Last updated on June 22nd, 2022
Welcome to the FAQs, the pressing questions parents ask when they desperately want to help their son or daughter recover from an eating disorder, in particular from anorexia. This page is a bit of encyclopedia. You'll find quick answers, links to entire chapters in my book, and to blog posts from myself and others.
Find your way around the FAQs
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Listen on the go
Bitesize is a collection of very short audios, each answering an FAQ
What is an eating disorder?
What are the different types of eating disorder?
I answer this in more detail here. Briefly, eating disorders are classified in the DSM-5 diagnostic manual as anorexia nervosa, bulimia nervosa, binge eating disorder, rumination disorder, and pica. There is also 'other specified feeding or eating disorder (OSFED)', which covers a variety of conditions. Many people get diagnosed with OSFED when they don't tick all the boxes for anorexia, bulimia or binge eating disorder — their eating disorder may be referred to as 'atypical' and be just as urgently in need of treatment. A very different type of eating disorder is 'avoidant/restrictive intake disorder (ARFID)', which includes a wide variety of difficulties around eating, often from a very young age. Finally there is UFED, which stands for ‘Unspecified Feeding or Eating Disorder’, and is a useful classification when there is not enough information to make a more specific diagnosis.
One more term you may have heard of is EDNOS (eating disorder not otherwise specified). This is an old category (from an earlier version of the diagnostic manual, DSM-IV) which used to apply to a majority of eating-disorder sufferers as it covered everything that couldn't be categorised as anorexia or bulimia.
For a more detailed description of each of those conditions, see here. For more on how to get diagnosis and referral to a competent clinician, see Chapter 3 ('Your part in diagnosis') of my book, which you can read in here.
Can you have both anorexia and bulimia?
People can go back and forth between the different eating disorders at different times. If your child is underweight, restricting their food for major parts of the day but also having binges, he or she may actually have "binge-purge anorexia".
How common are the various types of eating disorder?
So common that every school and doctor and sports club should know what to do about them. Yet there is a widespread myth that they are rare. I've gathered statistics for you here for prevalence. And not to scare you parents, but to get the attention of those who need to take action, I included some figures on mortality. All here.
What about people obsessed with clean eating, healthy eating or body building?
I describe a few conditions that are similar to eating disorders and that can be just as serious here. They include diabulimia, orthorexia, drunkorexia, and muscle dysmorphia, also called bigorexia or reverse anorexia. Some of these, especially orthorexia, can be precursors to a diagnosable eating disorder like anorexia.
From my Bitesize audio collection: Hear more on how these are related to eating disorders :
The dangers of eating disorders
What is the minimum a parent needs to know about the dangers?
Some treatment providers require families to sit through slide after slide of dire warnings about the effects of an eating disorder. It's supposed to motivate parents to engage with our child's treatment. If you need that kind of motivation, read on. But if you already care about helping your child, I recommend you skip the next few questions and concentrate on what you need to do, and can do, right now, using an approach which wasn't dreamed of when most of the statistics were collected.
Which of the eating disorders is the most dangerous?
All the eating disorders present immediate and long-term risks. It is easy to see the great danger an underweight person with anorexia is in, but people who binge or who purge are at high risk from malnutrition and electrolyte imbalance. All eating disorders also come with high risks from suicide or self-harm. Whatever your child's eating disorder, he or she need regular medical checks and specialised treatment.
What are the statistics for suicide and eating disorders?
People with an eating disorder are several times more likely to commit suicide than those without an eating disorder, and I present statistics and charts here. Dear parents, if your child is suicidal, take it seriously. Otherwise, get on with compassionate treatment and leave these statistics to policy-makers.
What causes an eating disorder?
Do parents cause eating disorders?
Only by passing on your genes, which were passed on to you by your parents. These would be genes associated with metabolism, and with some personality traits.
Genes do not, by themselves, make the illness happen, but they make it more likely if the environment interacts in such a way as to switch those gene functions on. An example of a high-risk environmental factor that is seen, so often, to trigger an eating disorder, is weight loss or being underweight. And the stressors around the Covid-19 pandemic have been associated by a rise in eating disorders by a factor of up to four.
Parents are precious resources in the treatment of eating disorders, and are welcomed by all the good therapists. See for instance this video by Adele Lafrance, of Emotion-Focused Family Therapy (EFFT): 'The Why of Parental and Caregiver Involvement in the Treatment of Mental Health Issues'.
Yes but did I cause my child's eating disorder?
I regret some bits of how I brought up my child. Did I cause the eating disorder?
Are you just saying that to make me feel less guilty?
No. Researchers have looked for all the typical causes you might think of, and they haven't found any links. Maybe you were dieting all the time and your child got anorexia? OK, so I didn't diet and my child got anorexia. Maybe you regret being strict, working too much? I was quite laissez-faire and prioritised home life. And so it goes on.
I have written in plenty of detail about causation: what is known, what has been disproved, what are the myths. I wrote a briefer account in Chapter 5 of my book here. I also recommend video 'Do parents cause eating disorders? The experts speak' as well as podcasts (episodes 1 and 2) from Laura Collins Lyster-Mensch, so you hear it directly from the most enlightened professionals.
Is it true it's all in the genes?
Partly. Genetics and environment affect each other. The genetic studies so far highlight the extent to which anorexia (more to come on other eating disorders) is a biopsychosocial illness: similar genetic markers are found in OCD, depression, schizophrenia and anxiety, in attainment of academic degrees, the drive to exercise or move, some metabolic traits, and the tendency to low body-fat. As I say more on my page on causation.
Could the eating disorder be due to bad gut microbes?
There's tentative research on this, in particular for anorexia. As explained on 'Could targeting gut microbes help treat anorexia nervosa?' it's unclear if gut health is part of causation and/or part of the solution, for some people. If you are looking into the use of probiotics, prebiotics or synbiotics, note that these are unlikely to provide a total solution, so keep your focus on standard treatment as well.
Could the eating disorder be due to brain inflammation, like PANDAS?
If your child is displaying some really weird symptoms, you might have come across a syndrome called PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) , and a subset of it called PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) . I tell you more about these here.
But before you go down that route, which will require some specialist neurologist to investigate, I invite you to first read my post on bizarre yet normal eating disorder symptoms.
I feel bad about the eating and body-shape messages I gave my child
Join the club. We are in a toxic environment which shames various body shapes and has made eating for health very complicated. When our own country's health agencies are preaching harmful messages to kids about calorie-counting and obesity, what can poor parents do?
You can buffer your child against some of our crazy environment by modelling a positive attitude to eating and body shape (this podcast series is helpful). This may protect your child, to some extent, against disordered eating. However, there are plenty of examples of families where there was a wise attitude to eating and body shape in the home, and the child still went on a diet and got caught in an eating disorder.
First steps: getting help for my child
I'm new to all this. What should I do right now?
Answers are in Chapter 4 of my book, which is entirely available here. Or for something even briefer, see the first two pages of my free helpsheets or hop onto one of my regular workshops.
Here are the main points:
- Get a doctor to check on your child's health right now, especially if there's been weight loss, or vomiting, or over-exercising or excessive muscle-building. If your child is currently eating extremely little, get them monitored for refeeding syndrome (more further down these FAQs) to be on the safe side.
- Insist on an urgent referral to a specialist (in England for instance, treatment of youngsters must start within one week — that's how fast you should get expert guidance)
- You can't make your child's (suspected) eating disorder worse by paying attention to it (as long as you stay kind and supportive)
- Make it very clear to your child you are on their side and do not judge them. Do not indulge in your own why's and self-blame. Shit happens, people get ill… and the good thing about eating disorders is that with modern treatment, youngsters recover.
- A good sign that someone does have an eating disorder is that their parents are concerned — don't let yourself be labelled as "over-anxious" and don't accept "it's a phase" or "come back in two weeks".
- While you're waiting for specialist help, start supporting your child to eat 3 meals and 3 snacks a day, and to stop any purging. You're aiming for enough to regain any lost weight. Get the school to help you, or keep your child at home.
