When Food is Family
a loving approach to heal eating disorders
Judy Scheel, PhD, LCSW
Foreword by Kathryn Zerbe, MD
Smashwords Edition
Copyright 2011, Idyll Arbor, Inc. All rights reserved under International and Pan American Copyright Conventions. No part of this book may be reproduced, stored in a retrieval system, or transcribed, in any form or by any means — electronic, mechanical, photocopying, recording, or otherwise — without the prior written permission of the publisher.
Idyll Arbor editor: Thomas M. Blaschko
Cover art: Sandra Swenby
Cover photograph: Andrew Cohen
Ebook License Notes
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For my mother, in whose kitchen I finished up the last of this book in the early morning hours prior to her burial. I trust you are dancing in the heavens, momma.
Contents
When Food Becomes Family: Why Broken Attachments Underlie Eating Disorders
Focus on Family: Understanding Which Patterns in Your Family Contributed to the Eating Disorder
Develop a Language of Emotions: Learning to Experience and Express Feelings
Create Healthy Boundaries: Making Space for Your Child to Grow
Appendix: The Importance of Therapy
Acknowledgement
My family is my food — nourishing, calming, interesting, and fun, and a stabilizing force in my life — the necessary ingredients for a healthy existence. I have had the remarkable fortune of raising two children who gave me the opportunity to restore and, in many ways, create for the first time relationships based on deep trust, empathy, respect, and love. They have encouraged me, and continue to do so, to face my shortcomings, confront my mistakes as a parent, and take responsibility. It is their wisdom and love that continue to guide me every day. My gratitude, Meagan and Ian, are beyond measure. Thank you Michael for raising our children together in a loving, safe, open, and respectful home.
I fantasized, from time to time, about how I would thank my patients and their families when I finally finished writing this book. Their lives and experiences are woven into my core. Their courage to face the challenges that come with recovery is remarkable. My perspective, insight, maturity, and deepening empathy are the gifts they have provided. They continue to teach me about forgiveness and compassion for others and myself. I am grateful for their trust, respect, challenge of me, and their kindness. Watching patients grow and evolve into authentic selves and being part of their familial healing process continues to be a source of gratification. It is my belief that through living an authentic life one can affect the lives of others.
It is impossible to imagine this book without the foundation from which it comes. Cedar Associates, the outpatient group treatment practice that I founded in 1994 and now serve as Executive Director, is a unique environment whose strength and longevity have been because of the integrity of the people who work there. It is my colleagues’ talent, skill, clinical expertise, practicing with each other what we preach to our patients, and sound advice to me that maintains the success and reputation of Cedar. Thank you, Kristin Lore, LCSW, Director of Cedar’s Mt. Kisco office and Elissa Zelman, Psy.D., Director of Cedar’s Scarsdale office. You serve as role models to our patients with eating disorders. Thank you Susan Schrott, LCSW, and Jacqueline Reilly, LMSW, who also have been part of the fabric and integrity of Cedar and my life for many years.
I am extremely grateful to the wider community of eating disorder colleagues and professionals who have known and trusted Cedar Associates over the years. The Renfrew Center, Avalon Hills, Timberline Knolls, The Meadows, and Columbia Presbyterian Hospital have worked with us to provide care to our seriously ill patients and have trusted us in discharging their patients to us. Thank you to the local community of health care providers who have cared for our patients and for whom we have provided treatment over the many years of Cedar’s existence. Special thanks to Lisa Bardack, MD, and I. Jill Ratner, MD, and their colleagues at the Mt. Kisco Medical Group, Marcie Schneider, MD of Greenwich Hospital, Ann Engelland, MD, Gayle Augenbaum, MD, Flemming Graae, MD, and Maureen Empfield, MD.
When Food is Family went through several transformations and editorial relationships. As with all relationships, a good fit takes time, sometimes a long time, to find. Thank you Spencer Smith for getting the essence of this book and for your editorial expertise and creative conceptualization. Your editorial efforts are second to none.
Thank you Lyndsey Cohn of Gürze Books for working with me in the earlier stages and for your spontaneous and seemingly effortless naming of When Food is Family.
