My psychotherapy practice has been filled with eating disordered patients who have met with recovery failure in previous treatment attempts. Their stories all seemed disturbingly similar.... Parents and families had been denied access to the child's treatment by their child's clinicians. After months or even years of treatment, parents were at a loss to understand what eating disorders are and what they imply about their child's needs, concerns, and emotional resiliency. Having been kept out of the wellness loop and denied the opportunity to facilitate their child's healing and their family's well-being, their relationship with their child had been undermined. Eating disorders are typically held in the family system as the secret that everyone knows but feels forbidden to acknowledge. When parents and families are excluded from treatment, secrets, along with misunderstandings, alienation, and intolerance are further embedded in the family system. As a psychotherapist specializing in tne treatment of eating disorders for the past 28 years, I have found that there exists a more profitable role for parents and families. When parents become involved in treatment as mentors and advocates of the recovery process, they can become one of the most critical factors in cure.

EATING DISORDERS ARE FAMILY DISEASES

The emotional issues and genetics that underlie and drive anorexia and bulimia are typically carried in families for generations before emerging in the form of a clinical eating disorder in a child.

Anorexia and bulimia interface as a pernicious third party in the child's 3 relationship with family members. The symptoms of these diseases are pal pably present, evolving and unfolding before everyone's eyes at home. They appear in kitchens, bathrooms, and bedrooms far more readily than they do in doctors' or therapists' offices. It is typically up to parents to form the initial diagnostic hunch and to respond.

Treatment, in most instances, can be enhanced and better sustained through treating the entire family unit. When families understand the disease and the efforts and struggles of the recovering child, and when they are able to make their own, parallel changes to accommodate and reinforce the child's changes, healing becomes more timely, effective and long-lasting.

Current research out of the Institute of Psychiatry and the Maudsley Hospital of London, England has shown conclusively that anorexics who have been ill for less than three years and who live under their parents' roof are most effectively treated in family therapy.

In this age of managed care, access to professional care is restricted. Severely ill youngsters are being released from hospital care prematurely, returning home to carry out their eating disorder recoveries alongside par ents and families. Parents have little choice but to learn to enable the child's treatment and recovery through homebound outpatient care, which is rap idly becoming the only option. In some instances, particularly with younger children, parents may need to assist the recovery process by becoming symp tom managers, by providing food, or monitoring behaviors. The child who spends 45 minutes a week with an outpatient therapist and the rest of her waking hours at home or at school requires substantive and appropriate input from those with whom she shares her life.

An educated and empowered parent who participates as part of the recovery team is in a pivotal position to support and reinforce the work and goals of the eating disorder professionals, as well as the child.

In claiming that eating disorders are family diseases, in no way do I mean to imply that parents are the cause of their child's disease. Evidence indicates that the roots of these problems lie in genetics, body chemistry, and temperament. At the same time, however, environmental factors includ ing life experiences and family dynamics can be significant in triggering an eating disorder in an already susceptible child. An eating disorder is not a circumscribed phenomenon that singularly affects the afflicted individual, and parents who do not become part of the solution are at risk for becoming part of the problem.

PARENTS NEED TO BECOME EDUCATED

Parents are encumbered and blind-sighted by myths and misconceptions that surround eating disorders, the adolescent life stage, nutrition, and the psychotherapy process. Most parents believe that eating disorders are about food and weight management; they fail to see what these diseases signify about their child's incapacity to confront and effectively resolve life's problems. They assume that eating disorders are incurable, or regard them as a normal rite of passage, a "teenage girl thing," a passing phase. They believe that all teens are emotionally volatile, rude, noncommunicative, and obsessed with their appearance. Many are reluctant to speak out to their child with an honest voice, fearful that they will antagonize and alienate her. They forget that problem definition is the first step towards problem resolution.

Having lost trust in their own instincts about how best to feed their child, parents are confused by conflicting messages in the media about what constitutes healthy eating and healthy living. They assume that healthy eating is fatfree eating, that a person becomes fat by eating fat, and that dieting is the best and only way to lose weight. They see their child as a spontaneously competent individual who needs precious little in the way of input from them. Many assume that a child grows to be independent by leaving her to her own devices; many professionals corroborate this myth by implying that parental involvement in eating disorder treatment constitutes an invasion of privacy, a deterrent to the child's autonomy and capacity to emotionally separate from the family. In addition, many therapists believe that including parents in treatment threatens the child's confidentiality as well as the patient-therapist privilege. In actual fact, the most healthy and successful separations of children from their families stem not from a random imposition of barriers, but from a healthful and secure emotional bonding between child and family.

PROFESSIONALS ARE KEY TO EMPOWERING PARENTS

Parents, feeling lost, guilty, or frightened in the face of these diseases, are typically eager to defer unconditionally to their child's professionals, giving them sole authority and responsibility to "fix what is broken." Many parents are not willing or even capable of becoming a constructive factor in the recovery equation; chaotic, boundaryless and abusive families may be unable to achieve the insights and accomplish the emotional tasks required to assist the afflicted child. In these instances, the patient is best treated solely as an individual. However, the majority of parents want to do what is best for their child and they deserve to be taught how.