- If your child has lost weight and/or isn't eating enough and/or is compulsively exercising, put exercise on hold.
- Learn as fast as you can to do the above with kindness and persistence. Know that an eating disorder puts your child in a near-constant state of fear. Having to eat, gain weight, stop exercise, further increases their anxiety, so be their compassionate coach. Out of all my resources, your fastest learning at this initial stage is probably through my Bitesize audios.
- Avoid making any deals, any promises — there will no doubt be some changes to makes as you learn more.
- Choose or vet your specialists with care. Nowadays it's not OK to give a young person individual therapy before trying a family-based approach. More on this in Chapter 12, which is entirely on this website here.
- Take care of your own wellbeing. This is a shock for you. With good information and good support, you can stay well and give your child the active, practical love they need to fully recover.
From my Bitesize audio collection: First conversation with your child about the eating disorder:
Maybe my son/daughter doesn't need treatment? The doctor's advice is to wait
Early intervention, or intervention at the 'prodromal' stage — before it ticks all the boxes for diagnosis — is the best thing you can do for your child. Parents tend to worry that they could make their child worse by 'making an issue of it' or 'labelling' them with an illness. They hope it's just 'a phase' that will pass better if everyone pretends everything's fine. To reassure you that none of this is true, and that you can intervene swiftly and simply, read 'Can FBT strategies be used for early eating disorder intervention and prevention?'.
Very few clinicians have the up-to-date knowledge required to gauge how urgent or serious your child's situation is. You need a referral to a specialist right away. I explain this in Chapter 4 ('Treatment: the essentials) of my book. Read it here.
The family doctor/GP says my teen is fine
This is a common problem and you can avoid it by preparing a list of symptoms that will leave the GP in no doubt that this is no ordinary fad or passing phase. I offer lots of help on this in Chapter 3 ('The parent's part in diagnosis') which is on this site in its entirety.
The family doctor/GP is not giving us a referral
Early referral to a specialist eating disorder service is so important, and has so much scientific evidence behind it, that in England, a standard requires the health service to allow self-referrals to specialists eating disorder teams. Treatment for urgent cases must begin within one week of the parents' or patients' first phone call, and for everyone else the maximum is four weeks. Wherever you are in the world, kick up a fuss if you are made to wait, and use all the help you can from my Chapter 3 ('The parent's part in diagnosis') . And while you shake up the system, also get yourself informed: as my book and this website shows, there is much important work you can do right now.
I say more on treatment further down.
Treatment for adults or young adults
Where can I get help on adult treatment?
At present my expertise is mostly on children and adolescents, though I do speak to a number of parents of university-age people. For approaches that are similar to the resources I value for youngsters, but made to work for independent aduts, I recommend Tabitha Farrar's website, podcasts and discussion groups. You will find quality information and real positive action you and your son or daughter can take. Also packed with resources is Gwyneth Olwyn's website edinstitute.org. I love the insightful account from a 40-yr old: 'Reflections on my recovery at 40 – a journey with my parents' who used her parents for the same kind of support a teen needs. Really insightful, also, is the session at FEAST of Knowledge 2022 (you may still have to pay for access) where adult Shira Rosenbluth describes how her friend Lauren Muhlheim (therapist) helped her meal by meal.
Hope for better adult treatment: Temperament-Based Therapy with Supports
I am excited by Temperament-Based Therapy with Supports (TBT-S), for any age. The person with the eating disorder has support people (parents, friends etc) that they chose to help them throughout the treatment, guided by clinicians. The stance seems to be genuinely respectful and empowering of all those involved. I say more and guide you to the TBT-S manual here.
Indeed there are plenty of adults who recovered with the help of their own parents. From my Bitesize audio collection: “I was desperate for my parents to feed me”:
Everyone can learn a lot from Emily Boring, in her mid-twenties, describing her state of mind when she's been underweight and comparing it with her ease of life and freedom of thought after treatment and weight recovery. I love this piece of hers, as well as her two-part interview on a podcast, and her talk at FEAST of Knowledge 2022 (you may still have to pay for access).
Is treatment for children and adolescents different from treatment for adults?
Yes, it's very different. And that is a shame and I hope it will change. Adults tend to have treatment similar to what was done throughout the 20th century. There's very little good research to motivate radical change. Adult treatment emphasises psychological approaches, getting the patient to be motivated to get well, to gain insight, and to work on their recovery on their own, with weekly outpatient appointments. There can be a lack of ambition in getting them to fully recover, possibly because a fair number of adult patients are chronic sufferers. Often treatment for anorexia stops before the person has reached a normal weight, and people are left to their own devices before they're well enough to take care of themselves. Sometimes treatment stops because the adult is kicked out for lack of sufficient motivation.
If weekly outpatient appointments don't work, in the US there are partial hospitalisation programs (PHP) and in some countries (including the UK) there are day treatment programs. People get help to eat several meals a day, but are often required to muster some willpower back home alone. Again, they may get kicked out if that fails. Some adults can be in limbo until they get 'sufficiently' ill to be admitted to an inpatient unit, where there is more robust help to get them to eat, stop exercising and purging, and gain weight. If they can't eat and are very ill, the mental health act kicks in and they are tube-fed — if necessary against their will.
With most adult treatments, if there is any 'family therapy', it looks at the interactions between family members, on the basis that dysfunctional relationships may have caused, or may be maintaining the illness. When I talk to parents in this situation, they generally feel blamed, disempowered and helpless, and it may become even harder for them to help their child eat at home.
The picture is a lot more positive with children and teens, thanks to research on a totally different concept of family therapy for anorexia. On this site, when I talk of 'family therapy', I refer to an evidence-based approach whereby parents are part of the team and are empowered to take charge of meals and of normalising behaviours. The standards of many countries make this approach either highly recommended or mandatory, as the first approach to try. The beauty of it is that this treatment does not require the child or teen to have motivation or insight, and it addresses the biological aspects of an illness that cannot be healed while the body and brain are malnourished. My book, my 'Bitesize' audio collection, and this website, are designed to help you support your child in this way.
There are good chances that family therapy for eating disorders, or some variant of it, could help people beyond their teen years. See my article 'Young adults with anorexia: family-based treatment for 17-25 year olds'.
An all-age treatment service
Some eating disorder services treat all ages, which means that adults benefit from the best treatment principles used for teens. From a therapist on a video interview I did : "A colleague of mine said, it's brilliant because they actually get better!"
Autism combined with an eating disorder: tools for all of us
Whether your child is autistic or not, they're likely to show signs that are typical of autism, as a result of starvation. As we learn to support autistic people through their times of high stress, we learn skills that are useful to everybody.
Be alert: it may be that around one third of people experiencing an eating disorder (any eating disorder) may be autistic or present with high levels of autistic traits.
The expertise on how eating disorder treatment must be adapted for autistic people is growing. Do jump to my page on autism as it's full of examples from parents and of links to good sources. One of these good sources is PEACE Pathway, a resources set up by clinicians with experts by experience — in particular this page about making meals easier.
What is the recommended treatment for anorexia?
For children and young people, the first line of treatment for anorexia is very clearly and firmly a family-based approach. That might mean 'Family-Based Treatment (FBT)' or a variant of it (in the UK they have a catch-all name: 'anorexia nervosa-focused family therapy'). Most English-speaking countries have national or professional bodies recommending this. The most recent review of the science was done in England by NICE, and I explain their recommendations here.
Individual therapy only has a place if a family-based approach is unacceptable, contraindicated or ineffective. Mostly, if parents are unwilling to do it. I explain alternatives here.
If you are consulting a therapist for your teen with anorexia and they are not fully using you to feed your child at home, and they want to give your child one-on-one therapy, then my view is you should go elsewhere. Even if that therapist charges a huge amount and has a fancy office. There is no justification for not giving your child the best treatment available.
