Parents ask: ‘Did we cause our child’s eating disorder?’

The short answer: no

(Note: a version of this used to be in Chapter 5 of my book, which you can read here. The chapter still covers this topic, but I've updated it (there's been advances on genetics), and I've cut a lot out and made the chapter much shorter so that readers can get on with the work)

There are many outdated theories about what causes eating disorders. Here’s what you need to know so that you can focus on what matters. If your mum thinks you gave your child an eating disorder, show her this.

This may surprise you, but it’s not considered helpful to spend very long reflecting on how your child got an eating disorder. You’ll probably not be able to help yourself from wondering, but the priority is to treat, and treatment doesn’t require insight into causes. In that respect, it’s no different from many other illnesses.

“I treat patients with leukemia. I don’t need to know how they got it to treat them.”[1]

No scientist has nailed down causation. If anyone claims to know the cause of eating disorders in general, or the cause of your child’s problems in particular, they are either wrong, or they only have part of a complex picture.

There are a number of hypotheses based on epidemiology studies, research on twins, genetic testing, randomised controlled trials of treatment methods and functional magnetic resonance imaging.[2] You can find a thorough and highly readable round-up of the science behind anorexia in Carrie Arnold’s book Decoding Anorexia.[3] I have used her book and various research papers (referenced in the endnotes) to put together the essentials that parents need to know to be effective right away.

A treatable brain disorder with genetic and environmental components

If you have 12 minutes, this is a very nicely put-together video on causation, from Cynthia Bulik, who has been leading genetics research on eating disorders.

It is probably safe to describe eating disorders as biopsychosocial. Like cancer, asthma or schizophrenia, they result from a complex interaction of genes and the environment.

“I wish our therapist had told us what took us so long to find out: ‘This isn't anyone's fault and your child isn't doing this deliberately.’”

Unlike many mental illnesses, eating disorders are treatable, and presently the treatment is not pills, but early intervention with nutrition, systematic normalisation of behaviours, and emotional support.

We’re now familiar with schizophrenia and autism being brain disorders. When an aged aunt develops Alzheimer’s disease, we know that neurologically and biologically, things are not happening the way they used to. We don’t ‘analyse’ her or decree that her dementia is a cry for help because she was hurt by life. We don’t trivialise her illness by categorising it as a lifestyle choice.

The same applies to eating disorders. The dysfunctional thoughts and behaviours may look like causes of the illness, but more likely they are symptoms, which also reinforce and maintain the illness. Causation, once more, is still a mystery.

The environment has a role to play. Weight loss can trigger the illness, prolong it, or cause relapse. Stress too: with all the upheavals and uncertainty of the Covid pandemic, there was an estimated three to four-fold rise in eating disorders.

Before the science of epigenetics, the thinking was that genes create a predisposition for an illness and the environment creates precipitating factors (‘genes load the gun and the environment pulls the trigger’). Experts now say that the environment acts on genes to switch them on or off, or to dial them up or down. Environmental factors are more than a trigger – they change how that gun will fire and they may even disable it.

“Environmental and genetic influences seem to work together, to require each other, till it is impossible to say which is cause and which is effect.” (Matt Ridley, writing about ‘The madness of causes’ in relation to schizophrenia)[4]

You can have the genes and never get an eating disorder. Sure, the risk of developing an eating disorder is greater among children whose parents or close relatives had the illness. But even among identical twins (who share the same genes), one twin can get anorexia while the other one doesn’t. Genes do not, on their own, determine who will get ill. Environmental factors are necessary too.

If you’d like an analogy, consider asthma. Dust may irritate you and make you sneeze, and you may not like cat hairs over your sofa, but for someone with a genetic vulnerability to asthma, dust and cats are major environmental factors that can precipitate an asthma attack. The environment also changes the way genes work and whether they’re activated or not. For instance, early exposure to bacteria in soil are thought to have a protective effect.

Nobody yet knows for sure which genes might be involved in eating disorders, which of the many possible environmental factors actually matter, and how everything interacts with everything else. It seems that eating disorders arise when a number of risk factors collectively tip someone above some threshold. You could think of it as many streams all feeding into a river. The research goes on.

Risk factors, whether genetic or environmental, are just indicators of risk, not predictors. For instance, smoking is a risk factor for lung cancer, but not all smokers get lung cancer, and some smokers never get lung cancer.

Most of the research on causation is for anorexia, so I’ll say more about that. One environmental factor we do know about is body weight. It is common for anorexia symptoms to appear with weight loss through a diet. Did the person diet, like their peers, because of environmental pressures, or was there a genetic factor which made restriction extra attractive? And given that most people (very wisely) can’t stick to a diet, what is it in the physiology of anorexia that makes ongoing restriction so compulsive? Why do people (including my daughter, age 15) relapse in spite of their best intentions? There is so much we don’t yet understand.

