There’s still so much to do

Today we’re going to hear from April, who is feeling a bit stuck with her daughter’s recovery progress. While her daughter is weight restored, April still sees a lot of signs of the eating disorder and isn’t sure what to do about it. 

The letter

Dear Ginny,

My daughter is 15 and we’ve been dealing with anorexia for almost two years. She attended an outpatient program for a few months and we did FBT. She became weight-restored at the lowest level recommended. The truth is that she’s really not recovered. I still see all the signs of the eating disorder. 

She’s not technically underweight and she’s not throwing fits to the same degree she was before weight restoration, but she’s still definitely not gaining weight and has lost a few critical pounds in the past six weeks. 

I really don’t know what to do. I can see that she’s anxious about everything but she doesn’t want to go to therapy. She says it’s a waste of time.

I feel so stuck and alone. What am I supposed to do at this point? We’ve been through so much, but there’s still so much to do.

Signed, April

My response

Hi April, I’m so glad you sent me this letter because you are not alone. 

I often hear from parents who really hope that weight restoration will be the road that leads to recovery. And as you know, weight restoration is essential to even consider recovery, yet weight restoration is not the same thing as recovery for most people.

This is why weight as a measurement of recovery is so tricky. Yes, we need people to have the minimum weight and nutrition necessary for cognitive function, but recovery from an eating disorder goes way beyond weight. 

You have put so much effort into your daughter’s recovery, and it makes sense that you were hoping to see greater progress at this point. So the first thing I want to say is that you’ve made some big strides, and let’s not lose sight of that. 

Eating disorders are so tricky, and so hard to treat, and maintaining a minimum weight is not nothing. It’s an achievement for both of you.

Let’s take a bit of time to review why eating disorders show up and stick around. Keep in mind that talking about eating disorders is a bit like describing the view from a house that has 100 windows. Each window will give you a slightly different perspective.

So if some parts of what I say don’t seem to fit for you, that’s OK. It just means we may want to try another window next time.

Biological factors

We’ll start with the biological aspects. 

As I’m sure you know, there appear to be strong hereditary components that predispose some people to develop an eating disorder.

These inherited traits can make a person more sensitive to the five senses – that is, smell, taste, touch, sound, and sight. For example, your daughter may find food extremely triggering to one or several of her senses.

Inherited traits also dictate a person’s sensitivity to emotional stimuli. For example, highly sensitive people react more strongly to social cues, social rejection, and emotions like embarrassment, shame, and anxiety. This is something we see a lot in people who have eating disorders.

Your daughter may also be very sensitive to the emotional states of the people around her, and this sensitivity can make her more susceptible to an eating disorder.

Psychological factors

The second element of eating disorders is the psychological side. That is – how your daughter’s psychology has developed in relation to her biological sensitivities. 

All people want to avoid things that make them uncomfortable. But you can imagine that if you are particularly sensitive based on inherited traits, you’re going to be avoiding a lot more things than a less-sensitive person. This avoidance is a key feature of eating disorders.

One of the most compelling aspects of an eating disorder is that it provides a set of behaviors that help the person avoid the feelings, sensations, and emotions that make them so deeply uncomfortable. 

In this way, eating disorder behaviors can feel soothing even if the person knows they are not ideal and honestly wants to recover.

Social factors

The third element of an eating disorder is the social aspect. Eating disorders blossom in our highly body-critical and weight-focused culture. 

From the time our kids are born, every well-child visit includes a weight check and a reminder to feed them properly. 

Weight stigma is a major problem in healthcare, and it impacts kids and parents and changes how we feel about kids’ bodies. 

Also, even if the feeding advice is technically appropriate, in our weight-critical, food-shaming society, it feels loaded with judgment and diet culture. 

When they go to school, their teachers use worksheets that further solidify the idea that foods are either good or bad. Then there’s the media, which constantly reinforces the message that fat is bad and thin is good.

In millions of ways, our society nurtures eating disorders. 

Family dynamics

But there’s another aspect of social patterns that we need to examine, and that’s family dynamics. This one is a bit scary, as historically parents have felt harshly blamed and shamed when their kids have problems.

Some mothers of grown children have told me heartbreaking stories of being told to just stay away from their children to avoid doing, as they said, “any more damage.”

