Clara was 15, and her parents Tina and John were terrified that her eating disorder was not budging. “I think it started when she was about 12 years old and she started complaining about her body,” says Tina. “Then I noticed she was restricting food and skipping meals. She began exercising a lot more than I’d ever seen before, and then I started suspecting she was purging some meals, which turned out to be true.”
When Tina and John tried to get Clara to eat regular meals with them, she became visibly distressed and began what seemed like an endless list of excuses and attempts to get out of eating. “It just feels like there’s no winning with her,” says Tina. “The debates about eating seem endless, and I’m just totally exhausted by it all.”
She also body-checked constantly and wanted to talk with Tina about her weight and appearance. “It started small and I really thought I was doing the right thing when I told her how beautiful she was and assured her she was thin,” says Tina. “But it’s totally snowballed, and now I feel like I’m being manipulated into these awful conversations where I just can’t win no matter what I say.”
Tina and John got Clara into treatment for her eating disorder, but since she was medically stable, there wasn’t a whole lot of intensity to the programming. Also, Clara seemed completely disengaged and was just going through the motions. There hadn’t been any progress in many months, and in several ways, things were getting worse.
Tina and John felt they were treading water, desperate to keep Clara healthy without losing their minds. “I feel like it’s totally taken over my life,” says Tina. “I’m not sleeping, my own eating patterns are disrupted, and I feel so worn out that I’m not showing up in the same way at work, with my friends, and definitely not with my family. I feel we’ve lost so much and are totally trapped in this.”
One of the first symptoms of Clara’s eating disorder was cutting out meat from her diet. “We thought this was a positive sign and were proud of her for thinking about her health and the environment,” says Tina. “I couldn’t see the harm in reducing our meat consumption, so I started trying out new recipes, which was pretty fun at first.”
But soon Clara’s meals became smaller and more limited. She became more resistant to eating. Every meal became a debate about what Clara would and would not eat.
The snowball effect
Then Clara insisted that the family stop buying and serving meat in the house entirely. “That was a real shock,” said Tina. “I felt so helpless though. I mean, we had supported her in making the change, so were we being hypocrites by keeping meat in the house? It just seemed really confusing and overwhelming, so we stopped eating meat at home.”
John was furious about the change. “It felt really wrong to not be able to eat a hamburger or even a tuna sandwich in my own home,” says John. “I took to eating breakfast and lunch in restaurants a lot more than I did before because at least then I felt like I was in control. Sometimes I even hide meat inside other containers in the fridge, partly because I want it, but also because I hate being controlled in my own house.”
Clara asked Tina questions about her weight and appearance frequently. “I feel like a deer in the headlights when this happens,” says Tina. “What am I supposed to say when Clara starts talking about her body? I usually say as little as possible, try to change the subject, or just leave the room. I feel like there’s no winning those conversations so I avoid them.”
The family impact of the eating disorder
Clara’s parents were becoming increasingly anxious and often fought over how to handle Clara’s food and eating issues. Their social circle became smaller, and they found themselves worrying constantly about what Clara had eaten that day and what she would possibly eat that night. Tina kept a running tally in her head of how many calories she estimated Clara had eaten.
Tina took Clara to meet with a therapist and dietitian regularly. She was also being checked by her medical doctor. While Clara remained medically stable, her behavior was difficult for Tina and John to handle. Clara said she didn’t need the ongoing treatment because from her perspective she was recovered.
Clara’s therapist gave Tina an article about parental accommodation and how it can “maintain” an eating disorder. But John and Tina were unsure exactly what parental accommodation was and how they could change their behavior without making the eating disorder worse.
Trying SPACE treatment for Clara
Clara’s therapist suggested trying SPACE treatment, which I have adjusted to fit eating disorder accommodation. Clara’s parents began SPACE 4ED treatment, hoping to find a way to help their daughter. In treatment, they agreed to work on their behavior to help Clara’s recovery. Here are some of the accommodation patterns they identified that could be supporting the eating disorder:
- Not able to eat meat in front of Clara or have meat at home
- Constant body-checking
- Not able to talk about food with Clara
- Clara avoids social outings because of food anxiety
- Conflict between Clara and her parents
- High levels of anxiety and stress for Tina and John
Tina and John learned the foundation for SPACE and began adjusting how they behaved with Clara. They worked on:
- Reducing food-related stress
- Increasing supportive statements
- Charting family accommodation
- Making a plan
- Telling Clara about the plan
- Reducing accommodation
Working through SPACE
During SPACE, Clara’s parents noticed she was uncomfortable but able to cope with the changes they were making. They started serving meat at dinner without asking her to eat it – just tolerate it on the table. One night when they were eating sushi she took a piece of a California roll without prompting.