I imagine that you blame yourself for the part you played in the environmental factors. Parents, peers, the media, models – any of these can unintentionally provide triggers that lead a person to diet (and let’s be clear, if any of us knew what to do better, we’d have done it). But even stronger influences are environmental factors that affect the individual (as opposed to, say, siblings): life events such as bullying, but also pre- and perinatal effects and viral or bacterial infections, even exposure to hormones in the womb or the time of year you were born.

Our behaviours, our thoughts, how we handle stress and emotions, alter our brain (this is brain plasticity) and these are other types of environmental factors which affect the expression of genes. We really can change ourselves.

Genome studies are ongoing — follow the work of Cynthia Bulik for the latest. [5] As in most illnesses, the predisposition is expected to come from a combination of many genes, some linked to personality, and some linked to physiology and brain function. There is an association between the genetic makeup of people with anorexia (genome studies on other eating disorders are currently being done) and people with other psychiatric conditions: OCD, depression, schizophrenia and anxiety. This makes sense to all the parents whose child with anorexia also suffered from anxiety or OCD before the illness struck. Other associations include: attainment of academic degrees, the drive to exercise or move, some metabolic traits, and the tendency to low body-fat.

Research has uncovered a dysregulation of serotonin and other neurotransmitters, and abnormalities in the insula. Of particular relevance to carers: brain scans of people with anorexia show that food deprivation has a calming effect.[6] Some brain abnormalities may remain after a patient’s weight recovery and some may have been present before the onset of anorexia.

As for the genes linked to personality, people prone to anorexia seem to be blessed with some very lovely characteristics: they are often very smart, conscientious, high achieving, determined, sensitive and kind. Individual traits that are handed down through genes might be positive, but as they interact with each other and with environmental influences, they contribute to the risk of getting an eating disorder.

Some of the unwelcome traits associated with anorexia include perfectionism, difficulty in set-shifting (the ability to adapt, change course, be flexible), black-and-white thinking, and a vulnerability to depression or anxiety. Most studies look at people while they’re suffering from anorexia, not before, so they are not able to distinguish cause and effect. Many parents note that their child suffered from anxiety or perfectionism since they were toddlers, but then plenty don’t. My daughter displayed mental rigidity only while the anorexia was strong. As she recovered, she became her old emotionally intelligent self again.

There's ongoing research on some biological factors that might be related to the eating disorder of some (but not all) people. Most research focuses on anorexia. For SOME of our children, there may be a specific biological cause to the eating disorder, which may be addressed with medication. It's not a magic bullet though: your child will most likely also need standard treatment to overcome what they have grown to fear, and to combat their learned safety behaviours.

One such biological consideration is gut microbiota. Read for instance 'Could targeting gut microbes help treat anorexia nervosa?' There are also questions when a child's eating disorder seemed to emerge from an infection: I say more on the controversial topic of PANS or PANDAS here.

Triggers

The reasons your child has a vulnerability to eating disorders may never be clear. But you may be acutely aware of one factor that triggered the illness – bullying, for instance. In other words, you may be able to put your finger on one cause among the whole complex web of causes. A cause that tipped your child over a risk threshold.

People with eating disorders commonly report that the illness began with a diet or exercise regime because of healthy-eating messages in school, being called ‘fat’ by bullies, being judged as overweight by a health professional, being told to lose weight by a dance teacher, or getting drawn into a body-building culture.

As parents, teachers, friends, or relatives, we can mourn the fact that we unwittingly provided someone with a trigger when they were genetically susceptible to an eating disorder. But how could we have known? Until the disorder comes into our lives, most of us were ignorant about the whole topic. All the same, many of us parents have some grief in this area, and in Chapter 15 I offer ways to deal with it.

There are some risk factors that we have no control over:

 “My son suffered from a food infection and lost quite a lot of weight. That seemed to kick-start the anorexia.”

And there are triggers just about everywhere. I wonder how many slimming messages there are in a typical day of a child’s life. I bet the number is in double or triple figures. Once your child has an eating disorder, these can be factors that maintain the illness and make it harder to treat. During all the time my daughter struggled to recover, I could remove access to magazines but I couldn’t protect her from everything:

“Within the first ten minutes of our holiday, this huge woman in front of us turned round and said, ‘I love coming here. What kills me is the food is so good, I always put on tons of weight.’”

As your child recovers, you may begin to welcome potential triggers as an opportunity for her to practise self-care skills and become more resilient.

Myths, bad science and pop psychology

Some of the most harmful but persistent models of eating disorders come from beliefs held up as obvious truths by a small number of individuals several decades ago.[7] These models are typically theories of what’s going on in a patient’s unconscious mind, so they can be neither proven nor disproven. If I claim that invisible goblins are dancing the Gay Gordon’s at the back of my garden, I defy you to prove me wrong.

