Sometimes parents are told to “back off” eating disorder treatment so a child can choose to recover. I’ll tell you why this all-too-common advice is terrible, and what you can do instead.
The letter
Dear Ginny,
Our 16-year-old son has an eating disorder. He has been seeing a therapist for anxiety and participating in an eating disorder group. The group was recommended by and is covered by our insurance. There are not currently any medical complications, and he is not considered underweight or at risk. Despite this, we see the eating disorder getting stronger and more intense.
The group seems more dangerous than helpful. He is with much sicker people and is being exposed to a lot of ideas. I don’t have any faith in the group as an effective treatment for him.
We want to get more aggressive about the eating disorder. But his anxiety therapist says that we should back off and let him choose recovery for himself. What do you think about this? Is the therapist correct that we should just wait for him to want to recover? Or is there something we can be doing to avoid a slide into a much worse disorder?
Signed, Anh
My response
Hi Anh, I’m so sorry to hear this, and I’m glad you reached out. Unfortunately, many parents are told to back off eating disorder treatment, and it’s not good advice at all. Let’s go through some of the different points in your letter.
You recognize your son has a serious eating disorder, but the system of care is not responding assertively. This is something that happens, unfortunately. If a person is medically underweight, their eating disorder is treated aggressively. But otherwise, there can be an element of “wait and see” or even “it’s not that bad.”
But eating disorders are mental disorders. Their symptoms are mental and psychological in nature. That means we’re looking for symptoms like preoccupation, obsession, and compulsive behaviors with food and the body.
⭐ Get ready for recovery and find out how you can prepare yourself for maximum success.
⭐ Find out the essential steps and family rules you need to have in place for recovery.
⭐ Make your home recovery-ready with six simple steps that anyone can do.
The eating disorder diagnosis
Anorexia is the only mental disorder that has a weight limit. And many of us in the eating disorder advocacy field are desperate to see that change. Because it sets up an unfortunate hierarchy of disorders and puts people who have severe, dangerous eating disorders at risk. Just because they are not underweight according to BMI standards does not mean they don’t have an eating disorder.
There is no weight limit for schizophrenia, autism, bipolar disorder, or anxiety. Professionals observe the behaviors and impact of the disorder and treat it accordingly.
Anorexia has a weight limit, so sometimes professionals don’t understand eating disorder symptoms that are not accompanied by low BMI. It should be said that BMI is a crude and completely inaccurate measure of physical health, let alone mental health.
Sometimes it almost feels as if you have to prove you really have an eating disorder by achieving a weight loss goal. This is absurd.
Is group therapy helpful?
So what I’m saying is that you’re right to be concerned about your son. You can see that his behaviors and beliefs are disordered. And you’re not seeing the sort of low BMI that would bump up his level of care. But you know he has a disorder and would like to treat it.
Your observations of the challenges with group therapy are also valid. Eating disorders span a huge range of symptoms and presentations.
Arbitrarily putting anyone with any eating disorder into a group is like putting together a bunch of people who like the color orange and expecting them to all be the same. It doesn’t make a lot of sense. Group therapy can be very helpful, but it should be carefully constructed and very carefully managed.
Good therapists pick and choose individuals for their groups. They don’t just put people together at different stages and types of a disorder and expect that to be helpful.
If your son was seeing a certified eating disorder therapist who suggested a group based on your son’s individual presentation that would be different. But what I’m hearing is that this was put together by your insurance company, so it makes sense that you are concerned.
Should parents back off?
Next up, the anxiety therapist’s advice that you take a “wait and see” approach to this eating disorder could be harmful given what we know about eating disorders. It sounds as if the therapist does not have any modern training on eating disorders and is not aware of the symptomatology and treatment.
The most effective treatments work with parents since parents are almost always directly involved in anxiety and eating disorders. It’s not that parents cause anxiety and eating disorders, but their behavior makes a huge difference in recovery.
An anxiety therapist who tells parents to back off concerns me, because I’m worried that they don’t recognize the interpersonal nature of anxiety, and this therapist definitely doesn’t recognize how eating disorders interact with family dynamics.
