“I just can’t swallow normally anymore. My doctor has done months of tests but they can’t seem to find out what is wrong with me. Maybe if I get another MRI…?”
“Our daughter just has a really high metabolism. I was a skinny kid too. I watch her eat regularly, sometimes she really binges. It is confusing that she never seems to gain any weight.”
“I want to gain 20lb, but I just can’t no matter how hard I try. I know I am underweight and I don’t like how I look.”
“Fitness is just a way of life for him, besides he’s training for the wrestling team. He has to go to extremes to get ahead.”
“I’ve always been thin naturally even when I was a kid. I honestly don’t think about food that much.”
“These allergies are just terrible, I am allergic to so many different kinds of food that my diet has to be really specific.”
“I keep throwing up involuntarily and the doctor doesn’t know what is wrong. It’s not like I am doing it on purpose though.”
During my work specializing in eating disorders, I have heard all these comments from clients and their families. In all the excerpts above, the client was able to restore normal weight and start eating regularly after counseling intervention. Sometimes parents and doctors refer patients to me totally convinced that genes and metabolism are accounting for the low weight. In one instance, the 9-year old client was in the 5th percentile for her weight and everyone thought she would stay that way through biological determinism. We initiated therapy and the client doubled her weight in a year and sustained it. One of the things that makes Anorexia Nervosa and Bulimia Nervosa so dangerous and difficult to treat is that they are not properly diagnosed. People don’t seek treatment, don’t bring their sons and daughters to counseling because all these other variables obfuscate the clinical picture. Of course there are as many instances as not that the low weight and food-related difficulties are, in fact, purely couched in physical and medical origins. But sometimes they aren’t physically-caused at all. The need to be vigilant and attentive to the very real medical etiologies cannot be understated. However, I recommend that, in addition to the medical rigor, we be equally attuned to the very real possibility that the eating and weight-related problem in question may really be psychologically and socially caused. Investigating and intervening on both ends of the causal spectrum (psychological and medical) is the best way to quickly restore patients to health and functioning. Counselors and family members should never dismiss an eating disorder just because it doesn’t fit neatly into the categories outlined in diagnostic manuals. These illnesses are good at hiding, and sometimes they masquerade as anything BUT what they truly are. Our ability to read between the lines and spot eating disorders early on can mean the difference between life and death, health or illness, for those we serve and love.
To understand why eating disorders get so much worse during adolescence, we must look to the social issues that characterize this period. As much as researchers invest time and resources into understanding the genetic and hormonal issues in teens, to me, eating disorders worsen mostly due to social variables in the family. In particular, when the person can no longer successfully please the self and the social system, it creates a strain that manifests in the form of eating problems. The emerging drive to individuate gets stronger and stronger, and with it, the family can sometimes push harder on the child as a means of resisting that change. I have encountered clients who are much more responsible than most adults, at age 17, never being allowed to have any unsupervised alone time with a boyfriend, even when folks are at home. I have heard children say how they want to go to community college just so they can live with mom forever. I have met sons who at age 17 were not allowed to go on a walk alone or use the stove when parents weren’t home. I have had married clients move home to be with their parents again because they felt that mom and dad needed them. Often the child who is not allowed to ‘grow up’ is really being stopped from achieving her own identity separate from what mom and dad want. The rigid rules that are ‘for her/his protection’ are really most about the needs of the parents, and not the needs of the child. These rules have the effect of reinforcing in that child that the preferences of the family are much more important than the preferences of the self. How the person views the needs of the family, her or his particular role obligations within that system becomes very rigid, almost unrealistic and unfulfillable. Then, during adolescence, the need to individuate and become an independent self emerges, threatening the role that the child has thus far played in the family. If this conflict between self and family cannot be resolved, certain susceptible individuals will feel that they have failed the family and this creates disturbance in body image and problems eating. Sometimes, the perceived needs of the family become so loud in the person’s mind, that he or she will start to sacrifice the needs of the self in order to continue fulfilling the needs of the social system. When this happens, the needs of the self don’t simply disappear, the manifest in other ways like mood problems, anxiety and eating issues. In order to help adolescents overcome the teen obstacles, we have to help them to challenge some of the internalized rules that are untenable. Therapists should help clients understand what they expect from themselves in terms of making others happy, compensating others for life circumstances, taking responsibility for other people’s relationships and other people’s choices. We must empower our clients to say ‘yes’ to the self more often and say ‘no’ to the unrealistic (perceived) demands of the family. Most of the time they will realize that pushing forward in achieving individuality will not cause the sky to fall on those we love. The families are most of the time much healthier after the unrealistic dynamics are corrected. Once this is resolved, the self is able to grow, the needs of individuation are met, and the eating disorder disappears.