How to Help Someone with an Eating Disorder
Thoughts on doing more good than harm when someone you care about is ill.
Posted Nov 09, 2015
What should you do if you think or know that someone you care about has an eating disorder? What shouldn’t you do? What can you do?
This post is primarily for you, the bystander: for you who watch someone who matters to you do themselves harm. (If you want some tips on how specifically to navigate through the rest of this blog if you’re worried about someone else, please skip to the end of the post. And please note that the following probably doesn’t apply to the role of the parent of a child who hasn’t yet reached adulthood; there, the extent of one’s duty of care is rather different. On the other hand, it may also apply to other related health conditions, like depression, anxiety disorder, and addiction.)
Before I go any further, though, if you’re reading this and you know or suspect that someone else is worrying about you, and however that makes you feel, you might consider reading this too. If you read on, I hope that reading might help give you a little bit of insight into how it is for that person who is concerned.
On both sides, the failure to really understand how the other feels or what the other is doing can be a real stumbling block. This is often said of the person suffering from an eating disorder: no one who hasn’t had one can really understand. But it applies the other way around too: if you haven’t experienced the fear, the helplessness, the anger, and, not least, precisely the incomprehension of looking on as someone dear to you apparently knowingly destroys themselves, it’s difficult quite to imagine what it’s like.
It’s easy to be both too confident and too unsure about the possibility of knowing what it’s like to be someone else. On the one hand, the problem of other minds is a real problem, however you look at it. In philosophy it’s been memorably encapsulated in Thomas Nagel’s 1970 paper ‘What is it like to be a bat?’ and in the notion of the ‘philosophical zombie’, who is identical to us in all respects except that she isn’t conscious. It’s hard to know whether there is anything it could mean to empathise, really and truly, with someone else – and correspondingly hard to know how well founded one’s empathic feelings are when one has them. But the difficulty is of a different order when there’s an obvious gulf between the two of you, a gulf that has a scary name and is full of things that bear some resemblance to your own experience (dieting, insecurity, etc.) but all with the extremism of the completely alien.
Those elements of common ground can sometimes be the root of a misplaced assumption that anorexia is, say, just a rather extreme kind of diet, or that starvation-induced depression is kind of like having a really bad day. Obviously, those kinds of parallels are rarely drawn explicitly, or with such crudeness, but they can lurk half-submerged and come to the surface in phrases like ‘I know how you feel,’ which can come across as belittling to someone trying to cope with a serious illness.
The upshot of this little philosophical digression is that everything is likely to go better if an effort at understanding how the other might be feeling is made on both sides.
So, back to the questions I started with.
Phase One: Early Uncertainties
The most common approach is to do and say nothing. This is also probably the most appropriate course of (in)action in the early days of noticing that something might be wrong, at least if the person you’re worried about isn’t obviously an immediate danger to themselves or others. A reasonable thing to do is to wait, to watch, and to continue to be a friend – or a parent, or a partner, or a colleague, or whatever else is most important in your relationship.
The priorities at this point should be firstly to keep that relationship and an open line of communication going, and secondly to establish the facts about the condition the person is currently in. In this second respect, it’s important to ascertain some basics: as far as you can reasonably judge, how much is the person eating, vomiting, exercising; how much are their eating or exercise habits jeopardising their ability to live an ordinary life; is their mood consistently low or very variable; are they suicidal in thought and/or action? Talking to mutual friends, or to the person's family if you know them, could be very helpful here too; there’s no point in lots of people fretting and duplicating efforts that could be shared. It may feel like you’re spying on the person you care about; but in these circumstances, making observations, and trying not to make it too obvious that you are observing, is perfectly justified: it’s good and important to have as many facts straight as you can before you decide whether any other kind of action ought to be taken.
At some point you may then establish to your own satisfaction that the person you were worried about (whom henceforth I’ll call P) was either just temporarily under the weather or has some other innocuous explanation for the things that struck you as abnormal – or that (s)he has a physical condition which needs direct medical attention. In the former case, with any luck you’ve been able to observe without it becoming clear what you were doing; but if not, and you had already voiced your concern, P will hopefully take it well, as a marker of the fact that you care.
