In the dining room, the elephant gets all of the attention

elephant mask young handsome bearded hipster man

Nancy sits down with her son James, who is an adorable 12-year old boy. He constantly looks lovingly up at his mother in a way that reminds me of how my sons (occasionally!) look at me, melting my heart.

“Mealtimes are really hard for us all. I have been given a lot of suggestions on what to do but nothing seems to really resolve the problem. There’s just things that he won’t eat and the list of items on that menu is decreasing all the time. I feel a lot of stress already having to cook for a big family, but now I also have to make whatever James is able to eat and it is really a strain. Also, my husband gets irritated with me for catering to him so much because he’s kind of a traditional dad. We all, even the little kids, tend to center our whole conversation and activity around whether or not James is eating, and the dinnertime is then lost to the stress everyone feels. I’m always caught in the middle and I could really use your help.” Nancy implores.

While listening very attentively at his mom, James gets tense and fidgety, even seems to have some tears in his eyes.

“I bet this is also really stressful for you too isn’t it,¬† James?” I ask.

“Yeah I don’t like upsetting everyone and then dad gets mad at mom and mom is unhappy and the other kids are unhappy and I feel like it’s all my fault.” James says.

“Well, I’m hoping today I can help with that. A really important thing to remember here is that your family dinner time is usually the only time that everyone can get together and share their feelings, experiences, thoughts and moods with each other during the day. It’s a really essential time Nancy, I agree. Remember when we were talking earlier about how emotions tend to build up and kind of make a ball in your stomach, James, which causes you to not be able to eat?” I ask.

“I remember, and I think that is really true. Some days if there is stuff going on between me and my parents or if I have been fighting with them, I can’t eat, and other days if we are all getting along, I can eat just fine.” He comments.

“Ok, so building on that idea, if dinner time is when the family gets together and it is what allows us to express our emotions, understand and take care of each other’s feelings and thoughts, then that contact is probably pretty important. Sitting down and talking to your family is what prevents those emotional buildups from happening. What’s interesting is that you guys seem to be caught in a self-perpetuating cycle. Eating problems disrupt dinnertime and make everyone stressed talking about food and not about each other. Dinner is the most important time that the family has to connect, and that has been taken away by the eating problems. Take away the time that you guys connect, and the emotional build-up and family estrangement that creates the eating problem in the first place gets worse. As the symptoms get worse, dinnertime becomes harder and harder, thereby reducing the amount of focus you have for each other.” I take a deep breath.

“Oh. I think that makes a lot of sense. I never really heard it put that way before but it was right there the whole time.” remarks Nancy.

“You’ve got to get the elephant out of the room. The elephant is the eating problem and he is getting all the attention. The more we divert the attention and focus and effort toward the elephant, the less we devote it to James, the less he feels heard, the more he feels that he is causing everyone stress, and the harder it becomes for him to eat. Everyone in this scenario suffers.” I say.

The homework assignment for this family was for mom to cook dinner as usual and serve it as usual. No one is to talk about food or eating at the table, in particular whether or not James is eating. Mom keeps a stash of appropriate food that James can go get on his own and bring to the table if he wants to eat something other than what is prepared. This will all be done without comment, thereby enabling the family to give their attunement and care toward each other and toward James, which will strengthen the emotional foundation upon which James’s appetite actually sits. This will restore his appetite naturally and eventually food will be no big deal again.

I understand that this technique is rather antithetical to the Maudsley method, which has been clinically indicated as effective for restoring normal eating in children with eating disorders. However, the Maudsley method is not founded on any etiological theory–it’s approach never ties back to a thesis on how the eating problem with the child started in the first place. I believe good therapies should not only fix the symptoms, but their methodologies should tie back to the origins of the illness itself. Maudsley¬† takes the symptoms and controls them directly rather than addressing the underlying causes of those symptoms. I prefer to understand why the eating problem happens in the first place and help families redirect their energy toward the deficits that created the unmet need, which is what led to pathology. The family I write about here must do additional work which involves restoration of internal boundaries and implementing some critical adjustments on James’s behalf. Simply not talking about eating at the dinner table will not be sufficient to restore normal eating in James. However, getting the attention off of the elephant in the room will free up everyone to focus on the family relationships, and that is where the real work can and must begin.

The disappearing act: First the person, then the body

 

rough sketch of man on grungy paper

“light as a feather, floating on air, I want to be perfect, barely there.”

This is a quote from a Pro-Anorexia website. This is one of the best summaries of the experience of an eating disorder that I have ever heard. In particular, the comparison of being perfect with being ‘barely there.’ If you really look at the Anorexia the disease and not the manifestation of it (which is the weight loss part), what you might see is that this is an illness of disappearing first as a person, and then as a body. What does it mean to ‘take up space’ as a person? To me it means that your needs, wants, preferences, feelings, wellbeing and vulnerabilities are made known to those who matter to you in your world. In other words, you are not afraid to let others know how they can nurture you, what you feel, and what you need for your self. You can and do ask others to make room for your needs in the daily goings on of the family system or in the lives and agendas of those who love you. You don’t see your vulnerabilities and needs as a liability, you don’t resent yourself for being human. Unfortunately, most people with eating disorders do resent their needs, they feel their needs are a burden, are a liability or an endangerment to those they love. They are afraid to ask for accommodation of their self-needs because doing so shows lack of gratitude, makes the family worry or is a sign that one is ungrateful. The degree to which these needs can be hidden or minimized is the degree to which one achieves ‘perfection’ in their role obligations. The process of Anorexia is not just about being perfectly restricted physically–that is the last step in the process. Before any of that happens, one learns to restrict their needs psychologically and socially. The contempt one feels for needing food is an extension of the contempt one feels for needing anything at all. In this process, first the person disappears, and then the body starts to disappear. I don’t ever push someone with Anorexia to gain weight because doing so puts the cart before the horse (plus I would probably only be the 714th person to have told them this, so what on Earth would be the point?) What I do suggest (which elicits much less fear and more commitment) is rethinking some of the internalized role obligations that have caused the person themselves to disappear. The body part will only reappear once the person within is allowed to reappear.