"What do I do if I think my friend has an eating disorder?" At all the psychoeducational workshops I have led with adolescents, this question is asked. With the increasing prevalence of eating disorders across all age groups, there is a good chance that at least one teen in the group will have a friend with either anorexia or bulimia. (In this one post, I specifically address this question when asked in school groups. However, much of the information can be used with all age groups, male and female.)
This is actually a two part question. The first part is: how does one express ones concerns about a friend's perceived eating disorder and encourage her/him to seek help? The second component is:
once a friend is in treatment, how does one support her/him through what is often a very difficult treatment process?
In response to part one, sometimes I do a role play with the group. I suggest that the concerned friend choose a quiet time and place where there are few distractions, where it feels safe for the concerned friend to express her feelings and concerns and where the teen who may have an eating disorder feels safe to respond.
Try to express your concerns not only in terms of weight and food, but also in terms of how you have noticed that your friend's behavior and moods have changed. This may help the ill teen to see that her eating behavior, whether it is restricting her intake or binging and purging, is affecting her in multiple ways, not just in her food intake. Eating disorders are not just about weight and food, they affect all areas of the sufferer's life, including her relationships with friends and family.
In a nonjudgmental and calm way use "I" statements. For example, instead of stating, "You look too skinny." Try, "I value our friendship," or, "You mean a lot to me and I have noticed that you don't like to do things after school anymore. You no longer come to parties. I miss sitting with you in the cafeteria at lunch time. I'm concerned. Is there something wrong?"
Your friend may respond in several ways. If she tells you that she is upset about something and does not know how to deal with it or is afraid to talk about it, you can offer to accompany her to talk to an adult. The adult might be a parent, teacher, or school counselor, who can help her to get professional help.
A more likely outcome is that she will become defensive and deny that anything is wrong. She may become angry, telling you that everything is fine. She may say, "Nothing is wrong. I just haven't been very hungry lately." Or she may say, "You're just jealous of my thinness and that I fit into a size zero." There is a good chance that she will push you away.
Try not to let the discussion escalate into a heated argument. In response to her denial, you might say, "It's just that I care about you and want you to be healthy. If you change your mind and want to talk, I'm here." Try not to take her reaction, whether it is anger, denial, or rejection, personally as all of these responses are often a part of the eating disorder. Do NOT give up.
Wait a few days or a week at the most and raise the issue once more. If she continues to deny that there is a problem and responds in a similar way, then seek out an adult you trust and express your concerns.
It is usually not helpful to approach the sufferer's parents by yourself. Go with another adult or if you feel uncomfortable, let the adult go alone. It can be very difficult for parents to admit that their child has a problem. The parents too may respond in denial or anger, especially when it is their child's peer telling them about the problem. It may be easier for the parents to hear about their child's illness from another adult, although this too is painful.
When your friend learns that you or an adult has spoken to her parents, she may get angry at you. She may feel that you have betrayed her and that she cannot trust you any longer. Nothing is farther from the truth. When in the grips of an eating disorder, the sooner one gets helps, the better the chances of recovery and the less disrupted her physical and emotional growth will be. The earlier a sufferer gets help, the less likely the eating disorder will become chronic or even fatal. You are being a true friend!
Hopefully the sufferer will get professional help. Once she does, how can you support her? As an adolescent yourself, you may have your own age appropriate developmental struggles, such as the push and pull of individuation and separation, finding your identity and place within your peer group, and negotiating your relationships with peers and family. You can be a good listener and support your friend's path to recovery without taking on her struggles as well.
Recovery from anorexia or bulimia can feel like pushing a boulder up a mountain. The sufferer developed the illness in order to cope with inner conflicts and stresses. She now needs to learn other ways to express herself and how to deal with these stresses. It is often a period of fear, anxiety, sadness, and doubt. It is never an even and steady path. There is frequently a back and forth motion.
Be aware that even once your friend is weight restored and her eating has stabilized, she is not fully recovered. It takes much longer to deal with the inner struggles which led to the illness. Patience and persistence are key.
Be there with your friend. You cannot know exactly how she is feeling, but you can listen to her and let her know that you are there for her through the fear and anxiety. She may be moody and tearful. This is all part of the slow and often grueling process. Encourage her steps towards mental and physical health. If she is in an inpatient program, call her, email her, or if possible, visit. If she is receiving outpatient treatment and needs to eat an extra snack at school, sit with her. Recovery can feel like a very lonely process. Let her know she is not alone.
If the situation were reversed, you would want your friend to be there for you. So be there with her.
When I speak with adolescents, I sometimes share my own experience with my peers. When I developed anorexia in college, several of my close friends expressed their concerns and urged my to seek treatment. I did get professional help, but it was not the right treatment. My illness grew stronger. I restricted my eating and exercised more, becoming even more consumed by the anorexia. I'm sure I pushed my friends away as there was no space left for them.
I never asked them about it afterwards, but maybe if my friends had understood that my behavior was part of the illness, they would have stood by me when I finally agreed to an inpatient treatment program. Once I entered the inpatient program, my friends went on without me. They seemed to disappear.
When I returned to school I had no close friends. I felt very isolated and alone. The transition back to school was difficult and I did not have the proper therapeutic supports in place to help me deal with the challenges. Without these supports and without any support from friends, I relapsed into a familiar but deadly coping mechanism, my anorexia.
Anorexia is a difficult disease to treat and there are frequent relapses. It is true that even with close peer relationships, I might have relapsed. However, it is possible that with even one close pal, anorexia would not have taken the place of a best friend.