Phase Two: The Extended In-Between
Having concrete information at your disposal is particularly helpful when it comes to one way the next stage might go: the gentle initiation of conversations that relate to the problem. The most common response on P’s part is denial: not necessarily aggressive why-the-hell-would-you-think-that denial, but quite likely a quiet rebuttal along the lines of: ‘no, really, I’m fine’, or ‘I’ve just been a bit tired/stressed/under the weather lately, it’s nothing’. If you have concrete evidence that there’s likely to be more to the situation than this, that doesn’t give you a mandate to push and push until P crumbles and pours out their life story. But it does make you different from others who might accept the ‘I’m fine’ story without giving it much more thought. It puts you in a position to be there for P in a way that might be really meaningful – might even be the difference between life and death, or life and prolonged illness.
My friend Phoebe made that difference for me, and I suppose the action she took, when she finally did take it, was based on some period of observation, of reflection, of reading and researching and joining up the dots – which culminated in her secretly ringing my mother, and telling her something she’d known for ten years: I think your daughter has anorexia. Different things become salient to people at different times, and there were certainly things that had got worse for me that year – worse enough that I both needed help more, and was slightly closer to accepting that I needed it, or at least that something had to change, regardless of how.
So this second phase, then, might be thought of as maintaining the relationship, but pushing a little at its boundaries. If you’re fairly sure something is wrong, there are a few obvious things you might want to try next: simply carry on finding out more, encourage P to acknowledge she or he has a problem and/or to seek help for it, and/or signal to P that you know (s)he has a problem. Broaching the topic at not too infrequent intervals achieves all these things. But it’s important not to end up feeling like all you do is pester or fret or criticise; the aim should be more to give P an opportunity to talk openly than to force him or her to. Some people would even say you shouldn’t ever ask direct questions about the problem, but simply let P know you’re there if (s)he ever wants to talk. How much, how often, and how directly it’s appropriate to start a dialogue in any given situation might have to be worked out by trial and error. However awkward or even painful or frightening the error part of the equation can be, it’s no bad thing to be pragmatic about this, and to try to establish what works best. That means: what brings about, the greatest proportion of times, the best ratio of good to bad. It doesn't mean: what never risks doing any bad at all? There is no such course of action, including and especially inaction.
To maximize the chance of doing good, the questions, the prompts, probably shouldn’t be directly about food or body issues. Asking P how much (s)he’s eaten today, or how much (s)he weighs, or commenting on how much time (s)he spends exercising, is unlikely to prompt anything but silence or untruths. Someone who has an eating disorder may well feel ashamed of it already, so forcing P’s attention on to the focal point of that shame risks intensifying it to no good effect. Pressing food on P is also unlikely to achieve much; like hovering around while (s)he prepares food, it’s likely to create jumpy anxiety more than anything. In an account of my illness I wrote based on my diaries, I described one night with my housemate in Germany, trying to be friendly but not very well even to pretend, let alone to really focus on what he was talking to me about:
Henry came back from a long day of lectures inexplicably, unprecedentedly talkative – unfortunately, I was just finishing cooking when he decided to come and sit in the kitchen with me and describe in great detail every aspect of his course, so I was worrying about my pasta going cold instead of paying attention to the intricacies of programming and notation that he was explaining to me – but we at least made another communal cooking date for Wednesday – he promises to do Chinese (21.10.02). I remember standing there by the stove, worrying not just about the heat of the pasta, but about whether he could see what and how much there was of everything, about how to lean at ease and look alert and keep enough of my brain spare to say the right words in his pauses while thinking how to make my escape with no appearance of obsessive secrecy; irritated with him for not noticing my embarrassment, relieved that he hadn’t noticed; irritated with myself for it all.
Eating disorders are often about exerting control in a frighteningly uncontrolled universe. So someone else coming along and attempting – in however minor and well-meaning a manner – to take control away, especially in that fragile hub of the whole grand network, food, is most likely to be seen as one more threat amongst an already overwhelming onslaught of them. For the same reason, tackling sensitive things at mealtimes is unlikely to work very well: P will probably be at his or her most distracted and highly strung.