Models can be helpful: they help us make sense of our child’s behaviour. I am constantly trying to guess what’s going on in other people’s minds in order to respond the best I can. But we should hold all models lightly because they may be wrong, and they’re sure to be imperfect.

What we can do is ask, ‘If I work with this model, does it lead to better treatment outcomes?’ Below, I list a number of beliefs where the answer is no. You get better results with diametrically opposed models or when you take an agnostic position (we don’t know the causes and we don’t need to know).

These are models, beliefs or myths that I suggest you discard entirely or regard with extreme suspicion. I'll list some below and may I also recommend the website Anorexia Myths. It is full of brilliant well-researched, well presented myth-busting.

Not validated: Vain and narcissistic

‘Girls choose to have anorexia or bulimia in order to look thin, or to bring attention to themselves, or because they’re vain, self-centred, narcissistic or selfish.’

This is a terribly cruel interpretation of what is just a set of symptoms, and it says more about the people who buy into it than about patients. I had a university friend who nibbled carrot sticks when we ate out and bored me with details of her running programme and her plans to fast for Africa. Her face was covered with fine hair and I still didn’t twig she was actually ill. I can assure you I wasn’t full of compassion for Rosie. I am now. You have to be very close to see the distress, self-hate and guilt that an eating disorder brings with it.

Not validated: Issues with growing up and sexuality

‘Adolescents get anorexia as a way of avoiding growing up/avoiding hang-ups about their developing sexuality.’

If puberty is at fault, it’s because biological changes are switching on the genes that predispose your child to an eating disorder. The hang-ups theory is a legacy of the early days of psychology when psychoanalysis (Freud and followers) was the only show in town. Indeed, anorexia starts mostly at puberty, it restricts physical development, and patients are uninterested in just about everything. Doctors confused correlation with causation, as well as cause and effect, a double whammy of bad statistics. Remember the Minnesota Starvation Study? When the men starved, they lost any interest in sex.

Not validated: The media are to blame

‘Eating disorders are caused by the media and zero-size models.’

If that were true, Vogue magazine would have caused the entire Western world to be anorexic. And anorexia would be a modern phenomenon. It might be more accurate to say that the ‘thin’ culture is one of the environmental factors that piles onto other risk factors, and that frequently provides triggers. We go on a diet, and if we have a genetic vulnerability to eating disorders, we’re hooked. Otherwise, we just lose a bit of weight and promptly put a lot more back on and feel inadequate. We don’t blame soap adverts for causing OCD. I am distressed about how the media manipulates our thinking to create false needs. But there is no evidence that media images cause anything more than dissatisfaction.[8] So however much we hate the obsession with ‘thin’, let’s not make wild assumptions about causation.

Not validated: Dying to be thin

‘People get anorexia because they’re obsessed with weight and body shape.’

No, it’s the other way round: people with anorexia often display an obsession with their shape. They also commonly have a distorted image of their body. If you’ve ever seen someone with anorexia grabbing their non-existent tummy in a hysterical fit of despair, you’ll have no trouble seeing anorexia as a mental illness that causes delusions. It’s a joy to see how, as we help our children to put on weight, their symptoms fade, including their obsessions around body shape.

I wonder if, when sufferers need to make sense of the confusing and distressing signals from their brain and from their stomach, they settle on the desire to be thin. In our culture, it works as a plausible interpretation. I wonder if it’s a red herring.

Some people with anorexia don’t suffer from a distorted body image, hate being thin, and really want to put on weight. They know their life is in danger. But for them, eating is excruciatingly difficult and anxiety-inducing.

In medieval times, the symptoms of anorexia had a different interpretation. When anorexics starved, denied and cut themselves, they didn’t aspire to being thin, but to holiness.[9]

I imagine medieval mums desperately trying to convince their daughters that there was nothing holy about rejecting God’s food and becoming skeletal. And I imagine that they were wasting their time, just as we waste our time nowadays if we tell our children they’re not fat.

Even in modern days, in cultures that don’t prize the ‘thin’ ideal, people may explain their self-starvation in religious terms.[10] Aspirations to living on nothing but light still exist in some circles today. The talk is about spirituality and purity, rather than body shape, but it looks like anorexia to me.

Not validated: It’s about denial of deeper issues

‘Anorexics are in denial about their illness.’

Should we accuse colour-blind people of being in denial about the difference between red and green? Are Alzheimer's disease sufferers in denial when they fail to recognise their own children? In the acute, underweight stage of anorexia, most sufferers are genuinely unable to believe that they have an illness or to appreciate its severity. The term for this condition is anosognosia. It makes complete sense for people with anosognosia to refuse treatment because as far as they’re concerned, they’re not ill. To make things harder, anorexia is much of the time an egosyntonic illness, i.e. it feels right. And to make things extra hard for patients, the treatment for anorexia is a lot more terrifying than taking medication.

Anosognosia is a neurological condition which often corresponds to brain injury. It affects about half of those suffering from schizophrenia and from bipolar disorder.