Thank you Tom Blaschko, Idyll Arbor, Inc, publisher of When Food is Family for accepting this project and for understanding the role that family members play in eating disorders and why delivering this delicate and vital message can serve to aid in recovery and familial healing.
Psychotherapy is an academic and artistic process. My growth as a therapist continues to strengthen through the relationships I have with patients, colleagues, and those in my life who know me personally. The artists in my life have been as professionally and personally influential as the academic training has been.
Andrew Cohen, artist, photographer, and my friend for more than 30 years has helped me see the visual beauty and depth in the human form beyond the body perfect.
Finally, to you Ken Kelsch, ASC, cinematographer extraordinaire and great cook who feeds me every day and reminds me about the calm that comes with trusting and letting go. Your love and wisdom guide me. I am grateful.
Foreword
A family that has a child or loved one with an eating disorder struggles under enormous strain and with unrelenting worry. Anorexia nervosa, bulimia nervosa, and binge eating disorder take a substantial toll on the individual’s quality of living and may threaten life itself.
The normal trajectory of growth and development suddenly stops as the child focuses on body image, dieting, achieving and maintaining an unhealthy weight, or overexercise. Often quite consciously, the child’s sense of self-worth or level of self-comfort is now derived from these unhealthy behaviors. When family members become aware of the high mortality statistics associated with these illnesses, which rarely yield to any “quick fix” solution from medical or mental health providers, they understandably begin to wonder if they play a role in what caused the problem and what, if anything, they can do to help. For parents and other primary caretakers who are determined to assist their child on the perplexing and often stormy journey of recovery, Judy Scheel’s book is an invaluable asset.
Dr. Scheel is a clinician who has worked in the field of eating disorders for over two decades. As the case examples from individual and family sessions make clear, Dr. Scheel knows the terrain of these disorders thoroughly and understands why it is often difficult for the patient to engage in treatment. She offers expert guidance and practical advice that assist the patient and family members on the road back from an eating disorder.
Her therapeutic exercises (that are actually chock full of important questions to make one pause, reflect, and then carefully answer) offer substantial hope because they empower. The tasks Dr. Scheel advises should be undertaken thoughtfully and with paper and pencil. Although they do not lend themselves to easy answers, those who work at the questions will come away with better knowledge of themselves, their family of origin, their child, and perhaps most importantly, a new confidence that “I can do something about this problem. I can help my child.”
It is important for the reader to know at the outset that Dr. Scheel bases her approach to treating eating disorders on Attachment Theory and Therapy, one of the most highly researched and evidence-based forms of psychotherapy in the early 21st Century. Attachment Theory is now being applied to help many different types of mental health issues, and the results are robust.
Begun in England in the 1960s by the psychoanalyst and researcher John Bowlby, who originally studied how an individual is affected by sudden and protracted loss, Attachment Theory expanded to include the work of Mary Main and Mary Ainsworth in the 1970s and 1980s (who clarified normal and disrupted attachment patterns in children) and from the 1990s to the present by Peter Fonagy and Mary Target (who have helped trauma victims through their discoveries about adult attachment patterns and personality development).
Utilizing the strong research base of Attachment Theory and applying its findings to eating disorders is a unique contribution of this book and one that parents will find as beneficial as it is relevant in the effort to build trust and instill confidence in the recovery process of their child.
As a practicing psychiatrist and educator who treats eating disorders, I am often asked the question by a patient, family member, or student, “What are the best available books to assist in the ‘real world’ treatment of eating disorders? Are there any books that offer guidelines that are accessible, sound, and not ‘watered down’?” Dr. Judy Scheel’s When Food is Family is such a text. I recommend it enthusiastically and will keep it on my bookshelf to suggest to families who come for consultation and treatment.
Kathryn J. Zerbe, MD
Professor of Psychiatry and Training
and Supervising
Psychoanalyst, Portland, OR
Chapter
1
Introduction:
Why Eating Disorders are a Family Affair
Eating disorders are scary, especially for parents and other family members. When you watch your child engaging in a behavior that inhibits her ability to nourish her body and grow, it is terrifying. Standing by, watching her starve herself, binge, purge, or engage in other disordered eating behaviors can make families feel completely powerless.
