By Psychologist Sarah McMahon
At BodyMatters we have a constant stream of people contacting us because someone they love has an eating disorder- and they don’t quite know what to do. Unfortunately eating disorders don’t come with a manual, and so I am attempting to cover the very basics of what you should do if you find yourself in this position. Needless to say this information is general and I encourage you to get in contact with us directly for more customised thoughts. There are also some EXCELLENT resources, including other places you can contact for help, listed at the bottom of this article.
Sometimes the initial discovery that someone you love has an eating disorder is by way of their personal disclosure. More often, parents & partners simply have a sneaking suspicion or encounter something that confirms the same. One thing that you always need to remember is that, whether or not a person discloses to you that they have an eating problem, their motivation about recovery is likely to be dynamic in that there are times it may be high- and other times where they don’t want to get better at all. This fact is beyond the scope of this article, however it is something that you need to take into consideration regarding how you approach this issue. Eating disorders are one of the few mental health conditions that are egosyntonic – some sufferers actually appear to “want” to have one. This is usually, but not always, due to fear of weight gain in recovery- even for sufferers who have not actually lost weight as part of the onset. Lets face it, we live in a culture where thinness is glorified at any cost; the times I have even heard people in the general public say they “wouldn’t mind a bit of anorexia for a day” is astounding. You certainly would not hear that about other mental illnesses such as schizophrenia or depression.
When you are told
If you are reading this article, your loved one may have already told you they have a problem with food, so it is too late for me to say keep calm & try not to get angry or upset! However this is what you should do in any future dealings regarding this issue. Often parents and partners say they are not quite sure what they need to do after they are told. The answer is quite simple and is twofold: (i) continue being their parent or partner (not their therapist!)- keep loving them and treating them like a human being; (ii) get them into specialised treatment for the eating disorder- it is a serious, potentially life threatening mental illness. People rarely recover without specialised intervention.
When you discover it by accident, or “accidently-on-purpose”
It can be a lot more difficult- and a lot more common- when the sufferer does not realise you are aware of their problem. Eating disorders are highly secretive illnesses and are usually shame & fear based. Research suggests that sufferers with bulimic symptoms typically hide their behaviour from loved ones for 8-10 years before disclosing it. Usually this level of secrecy is totally out of character for the sufferer, and so it can be helpful to try to externalise them from this “eating disorder behaviour”. When you have determined that there is a problem it is important to approach the sufferer directly to tell them of your concerns. However manage your expectations here, your ultimate aim is facilitating them into specialised treatment and this will usually be over many many conversations- not just one. Expect defensiveness and even denial to begin with.
How you handle approaching your loved one and facilitating their access into treatment will also obviously depend on the age of your loved one- if you are a parent to a 10 year old, you will handle this very differently to if you have found out that your partner of 10 years is unwell. Generally speaking, if you are a parent of a young one who denies their illness and/ or does not want to get better, you can commence Family Based Treatment (discussed below) immediately. If they are older and candidates for individual treatment they will normally require some level of insight and motivation to benefit from treatment.
Unfortunately it is much easier to give feedback on what not to say. We have some basic tips about speaking to your loved one here. Our Psychologist Kellie Hodder has also written about this previously here.
Diagnosis (or not)
At BodyMatters we take a transdiagnostic approach as all eating disorders, even seemingly “sub clinical” eating disorders are serious. Anorexia Nervosa (restriction of food and refusal to maintain an appropriate body weight) is the least common yet most well known eating disorder, usually because of the visually shocking nature of the presentation. Bulimia Nervosa (binge eating followed by compensation for the binge, usually by way of vomiting) is about five times more common than Anorexia. Binge Eating Disorder is also now being recognised as an eating disorder and is also very common.
You may be interested to discover that under the DSM IV TR criteria, which describes all the various diagnoses (and has been recently updated), up to 90% with eating problems would fall into the category you may have never heard of called “Eating Disorders Not Otherwise Specified” (EDNOS). This is a waste-paper basket diagnostic category for people who do not meet the strict criteria of Anorexia, Bulimia & Binge Eating Disorder- but it is just as serious. Don’t wait until your loved one is “sick enough” or has all the signs of Anorexia or Bulimia to express your concern: eating disorders are typically a regressive, spectrum based group of illness and research suggests that early intervention is the best predictor of recovery.
Some general guidelines for treatment are as follows, however a comprehensive assessment by an eating disorder expert should clarify what treatment option is best. We would also usually recommend consulting a General Practitioner who specialises in eating disorders as the first point of call. If your loved one exhibts ambivalence about recovery, or reluctance to seek treatment, this could be done as part of a “check up” or “health check”. If your loved one is adamant that they are “OK” or there is “nothing wrong” you could also encourage this medical check just to clarify the same- just ensure the doctor they consult does have expertise in this area to ensure that a diagnosis that should be made is not missed.
Family Based Treatment
Family based treatment, known as Maudsley Family Therapy, is a highly specialised treatment approach used for teenagers with Anorexia Nervosa (or someone on the pathway to developing Anorexia Nervosa). It involves the whole family as a resource for recovery and has the highest effectiveness of any treatment approach with demonstrated efficacy to the age of 21 years. We have written more about Maudsley Family Therapy in several blogs recently which can be accessed here, here & here. If your loved one is a teenager, living at home, with restrictive symptoms, this should be the first starting place for treatment. The good thing about this treatment as it does not rely on the young person having insight into their illness or motivation to recover.
Individual treatment, as the name suggests, is usually provided without the family present. It is also an evidence based intervention: Cognitive Behavioural Therapy & Mindfulness are known as being the most effective types of individual therapies, however many clinicians are eclectic in their approach. However if there is ambivalence about recovery the therapist will usually start treatment by building engagement and motivation. This lays the foundation for change to occur.
Individual Treatment is typically used for older sufferers (ie not teenagers) with restrictive symptoms, and younger sufferers with bulimic and binge eating symptoms. We often hear from parents and partners who want their loved one to commence individual treatment when they are not motivated to do so or do not realise they are even sick. In these instances we would suggest considering if there are other avenues to access treatment or medical monitoring, such as anxiety or depression (which are often comorbid to eating disorders) that the loved one may be more motivated to work on.
During individual treatment at BodyMatters we typically try to include parents & partners in individual treatment when appropriate, however this is in a supportive capacity rather than as the agent of change in the way that family are utilised in family based treatment.
Cost of treatment
Unfortunately eating disorders can be expensive to treat as treatment usually involves regular (ie weekly) sessions for a minimum of 6-12 months. If you are in Australia we recommend you access a mental health care plan via medicare to help with this (you will need to consult your General Practitioner for this). Once the medicare entitlements are exhausted, you can access treatment via your private health insurance policy, if you have one. The Butterfly Foundation provides financial support that you can apply for. Bodymatters also provides low cost counselling for people who otherwise cannot access treatment, however unfortunately this is also limited.
If you are in Australia, the best place to start is national eating disorder charity, The Butterfly Foundation, Queensland’s Eating Disorder Association or Victoria’s Eating Disorder Foundation. These fabulous organisations offer telephone & email support, provide information about treatment options and provide support groups for sufferers and their parents & partners.
If the person you love is a candidate for Maudsley Family Therapy there are some excellent books out there for you- we would recommend you look at that section of our bookshop for our favourites.
We would recommend Janet Treasures’s Skills Based Learning book for everyone, however if you are a partner rather than a parent, and if you are undergoing Maudsley Family Therapy we would recommend you read & interpret it with a bit of creativity given this book was predominantly written for parents of adult/ young adult eating disorder sufferers.