Just Listen

Hello Dr. Goulston,

My sister and my daughter both suffered from anorexia. Both have sensitive, artistic temperaments by nature. Both have some difficulty when they feel others are critical of them (my daughter often over-interprets the emotions of others, thinking they are angry when they aren’t). Both are somewhat socially anxious.

I can’t speak to this young woman’s personal situation, but as a mother of 3 now adult children, as a social worker and as someone who works with kids professionally here is what I can tell you based on my experience:

• Anorexia Nervosa is an incredibly hard illness on any family. It can cause triangulation and stress in the most previously solid of marriages. I am not surprised that the family you encountered was showing signs of trauma. How would you feel, watching your beloved child starve to death, being unable to stop it and perhaps feeling blamed for it by the medical community (quite likely 32 years ago, I might add)? Desperate? Guilty? Downright awful? Ineffective as a parent? All of the above? It is very difficult to see a ‘snapshot’ of a family at a troubled moment in time and deem the problem ‘starved for love’ when in fact this family may well have loved their daughter very much, have been absolutely wild with frustration, anger (yes, anger, if they viewed her anorexia as a ‘choice’ she was making rather than a brain disturbance and a mental illness) and grief at their inability to change the situation. And families feel judged when they enter a hospital environment in the presence of professionals.

• Severe weight loss causes cognitive dysfunction. Nancy's lack of ‘verbalness’, her fatigue, even her moodiness could be directly related to her starved stated. It may or may not have been emotions driven by a lack of love in her life.

• Nancy knew she was being admitted to the hospital where, presumably, she would be supervised with her eating. She may have felt more ‘safe’ and ‘structured’ there, so was willing to eat a candy bar. She also may have realized it would be harder to avoid eating. The control was taken from her. This may have acted as an anxiety reducer which was helpful to her.

Family-based therapy is based on this approach and is shown to be the most effective, evidence-based treatment yet available for anorexia. It was modeled after the very structured feeding approached used by nurses in hospital settings. I can’t say exactly why Nancy chose to eat this one candy bar. Maybe you are right and it was the feeling of your listening and a longing for love. Maybe you are not right. But it is in my opinion not scientific to say that she was starved for loved based on this one incident. What we DO know is that she was starved for FOOD based on her history of weight loss and 4 hospitalizations. Only going back and knowing how she did in treatment and how she is doing now would give you some understanding.

What the hospital did was essential right. You made her safe and fed her. Professionals have a duty to remember that ill patients are part of a greater family system. Family systems are usually doing their best and want the best for 'the whole'. I don't think love (or lack of)is usually the problem. For families, I think being empowered to know how and when to act effectively is.

anne56

I would say that every 14 year old is working on separation and individuation issues. These are normal developmental tasks for the age.

This was also the age my daughter was when illness struck. It resulted in both physical and emotional regression. I do believe she was anxious about growing up (I remember having some of those fears myself, altho didn't starve myself over them). I do not believe it caused her illness, although self-image concerns may have led her to try losing some weight.

Every adolescent is a work in progress. While her fear may have been greater than some teens, it doesn't make sense to me that she would starve so severely over a 'normal for her age' experience--unless, as Dr. Walter Kaye's research indicates, she had the genetics for it, it acted in some way as an anxiety reducer for her and she got caught up in a vicious cycle she at first denied and then couldn't escape. But, loved she was, is and always will be.

What a disservice you do to families to suggest that this patient, and by extension, others who suffer from eating disorders, are also suffering from a lack of love and appropriate parenting. Did it ever occur to you when you were assessing "Nancy" and judging her parents that the 4 years that this family had been facing the terror of watching their daughter disappear before their eyes had taken a major toll on the marital relationship, the emotional and physical health of the parents, and the family relationship in general? It may be true that "Nancy" was suffering from a lack of love but no professional should make that judgment based on the interactions of a family watching their precious child fade away in front of them. Obviously, you've never had that experience or you would understand what a toll it takes on a family. And the disservice of an essay such as yours is that it is perceived as a generalization as to the cause of an eating disorder, whether you intended that way or not. If one's child becomes ill with cancer, there is generally an accepted protocol established for medical care and treatment. Obviously, there are cases which fall outside the norm and have to be treated differently but there are experts -- surgeons, oncologists, radiologists, etc. When a child falls ill with an eating disorder, it's as if your child was injured in an accident but you can't tell where or what the injuries are and so you don't know what kind of treatment to get or who the specialists are. Then if you are tenacious enough to actually navigate the mental health system and put together a treatment team which uses evidence-based care, you still can't be sure that you have done the right thing or enough of the right thing. And it goes on and on. You owe an apology to eating disorder sufferers and their families for your ignorant generalization.

This fear is not unfounded on the part of parents since anorexia has the highest mortality rate of any psychiatric illness.

I was honest about my fears with my daughter--about the health effects it was having on her body, about the mortality rate. What I realized quickly was that I couldn't convince her using logic because this wasn't a rational illness. Her behaviors continued.

I was dying for her help to get better. She didn't want feel there was anything to get better from--in fact, she told me she liked what she was doing.

This illness has been described as egosyntonic and anosognosic. It seems to be a classic symptom of the illness.

What I think families need to be given Day 1 is Eating Disorders 101 training. They need to understand the illness. They need practical, 'how to' help dealing with it. This means the food and eating aspects of it, yes, but also the behavioral aspects too. They need old myths dispelled. I do believe there is a role for counselors, both as 'educators' and as support for family members (not in the sense of 'what's wrong with this family' but in the sense of 'how can we support this family to support this patient back to health?")

Therapy that presumes pathology is not helpful. I believe your brief intervention did reach a part of this young woman at that moment in time. I also don't think it necessarily means she was starved for love, or that her parents weren't good, or anything of that. That is simply reading too much into it and has the potential to be read as " she was under loved and it contributed to her anorexic state". That is hurtful to families and unproven. I don't think you intended this, but we are a sensitive lot having been blamed and excluded from treatment for so many years (only 6 years has past since my daughter's hospitalization and I was not allowed to visit her for 6 weeks).
Can you imagine that happening if she had been a cancer victim? There has been parent blame. It is simply not right. It is hurtful and damaging. I know you didn't intend that in your article, but I felt the need to speak up about what we know, don't know and how even simple presumptions may be wrong.

I think it was partly the subtitle "Looking for Love in all the Wrong Places CAUSES Anorexia" that really bothered me. It's way too much of a simplification of this neuro-biologically based mental illness. It simply doesn't cause it. Feeling un or under loved is not a pleasant feeling. But it is a feeling we have all felt at one time or another and, if this caused anorexia, many more of us would have it.