This post was originally published on June 12, 2013. 

We’ve all heard from parents whose child had (or has) an eating disorder and who re-feed them at home, single-handedly and successfully. The Around the Dinner Table forum is full of such stories from parents who help other parents trying to do the same. But not all children’s illnesses can be so managed. At Kartini Clinic we practice a day treatment model of family-based care (as well as inpatient medical stabilization and outpatient follow-up, where needed). Everybody knows that we are firm - nay, fanatic - in our belief that parents do not cause eating disorders and cannot be “the problem,” although that’s not to say that we parents can’t sometimes be problematic. No, make that: we humans can be problematic.  

In this blog I would like to touch on some of the reasons we have observed why family-based treatment models, while the highest and best models out there, can be so danged hard.

  1. Awesome responsibility: it’s always easier to punt treatment to “the professionals,” to decline to engage in a thoughtful review of the literature yourself, to get informed about what is known about an illness, to get involved in decision-making and to be a proactive part of the team. It is easier to punt to others because you are scared and the stakes are so high.

  2. Distress tolerance: it can be supremely difficult to tolerate your own child’s distress, even when you know that it is necessary to do so. I have listed this difficulty second, but it is probably first, both in its potential for interfering with good treatment outcome and the frequency with which we see it. The closer you are to your child, the harder it may be to see them struggle, feel bad, get despondent and down. In the case of anorexia nervosa, where the patient may actively resist getting well or gaining weight, mood is not a good indicator of efficacy of treatment. In fact, when you are the most successful, the patient may feel the most despondent, because, after all, with an eating disorder it’s “lose weight, get happy.”

  3. Your own fears about weight gain: we are bombarded daily with the message that losing weight is an unmitigated good and gaining weight to be avoided at all costs. And if this were always just the counsel of fools it would be easier to ignore, but we hear it from doctors, nurses, even highly-placed politicians and their wives. So as your child’s weight goes up and their desperation to discuss and dissect this weight gain increases, parents may find that they, too, become anxious about whether or not their child is being asked to “gain too much weight.”

  4. The rest of your family: balancing the demands of other children and the often-unhelpful “advice” from other adults in the family (some of whom may themselves struggle with an eating disorder) is crazy-making.  Kartini Clinic demands that families prepare meals at home and eat them together. This is a lost art in our country’s dominant culture and attempts to do so are not always met with cooperation. Other teenagers in the family may resent this “intrusion” into their independence, your spouse may resent having to eat a meal when they want to go to the gym or go running. Individual food preferences can be hard to balance when you are actually cooking, as opposed to providing groceries for everyone to heat up on their own as they see fit.  

  5. The Gods of Exercise: we are bombarded with information telling us that everything, but everything, from high blood pressure, beauty, longevity, our job performance and Alzheimer’s, is improved with exercise. Yet you may have to enforce the supremely thankless task of containing your eating disordered child’s exercise. And painfully, it may mean containing your own exercise regimen as well.

  6. You have to cook: no, you really do. As I quoted in a previous blog: “You’ll gladly die for your children, why won’t you cook for them?” There will be no substitute for cooking food and eating it together. Yep. Together.  

  7. Kids fight back: tantrums, and I do mean tantrums, and threats (“I’d rather die,” “I’ll run away,” and so on) are a common occurrence when parents need to enforce sufficient food to gain or maintain weight. A cascade of arguments along the lines of “no one else has to” and “so-and-so eats nothing and they are just fine,” “you can’t make me,” and “it’s my life” will hit you full in the face. Be prepared. Go on the Around the Dinner Table forum and get moral support from other parents, or check out the films of C&M Productions. Be strong. This is about the welfare of your child.

  8. Parental divide: this kind of challenging and difficult family-based intervention can cause or worsen parental strife. One parent - usually, but not always, the mother - is primarily responsible for enforcing food intake and exercise rules. To the extent this responsibility can be shared, it’s best. But today many families are not mother-father; they may be mother-mother; single mother, single father, father-father or even mother, divorced father, other mother, step-mother, etc, etc. You get the point. It can be very hard to achieve a perfect coalition among so many adults, some of whom may not always get along with each other.

  9. The Web: the Web has empowered us. It has also enslaved us and lead us astray. Kids can download apps to calculate calories and grams of fat; they can download “thinspirational” pictures, recipes, etc. As I speak, worse things are being developed with the speed of cellular replication. But you have be the adult in the room. Track, monitor and take charge. And my goodness, it is hard.

  10. You get tired: all I can say is that you can get tired. Very tired. No one can help you much, and rest is hard. The mission is challenging, but not impossible. Draw from reserves of strength you may not have drawn from in years. Find someone to talk to. Take heart in the knowledge that help is our there and recovery is possible.