The problem is complicated even further when the disordered eating behavior begins to take hold of the family and contorts or controls your day-to-day life. As a parent, you may start catering to your child’s anorexic behaviors, e.g., fixing special breakfasts based on her demands, because you’re afraid if you don’t, she won’t eat. Or you and your husband may sit staring at each other, unable to speak, as your child spends hours in the bathroom vomiting. All the while your resentment of the situation, each other, and even your ill child silently grows.
If you have picked up this book, I assume you are either a parent or family member of someone who has an eating disorder or you may have an eating disorder yourself. That means these dynamics are all too familiar to you.
Eating disorders are no one’s “fault.” The person with the disorder doesn’t want it (at least, down deep she wishes it didn’t exist), and most parents don’t raise their children hoping they will develop dysfunctional eating patterns. So, judging yourself or your child is not helpful.
That said, eating disorders affect not just the person who has it, but every member of that person’s family because, more often than not, the disorder lives with the family. Eating disorders are often a family affair.
Your family feeds you. Your parents provide you with what you need to help your body grow when you are young. But this is only the most basic way your family feeds you. Your family also nourishes you psychologically and spiritually — feeding you from the well of their own emotional experiences.
When it comes to emotional sustenance, the “bread” you are fed is your parents’ language and actions. If their language and actions reflect love, support, empathy, and understanding (even of difficult emotional experiences), a bond is created between you and your parents that forms the foundation of your sense of self-esteem and self-worth throughout your life. Healthy bonds make healthy people. Your family becomes your most nourishing “food.”
Sometimes these bonds don’t develop properly due to circumstances unique to the individual. Family strife or stressors or a predisposing mental health issue for any member, such as anxiety and moderate to severe depression, weakens the family’s capacity to provide support, understanding, and empathy. Sometimes the family is unable to identify and articulate emotions in a positive way or does not know how to communicate appropriately, especially when there are familial conflicts. Sometimes there are serious psychological issues for parents or marital issues that impact their capacity to parent. Sometimes the “fit” between parent and child is not natural from very early on. A climate of misunderstanding, perceived or actual criticism, frustration, and helplessness sets in for both parent and child. Eating disorders can flourish in response to this mismatch of personalities and sensibilities.
Support, understanding, empathy, identifying and expressing emotions, and communication provide the psychological nourishment necessary to support the child in building self-esteem and self-worth. Without the development of these abilities within the family, individuals are left psychologically vulnerable. As a result, the child may grow up with a set of challenges that contribute to a range of psychological and interpersonal issues from mild self-esteem problems to more profound disorders like an eating disorder.
Such issues constitute the basic framework of attachment theory — the psychological foundation on which this book, and my professional work, is based. Attachment theory tells us that emotional support, understanding, and acceptance during a child’s development provide a foundation of safety and trust in the family, and all of these foster self-esteem and self-worth throughout life. The experience of attachment — of being understood, accepted, and loved for who we are, usually within the context of a family — is critical to our healthy development.
Problems in attachment restrict and erode connection and closeness among family members, particularly between parents and children. Dysfunctional family dynamics and confusing or inappropriate patterns of communication can easily emerge, which can leave a child, particularly one predisposed to an eating disorder, feeling insecure, doubtful, and deeply mistrustful. These factors contribute to the development of an eating disorder.
The unfortunate reality is that many individuals with eating disorders lack or struggle with attachment. They often feel doubtful and mistrustful of others and do not grow up in ways that leave them feeling secure with themselves. Often, they do not feel connected or close to the people around them. They do not feel accepted for who they are or feel that they are unacceptable to others. They are often unable to tell you how they feel or identify what is bothering them. For whatever reason, they do not experience the emotional sustenance they need to develop a healthy sense of self-esteem and self-worth. The sad result is that they are unable to experience empathy toward themselves. This ultimately leads to a devalued self-image. Once this self-doubt sets in, their ability to know how they really feel and to trust their own internal cues weakens. They then seek out ways to feel better.
