abusive family situation. Sometimes there are too many children, and the competition for attention and recognition is too tough. Whatever the reason, some kids get lost in a family. The lost child is the child who learns to cope with family pain or problems by avoidance. This child spends a lot of time alone and avoids interaction because she has learned that it is painful. She also wants to be good and not a problem. She cannot discuss her feelings and keeps everything in. Consequently, this individual's self-esteem is low. If she discovers that dieting wins approval from her peers (which it almost always does) and gives her something to be good at and talked to about, then she continues because it is reinforcing. "What else do I have?" she might say, or at least think and feel. Also, I have seen the lost child who takes comfort in night binges as a way to ease loneliness and the inability to reach out and make meaningful relationships.

The lost child who develops an eating disorder may also discover a sense of power in having some effect on the family. This power is hard to give up. Even though she really may not want to cause family problems, her new special identity is too hard to surrender. It may be the first real one she has had. Some patients, who are conflicted about desperately wanting their disorder but desperately not wanting to cause the family pain, often tell me or write in their journals that they think it would be better if they were dead.