Denial is a very different thing. It is a psychological concept. It means that patients are aware that something is very wrong but they suppress the knowledge. It may mean that they unconsciously use the illness as a defence mechanism to protect themselves from facing another problem. Or perhaps they are too proud or stubborn to admit they’re not well. It’s alienating for someone who truly cannot sense they’re ill to be told they’re lying or kidding themselves. And it wastes time. We can be more efficient and compassionate if we take anosognosia as a given and get our children to eat in spite of it.[11]

Not validated: It’s an attempt to deal with painful emotions and to be in control

‘Eating disorders are how some people deal with difficult and painful emotions, how they try to get a sense of control and gain self-esteem.’

My favourite piece on this myth is: Myth: Anorexia is all About Control.

Society takes this psychological explanation for granted. It’s a model therapists have used for many years, dating back to a time when neuroscience didn’t exist. It’s been around for so long it now seems obvious. We see a person who’s suffering terribly, who’s bingeing or starving, and we conclude they’re trying to meet some deep need.

Abstinence from food is seen as self-control, when actually the illness controls people and gives them no choice. Many of us parents have heard our children say, ‘I want to eat. But I can’t.’ Our children can look rather victorious, with their half-hidden smiles, when they’ve managed to avoid a meal, yet several years later, some recount how every missed meal was a reprieve from terror.

A huge number of people who have recovered from an eating disorder interpret their experience in psychological terms. They know they were extremely unhappy at the time food ruled their lives, and it makes perfect sense to them that this caused the eating disorder. I know of some youngsters who have struggled with guilt and shame around this, because of their inability to fix themselves. When they were given the current scientific position that eating disorders are treatable, brain-based illnesses, it not only made sense, it was also a huge relief.

I know what it’s like to attribute psychological causes to biological effects. For a few weeks in my life, I suffered from the most horrible, debilitating anxiety. I groped for possible causes, looking for things to fix in my emotional life. And then my thyroid specialist ordered a blood test and found that my thyroid medication had become far too strong for me. I corrected the dose, and the anxiety left.

Psychological explanations for eating disorders can lead to ineffective psychotherapy treatments, during which patients continue to suffer and starve. The other danger with the model is that too often it is assumed that the parents are responsible for causing psychological harm to their child. Therapists look for evidence that the parents are over-controlling, over-enmeshed, insecurely attached to their child, or over-anxious. They point the finger at parenting style. They look for signs of physical, sexual or emotional abuse. It is very hard to reconcile this model with the one, validated in randomised controlled trials, in which parents take charge of their child’s eating, exercising and purging. More about the parents’ role in causation and in treatment later in this chapter.

Your child didn’t choose to have an eating disorder

(This is in Chapter 5 of the book)

Biochemistry or free will?

But surely, you may say, surely we all have will power? Surely your kid could try a little harder? This judgemental question lingered with me for a long time. I knew that the body and the mind act on each other, but it’s as if I wanted my kid to be all free will and no biochemistry.

Do you accept that alcohol affects the brain? That recreational drugs make people see weird things, think strange thoughts, experience intense feelings and behave irrationally? Have you ever felt suddenly depressed, anxious or angry for no obvious reason, until you remembered that your last meal, was a sugar-packed rocky road chocolate cookie six hours ago? Have you experienced the effect of B12 deficiency, and the turnaround in your mood and energy levels once this is corrected? Do you know anyone with Alzheimer’s?

Every day, we have demonstrations of how biochemical processes determine how we think, feel and behave. We may kid ourselves that our thoughts, moods and behaviours are under our conscious control, but it only takes a couple of alcoholic drinks or a rise in progesterone to remind us we are beholden to our biochemistry. Yet we persist in thinking that when our most complex organ, the brain, malfunctions, we should pull our socks up and think ourselves better. Then we tyrannise our loved ones with the same impossible expectations.

These days I can’t understand how a psychologist can begin any kind of psychotherapy before sending their client off for blood tests.

Most of us sorrowfully accept that lungs or glands can malfunction, but we’re rather touchy about brains. Our sense of humanity and of identity (Who am I? What makes me me?) are under threat. When a loved one is affected it’s as though the person has vanished. I’m sure all parents can relate to the sense of loss when a child has an eating disorder.

It’s painful to see someone suffer from a mental illness when there is no quick cure. It’s scary to think that our own brains might be just as vulnerable and helpless. We seek to protect ourselves by dehumanising sufferers and holding them responsible, and expecting them to will themselves out of their troubles. ‘Mad’ and ‘crazy’ are offensive or funny, throwaway words that stigmatise and help us distance ourselves from our pain. It is confusing and scary to stay with the puzzles of the mind, and the mystery of free will and of what makes us us.

If you’re anything like I was, you’ll regularly catch yourself judging your child for her latest outburst, for trying to hide food, for lying, or for ‘not trying hard enough’. Perhaps this reflects quite how much we wish that the illness was easier to handle, to fix.