Despite these emotional struggles, their inherent craving for these attachments remains and even grows. They may begin to seek fulfillment, closeness, and comfort through food, body image, and weight obsession. In this way, an eating disorder becomes a metaphor — a symbol of their quest for comfort through food, a totem of their guilt for wanting, needing, feeling, and disagreeing, as evidenced by the self-destructive nature of all eating disorders. They create this relationship/attachment to food because the feeling of connection they crave in their relationships — the attachments they truly seek — feel too complicated. Eventually, eating disorders can develop and may become their relationship of choice because real relationships are problematic at best, deeply damaged at worse. The breakdown or void in familial relationships may set the stage for this dynamic to develop.
What causes eating disorders?
Over the last few decades much research has been done into the development of eating disorders and many answers to these questions have been proposed. Clearly our culture, obsessed with body image and thinness at all costs, impacts our perception about our body: shape, size, and weight. Data show that media profoundly influence our body image, that this starts at a very young age, and that the more negative media influences we are exposed to, the more likely it is we will struggle with body-image issues.
But are the expectations of our society and the influence of media the real reasons girls develop eating disorders? If so, why don’t all women have anorexia, bulimia, or binge-eating disorder? We all receive cultural messages about the importance of thinness, but we don’t all have eating disorders. There must be other causes of the condition. As important as it is to be aware of and critical of these influences, I would argue that cultural expectations are a catalyst for eating disorders, not a principal cause.
A lot of attention has also been given in recent years to the role that innate personality dispositions, biochemical causes, and genetic factors play in the development of eating disorders. While it’s clear that each may play an important role and more research certainly needs to be done, the studies to date are inconclusive. We are learning that inherent nature, the disposition we pop out of the womb bearing, may predispose some individuals down the road toward developing an eating disorder. Clinical expertise and more research will hopefully lead to a greater understanding about the causes of eating disorders resulting in more thorough, integrative approaches to treatment.
Most experts and therapists do agree that eating disorders are accompanied by a range of interpersonal problems. People with eating disorders tend to have difficulties in relationships. Often, therapists see these issues as the result of the eating disorder, not the cause. I have come to a wider view.
In more than twenty years of treating people with eating disorders I have come to believe that, although the causes are complicated, childhood relationships and experiences play a significant role in contributing to the development of eating disorders. Relationships impact the development of self-worth and self-esteem. How caregivers interact with, convey their feelings to, and respond to children and each other, and what children perceive and imagine all impact development and identity. Eating disorders tend to center around families. Everyone I have met with an eating disorder had a variety of family issues prior to the development of the eating disorder. And these issues certainly continued or were exacerbated during the life of the illness. Even though the proverbial deck of cards may be stacked by societal influences or genetic predisposition, how the hand is played in family relationships strongly influences whether or not an eating disorder has a climate in which to take hold and flourish. Disordered family relationships provide a springboard to disordered eating patterns.
In recent years, family and relationships have not been considered essential elements in the development of eating disorders. Prior to that, family members, particularly mothers, were “blamed” for causing their child to get sick. Because of this damning view of parents, we lost a lot of support from the professional mental health community and disenfranchised family members who feared blame and shame. That view is changing, and treatment methods are integrating family therapy, not only as a means to help families learn how to deal with the eating disorder once it has been diagnosed but also to examine the impact relationships have on eating disorders. That is what we will focus on in this book: how relationships impact the development and maintenance of eating disorders.
As difficult as it may be to accept, the existence of your child’s dysfunctional behavior suggests that there may be problems in your family dynamics and that attachment has weakened. For some, an eating disorder is a voice representing an adaptation to a difficult or intolerable family situation or family relationship. For others, an eating disorder is the vehicle to express and relieve painful or uncomfortable emotions. If emotion is not experienced and expressed, it does not just disappear. An eating disorder is a way to both experience and express what cannot be tolerated. If the person with the disorder were able to experience, accept, and express her emotions and feel able to seek out comfort and support within her relationships, she would be better able to tolerate her “being.” Perhaps then an eating disorder would have less chance to develop. She could soothe herself or reach out to others for soothing rather than needing food as the method to soothe internally what she feels unable to tolerate.