Is treatment for bulimia or binge eating disorder different from treatment for anorexia?
There is less research, and more uncertainty, about what treatment is best for bulimia. The UK's health service advisory body, NICE, recently reviewed all the evidence and concluded that for young people a family-based approach must be the first line of treatment for both anorexia and bulimia. There are small differences between the two. If that fails, a specialised form of CBT is next in line. I explain all this in more depth here.
For binge eating disorder, there really is very little research. If it was my child I would adapt the family therapy approach, with an emphasis on regular meals. The official recommendation coming out of NICE's most recent review is first of all 'guided self-help'. If it were my child, I would want to be part of that 'guiding', in a manner similar to that of family-based treatment. In particular I would want to support my child to eat regular meals. If guided self-help doesn't work, the next recommendation is for a specialised form of CBT for eating disorders. These recommendations apply to any age (presumably because there is not enough research to be more specific). CBT for eating disorders has been developed and tested mostly for adults but it can work with motivated and self-aware teens. More on this in Chapter 12 ('Which treatments work?') which you can read in its entirety here.
On the whole, if your child is purging or binge eating, the treatment involves regularising their food intake. So someone who binges needs help to eat the next meal at the regular time even though they really don't want to eat. And everyone needs help to eat every few hours, hunger or no hunger, in order to prevent big hunger cues later, which lead to bingeing.
I've been told I have to be involved in my child's treatment. Is that true?
Yes. The the key is nutrition with loving family support. Chapter 4, which you can read here ('Treatment: the essentials) gives an outline of what's involved. There's a very brief summary on one of my free helpsheets to help you get set up for success.
I explain treatments (the good and the bad) in detail in Chapter 12 of my book, which you can read in its entirety here.
Isn't my son or daughter too old for us to take charge?
The family-based approach has been validated on 12-to-18 year olds, so don't let anyone tell you your teen is too old for what is generally the most effective treatment. Even adults need hands-on help at mealtimes.
Is my college/university-age child too old for family therapy?
Plenty of parents report that family-based treatment for their college-age child works. It can work for a 40-year old! This article of mine describes how the creators of FBT are testing it out on 17-25s. My experience of supporting parents with a son or daughter in that age group is that everyone very much benefits from the parents taking an active role. Traditionally, treatment providers have overestimated how much someone with anorexia can recover alone, and have only paid lip-service to family involvement.
Why would our child accept our help when they don't want to get better?
You will help your child one meal at a time, even one bite at a time. Your confidence and your kindness will make it possible. The beauty of a family-based treatment approach is that your child can recover without every having decided they want to.
Hear more on this, and other 'taking charge' questions, in Bitesize:
How long does treatment take and what are our chances of success?
It depends. All explained in Chapter 4 of my book, in this section here. The immediate message, if you are currently living a nightmare, is that if you use family therapy for eating disorders without too much delay, you will soon be breathing a huge sigh of relief.
Will my child end up in hospital?
There is still a role for day treatment or inpatient treatment for very ill children and teens, but with family therapy for eating disorders becoming more common, and early intervention, teams in the UK and in Scotland report that the need for admissions has dramatically reduced.
What is hospital treatment like?
Traditionally, people have been admitted to inpatient eating disorder units for long periods of time. Some discharge when the patient's weight is restored, some much earlier. The key question is to take care of the transition to home: you need to know how to support your child once he or she has left the unit. A good unit will let you practice so that you're all comfortable and skilled. See for instance: 'Can hospital equip you for family-based treatment? A parent's inspirational account'
Things are changing as clinicians appreciate the power of treatment at home within the family. Children and teens may go for a few days in medical/paediatric unit for medical stabilisation (blood tests, nutritional supplements or tube feeding) with frequent involvement from the outpatient specialists and the parents. The parents get to do a lot of the feeding. This means everyone is ready to support the child when it's safe to take him or her home.
For some, long hospitalisations are necessary because the illness is severe and complex. Chapter 12 talks about inpatient treatment here.
I have worries about NG tube feeding
I put many questions to the authors of guidance on nasogastric tube feeding — voluntary or under restraint. Read their replies on: 'NG Tube feeding: parents' questions'
I have worries about psychiatric drugs
For some kids, teens and adults, psychotropic medication has a place within eating disorder treatment. It can make the hard work a little bit easier. For a round-up of the evidence for various types of eating disorder, see the AED 'Guidebook for Nutrition Treatment of eating disorders' (page 27 onwards).
For a restrictive eating disorder, you may see anti-anxiety or anti-depressants prescribed. They may not work on a very underweight body, and the drug most frequently used early in treatment is an anti-psychotic, such as Olanzapine (it doesn't mean your child has psychosis and hears voices). Dr Julie O'Toole talks about it on her blog here and also on the F.E.A.S.T site here.
Many youngsters recover from an eating disorder without any assistance from psychiatric medicines. But for some kids it makes sense for a psychiatrist to consider drugs to take the edge off an overwhelming level of terror, or with an uncontrollable need to move/exercise, or with a suicidal state. Medication has side effects, so be empowered to discuss pros and cons with a psychiatrist specialised in eating disorders, and to ask for regular reviews.
My child isn't progressing as fast as others. Who's to blame?
- Your child isn't getting the best treatment available, or the treatment isn't delivered by skilled, experienced clinicians. Or there is some loophole you are missing — for instance what's happening with your child's eating in school? Check out my resources and work it out.
- The treatment your child is getting is not suited to his/her particular needs (for example, family treatment doesn't work for everyone). Discuss it with his or her team.
- Eating disorders affect different people with different levels of severity, they are tough illnesses and treatment is still in its infancy. Perhaps you are all doing the best that can be done with our current knowledge, and your child would be more ill otherwise. Keep going. And if therapist is blaming you or your child for lack of progress, find another. [A good article on this by Julie O'Toole: 'Why can't everyone get a good result?']
- Perhaps comorbids need addressed sooner rather than later, for instance OCD (obsessive-compulsive disorder) or particular needs related to autism or to an earlier trauma. Perhaps your child needs more targeted help (drugs and/or psychotherapy) with depression or anxiety, or with volatile emotions as in borderline personality disorder (BPD). Perhaps there is a biological component that is maintaining the illness, as in gut microbiota and in basal ganglia encephalitis (BGE), which I say more about on this page.
My child isn't making use of what he/she learned in therapy
Your child is failing in spite of individual therapy, and you feel like beating him or her up for not trying harder. Telling someone ‘Stop shouting and do your bloody CBT!’ isn’t going to work. Here's a piece about giving your child a break. Also, please bear in mind that individual therapy is not the first choice for under-18s with anorexia, as explained in Chapter 12.
England’s new eating-disorder treatment standard: a model for the rest of the world?
Very, very exciting improvements have been underway in England. Here is an idiot's guide to the 'Access and Waiting Time standard for children and young people with an eating disorder'. Policy-shapers worldwide take note: we all need something as good as this, and we need it to include adult treatment too.
What does good treatment for an eating disorder look like?
Watch this video interview I made of two inspiring clinicians in Norfolk who are delivering the kind of service that's needed everywhere. The interview was in 2016 and it's still relevant. I hope that you have access to something at least as good and if so, hurray for your clinicians!
There's talk of 'underlying issues' and of my child getting 'insight' into causes
This is normal for psychotherapists who don't specialise in eating disorders, and that's why your child needs a specialist. With specialisation, therapists learn about the biological and genetic factors, and they train in evidence-based treatments. Even then, it takes a while for therapists to really 'get' the family-based approach. I discuss this in "Eating disorders: understand where psychotherapists are coming from" here.
The therapist says it's inappropriate for parents to be involved with the care of an adolescent
Get another therapist urgently. In "Eating disorders: understand where psychotherapists are coming from" (here) I talk about autonomy and what is appropriate when.
It feels like my child's therapist is undermining me
Some therapists have learned the theory of family therapy for eating disorders, but it is such a huge shift from previous psychological training they've grown up with, that blame leaks out in more or less subtle ways. This is why even specialised therapists need supervision from experts.