A better idea might be to make space for thoughts and feelings rather than focusing on behaviours: ‘is there anything on your mind at the moment?’, ‘how are you feeling?’, ‘just say if there’s anything you’d like to talk about’. Then it’s up to P to decide whether to respond with small talk or trust. As to what you do or say if and when P opens up to you a little – that is tricky too. In my limited experience of talking with someone ill face to face, I’ve gravitated towards a mixture of simply listening and offering gentle challenges to their automatic ways of thinking about things, and has seemed to work reasonably well. But then I’ve been speaking from a post-anorexic perspective myself, which must make quite a difference, to them and me.
The obvious ideal is to try to listen without judging – certainly without leaping to judgements. But that can be hard, when what’s being said seems to leave itself so obviously open to all kinds of replies that should, if anything were working normally, be knock-down arguments to open P’s eyes, cast off the burden, and let the light back in. The cliché springs to mind about what women want from men being not a solution but a sympathetic listening ear: not ‘well, take the other route tomorrow, then’, but ‘poor you, what idiots all those other drivers are for getting in your way’. Sometimes you may be able to give genuinely good advice, and P may be in a position to hear it, even act on it; sometimes, that isn’t needed or wanted, and the fact of being there for them, giving your time and your patience, is what matters.
The flipside of taking away the pressure to say the perfect thing that makes a difference – which I feel myself haunted by, almost constantly, whenever I speak to someone with an eating disorder – is that you have to somehow lose the expectation that what you say is likely to make any difference at all, let alone in any grand eureka-like way. Occasionally it does happen that a particular new way of seeing things opens someone’s eyes – and even if not at the time, perhaps weeks or months later. In the last year of my illness, I was walking on the beach with my aunt, and she told me how sad it was to see someone at my age with a life narrowing to a single point instead of widening out into possibility. It was as much the gesture she made – the fingertips funnelling in on each other or splayed out to take in the whole world – as what she said, and it didn’t mean much to me at the time, with the blinkers still on. But it offered a reassuring reference point once I started recovery: yes, the point of all this discomfort and fear is to let my life open outwards again. More often, though, people who care say things that are thoughtful, insightful, and patently true, and they don’t get through, because the eating disorder makes it impossible to listen properly and to understand, let alone to act.
With anorexia in particular, the problem can, especially in already close relationships, be the opposite of encouraging P to open up: sufferers can often be conspicuously lucid about their condition, and ready – especially in the later stages, once it’s all infinitely familiar – to talk for hours about its fascinatingly paradoxical ins and outs, as I used to do with my mother. Talking at all may sometimes be better than not. But in this case the dangers are different: sliding into offering the disorder tacit validation for its intellectual complexity, rather than alienating P through unwanted encroachments on silence.
Giving the eating disorder too much attention is easy to do: it’s right there staring you in the face every time you look at P, every time you have a meal with him or her and remember how it used to be, every time you catch yourself worrying about him or her and realise you never used to. But giving the eating disorder too much – time, space, attention, credit – is what P does; in part, your job is not to do and be the same. A lot of that, as I say, is about continuing to be there for P in whatever capacity you always were. That might well require you, however, to develop a slightly thicker skin. Things that were easy before probably won’t be any more: where once P might have said yes to most of your invitations to do things, now (s)he won’t, and you’ll find either you have to resign yourself to always being rejected (however gently and regretfully) or you have to be a bit more persistent: invite more than once, reiterate that it’d be really nice if (s)he came. The great power inherent in doing this is demonstrating that you really care: that his or her company really is wanted. One of the most insidious kinds of damage an eating disorder does is not just to chip away at one’s self-esteem, but to wear away one’s sense of existing at all beyond the disorder. Reminding someone that (s)he is still valued for what (s)he is can be a beautiful gesture of confidence and commitment.
Some anger and some frustration and defensiveness from P from time to time is only to be expected, if you engage in any substantive way at all with his or her illness. And both could be seen as evidence that you are actually helping P tackle the problem. So try not to be too daunted when nothing happens in the way you’d hoped; maybe one day it will, or maybe you’ll have to try a slightly different tack. Nothing, in any case, is the end of the world.