Relationships run into difficulty for many reasons. I don’t mean to suggest you don’t understand your child, but you need to ask yourself if the issues or patterns in your family have made it difficult for your child to feel understood and supported or if her eating disorder may be a way to find a voice for what ails her. If you answered, yes, then there are insights and skills you can learn to provide support and understanding in a way that is most nourishing and meaningful.
The good news is that you can learn those skills and restore attachment in your family. You can begin re-experiencing or experiencing for the first time, deep love, empathy, compassion, and support for each other. By doing so you can set a new stage on which your family can function — a stage that will allow the eating disorder to resolve and the person with the disorder, as well as the family, to heal. I wrote this book to help you achieve that goal.
Who I Am and Why I Wrote This Book
I have been treating people with eating disorders and their families for more than twenty years. I founded an outpatient treatment center for people with eating disorders and a not-for-profit organization for prevention of and education about them. I have also lectured, taught, and written articles on this subject. I advocate for patients, attend conferences, and generally keep myself tuned in to the eating disorder community.
The theories on eating disorders have evolved over time but we still are struggling with many of the same frustrations regarding why recovery rates remain low and recurrence rates remain high. Why can’t we effectively treat people with disordered eating and distorted body images?
I believe it is because we are not looking in enough places for answers. We are on some of the right paths — predisposing factors and perhaps genetics (the nature aspects), but how a child is raised and regarded, the messages she receives from caregivers during childhood, the experiences she has in and outside of her family (the nurture aspects) play a role as well. A breakdown in family connection and attachment can contribute to the development of anorexia, bulimia, and binge or compulsive eating. Of course, the complete causes of any eating disorder are complex and no single explanation is likely to be uncovered. What we do know, for sure, is that eating disorders are not created by the desire to be thin, even though that is what the person with the disorder starts out believing. We also know that genetic predispositions toward anxiety and depression, and even personality may play a role. But I believe that focusing on these aspects of how eating disorders evolve limits our ability to examine the relational underpinnings that may cause eating disorders to manifest themselves. In short, we have been seduced by the push toward an overly simplistic view of how these difficulties evolve.
I have come to the view that, first and foremost, eating disorders occur because of disorders of relationship, with others and with oneself. By healing these critical relationships, we see long-term healing for the person with the disorder and their family.
I believe that, aside from our physical health, the strength of our relationships sustains us throughout our lives. When our ability to relate to others and ourselves is damaged, it casts a huge shadow that may eventually turn into an eating disorder or an assortment of other psychological problems.
If this is true — if a disruption in family relationships can set the stage or contribute to an eating disorder — then part of the foundation for recovery must revolve around bringing those relationships into greater harmony. If a lack of attachment has contributed to the eating disorder, then rebuilding the attachment is one of the essential steps on the road to recovery.
My goal in writing this book is to teach you how to do that in your own home. This book is a hands-on, working guide to eating disorder recovery that will help you understand some of the psychological and relational underpinnings of eating disorders and the impact they have on both the person with a disorder and the family. This book will teach you ways to work together to heal, repair, and rebuild positive relationships.
This book is written primarily for parents, guardians, and other family members who have a child with an eating disorder still in the home. By explaining the thinking behind my work and using case histories and step-by-step exercises, I will show you techniques you can use to reestablish and deepen the attachment you have with your children. I will lead you through a process of identifying and healing negative family patterns so that your child no longer has to use food as a substitute for relationships, or as metaphors for her life. She will find other ways to express emotions.
Whether or not the person with the disorder reads the book is a decision you should come to as a family. I would not encourage you to “force” her to read this book. Though it will definitely give her some insight into the nature of her eating disorder, she may not be ready to take that step quite yet.
Be aware that I have provided a few exercises throughout the book that are specifically directed toward the person with the disorder. These exercises are designed to help her connect the existence of her eating disorder with the underlying emotional issues that are driving it. They will help her understand and rebuild attachment with you, just as you are working to rebuild attachment with her.