Even when we are not blamed for causing the illness, we can be judged as maintaining it. My experience of supporting parents is that it adds to their burden and weakens them, especially if the child is present while the disparaging comments are made. In my own family we were lucky, as right from the start, we parents were validated for all our efforts and the mistakes we inevitably made as we struggled to get our child to eat were written off as quite natural. If you are able to give feedback to your therapists, do so. They may also see a model of parent empowerment in this talk by FBT therapist Dr Rebecka Peebles:
The therapist says I have an unconscious need for my child to stay ill
This is 'Systems Family Therapy' badly done, and at its very, old-fashioned worst. The idea is that for you, the parent, to be OK, you need your child to stay ill so you can keep having them close by, and keep having an important role in your life. Yes, even though your life is hellish and you keep asking for better treatment and second opinions to get your child out of this nightmare.
This psycho-bollocks has nothing to do with family therapy for eating disorders (such as FBT), which supports parents to care for their child and is not interested in finding stuff that's wrong with you.
If the child is staying ill, it's most probably because of inexpert treatment. The parents are not getting support, or clinicians have not energetically guided the family so that they child eats, gains weight, sheds eating-disorder behaviours etc. Lots of reasons, all pointing to poor treatment, rather than sick parents.
What psychotherapy approaches might help my child… or myself?
Navigate your way through the alphabet of therapies that may be on offer, and some you may want to actively seek out. They include Positive psychology, NVC, ACT, CBT, DBT, Psychodynamic therapies, EMDR (for Post-Traumatic Stress Disorder PTSD) and Cognitive Remediation CRT. I outline them here.
What's the best treatment for post-traumatic stress disorder (PTSD)?
If your child has anorexia and you believe a trauma has triggered it, treating the trauma will probably not shift the anorexia: you will still need to do refeeding work. Still, if your child is receptive (or if you yourself are suffering from PTSD), check out my explanations on three treatment approaches for PTSD that stand out, either because they're in health standards or because there's a lot of research behind them. They are: Trauma-focused cognitive behavioural therapy (TF-CBT), Eye movement desensitisation and reprocessing (EMDR) and Emotional Freedom Technique (EFT, or 'Tapping').
Is recovery from an eating disorder possible? What does 'remission' mean?
Therapists, families and especially researchers tend to mean different things by 'recovery'. It's an emotional word for carers and sufferers. Some therapists work towards full recovery as a realistic goal, while others believe the patient will always need to manage some level of risk. Whichever way you look at it, there is hope for your child — lots of it, as I discuss here.
How do I get started?
It's normal you should be rather overwhelmed, that you should have a huge learning curve, and that you fear making things worse with a son or daughter who is likely to put up resistance.
I also take you by the hand in more depth in Chapter 6 of my book: 'Practical steps to help your child beat the eating disorder'.
And check out my online workshops:
How do I help my child with meals?
What do parents need to do about meals?
If your child has anorexia (or another eating disorder that drives them to restrict their eating), then the best treatment requires you, the parent, to find a way to get your child to eat. And to eat enough for weight recovery. And at some stage parents also help their child manage foods that have become fear foods. Usually that means that parents take charge of meals for as long as their son or daughter cannot safely and reliably take care of their nutrition.
Is there a danger in suddenly refeeding someone with anorexia?
Yes, though nowadays there is talk about this having been overblown. It's called refeeding syndrome, it can be fatal, and it's caused by sudden drops in the levels of some electrolytes. There are no external signs of it, just blood tests to monitor it. As I explain in Chapter 6, it is rare, and the risk is mainly if your child has eaten little or nothing for a long time. Traditionally, hospitals have refed very slowly because of the risk of refeeding syndrome, but more recent studies (and first-hand experiences from experienced therapists) indicate that the risk is far lower than previously thought. Much more common is the damage done by under-feeding.
There is guidance for your doctor on assessing for refeeding syndrome in section 8 of the Academy for Eating Disorders (AED) Guidebook for Nutrition Treatment of eating disorders (2020).
How much should I feed my child?
If you've been told the risk of refeeding syndrome is not an issue in your case, if your child has lost weight you're aiming at a gain of 0.5 kg to 1 kg a week. Or more. Do not tip-toe around weight gain: your child needs nutrition. Studies show that fast gains in the first few weeks predict better outcomes. So unless your clinicians tell you otherwise, go for it.
I've heard it's better to go slowly
Assuming the risk of refeeding syndrome is now over, there is no good reason to slow down weight gain. In adult treatment, traditionally, there was a fear that rapid gain would scare patients away. This has leaked into the thinking of some of those treating youngsters, for no good reason. Your child will be scared of eating and of weight gain anyway, and you will support them through their fear.
What should I feed my child?
Obviously, there's lots in my book and in Bitesize about this.
Briefly: you should quickly get to the stage you can feed your child 3 meals and 3 snacks a day, in quantities that will give any weight gain required, fast.
Some therapists will give you a meal plan. That may or may not help you. You can also get high calorie meal ideas here.
You can give normal food — just in bigger quantities. It's helpful to make the food 'dense': lots of calories in a smaller volume. That usually means using rich ingredients like fats.
If your child needs to gain weight, that's your priority, so it's OK to stick to the foods they are just about comfortable with. But if your child is only eating vegetables and quinoa, you will have no choice but to serve richer food right from the start.
Once you're reasonably confident you can feed your child for weight gain, consider introducing some 'fear foods'. It's up to you how soon you do this, but it has to be done eventually. You can't have recovery from an eating disorder if you continue avoiding the foods you used to love, or the foods that are part of normal life.'
Can I let my child be vegetarian or vegan?
If your child became vegetarian or vegan as part of their descent into an eating disorder, the normal rule is that you should re-introduce the dairy or meat that they've been avoiding. The idea is to help your child your child let go of anxiety-driven or perfectionist rules. You can share their sadness over the suffering of animals: the point is that once they are truly recovered, they can make choices from a place of wisdom, not a place of restriction.
If your child was vegetarian or vegan a very long time before the eating disorder started (because who knows when they really started to restrict), and if you totally trust that your child became vegetarian or vegan for ethical reasons rather than from an anxious drive to 'eat healthy', then it might be fine refeeding them with these dietary choices.
But first, are you confident that if you do so, you will be able to re-nourish your child fast, both for weight and nutritional balance? Most (but not all) parents I speak to feel far too limited with vegan foods and don't know how to bring in enough calories. Personally I wouldn't know how to do it with veganism, whereas in my family we've almost always been vegetarian. If you think that refeeding along veggie/vegan rules will be slow, then consider that 'food is medicine' — we take medicine we don't particularly like, if it's going to help us recover.
There's a lot more help on this page which two expert dieticians wrote for me: 'Is it OK for my child to be vegan during eating disorder treatment?'
Can I 'hide' ingredients in the food?
I'm fascinated that some therapists say that's an absolute 'No'. That can make refeeding very hard and slow, given that most of our children fear just about any high-calorie food. The illness drags on as we try and be 'honest' and agree to tell them how many grams of butter is in the pasta.
Meanwhile, it seems to me that we strengthen their eating-disordered obsessive thinking, as they agonise over ingredients and quantities.
Most parents I know, who have succeeded in supporting their child to recovery, are very comfortable with adding cream, butter, oil to all kinds of food.
When your child asks, you say, "Darling, I can see how you would think it's helpful to know what's in the food. And at the same time, we know it makes things harder. So for a while, we're not going to discuss ingredients. Trust us to serve you what you need. I've heard of a great new series on Netflix, by the way, would you find it for us?"
Can I let my child choose their food?
With old-style treatments, patients were involved in all the food choices. Meal plans would be negotiated with clinicians a week at a time. Sometimes calories were counted, food weighed. Parents were told to stay away while their child cooked and at in their bedroom.
