The following is a blog post I wrote in collaboration with Danielle Small, MS, LMFT, our Clinical Director of the Clementine Adolescent Treatment Program in Briarcliff Manor, NY. Our goal is to provide guidance and support for families with daughters transitioning home from eating disorder treatment. View the post as it appears on the Clementine blog and explore more information on eating disorder treatment here: clementine programs.com.
When a client arrives at Clementine we educate the family on the 6 key maintaining factors for their child’s eating disorder: Dietary Restriction and Disruption, Temperament and Personality, Relationship Patterns, Anxiety and Mood, Beliefs about the Positive Effect of the Eating Disorder, and Avoidance of Emotional Intensity. It is our goal to partner with them in exploring these factors as well as creating an optimal home environment for challenging these factors. Parents are often relieved to come to a greater understanding of the etiology of their child’s disorder and feel empowered when given concrete tools and new language to communicate their support.
However, a dialectic may also exist in making such profound changes. Understandably, all families have their own unique micro-culture. We become comfortable within this culture as it helps us organize who we are. Within its safety our roles are defined and our beliefs are clear. This culture can feel threatened when their child expresses repressed emotion, learns to self-soothe and manage impulsivity, and/or connects with insight as to how they want to show up differently in the world. Fears regarding the process of differentiation, patterns in expression of emotion, and views on food are the most commonly difficult shifts to navigate.
Differentiation
Families may struggle with remaining consistent, or be very firm in a particular response to their child’s desire (or lack of desire) for independence. It can be scary for families to let go and allow their child to learn from mistakes. Alternatively, it may be frightening to set firm boundaries that potentially will anger their child and possibly result in resistance in the form of increased behaviors. Work may need to center on tolerating the “fall-out” of holding the line, or managing the feeling that they are metaphorically allowing their child to run through traffic. Our clients often speak to the need for more containment when the pattern has been one of permissiveness. On the flip side, clients that have never made their own choices express wanting to feel trusted in order to build a sense of self-efficacy.
Emotional expression
In regards to emotional expression, the most common cultural issue to be addressed is a culture of silence. Many clients share that their eating disorders are the non-verbal expression of anger, fear, or sadness that they are unable to speak to directly. Parents may have tried to shelter their children from family stressors and inadvertently modeled not reaching for support or speaking to their own needs. Consequently, the team will encourage the family to open up about their own struggles as well as ask them to prioritize taking care of themselves emotionally and physically. The alternative is a family that has high expressed emotion levels and the client either feels there is not enough “space” for their feelings, or does not engage in any form of healthy self-regulation when overwhelmed. In this case, the team will work with the family on utilizing appropriate DBT skills to tolerate emotion and communicate in a more balanced way.
Views on Food
Family involvement in our nutrition programming is significant in the treatment of adolescent clients, as the ultimate goal of our work is to normalize the eating experience at home. Not only does each family have its own unique cultural food background, each family also has a particular set of food rules. During on-site meal training families are encouraged to reflect on the origins of their food rules, which are likely multigenerational and influenced by the diet culture of our society. Education is provided throughout the course of treatment to help each family consciously shift their relationship with food in the home to best support their loved one who is struggling with an eating disorder.
The Clementine nutrition model highlights both the physical and psychological connection to food. Our mindful approach envelops all components that influence eating (emotions, physical hunger/fullness cues, timing, access and taste preference) without judgment. Using language to label food based on moral judgment (“good” vs. “bad”) or based on calorie content is discouraged, as it can perpetuate the restrictive voice of an eating disorder. With this in mind, the goal is to move clients away from measuring their self-worth by weight or calories and being able to fulfill food wants and needs.
It can be challenging for families who adhere to restricted diets to embrace our meal plan, which incorporates a wide variety of food selections. While nutrient-density is one important value of food, there is also value in selecting food based on sensory, emotional and environmental cues. Maintaining a variety of meals and snacks at home is the best way for families to support their daughters’ flexibility with eating and challenge eating disordered food restrictions. All meal plans incorporate three meals and three snacks daily and are individualized for each family’s food preferences at discharge. The goal for our Clementine adolescents is to leave with a strong understanding of their nutritional needs and what they need to continue to work toward becoming a mindful eater.
In conclusion, part of the family work we endeavor to accomplish is to normalize the discomfort that comes from changing the family structure, give everyone permission to have a voice, and create healthy boundaries for how to navigate this new normal moving forward. We talk with the client about cultivating compassion for their family’s reactions, as well as educate parents and siblings on understanding why certain family traditions may inadvertently be sustaining factors for their loved one’s eating disorder.
A key Monte Nido tenet is “truth without judgement.” This is so integral to our family work. Our goal is to make the family feel comfortable enough to be vulnerable and speak honestly about the impact some aspects of their family culture have on one another. It is incredibly rewarding to see how brave and willing our families are in making these changes and we truly feel privileged by the trust they place in us.