Managing an Adolescent Eating Disorder

Eating disorders, carrying with them the very real threat of death, are highly anxiety provoking for many practitioners. However, it is not uncommon for families to present with a young person, recently discharged from hospital requesting support.

Case Example

This was the case with 16-year-old Grace who had spent 3 weeks in an eating disorders in patient unit and now declared herself ‘cured’. Her parents who were separated but living close to each other were not so sure. Grace had always been a ‘good’ child who appeared to have managed the separation of eight years with little disruption, moving between both parent’s homes as she chose which they and their new partners reported was a good arrangement from everyone’s perspective She achieved high grades, was co-operative and pleasant and was well liked by peers and teachers. Her earlier determination to lose weight in the face of all reason and cajoling by her parents and uncharacteristic rude and oppositional stance had come as a shock to them all and culminated in hospitalization when her weight dropped dangerously low. At the first session Grace was reasonable and pleasant if adamant that this life phase was behind her. Her parents and the practitioner were less certain. Their request was to support Grace and ensure the eating disorder did not reappear while hers was to be allowed to ‘get on with her life’.

Eating disorders evoke very central questions of inequality, authority and responsibility. At an age where most young people are effectively managing their bodies and should not be having this boundary intruded upon by others, the young person’s determination not to eat forces those who have overall responsibility to take charge of this, effectively evoking an earlier life phase. While the relationship becomes extremely unequal in that parents and medical staff may ’force’ the young person to eat the refusal and dangerous weight loss makes them remarkably powerful and families often find themselves accommodating more and more and desperately seeking solutions to entice eating. As one failed solution follows another key family members find themselves disagreeing as to the best approach further undermining their authority. With this the young person may further withdraw from those who support eating and seek the encouragement of others who celebrate the weight loss. A major fracture opens between the two. At the point where Grace and her parents presented the system has forcibly ‘taken charge’, the threat of death is less imminent and the question of how to effectively hand back proper authority and responsibility to the adolescent is of primary concern, while guiding against fracturing of her world.

The second key theoretical piece is the importance of attending to all parts of the system in which the symptom presents. As the symptom is so compelling it is easy to be focused totally on the person who is not eating and overlook the key role of family members, G.P’s, medical specialists, psychiatrists, dieticians,  friends made during hospitalization, on-line friends and other peers. The practitioner should have all these people in their thoughts as they fashion a response to the requests while being cognizant of and guarding against fracture.

Having fully mapped Grace’s world and the unfolding of this situation through the ecogram and timeline the practitioner’s task was to respond directly to the requests. The response needed to take account of issues of ownership and support the appropriate developmental step Grace maintained she was making while ensuring that if she was mistaken others would step in. This required the full support of the helping system around Grace and in particular the GP who was weighing Grace weekly. It also meant remaining vigilant to the presence of on-line or actual friends who would encourage her to take back authority through refusing to eat.

Advice

The advice was as follows:

1. Grace was congratulated on having taken steps to rejoin her appropriate developmental trajectory by taking charge of the eating
2. The centrality of her parent’s role in making this happen was also recognized
3. However, it was noted that eating disorders are remarkably persistent and easily seduce people back into the pattern, particularly evoking the help of others who have been trapped by them.
4. While the practitioner expressed full confidence in Grace’s intention to continue to manage her body safely, she was less confident that she would not need help to maintain this stance.
5. The practitioner asked permission to speak to all in the helper system in order to request that the GP readmit if her weight fell beneath a certain number and that the psychiatrist, and any other admitting medical professionals would support this. She was clear that if this were to happen, she would step back and allow Grace’s health to be restored but would re-engage once this was re-established.
6. As Grace moved between two household her parents were asked to communicate with each other about the meals she had been seen to take while in their care and if she had not eaten at the agreed time to ensure this happened when she arrived.
7. This was also framed as being supportive and protective of Grace’s decision not to starve while again making lines of authority and responsibility very clear.
8. A conversation with Grace allowed a visual mapping of those parts of her world that would support her losing weight and potentially dying and those who would fight for nd with her. She was asked to consider how she wished to manage this as some of the former had been very important to her.
9. A further conversation with Grace look to her unfolding identity as a young woman and her hopes and dreams for her future.

This advice attended to all the key parameters this case included. The practitioner was warned that it was more likely that she and the parents would need to step in and be prepared for this and not be disappointed in herself or her client.