The onset of an eating disorder indicates that the time is ripe to recapture a lost opportunity. It is up to the child's health professionals to encourage and enable parents to be authoritative and parental, to move their child towards the developmental tasks of childhood that have not yet been achieved. This can be accomplished through professionals offering parents the permission, responsibility, and opportunity to impart sound values, model effective problem-solving, and set appropriate limits that the child can ultimately integrate as personal self-controls The malnourished child is without the accuracy of perception to recognize this problem accurately on her own, nor is she able to demonstrate the judgment, problem-solving capacity, and motivation required to face and conquer the disorder. Though it is the child's job to recover, it is the parents, task to provide the opportunity, permission, and incentive to do so. The goal for parents is not to take control of the child, but only to take charge where the out of control child has dropped the ball and only until such time as the child can resume some measure of self-control. The task for professionals is to renew parents' confidence in themselves anc] in their role, and to show them how to proceed.

PROBLEMS FOR PROFESSIONALS AND SOME SOLUTIONS

Trained to diagnose and treat pathology, too many professionals find it counterintuitive to recognize and work with parental strengths. Health professionals need to learn to acknowledge and reinforce what parents have done right. That the family has come together for treatment already says a lot about their resourcefuiness, courage, and commitment to one another and to wellness, and to the effectiveness of their proactive problem-solving strategies. Many professionals do not feel comfortable fi~nctioning within the complex dynamics and emotional stimulation of family treatment. Others, in an effort to respect the confidentiality of the treatment process, hesitate to converse with parents at all for fear of breaching the inviolate privacy rights implicit in the child's treatment contract. Too many practitioners do not understand that educating and counseling parents about their role in reinforcing the child's recovery efforts, in no way violates the child's confidences.

Therapists need to talk with parents about their questions and concerns and to counse! them about how to parent an anorexic child; in addition, they need to allow parents to learn what they must about their children face-toface, through the family therapy session. Family therapy is essentially the therapist's most reliable deterrent to any potentially compromising situation that would other~vise result in an inappropriate disclosure of privileged information. The family therapy milieu allows parents to better understand their child and themselves, and gives the adroit therapist an opportunity to demonstrate clear and definitive boundaries and limits, modeling for parents the subtleties of effective discourse with their child. Through family treatment, the seeds of family bonding are sown and cultivated. The quality of the child/therapist relationship and the skill of the therapist will determine whether the same therapist should conduct both the individual and family treatments, an arrangement that often proves to be the most efficient means to integrate and accomplish the goals of all parties.

"Stay out of her food!" has become an almost universal professional battle cry meant to deter parents from becoming involved in fruitless power struggles. In fact, such warnings promote disempowerment and dishonesty for parents and siblings who see destructive behaviors in the child and yet are encouraged to pretend that they don't. In most instances, parents and the eating disordered child share a common goalÑto allow the child to grow up to be an emotionally resilient, productive, and fulfilled human being.

By acknowledging their mutual purpose and by taking up the battle against the disease together, parents and child can unite to seek out more effective ways to accomplish the shared task at hand. Power struggles typically indicate that one or both parties are not listening deeply enough.

The therapist's first goal in working with a child is to make it possible for the child's parents to succeed. Parents need to be taught to recognize the power of their influence over their child, of their words, and their example, well into their adolescent and young adult years. Chronology does not dilute a parent's concern and capacity to support a child, though it also should be recognized that the emotional development of an eating disordered individual in most instances will not match his chronological age. Though the opportunity and appropriateness of working with older children (particularly those who have become adults and have left home) becomes more questionable and less practicable, I have found that children who have access to the input of their loved ones, should they choose it and if parents are available to give it, recover more effectively regardless of their age or geographical distance.

A PARENT'S QUERY

Therapists need to listen "between the lines" as they interact with parents in much the same way that parents need to listen to and interact with their children. The mother of one of my patients came to me with the following request:

"My daughter has been so depressed this week. Did she speak to you about that in her session with you?" Rather than cut her off for what might be seen as a boundary breach, I chose instea(1 to use this opportunity to educate this parent about her own apparent need to understand her daughter's depression, to recognize what she may have done to contribute to it, and to know how she might best help to alleviate the problem at home.

"It sounds as though you may have some concerns about this depression, as well as your own role in Mary's problems and in her recovery," I replied. "Would you feel comfortable asking these questions directly of Mary, along with your husband, face to face in a conjoint family session?"

If parents are to become viably included in the eating disorder treatment process, that involvement must not be simply a continuation of inappropriate attachments, boundaries, and controls. It is left to the psychotherapist to educate and empower parents to create, resume, alter, or adjust attachments with their children that are less than optimal. Eating disordered children must learn to refeed themselves, or to be refed, physically and emotionally, as a prerequisite to benefiting maximally from the treatment process.

It takes an empowered and resourcefu1 child to face and cope with life's adversity effectively and to recover from an eating disorder. It takes an empowered, healthfully related parent who can model assertiveness, controls, effective conflict-resolution' and problem-solving as well as a healthy eating lifestyle to raise an empowered child. In fact, the resourceful child who knows how to face and resolve problems effectively is an unlikely candidate to succumb to an eating disorder in the first place.