This makes recovery very slow, or non-existent. Our children are too scared of food, and of weight gain, to make wise choices. Given too much choice, some eat less and less. Some eat just about enough to avoid hospital.
This is why a family-based approach normally works better: parents are mobilised to support their child to eat what's needed. Most often that means parents take charge of meals. Some parents call it 'Magic Plate': the plate appears in front of their child as if by magic, containing what the child needs to eat. The young person is not involved in shopping, and stays out of the kitchen. Negotiations are kept to a minimum — though the parents may listen out carefully for hints ("I imagine I will never eat ice-cream again" means, "Please make me eat ice-cream soon").
At some stage, of course, parents will stop being in charge. But even then, there must be a phase during which they will continue to guide, to coach, to correct. Our children just can't be expected to have the courage, or the perspective, to eat as much as they need, until they've had plenty of practice, until they have overcome all kinds of fears, and until their appetite and fullness cues are back on track.
This phase is often rushed or completely missed out (e.g. when kids are discharged from treatment too early), and I cover it in depth in Chapter 10 of my book.
How on earth can I get my child to eat?
It seems impossible. Hey, if it was easy, it wouldn't be anorexia, or bulimia or binge-eating disorder in its restrictive phases. But there are many ways of making it much more possible than you think. You can hear me explain and demonstrate tips in my Bitesize audios, and I share every useful tool in my book. Also, check out my online workshops.
You will find many tips and examples in Chapters 7 ('How do you get your child to eat in spite of the eating disorder?), Chapter 8 ('See the tools in action: mealtime scenarios') and Chapter 9 ('How to free your child of fears: exposure therapy'). More below…
Just give me a few tips: I need to feed my child right now!
- Read my tips on 'How can I get my child to eat'
- There's also a free helpsheet which you can download here.
- I summarised the big principles in an article : 'Getting your child with an eating disorder to eat'.
- And I explain 'Seven Tips for Getting a Person with an Eating Disorder to Eat' in a podcast with Tabitha Farrar.
I'm desperate. Give me just one thing that will help my child to eat!
I produced a very popular video 'Help your child eat with trust, not logic: the bungee jump'. For some parents, using that one principle made all the difference.
How long should I persist with a meal?
I am not a fan of simple, one size-fits-all rules like 'Life Stops Until You Eat' or '100 percent nutrition, 100 percent of the time'. It depends on your child's mental state, on whether you're about to do harm by finally losing your temper, on what you have learned works with your child, on your aims (weight gain? fear food?).
If you have a meal to serve right now, think 'compassionate persistence'.
If you have 7mn, read more on my post here: 'How long should I persist with a meal?'
If you have 20mn, watch my video, which talks you through your options.
It's not working. What can I do?
- If you've not read chapters 7 to 9 of my book, then do that.
- Reading may not be your thing and it's probably useful for you to hear this stuff too: that's what my Bitesize audios are designed to do.
- Ask your clinical team to give you coaching. Many teams don't do it, presumably because they themselves don't have that particular expertise. A few think it's better for parents to work it all out by themselves — I think that's a very weird (and ineffective) theory of empowerment, so keep asking.
- I offer online workshops.
- Ask your clinical team to send you help at home – some places have home feeding teams.
- If your child cannot eat enough to regain weight, then it may be necessary to use a day unit (PHP/partial hospital plan) or an inpatient unit to kick-start a change, and/or to tube feed and monitor their health.
Fear foods and rigidity
Can I stick to the foods my child finds easy?
It depends on the priorities at this stage of treatment. Does your child need to gain weight? Then rapid weight gain is your priority and will give you both the biggest bang for your buck. Rather than risk failed meals, serve up easy foods, if these foods allow for the required calories and cover the basic food groups: fat, protein and carbohydrates. I remember that we did well, when my daughter had lost a lot of weight, with serving up quiches almost every night.
If your child fears all fats, or all carbohydrates, then you have no choice: you will have to introduce some of these now to make any progress.
Once you can feed reasonably confidently for weight gain, start bringing in variety. If you do it as soon as you feel is manageable, there is less risk that your child's rigidity will increase — too often, we see our children making more and more foods a big 'No'. On the other hand, you can leave some of the worst fear foods for later, when your child is generally better, less anxious and more flexible.
If your child doesn't need weight gain, it's still likely that they have issues around rigidity around certain foods, eating in company, eating regularly. They can't beat the eating disorder without help around this.
If you think your child might be autistic (more from me on autism here), or has ARFID, and they've always had trouble with certain types of food, then get more advice. Most likely, you will be advised to help them return to the foods they used to be OK with. Any work on expanding their range needs to be done with great care (if at all).
How to do exposure to fear foods
Sadly the only method that consistently works to get rid of a fear, is to do the fearful thing. The brain goes, 'Oh, that wasn't so bad' and after some repetitions, it gets retrained, desensitised, 'rewired', so it doesn't send our poor children down the fear route'.
Then there's more help in Chapter 9 of my book: 'How to free your child of fears: exposure therapy'.
About fear of restaurants, or the compulsion to exercise?
Use the same principles as for fear foods. Until your child has freedom around everything that used to be natural to them, they need your help to practice 'normal'. I have a Bitesize audio specifically on progressive steps to manage restaurants.
What to do about exercise?
Exercise is, for many, very much part of the eating disorder. Parents are usually tasked with stopping or reducing exercise at first, often for medical reasons or to prioritise weight recovery. Some young people have revealed that they were relieved when they were made to rest, as they were so very tired.
The drive to move is, in some youngsters, is so strong that parents can hardly stop it. Do consult your professionals, so you know what to prioritise. Medication helps some youngsters, so insist on seeing a psychiatrist as anything to do with antipsychotics, antidepressants or anxiolytics is their domain. Some parents report that a strong, clear exercise veto from a clinician made all the difference.
Later on, treat exercise a bit like you do fear foods: gradually expose to whatever form of exercise seems to be an issue, monitor, explore your child's attitudes. Your aim is for your child to recover (or discover) the pleasure of movement, free of compulsion, rules and self-hate.
If your child was engaged in a high-level of sport, they may or may not return to it eventually. It's not clear what makes it OK for some and not for others. Take it slow and gradual, and don't make any promises.
What should my child weigh?
My child is scared of weight gain. Can I keep them thin?
The eating disorder will stay if your child is allowed to stay underweight — underweight meaning whatever your child needs for physical, mental and emotional stability. Their fear of weight will only pass by them going through the painful process of being exposed to that fear, and discovering it's OK. More on Weight Restoration: Why and How Much Weight Gain?
Should my child be given a weight target?
There are pros and cons to your child being told a target, and there's skilful ways of doing it. More on Weight Restoration: Why and How Much Weight Gain?
The weight target is something to do with BMI or 'Weight-for-Height'
It sounds like a 'one-size-fits-all' target, which is insufficient for roughly half the population. More on: Is your child’s target weight a gift to the eating disorder?
My child was told their BMI is too high and they're overweight
'Overweight', by definition, is over a threshold BMI. The problem is people also think that means 'fat', 'unhealthy', 'must lose weight'. Very often, that is not the case. BMI is just a very crude way of classifying big populations. More on What do BMI and Weight-For-Height mean? The general rule is that youngsters should not lose weight. Get yourself some specialist advice.
My 'overweight' child lost a lot of weight: that's good isn't it?
A child or teen who loses a lot of weight presents high medical risks, and sadly these are often missed by generalists who generally see a 'normal' BMI as a sign of health. If your child has the mental and behavioural symptoms of anorexia, consider them to have anorexia (though it may be named something else). Get your child checked out in the same way as if they were skeletal. They will need to regain all or most of the lost weight. More on Weight Restoration: Why and How Much Weight Gain?
I disagree with how our clinicians deal with weight
This is a problem commonly faced by parents who have got themselves super-educated about eating disorders. Not all clinicians are updating their practices. In my articles on weight (Weight Restoration: Why and How Much Weight Gain? and Is your child’s target weight a gift to the eating disorder? and What do BMI and Weight-For-Height mean?) I included references and quotes from top experts, whom your clinicians, hopefully, respect. I hope this helps you make your case. After all, you could be speaking to another clinician in the next county who insists on the very same things you want. By the way, in any difficult discussion, it helps to agree to a time period, then review.