The most acute context where a somewhat thicker skin can be helpful is at mealtimes. It’s one of the most awkward things in the world, trying to enjoy eating while someone sits and can’t or won’t join in, and all the more so when that non-participation is one symptom of a serious illness. But keeping on behaving as normal can be a powerful statement. It can say, firstly: not everything changes when I know, and you know that I know, that you are ill. Your honesty doesn’t throw everything up in the air; life goes on, and we can still have meals together, even if you don’t eat. Secondly, it can say: look, this is how to do it. Other people – people who are real and close, people you trust and respect – can have butter on their bread and cake with their tea without thinking about it. However little you might feel like a role model, and however little P may seem to treat you like one, in this sense you are.
Little acts of miraculous ordinariness like this can maybe do the greatest work of all: they can give P glimpses of the fact that life could be otherwise. Like the motes of dust dancing in a shaft of bright light which the heavy shutters have opened just enough to let in, the brightness revealed needn’t be momentous; tiny particles of normal life can work magic in a life that’s being drained of them.
Phase Three: Enough Is Enough
It’s very hard to generalise about timescales with any of this: how long each phase lasts will depend to a great extent on the nature of your relationship with P: how well you know each other, how much time you spend together. All this may happens in weeks or take years. At some point, though, a change in circumstances – physical collapse, a suicide attempt, an unmistakeable cry for help – may make it clear that now is the time to do more. That clarity may also not come from anything in particular; just like the conviction that P may one day feel for him or herself, it may be the result of a simple accumulation of small moments of impossibility, of long months and years of bleak precarity. It is now completely obvious that there is a problem, and if you don’t do something, no one else will. Sometimes that is enough. The reader whose question prompted this post expressed this sentiment powerfully: ‘I am willing to take a risk if it means that some day, years from now, she is happy.’
Whether it’s rushing P to hospital or ordering him or her to make a doctor’s appointment, whether it’s ringing his or her parents, or shouting or crying at them that you’re terrified and you can’t bear to watch a life being ruined like this any more – it’s OK to act when you feel you need to. And even if you’re not completely sure either way – like a sufferer’s own conviction about the need finally to get better, this too may often or usually be crowded around with ambivalence – it’s OK to do something just because it might make you feel better too.
In a more objective sense too, at some point in the process of perceptive long-term companionship, making sure P gets the professional care (s)he needs must outweigh the discomfort of having to take action. P may hate you for it, but with any luck that will only be temporary. Here the presence or absence of other people who care about P is highly relevant: if (s)he has loving parents who have already tried lots of different approaches, and are around and aware of the situation at present, the threshold for action may be rather higher than if you’re the only person who seems to know or care or be willing or able to act on the fact that something is wrong.
At any of the transition points between the phases I’ve outlined, you may feel that to act is to jeopardise your relationship with P. For some people, ever bringing up the disorder at all may seem to be incompatible with that relationship continuing. At some moments, though, those risks may seem worth taking – whether for the sake of P’s health or your own sanity, or both at once.
Last but Not Least: Remember Yourself
The last important factor I’d like to discuss here is your own wellbeing. And it doesn’t come last in terms of importance. It’s something my mother said in a guest post that caused much controversy: look after yourself. I’ve already touched on the importance of not expecting too much of yourself when it comes to having a positive influence on P. I’ve mentioned the power there can be in not giving the eating disorder limitless attention, and this matters for you as much as for P: telling the disorder that there are boundaries also safeguards space and time and energy for you, and prevents you from putting your life on hold because of it. Whatever your relationship with P, limitlessly compromising your own needs benefits no one.
I’ve said a lot about talking to P, but you should also remember to talk to other people: to confide in your family or friends about how this whole process of being there for P feels for you; perhaps to talk to P’s family or friends, who may help you feel less alone in your concern; and/or to see your own doctor or another healthcare professional or to call an ED helpline for guidance. If you don’t go into intimate details about P, this is not a betrayal of P; indeed, it’s helping him or her by keeping you grounded in the world beyond that relationship, and in touch with your own wellbeing other than as it affects P.