The more we let go of judgements and accept that our kids are the way they are, the more we can bring about change. Concentrate on living and breathing non-judgement and acceptance towards your child, and make that the culture in your household.

Parents don’t cause eating disorders

When something as massive as an eating disorder comes along, there’s a huge amount of grief, fear or regret as we wonder, What did I do wrong? How could I have prevented this?

Sometimes a child starts dieting because we did or said something that provided a trigger. As a parent, you can end up weighed down with regrets and what-ifs.

What I’d like to do right now is help you let go of the idea that, for your child to get himself in such a terrible state, you must have done something very, very wrong for a long time. That you caused his eating disorder. That if you’d been a different kind of parent, your child would have been fine.

• There is no evidence that parents cause eating disorders (and researchers have looked very hard for it).
• Self-judgement will affect how well you care for your child.

The Academy for Eating Disorders (AED) worked with international patient, advocacy, and parent groups to produce the “Nine Truths About Eating Disorders.” One of the nine is:

"Families are not to blame, and can be the patients’ and providers’ best allies in treatment"

and you can read the rationale in 'The Science Behind the Academy for Eating Disorders’ Nine Truths About Eating Disorders', Schaumberg et al 2017.

If guilt and regrets are not an issue for you, and if you’re already well-integrated in your child’s treatment team, feel free to skip this section.

Let’s look at parenting style. Some of us are strict, while some of us are laissez-faire. Some of us have academic qualifications and some of us left school early. Some of us have a united family and some of us are divorced. We can be into home-cooked family dinners or use convenience food, we can be overweight or thin, chronic dieters or non-dieters, rich or poor, working parents or stay-at-home parents. I have come across all these variations. None seem to make the slightest bit of difference to whether a kid gets an eating disorder or not.

Ivan Eisler and his Maudsley Hospital team took the bold step, in the 1980s, of putting parents in charge of their child’s treatment, because he could find no evidence that they were causing the illness:

‘There is no consistent pattern of family structure or family functioning in families where someone suffers from anorexia nervosa. What differences are found vary between studies and are often small and do not clearly define the family functioning in these families. They certainly do not add up to a picture of there being a particular type of family organization that is invariably found in anorexia nervosa.’[12]

The American Psychiatric Association notes:

“It is essential that the clinician avoid articulating theories that imply blame or permit family members to blame one another or themselves for the patient's disorder. No evidence exists to prove that families cause eating disorders. Furthermore, blaming family members harms their psychological wellbeing and often impairs their desire, willingness, and capacity to be helpful to patients and to participate actively and constructively in treatment and recovery. Rather, the point is to identify family stressors whose amelioration may facilitate recovery.”[13]

Your child needs you to not judge her. No blame, no shame. It’s going to be hard for you to maintain an objective, supportive stance if you yourself are burdened by guilt and self-blame. James Lock et al, in their evidence-based treatment manual, insist that uncritical acceptance is a key ingredient of your child’s recovery, and you need that for yourself as well.

They write:[14]

“In our experience, we have come to learn that parents burdened with guilt tend to be less successful in their efforts to help their daughter, and failure at this task may in fact exacerbate critical remarks towards the patient and her symptoms.”

Clinicians, researchers, and national psychiatric bodies are telling us to drop the hypothesis that parents are responsible for eating disorders.[15] For instance the American Academy of Pediatrics writes:

“It is no longer believed that eating disorders are caused mainly by family dysfunction.”[16]

The team behind Family-Based Treatment, after reviewing the research on the subject, [17] (some based on twins, some on tens of thousands of people), say:

“There appears to be no consistent structure or pattern of functioning in families with a member who suffers from an eating disorder; rather, eating disorders evolve in a multiplicity of family contexts.”[18]

What if science came up with one thing we, as parents, could have done differently to prevent the illness? That would be a cause of grieving and deep regret. And also a cause for celebration, because if we have younger children, we desperately want to know if there’s anything we can do to protect them (more on this in Chapter 11). But so far, it seems that the way we raise our kids neither causes nor prevents the illness.

Most of us are used to blaming and judging ourselves over just about everything, to the extent we can make a virtue of it. It takes work and self-awareness to let go of toxic shame. Well, now is the time to move on. If you think that’s self-indulgent, do it for the sake of your child. You need the mental bandwidth to deal with the present. You have meals to supervise, therapists to meet or to sack, schoolteachers to talk to, and if you’re American, it seems, insurance companies to battle.

When people in recovery blame their parents

You may have come across people who had, or still have, an eating disorder, and who very much lay the blame at their parents’ feet. They remember that family life was utter hell. Is it possible they had loving parents before the eating disorder hit them and the family home then turned into a war zone? Could it be, tragically, that the parents would have continued to be supportive if only they’d had better advice and tools?