What should I say when my child wails they're fat?
Lots of possible answers, depending on lots of things. In my Bitesize audio collection, I devote a number of audios to demonstrating a range of answers, and helping you get into your child's mind with compassion. Below is one of them, on how "You're not fat" fails to provide reassurance:
I also explain all this explain in detail in Chapter 14 of my book
I'm confused how to talk about weight, body shape and healthy eating!
Join the club! Most of us parents evolve in our own attitude, fat-phobias, healthy-eating guilt trips and so on, because we see the world through different eyes when our child has an eating disorder. Our current society is slightly mad and we're all bathing in that corrosive juice! You can find some sensible talk from many experts in The Full Bloom Podcast.
My child's psychological state
My child is socially isolated, withdrawn in their bedroom
This is common at any stage of the treatment. When they're very malnourished, do what you can to distract, allow plenty of rest, and refeed as fast as you can.
Sometimes the withdrawal is strongest when they're weight-restored. If they've heard they're supposed to now be well (they're not) then they have an extra burden of shame and hopelessness. Try to gauge where they need time for grief and rest (they've been through a huge illness, huge anxieties, the whole refeeding, and they are still worried about so much!), when to make time for side-by-side activities that engender connecting conversations, and when they need you to give them some structure.
Self-harming and suicidality
Both are relatively common at times. They can be at their worst when the young person is at their most malnourished, or as they get a little more energy as nourishment comes in.
Don't make it into a taboo. Talk. When I worked at the Samaritan's suicide helpline, we had to ask people if they felt suicidal. Bring it out into the open. You can't make someone more suicidal by asking.
Tips for asking about suicidal thoughts: 8 Gentle Ways to Ask Your Child If They're Considering Suicide
From Chapter 6 of my book: "Regarding suicidality, it’s not that our children want to kill themselves. They want relief from a level of suffering which seems almost unbearable. Give them empathy for that, validate their feelings (more in Chapter 14). Help them notice how feelings move on, and how they move faster when they connect with someone who cares for them. Ask them to give you some kind of sign when they’re feeling particularly vulnerable. At a good moment it might be worth explaining how, while they’re in fight-flight-freeze it’s normal that they’re scrabbling for any way to stop the pain, and at the same time no decision or plan should ever be made while in that state because our wise brain is temporarily offline."
Here is a template for a safety plan which may help you.
My child is weight restored – is he or she now safe?
Well done for getting to this stage. If your child is not only weight-restored but eating without excessive anxiety, you're through the first phase of treatment.
Treatment continues and very gradually starts to be less about feeding and more about helping your child practice normal behaviours over and over again: normal eating, normal exercising, normal reactions to stressful events. This rewires the brain, removes irrational fears, gives your child the confidence that they can live normally, and gives the body time to restore itself to full normal health.
It can take a year or more for normal hunger and fullness cues to return, so for a while people cannot eat completely independently – they need some degree of checking and correcting. Some physiological processes, some hormones, take a long time to get back to normal. Psychological changes take time and repetition too: your child will be scared of maintaining weight, of gaining weight, of eating various foods in various situations, of being among friends who are on diets.
Too often, treatment stops far too early, and then people talk of 'relapse'. You will know better.
If you prefer short audios, I cover this in detail in Bitesize. And sometimes I run an online workshop on the subject.
My child is weight restored but stuck. What to do?
It may be that your child isn't getting the treatment phase that comes after weight-restoration. Or it may be they are not truly weight-restored — that their body needs more in order for the mind to have a chance to heal. More on Weight Restoration: Why and How Much Weight Gain? If your child was given a 'one-size-fits-all' target (using BMI or 'Weight-for-Height) instead of an individualised target using their own growth chart and consideration of their symptoms, then there's a high chance that their weight target was too low. More on: Is your child’s target weight a gift to the eating disorder?
Can my child continue going to school?
Only if you know for sure that he or she is eating in school and not over-exercising. More in Chapter 10 of my book. Sometimes parents think it's OK for their child to miss lunch in school because they're serving plenty of food before and after. I notice that these young people are not progressing, and I reckon one reason is they need to eat every 3 or 4 hours.
Does the school have to help?
If your school is not helping to accommodate your child's needs — such as supervising meals — your country may have a legal tool that makes it clear they must.
What can I say when I discover my child has been binning food in school?
In Chapter 14 of my book I give you principles and examples of empathy and dialogue. Here is one more example you might relate to. The child has secretly been binning food in school and the parent is trying to connect, understand and find solutions. Read it here.
If your child is binning food in school they probably need more support than you thought. More on school support here.
Do you have materials to help schools?
Yes, lots. It's all here.
What should schools do about health promotion?
A thorny subject! I researched it carefully and produced guidance here.
How can I stop my school giving harmful messages about obesity and dieting?
My guidance for schools on this subject is, again, here.
How can my school do eating-disorder prevention work?
As I explain here the best prevention approach we have is to use a validated body confidence program. I also highlight common mistakes to avoid.
Can I get the school to help my child stay or return to classes?
Your child might benefit from going (back) to school, but some support measures need to be in place. Otherwise your child might go without morning snack or lunch, and that will stall or reverse recovery. Chapter 10 ('The road to full recovery') will help you work out what's right for you. Here's a checklist to remind you of issues to discuss with the school. And I've also produced lots of guidance for schools here.
Is my child safe to go on a school trip?
If you're in two minds about it, then your child probably needs the support of teachers, who need to be properly briefed. Here's a flowchart to use as a starting point for your discussion with the teachers who will be on the trip. I give guidance to schools on this subject here.
Care for the carer – how can parents survive?
There are psychological and wisdom tools to help us when we are going through terrible hardships. I put them together in Chapter 15 of my book. And my Bitesize audio collection includes many short clips, mostly just a couple of minutes each, to give you practical and compassionate tips so you can cope better, manage your temper or tears, your thoughts and emotions, and even perhaps begin to thrive.
I am sick of people telling me I should take care of myself
If all you've been told about self-care is to take bubble baths, the resources mentioned above will open your eyes.
Take a break from reading and listen to this podcast with Tabitha Farrar, where I discuss 'The surprising truth about care for parents and partners'. I hope it will make you feel understood, and will give you a boost too.
I also wrote a short piece on Preventing Caregiver Burnout for Mirror-Mirror.
And you may feel supported and inspired by my YouTube 'The hero's journey'
Here's one and a half minutes from my Bitesize audio collection, on 'The best psychological tools for these extraordinary times':
Are there any guided meditations to help me be at my best?
Yes! I've produced recordings of guided meditations to help you actually experience the power that lies with a compassionate state. They will help you shift your state towards more wellbeing. One of them is designed to let you drift off to sleep… Yay!
There's more on my page 'Help with compassion, self-compassion and sleep'
Help! I can't sleep from all the anxiety
One of my guided meditations fades away at the end, after giving you soothing sleep messages. There are also many YouTube resources: search for "sleep hypnosis".
I think I have post-traumatic stress disorder (PTSD)
On the internet, some parents report suffering from PTSD once their child starts to be well. Many report that therapy has fixed it. See my summary of three treatment approaches for PTSD. Please know that there is also such a thing as post-traumatic growth, and you emerge from this tough adventure wiser, kinder and with a greater appreciation of the good things in life. Rather than leave it to chance, learn very specific ways to take care of your mental health, in Chapter 15 of my book ('How to build up your own resilience and well-being').
How can a parent become more calm, confident and compassionate?
Why be calm and compassionate? Isn't it better to be firm?