Caring about yourself can also be an effective strategy with P: by replacing remarks like ‘you’re being so selfish’, or ‘can you not just try doing something different for a day?’ with statements which are about how the illness makes you feel (‘I’m worried about you because you never have lunch’, or ‘I get scared when I see you go off to the bathroom’), you not only give yourself a voice, you insist on the situated reality of an illness that has effects on others.
But the primary point of being yourself is to be yourself, to keep claiming back the right to be. Part of your permission for that is the fact that this is ultimately not in your hands. Even if you are a partner or a parent, you are only one factor among many. You can do a million sensible insightful things and P may still stay ill; if and when (s)he does start to recover the decision may be only peripherally prompted by your input – though that shouldn’t be taken personally or make you feel you should have cared more, or less, or differently. And equally, you can say something insensitive on the spur of a frightened or infuriated moment and it almost certainly won’t do any lasting damage. The balance of danger and benefit is nearly impossible to calculate in advance for any major or minor intervention, so you shouldn’t let the classic fear of ‘saying the wrong thing’ paralyse you. In general, probably the danger of saying something when there is no problem, or saying something unwelcome when there is, is far less than the danger of saying nothing at all. Even when it feels like everything hangs in the balance of a word or an act from you, it probably doesn’t.
Of course, self-confidence can tip over into recklessness, but the likelihood of that happening with you if you’re reading this blog and worried about how to do the right thing is much less than the probability of self-confidence seeping away into helplessness. No one has all the answers, and the answers that do exist lie as much in what you know about your relationship with P as in anything anyone knows about disordered eating.
Using this Blog
To conclude, I’d like to make a few suggestions about how to use this blog if there’s a P in your life.
If you’re still wondering whether P has an eating disorder or not, you could take a look at my post on ‘What’s the difference between being fussy and having an eating disorder?’. I reflect on how anorexia in particular takes hold and retains its grip in a post on the 'Six seductions of anorexia'. In 'Am I really this selfish, or is it just the anorexia?', I explore the ways that illness can steal away the character of the person you used to know – or be. And one post that might help give you one more glimpse of what it’s like to have anorexia, and how frightening it is to contemplate recovery, is the early one I wrote on ‘Defying my own conventions: The day I started eating again’.
Other articles I’ve written might give more of a sense of how to be helpful during recovery, which I haven’t talked about in this post. By and large similar principles probably apply, with a particular emphasis on showing appreciation for the things about P that are re-emerging as the eating disorder retreats: the personal qualities that you loved about him or her in the first place, which got lost when (s)he was ill, or simple habits and activities that you’re happy (s)he is starting to relearn. Two posts deal with the difficulties that arose with friends during my recovery: ‘A night with friends, overshadowed by food’ and ‘Bumps in the road to recovery’. One – ‘In my father's house: a weekend of food and memories’ – describes the beauty of becoming close to my father again after all the years which anorexia had made difficult.
Then there’s a clutch of posts in which other people close to me speak in their own voices: one written after my second well-again Christmas, when I asked my family to write in a little book about how I had seemed the previous year, how I seemed that year, and how they hoped I’d be next year; a conversation between me and my partner during the later stages of recovery; a radio interview my mother and I gave together; the guest post by my mother which I mentioned earlier; and a guest post by my current partner, who has known me only recovered.
Finally, a few posts you might consider sharing with P are a Q&A with an imagined sufferer, trying to address some of the many reasons why recovery might seem difficult or impossible; 'Recovering from anorexia: How and why to start', on closing the gap between insight and action; 'How to make the decision to get better', the second in a trio of posts about the practicalities of how to begin; or, especially for someone who isn't convinced they have a problem, 'The six seductions of anorexia', on the honeymoon period of early illness and what comes after it.
Beyond this blog, there are of course many excellent resources to support both those with eating disorders themselves, and those worried about a friend or relative. The major national eating disorder charities all have helplines: in the US, for example, there’s NEDA’s; in Canada, NEDIC’s; in the UK, Beat’s; in Australia, the Butterfly Foundation’s.