Whichever way the parents had behaved before the illness began, the eating disorder would probably have manifested itself eventually. Life, and in particular, our society, supplies triggers aplenty.

Child abuse: a precipitating factor, not a cause

There is no evidence that eating disorders are caused by abuse.[19] The general thinking is that abuse, trauma and any stressor can be precipitating factors for disordered eating or problems with body acceptance, and that with a genetic vulnerability they may indeed trigger an eating disorder.

Family therapy for eating disorders relies on the loving parent-child bond so it’s very unlikely to be the therapy of choice for youngsters who have been abused by their parents.

If you suspect your child has been subjected to major trauma or to repeated small traumatic events, make sure this is addressed in treatment. There is an overlap between trauma and eating disorders — especially the eating disorders involving bingeing or purging. This article from NEDA, 'Trauma & PTSD', provides a summary.

Parents with an eating disorder

Have you suffered from an eating disorder yourself? Do you presently suffer from one but manage to keep it under control? You may be scared that therapists will blame you for your child’s eating disorder, or that they will consider you incapable of contributing to your child’s treatment.

First, understand that because of genetics, it’s very common for both child and parent to be affected by an eating disorder.

It is perfectly appropriate that you should care for your child just the same as any parent. What matters is what you do now, not what you did in the past.

When James Lock and his team conducted trials to validate Family-Based Treatment, they did not exclude parents with eating disorders.

If you can get rid of any notion of shame around your own eating disorder, it will be easier for you to have unconditional acceptance of your child.

From what I’ve picked up through the grapevine, parents who suffer from an eating disorder are pretty good at keeping it under control while all their efforts go into supporting their child. Still, if you’re struggling, do seek help. If I were king, the clinics that treat our kids would also be set up to treat parents.

The only time a therapist should be interested in your eating disorder is if you might be driven to collude with the eating disorder. Now, we’ve all been taken in by our child’s pleading and bargaining – that’s not the level I’m talking about. I have met a teenager whose mother supplied her with laxatives and helped her bin food. Clearly someone else had to take on the child’s treatment – in her case, it was her older sister.

Family therapy: because we need fixing?

Now you may be plagued by another niggle. I know I was. If you’re having family therapy, you’ll have been told that you, the parent, are crucial to your child’s recovery. So … does it mean you were also the cause? No, it just means you’re the best-placed person to treat your child. If your young child was diagnosed as diabetic, or asthmatic, you would be trained to ensure they take their insulin or Ventolin. You’d also be encouraged to get rid of factors that maintain the diabetes or asthma and make it harder to treat. You’d change things that would, in the absence of the illness, be perfectly fine. If your child had asthma you’d take the hamster out of his bedroom. And because your child has an eating disorder, you probably talk about food and body shape in new ways.

Even though all our treatment providers made it clear that families don’t cause eating disorders, I went through our family therapy sessions waiting to be told how to be a better parent. The words ‘family therapy’ to me meant ‘fix the family’. I thought the therapists would identify defective ways in which we interacted and that we would be coached on how to communicate better. I didn’t think that there was anything particularly wrong with us, but there was hope in the thought that outsiders might see something that could be changed, and that once we’d made the change, everything would be all right.

It was only a long time after discharge that the penny dropped. They were never trying to fix anything. On the contrary, they were betting on us being so amazingly wonderful that we could be the instrument of our child’s recovery, and that this would produce better results than leaving our child forever in the hands of trained nurses.

This is a model of how family therapy for eating disorders should be done. Everyone is not so well served. I know parents who feel that clinicians are judging them. In some cases the blame is overt.

When you hear ‘family therapy’, check if the word ‘therapy’ is being used to mean treatment or psychotherapy. Certainly in family therapy specialised in eating disorders, sessions are supposed to be about tackling the tasks ahead, not fixing you.

Why? Why us? Let go of the search for causes

Even though nobody blamed us for our daughter’s eating disorder, my mind spent unproductive time groping for explanations, trying to fill the vacuum of ‘we just don’t know’. What I didn’t appreciate at the time is that, even if I had put my finger on some significant trauma from our child’s early years, it wouldn’t have made any difference to the treatment.

“When I was pregnant I avoided a long list of foods as they would make me extraordinarily sick. Now I think, ‘Perhaps I did wrong by being so careful. Perhaps eating these foods would have helped my daughter get used to them.’ These are terrible thoughts that are still haunting me.”

If you are losing precious energy asking ‘Why?’ or ‘Why us?’ here is my mantra:

“Shit happens.”

Sorry about that, but it works for me. It gives me the reality check I need to make me deal with the present. What those two words remind me of is that our lack of understanding is very sad, but that’s the present state of science. Right now, people are doing PhDs on eating disorders and neuroscience, research grants are being awarded, papers are being written. Thousands of man-hours are going into the search for causes, prevention and treatment. Until experts come up with something specific that we, as parents, can use, our working model is as good as, or bad as ‘shit happens’.