You can be calm, compassionate and firm. I call it compassionate persistence. What you want to avoid is blaming, judging and criticising your child. Research shows that when there's a lot of that, outcomes are poorer. But please understand that all parents occasionally lose their temper and say the wrong things — it's such a difficult illness — and no lasting harm is done. In a loving atmosphere, our children are actually quite resilient.
Your clinicians may have taught you to separate the illness from your child. If this is leading you to be outwardly critical 'of the illness', you might like my post: 'Could your rage at 'ED' show your child's progress?'
What has self-compassion got to do with parents?
Self-compassion is a great tool to transform tough emotions. It is the route to your internal power, your intelligence, and your ability to be kind to your child. It tells your brain you are safe and brings you out of fight-flight-freeze. Once you've got the hang of it you can help your child do the same.
How do I do self-compassion?
Chapter 13 ('Powerful tools for wellbeing and compassionate connection') in my book gives the how-to of compassion and self-compassion, along with examples. And there's more in Chapter 15, to help you cope in real tough situations.
I guide you step by step through self-compassion in one of my 'Four guided meditations'. The shortest one is great to get you in a useful state of mind to support the next meal
I hear that mindfulness could help me. What is it?
Mindfulness means paying attention to what's going on around you and within you, in the present moment, with an attitude of kindness and allowing. It gives you a break from the brain's tendency to interpret, to judge, to criticise and to add layers of anxious thought about the past or the future. If you learn how to do self-compassion you'll be doing mindfulness. I've collected more resources on mindfulness for you here. And Chapters 13, 14 and 15 of my book are all based on mindfulness.
I hear that I should 'let go' and 'accept'. How can that help my child?
Mindfulness teachers and stress gurus often talk of acceptance and letting go. This can easily be misinterpreted as resignation, giving up, or giving in, and that's no good at all when your child needs you. Yet the concept of 'acceptance' is really useful when used with skill. I guide you through this in Chapter 15, 'How to build up your own resilience and wellbeing'
Can you make mindfulness and self-compassion real simple? I'm in a hurry
OK! Using 'O for Observe' and 'K for Kindness'. 'OK' is the simplest way of quickly steering yourself out of distress and judgement, into a place of compassion and strength. More here.
What can I do with all the guilt and self-blame going round my head?
If you’re finding it hard to disentangle yourself from blame and shame, if you're stuck in an internal conflict, if you’re tortured by thoughts of what you could have done better, you need some skilled compassionate listening. Logic is unlikely to help. For now, you might like the self-compassion and acceptance exercise in this example: "Self-compassion and how to mediate arguments in your brain".
How can I communicate better with my child?
This question is so important that the answers are everywhere in my book and in my Bitesize audio collectio, where you can hear me modelling conversations. I also occasionally run an online workshop on the subject.
Communication is how you will make your child feel safe and loved and make the treatment possible. Chapter 13 gives you the big principles of compassionate communication (or Nonviolent Communication (NVC)), and Chapter 14 applies them to the most common situations with your child.
Here's what a parent wrote me. I hope it will inspire you:
For me your use of compassion was so powerful and linked me directly to [other aspects of my life]. To help my child get well way through love was a privilege and has taught me so much about the power of compassion. Your advice was invaluable and helped me save my daughter’s life.
I've heard I need to do 'tough love'
Gosh, that sounds harsh. Assuming you are suffering big time yourself, do you think 'tough love' is what you need?
It depends what people mean by 'tough love'.
Your child definitely needs love. You need to make it explicit ("I love you" in all its forms) because with the state of threat their nervous system is in, they feel they are unlovable, despicable, responsible for all the chaos that descended on your family. They are ashamed about their behaviours, and feel awful about every nasty comment they threw at you. All this could be going behind a polished, aggressive front, but I bet it's all there, hurting underneath.
With love, you calm the nervous system. The sense of threat lifts a little, leaving more space for a bit of rationality, a bit of happiness, and hopefully, lots of good eating.
What about the 'tough' of 'tough love'? Yes, if what is meant is 'persistence'. Generally, our children cannot lift themselves out of the pit they are in. We need to pull them out. That means supporting meals they don't want, that raise their anxiety. Same with exercise and purging. So yes, it's tough. But it should never be nasty, exasperated, punitive.
Instead of thinking 'though love', think 'compassionate persistence'.
Or 'loving persistence'.
I've heard I have to do 'Life Stops Until You Eat' (LSUYE)
You may have heard this mantra from parents on forums. Originally, it was an instruction for parents: Parents, put your life on hold until your child has eaten. Cancel your appointments. Get off your mobile phone. Give your whole support to your child during this meal. I approve.
But for many nowadays, 'Life stops until you eat' has become something parents tell their child to impress on them that there will be no school, no friends, no TV, no phone, no bed even, until they have eaten every last morsel. It is often tied to 'consequences' (punishments). It works for some. But I think it's a blunt instrument, and that compassionate persistence is (usually) more effective and definitely less risky. (See what I write about 'tough love' and 'consequences' in these FAQs.)
I've heard I need to do 'compassionate persistence'
Everything I say makes my child more cross
It could be your only tool is now silent empathy. It sounds like nothing, but it can be very powerful, if you can put yourself in a loving state of mind.
There's also a lot you can do to keep up the connection even while your child goes:
- "You don't listen!"
- "You don't care!"
- "You're so patronising!"
- "Why are you not doing x,y,z?"
Lots in my book and in Bitesize. The short answer: listen well, be interested, try and get into a non-judgemental state. Wait for a sense of connection and understanding before you give explanations, make suggestions, give fixes. Mealtimes is the exception: don't let empathy take up all the time: keep coming back to eating prompts.
Of course, it's hard for you to tap into your empathy if you yourself are depleted. Hence the importance of for self-care and great support for parents.
How do I set limits?
There's lots of advice out there for parents to 'set limits'.
Sadly, often that's a euphemism for punishing or shaming your child.
Setting limits should mean this: you tell your child, very clearly, when something is not acceptable, and you ask them, very clearly, to do something else. If necessary, you leave, or do whatever is needed to not get hit, not get abused, not be a doormat.
Such as, "DO NOT HIT ME!!! Speak! Use words. In this family we try and respect each other. I am listening. Come, darling, tell me what you have to say." Note the de-escalation — you are modeling going from high intensity to a calmer, more connected state.
I really can't see the point of people advising us to 'take away privileges'. Your child is hitting you, and you scream "That's it, you lose your mobile phone for a week!!!" How is that going to make your child considerate and connected?
As I demonstrate in Chapter 14 of my book, and in Bitesize, there is plenty you can do to be neither a victim nor a persecutor.
Do 'consequences' (punishments) and bribes work?
My book and Bitesize are packed with guidance for you to connect using compassionate persistence . I believe this is the most risk-free, productive way, of guiding your child, step by step, to manage a meal, to refrain from throwing their plate at a wall, to stay in the house when they were going to run away, to speak politely.
Compassionate persistence is more rational than 'taking away privileges'. Your child doesn't choose to find eating terrifying. Your child doesn't choose for their nervous system to be in such a state of threat that they become unrecognisable.
Your greatest strength, in getting done what needs to be done, is in your connection. And if you're wondering "Is it the eating disorder speaking, or the stroppy teenager?", I suggest that is irrelevant. The use of 'consequences' is a poor tool, whatever is driving any kid.
The carrot and stick approach gets far too big a airing on TV parenting shows, starting with 'the naughty step' for toddlers. Yet is only one method in a vast toolbox — in my view it's the most risky, the most likely to backfire, the most shaming and disconnecting, the least likely to promote thriving and wisdom.
Listen, it has worked for some, and on forums it's what you will hear of the most. If it can save a life, it has a place in your toolbox.
But… 'consequences' are a scarily blunt instrument. I speak to parents who don't dare to speak their truth on forums: punishments made things worse, and they're having a hard time getting any traction back on their child.
I have even spoken to parents who were told by therapists they had to use punishments, and how they were running out of punishments as nothing worked any more… and what a relief, and how much more effective they became, when I introduced them to compassionate persistence skills.