Look at these exercises as an opportunity to open the doors of communication between you and your child regarding her disordered eating. Ask her if she will do them and share her answers with you. If she refuses, you might try other ways to communicate with her, like sharing your answers to the exercises you do as suggested below. If she accepts your invitation, it’s a good sign that she wants to reestablish communication, too. However, it also means you will hear some difficult judgments from her about your parenting methods, your communication style, and other issues she finds problematic in her relationship with you. Part of your work is to learn to be present to these judgments without becoming defensive. I will discuss how to do this in more detail throughout this book.
The book may also be useful for adults who have an eating disorder or family members whose child no longer lives in the home but still has dysfunctional eating patterns. The exercises you find here may help you understand what led to the problem and may help you work through some of your relational issues. However, it has not been designed specifically for that purpose.
This book is not intended as a replacement for therapy. It can be used as a useful resource, reference, and teaching guide during a course of therapy. It will also help those of you who have not yet engaged in therapy to understand the therapeutic process and what will be asked of you, the person with the disorder, and other family members during a course of treatment.
The treatment method detailed in this book is what I believe provides the infrastructure for lasting recovery. The theory and philosophy behind this method is what fuels my thinking and provides the theoretical orientation for Cedar Associates, the treatment center I founded and am Executive Director of. I strongly believe that familial relationships and attachment issues addressed in therapy can strongly impact long-term recovery from an eating disorder.
Having said that, other methods of treatment and intervention are often useful and necessary to create a holistic program for overcoming eating disorders, providing support, enhancement, and practical approaches to recovery. I use a variety of treatment approaches in my work, and my center is particularly noted for its integrative approach. For example, the use of behavioral techniques and helping someone change their distorted thinking, commonly known as cognitive-behavioral therapy (CBT), is a component of the recovery “package.” Dialectical Behavioral Therapy (DBT), an approach that integrates CBT with Eastern (Zen) practices and focuses on mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance, has been gaining momentum in treating individuals with eating disorders and is a treatment approach we utilize at Cedar Associates.
Psycho-education for patients and family members, pertinent exercises and group participation to challenge and reflect back distorted views, and seeking input and recommendations of a nutritionist who specializes in eating disorders are all extremely valuable in recovery. In addition, some patients require medication for treatment of the depression and anxiety that often accompany eating disorders. Psychiatric medication is invaluable in helping some patients with, for instance, ruminating thoughts about food and body, lack of motivation to recover, irritability and agitation, and who have levels of anxiety ranging from fear to panic. For sound and responsible treatment, all patients require the care and attention from a physician who treats the unique medical issues surrounding eating disorders.
I want you to understand that the treatment method I prefer is inclusive rather than exclusive. An integrative approach using the best practices available is usually the most efficient in helping a person overcome the disorder. In this book, I focus on attachment theory, problematic relational issues that set the stage for the development of an eating disorder, and the existence of the disorder as a metaphor for otherwise hampered emotional expression for two important reasons:
1. I believe these issues underlie and impact the disorder, yet they are often ignored or marginalized both in therapy and within the home. I want to reverse this trend.
2. There is no other book currently available that focuses on healing broken attachments and analyzing the emotional underpinnings of the eating disorder in a step-by-step, self-help fashion. My goal in writing this book is to add another dimension to the literature on the topic, in the hopes that it offers readers like you a new perspective on the disorder and thus new hope for healing.
Whether you are in therapy now or using this book as a preliminary self-help treatment, keep in mind that the cornerstone of healing is the ability of the entire family to experience empathy and extend that sense of empathy to one another. True and lasting recovery has the opportunity to occur when forgiveness, respect, and the true nourishment of emotional intimacy replace denial, resistance, anger, and blame.
When Food is Family will show you that families can — and must — do more than understand and support a loved one with an eating disorder. It is only through the family working together that all family members can recover and heal. I welcome you on our journey together.
Accepting Your Part in the Problem
Through this process you will face difficult truths about how actions and words led to a breakdown of attachment between you and your child. For many parents this is one of the most difficult experiences they will ever have. After all, you love your kids more than anything in the world. I know that. Realizing that you have (albeit inadvertently) lent a hand in the psychological and relational issues that contributed to the development of your child’s illness is earthshaking. This is not an easy road to take.