This post was originally published on November 13, 2013.
Until I lived in the world of therapists and mental health professionals as part of the Kartini multidisciplinary team treating children with eating disorders, I had never actually heard the phrase “tolerating distress”, particularly as it pertained to parents. Like most parents, I have a very difficult time tolerating pain in my own children, either physical or emotional and, when put in that situation, I immediately get busy trying to save them.
How can that be wrong? It’s mother-bear behavior 101, right?
Well, yes. But like many things, this behavior can go awry and get in the way of a child’s best welfare, and that is what I would like to talk about today: how this behavior can affect treatment of eating disordered children.
Whether or not you are re-feeding your child at home or helping a treatment team do so in a more structured setting, there will be more than enough distress to go around. By definition, children (people) with anorexia nervosa feel distress during the refeeding process. A lot of distress. Sometimes every bone in their body will be crying out against taking in adequate calories and this distress may take many forms. They may develop (sincere) stomach pains, even episodes of diarrhea or constipation. They may complain of nausea. They may describe here-to-fore-unknown food aversions. They may even say they wish they were dead or insist that all this “extra food” is worsening their depression. Likely — in the case of hospitalized kids or those in day treatment — they will not directly identify food as a source of their depression (too obvious), but instead point to the fact that they are “missing school” or “their friends”. Occasionally they will convince a parent that treatment is “actually making me worse” and that they would “eat whatever I need to” if they could only “be in charge of my own eating”. They may voice extreme distress at being closely supervised before or after meals. They may insist their parents acknowledge that they have always been “trustworthy” and that it is insulting that no one on the team “trusts me”.
So how should a parent handle their child’s distress?
When is it appropriate to run interference, including (in its most extreme form) refusing further treatment? Clearly we can’t just go along with something we feel uneasy about or believe may be harming our child. Perhaps it would be helpful for parents to learn to frame the pain of refeeding and weight restoration as “tolerating my own child’s distress” as a necessary skill under some circumstances.
When our children are toddlers we take them for their shots, even when they cry. We refuse to let them eat only ice cream for dinner every night, even when they have a tantrum, and we make them go to school even when they are “tired” or “have a stomach ache”. We are able to look past their immediate distress for the sake of their long term welfare. And we must also learn to do this in the treatment of eating disorders.
Let’s take the hospital, the most obvious example. Parents are often highly distressed by their child’s unhappiness at being hospitalized and complain on their child’s behalf about the restrictions and tight structure, even when the reasons for it have been given them in writing and carefully discussed. Perhaps surprisingly, this occurs even when the parents actually agree with the restrictions themselves. It is important under those circumstances to realize that early, temporary distress can lead to less suffering in the long run. The less comfortable (within reason) a child is in the hospital, the better motivated they will be when back home to resist the temptation to (re)engage in the behaviors that got them there. And, believe me, they are going to need every scrap of determination they can find to cooperate with weight gain when it comes (as it must).
Once home, our team has identified the “inability to tolerate their child’s distress” as the number one reason parents find it hard (or impossible) to set boundaries around food, supervision, and exposures. When this has been identified in the parents, it is important — with compassion — to put a name to this and to help parents learn skills to keep this understandable impulse from becoming paralyzing and counterproductive.
It’s back to handling toddlerhood for us parents in order to keep our children safe from the demands of their eating disorder. Remember: it’s really about safety. Your child’s safety. In that quest we can learn to tolerate a lot.