The fact is that anxiety disorders and eating disorders are heavily influenced by parents and loved ones. There are even treatments for childhood anxiety that treat only the parents, not the child. These treatments are as effective as, even more effective than directly treating the child.
But even if a therapist is treating the child directly for anxiety, they should be educating the parents about the process and teaching them skills to avoid accommodating the anxiety. The same is true for eating disorders, and this is a major issue with the treatment available today. Parents are left out, sometimes even told to back off like you were.
Trust your gut
You sense there is something wrong. You want to help, and yet because the system can’t figure out how to effectively treat parents when there’s anxiety and an eating disorder, you’re told to back off. I’m sorry about that.
There does come a point at which your son will become responsible for choosing his own recovery. But right now there are things you can do to support recovery, even if he’s not choosing it for himself.
The first thing I would do is insist upon a certified eating disorder therapist and dietitian to treat your son. Your son may not qualify for residential or partial inpatient treatment, but he should at least have access to professionals who work with him individually and know how eating disorders work.
I would fight hard for this with your insurance company. I’m sure that if your son had cancer your insurance would pay for an oncologist. If he had diabetes they would pay for an endocrinologist. When a person has an eating disorder, they need to work with someone who has been specifically trained to treat eating disorders.
Do not back off
Next, do not back off. The key is actually to step in appropriately.
What we often see with anxiety and eating disorders is that parents are accidentally accommodating the disordered behaviors. This accommodation makes perfect sense and it’s what most loving parents do. For example, if your child was afraid of the dark, you might get him a night light. If that made the fear go away, that is an example of appropriate accommodation.
But more often what we see with anxiety and eating disorders is an escalation of the disorder after accommodation. So you get the night light, but then he also wants the door left open. Then he wants the hallway light left on. Then he wants you to stay with him all night to keep him safe. Pretty soon you are all held hostage to his fear of the dark.
This happens predictably with a child who has anxiety. Something that seems perfectly reasonable, like getting a night light, snowballs into a full-blown anxiety disorder that is running the whole household ragged.
⭐ Get ready for recovery and find out how you can prepare yourself for maximum success.
⭐ Find out the essential steps and family rules you need to have in place for recovery.
⭐ Make your home recovery-ready with six simple steps that anyone can do.
The snowball effect
This is what we typically see with eating disorders. It starts small: your son skips a meal, starts eating alone, or wants a special diet like no carbs or sugar. And while each accommodation might seem reasonable, over time you realize you have a snowball situation and now you are all accommodating the eating disorder, and, predictably, it keeps getting worse.
You don’t have to wait for your child to choose recovery, but you do have to get yourself into recovery from accommodating the eating disorder. Rather than back off like the anxiety therapist suggested, you need to recover from your own behavior, which is parental accommodation.
It can be hard to see accommodation at first, but once you start to notice it, you’ll see it everywhere. And the good news is that this is something over which you have control. Some common eating disorder accommodations that parents can recover from include: not insisting on family meals, making substitutions and allowing for special diets, reassuring the child that they won’t get fat if they eat, allowing the child to cancel treatment appointments, allowing a child to over-exercise, and engaging in lengthy debates and negotiations about your child’s treatment and care.
All of these things are hard habits to break, but if you get into recovery from accommodating the eating disorder, your child is more likely to step into recovery from their eating disorder.
Your area of influence
This is the area where you have the most impact and potential to influence your child’s mental health and motivate eating disorder recovery.
I will say that it’s not intuitive and will not feel easy or natural. Just like eating disorder recovery, recovering from parental accommodation is really hard and it’s best if you have professional support.
Anh, I know this seems like an impossible situation. Our care system is deeply imperfect, but there’s still a lot you can do. I’m so sorry that providers sometimes tell parents they should back off of eating disorder treatment.
I wish I could change the whole system, but for now, I can just assure you that your instincts are correct. Don’t back off. You don’t have to wait for your son to choose recovery to demand appropriate treatment and change your own behavior. You don’t have to wait for him to choose recovery for you to make it very hard for him to continue having an eating disorder while he’s still in your home.
When parents change, kids change.
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