That’s an outrageous approach. Parents are never to blame for an eating disorder and there are so many things that parents are uniquely qualified and positioned to do that can make an eating disorder less likely to stick around.

You know, for example, that doing FBT and getting her into treatment so she could achieve weight restoration helped repel the eating disorder enough that she is now medically stable. 

So now the question is: what else can you do? And the good news is there’s a lot you can do. 

Is therapy essential?

First I want to address the idea of therapy. I will first say that I am a huge fan of therapy, and I know many wonderful eating disorder therapists who are doing excellent work. 

But I also know that there are not enough eating disorder therapists to serve everyone right now. This means that a lot of people who do want therapy simply can’t get a qualified eating disorder therapist right now.

Then there’s the fact that therapists are not one-size-fits-all. Even the most qualified eating disorder therapist is not necessarily going to be a match for your child. 

And then, of course, most teenagers don’t want to go to therapy, particularly to talk about their eating disorders. Basically, therapy can be complicated. 

I would keep up the search and keep trying. If you can find a good therapist who your daughter likes, that can be recovery gold. 

Other options

But in the meantime, therapy is not your only option. 

For example, if you are noticing that her weight is dropping, then it’s probably time to bring FBT back. That’s not a sign of failure, just that she needs more eating support right now. Monitor her weight and evaluate whether she needs more serious treatment to get medically stable.

As you know, without medical and weight stabilization, it’s going to be very hard to make progress against the eating disorder.

You may also look into getting a non-diet, eating-disorder-qualified dietitian who can work with her. Dietitians are licensed and qualified, and they have more flexibility and are more likely to work remotely than therapists. So sometimes that’s a good alternative to therapy. 

Emotional regulation

If you’ve listened to my podcast before then you probably know that developing your own emotional regulation and co-regulation skills will help your daughter. 

Remember that the foundation of the eating disorder is biological. Your daughter is most likely highly sensitive to emotional triggers and fluctuations. These are biological, physical experiences are the basis of eating anxiety. 

If you can bring her back into a regulated emotional state regularly, over time she will gain resilience and flexibility she needs to recover. 

She’ll also learn to self-regulate, which, if she’s weight-restored, is the best way to get into full recovery from an eating disorder. 

You may want to check out my eBook if you want to learn more about emotional regulation.

Parental accommodation

Another big thing I’m focusing on right now is helping parents stop accommodating their kids’ demands to avoid the things they don’t want to do and feel. 

Remember how I said the psychology of avoiding negative feelings and experiences can contribute to eating disorders?

Well, this is an area where parents have a lot of influence. You see, the way we respond when our kids get upset and worried about food, weight, and eating issues can either help them avoid that fear or feel afraid and do the thing anyway. 

After FBT for weight restoration, ending anxiety accommodation is the most powerful way that parents can actively interrupt eating disorders and help their kids get into recovery.

Here’s what this looks like – your daughter says she ate a big lunch at school. So she doesn’t want the afternoon snack you have prepared for her.

You want to believe her, and maybe it’s even true that she did eat a big lunch. But you also know that she’s been losing weight, and it’s a slippery slope towards her previous low point. 

Avoiding her afternoon snack is what she wants to do. Of course. It makes sense. She has an eating disorder, and she will want to avoid eating on your terms. 

But begging her to eat, convincing her to eat just a few bites, changing what’s on her plate, or giving up entirely means you accidentally accommodate the anxiety. 

If instead, you stay firm and calm, present and focused. And keep the plate you served as-is, without variation. Then you have changed your behavior. You’ve made it harder for her to follow the eating disorder’s demands to avoid food.

This takes tremendous discipline on your part. It is simple but not easy. 

Get help

And there is a very specific method you can use to make it easier for you called SPACE. This is a parent-based treatment that helps reduce kids’ anxiety. 

It can help a lot with these power struggles. And it will help you feel confident and strong even when the eating disorder tries to wear you down. You can find out more about how SPACE can help with eating disorders here.

April, I know you’ve put so much into your daughter’s recovery already, and I understand why you’re worried right now. I hope this has given you some helpful information and some ideas about what you can do next. 

You can listen to this article as a podcast. Check it out and subscribe using your favorite podcast player.