Bribes (incentives) are very close to punishments: if your child can't manage what you asked of them, they lose the promised reward, and that can induce helplessness, despondency or lots of bargaining and resentment. Having said that, I know of situations where bribes can work: when your child has worked out with you things that will help them stay motivated.
Step out of the power play. Your child can always win power games: all they need to do (and many do that) is say, 'I don't care'. Often, it's true: what is the joy in a mobile phone, when they are in complete shut-down — when their life is so painful that they don't even want to live?
If this is strange to you, and you're wondering how to bring up any child or teen without carrot or stick, you'll find lots more in my resources.
My child has terrible meltdowns
Our children can go through periods of extreme panic, where they disconnect from reality, perhaps screaming, hitting themselves, and perhaps getting pretty delusional about their body shape.
As you expect, lots of help on this in my book (Chapter 14) and in Bitesize.
In short: of course you will aim to use your skills of compassion. But if your child is locked in their nightmare, they may not hear you, so your empathy doesn't get a way in.
In these situations it's often most effective to connect our children to reality.
Give them clear instructions that will make their body move, and that will distract them from their nightmarish thoughts: "Come brush your teeth. Yes, now. Come on."
Get them to reconnect with their physical senses: "Let's count five blue things in the room. Come on, I'll help you. There's the blue mug over there. What else?" Some youngsters have prepared a kit ahead of time, with items that are tactile. Some come back to reality when parent hugs them, or runs an ice cube over their face. You can also ask your child to guess what letter you are drawing as you run their finger on their arm or in the palm of their hand.
And obviously, model calm confidence. Your child needs to know there is no real danger. If you're not scared, maybe there's nothing to be scared about.
Eating disorders make emotions run high. What can parents do after the fireworks?
Your child has screamed, kicked, run away, and you need to work out what to do when things have got calmer. Chapter 14 of my book will help you ("Love no matter what: how to support your child with compassionate communication"). I also offer you this example of post-fireworks dialogue.
Trouble with family members
My partner and I disagree
It's common for marital stress when there is so much at stake. Obviously, do your best to work together. If your child knows you're not on the same page, it will be very hard to make progress — they will manipulate both of you so as to avoid challenges.
Concentrate on your common ground. You are both desperate for your child to be well. You are both very scared of doing the wrong thing. Your arguments stem from that fear. I speak to so many parents where one is accused of being "too tough" (shouting at their child in the hope it will make them eat), while the other is "too lenient" (prioritising kindness and connection over action). Both parents are desperately wanting their child to be well, and they get angry and scared that the other parent is making things worse. They get polarised, each in their extreme role.
And of course, parents get exhausted, and don't sleep well, and can be in a near-constant state of threat. They're not in a good place to work out their differences.
What can I say? Get help. Ask the therapists for sessions just for yourselves. Seek out your own therapist. Take turns supporting meals, so you each have at least two fun outings a week to replenish. Have long hugs: that will reduce cortisol and increase oxytocin in a way that words can't.
My other children are suffering
Yes, it is hard on the siblings. Chapter 11 of my book gives you pointers and links. Here's the main thing: you can't possibly give all your children the same amount of attention as their ill sibling gets. Let them know you care. Ask them how things are for them. Make all thoughts, all emotions acceptable. Don't preach.
Most of all, tell your children that you are strong, that you know what you're doing, that you have great resources. You have space for them. They don't need to spare you their own miseries. They don't need to close down and become 'tough' and go into extreme self-reliance.
Family-based treatment or similar approaches ought to include siblings. Some don't want to come — fair enough. Some may benefit from extra therapy support, or from extra care from the school.
Think very carefully about any role you give siblings. The general rule is they should not be tasked with feeding or supervising their ill brother or sister. That's your job.
Kim Piekunka provides great resources on siblings.
You get to know who your true friends are
Yes, for sure. At the same time, give people a chance. The minute you use a word like 'anorexia', it's normal that the person should jump to a whole history of notions of what that means. Take a few minutes to educate them, even if it's just "I've learned so much about it. It's not at all what I used to think — it's not about being vain, or having deep psychological issues or all that stuff you see in the media." And then give them a brief genetic explanation, or an analogy like "It's like he has a hijacker holding a gun to his head, saying that if he eats he'll be shot".
When your friend starts giving you unwelcome advice, see if you can tell them, "You know, I have learned so much about this, and I'm confident I know we're getting the best advice. From you, what would be most precious is your lovely friendship… listening to my woes, taking me out for drinks, sending me messages of encouragement…"
And of course, there are some people you won't even try with. More in Chapter 11.
Disagreements with therapists
A competent, up-to-date, well-informed and supportive therapist is an absolute joy. I have huge gratitude for the therapist who helped us when my daughter was 11. Even with a fantastic clinician, it's normal to disagree on some points. They are not at home, observing what we observe. And sadly there are clinicians that serve families very poorly.
Chapter 12, which you can see in its entirety on this website, proposes various ways of dealing with disagreements with your clinicians, or disagreements among the clinical team.
On the whole my guess is that most therapists will respond better to your polite 'compassionate persistence', where you make a good case about your knowledge of your child, making clear requests on something you would like to happen.
If it's hard to reach agreements, there's always help in "Let's try it for xxx time and then review".
As you get super-informed, you may be tempted to shower your clinicians with research papers to prove that you are right and they are wrong. Alternatively you may feel very confused, because shouldn't the professionals know more than you do? The truth is, some parents spend so many hours reading, researching, networking, listening to some of the world's top experts on podcasts, and becoming super-informed, they probably do end up being more knowledgeable and up to date than some clinicians. So what to do if you're unlucky enough to have such a clinician?
Well, you'd think that this clinician you're having trouble with would respond well to all the published evidence you throw at them, but from what I hear, parents tend to be told, "It doesn't apply in this case", or "I've worked in this field for 20 years and…." Sometimes it's very hard for parents as they hit a brick wall. You can see an extreme case of it in my YouTube interview of a parent in Switzerland. Sometimes super-informed parents get to the stage they find the clinicians are doing more harm than good, and they make a careful plan to go it alone (while keeping a doctor on board) or find another team (more in Chapter 12).
What's in your book / in Bitesize?
Where can I get your book?
Amazon, bookshops, ebook stores… anywhere worldwide. As a paperback or ebook. Links are here.
What's in your book?
Practical tips and emotional support for parents. It is mostly aimed at parents of children and teens, but I have had parents of adults and young adults tell me they got lots of useful help form it.
The table of contents is here.
Is your book reliable?
Yes, I work hard at keeping it up to date with the science, and also use the experience of many parents as well as mine. The book has been checked by experts and many professionals recommend it. See their reviews here.
There are so many books on eating disorders. Why yours?
Mine is the only book that gives you a detailed 'how' of supporting your child along family-based treatment lines. It is the only book that holds your hand through all the wider questions families face, like what to do about school, friends, relapse prevention, communication and emotions. As a parent said, it covers all the bases.
There are other books give you the 'why', the theory and history, more than mine does. There are a couple of shorter books that tell you what to do, which is great when you're in a hurry or overwhelmed. But you don't get all the answers on how to respond to the many real situations we encounter on this journey (which I do, and why my book is big!).
And then there are many books that are the memoirs of parents or sufferers, and I am not sure they're a wise choice. Inevitably, they relate to treatment, or lack of treatment, that has little in common with the up-to-date treatment I am talking about. So they tend to paint a rather horrific picture of the journey. I take care of my readers' emotions: my book is sympathetic and upbeat – the furthest you can get from a misery memoir.
Is there an audiobook?
No, but there is a big collection of very short audios, called Bitesize
Bitesize is a library of audios, each less than 5mn long, addressing the topics parents need the most. Get Bitesize if you don't like reading much, or if you want to hear me modelling conversations, or learn on the go. It complements the book nicely — what it doesn't have is all the references to back up what I say.
Tell me about your workshops
Where can I find a list of all your posts?
All my posts are listed here.