“After all those years of trying to convince her to just take a bite, I was pretty stunned when she did it without me asking her to,” says Tina. “I can’t say it was magic because I know all the work we did to get there, but it certainly felt like magic!”
Tina also learned how to respond effectively to body-checking. “I learned how to validate her feelings without accommodating the eating disorder’s demands,” says Tina. “I stopped avoiding the conversations, and the more I responded directly, the less frequent and stressful they became.”
While the process wasn’t easy, Tina and John gained confidence in Clara’s ability to cope with food and body stress.
At the end of treatment, Tina said that the stress level in their household was cut at least in half, and she was starting to sleep after years of insomnia. Clara still has her own work to do in her recovery, but her parents are now confident that the actions they’re taking are making a positive difference.
The SPACE solution
If your child has an eating disorder, then you know how hard it is to get your child to eat and stop body-checking. The constant reassurance, nagging, and negotiating are exhausting and overwhelming. You may be feeling burned out and hopeless. You may be seeing your social ties fraying, and if you’re in partnership or marriage, the eating disorder might be coming between you. It’s probably also impacting your other kids if you have them.
It can feel hopeless at times, and many parents feel shut out of treatment, helpless to make a difference. Luckily, there is evidence that parental accommodation is a factor in an eating disorder, and therefore ending accommodation can support recovery.
SPACE (Supportive Parenting for Anxious Childhood Emotions) is an evidence-based treatment program that helps kids who suffer from severe anxiety symptoms and where parental accommodation is present. With SPACE, children are the treatment targets, but parents are the ones who attend coaching sessions.
What SPACE helps with
SPACE treatment can help parents deal with eating disorder behaviors like food restrictions, refusal, and rituals. Because while the available treatments can be helpful, they require engagement from the kids and rarely teach parents how to respond effectively to the eating disorder behaviors when they show up at home.
With my SPACE 4ED treatment, I’m able to teach parents exactly what to do, what not to do, and how to make a difference in eating disorder behaviors.
Recently the creators of SPACE developed and tested SPACE-ARFID, which provides even more guidance about how I can help parents who are dealing with food restrictions, refusal, and rituals.
SPACE-ARFID is very effective in helping parents end eating disorder accommodation. It helps kids eat a greater variety of food, in more places. And the kids don’t need to show up or engage in a single session. Parents do the work, but the kids benefit from the treatment. This is especially helpful when the child is resistant to treatment.
Typical treatment for eating disorders
As any parent who has a kid with an eating disorder knows, eating disorders are extremely difficult to treat. It can be hard to understand, but someone who has an eating disorder often finds living with their eating disorder to be more comfortable than recovering from it.
Handling an eating disorder is not something most parents can do alone, and there are many treatment options available. Current therapy approaches commonly used to address eating disorders are:
- Cognitive-behavioral therapy
- Dialectal behavioral therapy
- Interpersonal therapy
- Family therapy
- Exposure therapy
These treatment options can help the individual who has an eating disorder. But they don’t address the ways in which parental behavior impacts the eating disorder.
Kids can and should continue any treatment they are currently receiving. The addition of SPACE can be done in partnership with and in addition to existing treatment methods.
When parents face kids with an eating disorder, they often feel overwhelmed and exhausted. This is because it takes tremendous effort to convince these kids to feed their bodies and take good care of themselves. The eating disorder behaviors often grow and expand even as parents make their best efforts to help their kids recover.
With SPACE, parents are the ones who attend coaching sessions. You don’t need to force kids to attend SPACE treatment sessions. Your kid doesn’t need to be engaged or motivated to change their behavior for SPACE to work.
SPACE is an 8-16-week coaching program that’s an effective way to:
- Increase food flexibility
- Reduce food rigidity
- Function better in a variety of food environments
- Expand the list of “accepted foods”
- Decrease food-related stress
- Respond to body-checking
- Reduce family accommodation
- Teach parents to support children through resistance and fear
What is SPACE?
SPACE, developed by Eli Lebowitz, is a treatment program for childhood anxiety delivered to parents. It’s a parent-based treatment for childhood anxiety symptoms including high levels of avoidance and family accommodation.
Clinical trials have demonstrated that SPACE is effective at reducing parental accommodation. And an initial trial showed that SPACE-ARFID is effective at both reducing accommodation and increasing food flexibility.
I train parents to use SPACE with their kids who have eating disorders because I believe it is an essential way that parents can make a difference in kids’ recovery. Let me know if you have any questions or would like to learn more about it!