The Serenity Prayer

The Serenity Prayer may be more to your taste: Grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.[20]

If you’re finding this hard to apply, you will find in Chapter 15 tools of acceptance and letting go. These may free you of the torment of guilt and give you access to inner power.

Treat without knowing the causes

One of the principles of family therapy is that therapists, parents and patients are ‘agnostic’ as to causation. Likewise, evidence-based cognitive behavioural therapy (CBT) for eating disorders is more interested in what maintains the disorder than in searching for causes. This frees you up to get on with the job. Otherwise your child could spend a lot of time just talking, and you could spend a very long time evaluating the strengths and weaknesses of thousands of scientific papers looking into causation[21].

Meanwhile, remember that your child needs food urgently and you need all your energy for the challenging task ahead. Don’t waste it on speculating on the past. Your focus should be on action. What’s going on with your child? What are her issues and her needs right now? How can you feed her? Every day you’re going to get better at it. That’s what matters.

[1] From a doctor at an eating disorder conference http://internationaleatingdisorderadvocacy.blogspot.com/2015/05/international-conference-on-eating.html

[2] For a highly readable overview of the present scientific position, read ‘The Anorexic Brain. Neuroimaging improves understanding of eating disorder’ in Science News (10 August 2013), Vol. 184, no. 3.

[3] Carrie Arnold’s highly recommended book for laypeople and specialists, Decoding Anorexia (http://amzn.to/10Y2Una).

[4] I recommend Matt Ridley’s book ‘Nature via nurture: genes, experience and what makes us human’ for how genes and environment work together (http://amzn.to/1KoESuy)

[5] Follow the work of Cynthia Bulik and her team. She is great at explaining results in language we can all understand, so look for the most recent YouTubes or podcasts featuring her. For instance this podcast shortly after the first anorexia results were published: Genetics of Anorexia Nervosa eatingdisorderrecoverypodcast.podbean.com/e/cynthia-bulik

And there's a good Q&A with Cynthia Bulik in this blog: Myth: 'There is no genetic link to anorexia nervosa'. And go to edgi.org for the latest on the genetics research on various eating disorders

[6] Kaye, W. H., Fudge, J. L. and Paulus, M., ‘New insights into symptoms and neurocircuit function of anorexia nervosa’ in Nature Reviews. Neuroscience (August 2009), vol. 10, pp. 573–84, http://www.nature.com/nrn/journal/v10/n8/execsumm/nrn2682.html

[7] Dr Sarah Ravin explains how Hilde Bruch’s theories, published in The Golden Cage (1978), became professional dogma: ‘Pride and Prejudice’, http://www.blog.drsarahravin.com/eating-disorders/pride-and-prejudice/

[8] Medieval ‘holy anorexics’ were not focused on thinness. See also this study showing how anorexia exists, whatever the culture: Bennett, D., Sharpe, M., Freeman, C. and Carson, A., ‘Anorexia nervosa among female secondary school students in Ghana’ in The British Journal of Psychiatry (October 2004), vol. 185, pp. 312–7, http://www.ncbi.nlm.nih.gov/pubmed/15458991

A commonly quoted study to ‘prove’ that television causes eating disorders is: Becker, A. E., Burwell, R. A., Herzog, D. B., Hamburg, P. and Gilman, S. E., ‘Eating behaviours and attitudes following prolonged exposure to television among ethnic Fijian adolescent girls’ in The British Journal of Psychiatry (2002), vol. 180, pp. 509–14, http://bjp.rcpsych.org/content/180/6/509.abstract

In fact, it looks like all we can conclude is that at a time TV became part of these girl’s lives, attitudes to food and body changed. The authors reported on ‘disordered eating’ and body dissatisfaction, not ‘eating disorders’ (even though self-induced vomiting was higher in the post-TV group). They found no cases of anorexia nervosa in the pre-TV group and the post-TV group (which by Western standards, would be expected, given the study included so few individuals) and the girls’ BMIs were higher post-TV. Further reading: Radford, B., ‘A closer look at a famous study linking TV exposure to eating disorders’, The Center for Inquiry (2011), and: Dr Sarah Ravin’s blog: ‘We’ll always have Fiji’, http://www.blog.drsarahravin.com/eating-disorders/well-always-have-fiji/

[9] The story of Saint Catherine of Siena is quite heartbreaking. Here’s one account you might be able to bear: Forcen, F. E., ‘Anorexia Mirabilis: The Practice of Fasting by Saint Catherine of Siena in the Late Middle Ages’, American Journal of Psychiatry (2013), vol. 170, pp. 370–1, http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2012.12111457

[10] Bennett, D., Sharpe, M., Freeman, C. and Carson, A., ‘Anorexia nervosa among female secondary school students in Ghana’ in The British Journal of Psychiatry (October 2004), vol. 185, pp. 312–17, http://www.ncbi.nlm.nih.gov/pubmed/15458991

[11] Parents will find much support in the book of schizophrenia expert Xavier Amador, I am not sick and I don’t need help! . He is also in some inspiring YouTube videos.

[12] Eisler, I., ‘The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa.’ In Journal of Family Therapy (2005) 27: 104-131 http://tinyurl.com/nqggotg

[13] The American Psychiatric Association's Practice Guideline for the Treatment of Patients With Eating Disorders, Third Edition, 2006, 'The American Psychiatric Association practice guidelines provide evidence-based recommendations for the assessment and treatment of psychiatric disorders.’ http://tinyurl.com/p2kjtp2

[14] Lock, J., Le Grange, D., Agras, W. S. and Dare, C., Treatment Manual for Anorexia Nervosa: A Family-Based Approach (http://amzn.to/ZkagY7). This book is written for clinicians but it’s totally accessible to parents and full of useful information.

[15] Watch a short video produced by Laura Collins in which one expert after another says that parents don’t cause eating disorders: https://youtu.be/wE3fyQV_chI

[16] Rosen, D. S. and the Committee on Adolescence, ‘Identification and Management of Eating Disorders in Children and Adolescents’ in Pediatrics, Official Journal of the American Academy of Pediatrics (2010), vol. 126, p 1240, http://pediatrics.aappublications.org/content/126/6/1240.full.pdf

[17] For instance, Nicholls, D. E. and Viner, R. M., ‘Childhood Risk Factors for Lifetime Anorexia Nervosa by Age 30 Years in a National Birth Cohort’, J. Am. Acad. Child Adolesc Psychiatry (August 2009), vol. 48, no. 8, http://www.ncbi.nlm.nih.gov/pubmed/19564797

[18] Le Grange, D., Lock, J., Loeb, K. and Nicholls, D. E., Academy for Eating Disorders Position Paper: ‘The Role of the Family in Eating Disorders’ in International Journal of Eating Disorders (January 2010) vol. 43, no. 1, pp. 1–5. http://maudsleyparents.org/images/Role_of_the_family_in_ED_-1.pdf

[19] Nicholls, D. E. and Viner, R. M., ‘Childhood Risk Factors for Lifetime Anorexia Nervosa by Age 30 Years in a National Birth Cohort’ in J. Am. Acad. Child Adolesc Psychiatry (August 2009) vol. 48, no. 8, http://www.ncbi.nlm.nih.gov/pubmed/19564797

[20] The serenity prayer and verses similar to it, are available on Wikipedia: http://en.wikipedia.org/wiki/Serenity_Prayer

[21] If you’d like to find out more about the causes of anorexia (and, of course, the treatments), you can read the research by going straight to the sources.

The best is from a recent paper also discussed in Chapter 11 (Protecting your other children). Stice, E., ‘Interactive and Mediational Etiologic Models of Eating Disorder Onset: Evidence from Prospective Studies’ in Annual Review of Clinical Psychology, vol. 12, pp. 359-381, http://www.annualreviews.org/doi/abs/10.1146/annurev-clinpsy-021815-093317

One densely written but incredibly informative scientific paper is from Shan Guisinger, ‘Adapted to Flee Famine: Adding an Evolutionary Perspective on Anorexia Nervosa’. http://www.adaptedtofamine.com/wp-content/uploads/2015/01/guisinger-an-pr-2003.pdf. If a member of your family is attached to an ignorant model of anorexia, this will hammer in quite how many theories are out there, and where they fall down or succeed.

Another relevant paper, should you want to go deeper, is: Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C. and Agras, W. S., ‘Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy’ in Psychol Bull (January 2004), vol. 130, no. 1, pp. 19–65, http://www.ncbi.nlm.nih.gov/pubmed/14717649

This study, looking at twins, found strong genetic influences but no detectable role for ‘shared environmental factors’, i.e. family environment: Klump, K. L., Suisman, J. L., Burt, S.A., McGue, M. and Iacono, W. G., ‘Genetic and environmental influences on disordered eating: An adoption study’ in J. Abnorm. Psychol. (November 2009), vol. 118, no. 4, pp. 797-805, http://www.ncbi.nlm.nih.gov/pubmed/19899849

I particularly value the wealth of up-to-date information on the F.E.A.S.T website. This parent-led organisation advocates research and education and is active in busting old myths and exposing bad science. The website contains links to scientific papers you can read for yourself. New studies come out all the time, so check the dates on the publications you read.

You can find more quotes and references about the causes of anorexia in the FEAST website (feast-ed.org/parents-do-not-cause-eating-disorders),which also shows Laura Collins’s short video in which experts are interviewed on the subject of parent-blame.

Or you could watch this video (http://tinyurl.com/cbbybct) of Chris Thornton speaking about the brain, the mind and eating disorders. He refers to recent neuroscience findings showing how the brain of someone with anorexia is affected and why this is a brain-based illness.