Myth: Parents Cause Anorexia Nervosa

On social media, I’ve recently noticed a few graphics like this one, about what to say to someone with an eating disorder:

Now, don’t get me wrong, these are all good things to say to someone with an eating disorder. But posts like this also highlight the vast chasm between treatment providers and the experience of parents and carers.

In the early months of my daughter’s illness, as I witnessed my beautiful child wasting away in front of my eyes, I will admit that I wanted to scream at her to eat. In fact, I did do that on more than one occasion. I wanted to shake her out of this absurd behaviour, to wake her up, to get her to see the danger she was in.

I wanted to stop her from dying. And I would do anything to save her.

It’s often mentioned how difficult it is for people with anorexia to go against their compulsion to restrict food — and there’s no doubt that it is painfully hard to fight this. But it’s rarely, if ever, discussed how extraordinarily difficult it is for parents to go against our instincts when we see our children starving. “I’m sorry that you’re hurting right now”, “I believe in you”, “I might not understand but I’m here for you” are not remotely natural reactions to the extreme situation that we’ve been thrown into. I’ll be honest, to react like that seems a bit like parachuting into a war zone and putting the kettle on. In fact, I would argue, that to stay this calm in a situation so grave goes entirely against nature.

Just think about it — a parent, a mother in particular, only really has one job when a baby is born: to feed that baby enough to keep it alive. This is true throughout the natural world, a pattern that is repeated again and again: robins bringing worms to their nests to stuff into eager beaks; sows patiently allowing their piglets to suck from their bodies until they’re satisfied; a lion sharing its kill with her cubs. Animals don’t have to learn to do this. They know that they must do it. Humans are no different. They know they have to feed their babies. And they are motivated by a profound, unfathomable love. So when our children don’t eat, we become overcome by fear and panic and react accordingly.

Parenting is something that you can never understand until you experience it. In those hazy months before the birth of a child, we plan everything in great detail, sometimes even including how we want the birth itself to proceed. We all hope we’re going to get it right. We make preparations, feather our nests, read all the books we can. Most mothers commit to breastfeeding, of course, because we all know that breast is best. And we promise that we will not succumb to the marketing of environmentally dubious toys, clothes and gadgets targeted at us and our little humans.

Reality hit us the day we brought our twin babies home from the hospital. We were determined not be those parents. You know, the ones who have a gizmo for everything, the ones who carry backpacks filled with pots and potions for every scenario. We were going to be hippy parents, free and relaxed and not materialistic in any way. On that first — entirely sleepless — night, our babies wailed as we tried to figure out how to sterilise bottles of milk. (Oh yes, I’d realised in the hospital that 100 per cent breastfeeding — as planned — was not realistic.) As dawn broke, we were hit by the shattering weight of the responsibility we suddenly had and just how hard it was all going to be. We rushed to the shops to buy a steriliser and an assortment of other gadgets that would make life easier. Yep, we cracked. Day one.

I learned that first night, sitting in the cold blue moonlight, trying to soothe two babies’ tears, that parenting is mostly putting out fires. There’s no right way to do it, and you’re never going to get ahead of the game. You’re always playing catch up.

There is no such thing as a perfect parent, yet for many years the idea persisted that parents were to blame for their children developing anorexia nervosa because they had somehow got parenting wrong. I suppose in a way you can see why this theory developed. If you view anorexia as a psychosocial disorder rather than a biological illness, you are going to come up with all kinds of weird and wonderful explanations as to why someone could be driven to such bizarre behaviour as self-starvation.

Hilde Bruch was a psychiatrist and psychoanalyst whose book, The Golden Cage: the Enigma of Anorexia Nervosa (1978, Harvard University Press) brought anorexia nervosa to the attention of the general public. Bruch treated many patients with anorexia, and understood the importance of nutrition first. She realised that patients wouldn’t respond to therapy until they were out of a state of malnutrition. But she got one thing very wrong: she laid the blame for the child’s condition squarely at the family’s door, in most cases singling out the mother: The development of anorexia nervosa is… closely related to abnormal patterns of family interaction.

In The Golden Cage Bruch contradictorily accuses the families of her patients of unrealistically striving for perfection or not being as perfect as they seem. She also describes how she believes a child learns to process hunger cues:

An observant mother will offer food when the child’s cry and behavior indicate a need for it, and thus a child will gradually learn to recognize “hunger” as a sensation distinct from other kinds of need. If, on the other hand, a mother’s reaction is continuously inappropriate, neglectful (not feeding when hungry) or oversolicitous (feeding upon any sign of discomfort), the child will fail to learn to discriminate between being hungry or sated, or between hunger and some other discomfort or tension.

Oh boy, that all sounds a bit complicated, doesn’t it? I mean, I’m pretty sure most mothers feed their kids when they need food, don’t they? And a child will eat it when they’re hungry. If it is such a delicate art form as Bruch suggests, and getting it wrong causes eating disorders — well, I’m surprised that we don’t all have one.

Additionally, various minutiae of family life are pinpointed as being the root of the dissatisfaction which has led each person on to a path of self-starvation, such as the mother allowing herself to be dominated by the grandmother or the parents giving gifts to a child without finding out what the child really wanted (and the child graciously receiving said gifts without complaint!). This book has a distinctly Stepford Wives feel to it, particularly in the description of the families, as Bruch mines the lives of seemingly harmonious households to find some flaw (like the ones mentioned above) and her gotcha moment.

But while she finds all kinds of ‘reasons’ for the development of anorexia, Bruch notices that the expression of the illness is almost exactly the same in every patient she sees: each finds comfort in the illness, feels a sense of superiority in self-starvation and none can give it up easily. It’s surprising then that she didn’t ponder why an illness supposedly brought on by such different individual circumstances wouldn’t manifest differently in each patient. When I read the book, I counted descriptions of 15 cases where a young person had developed anorexia nervosa after a period of dieting. Yet not once does Bruch consider that it might have been the resultant caloric deficit and weight loss that triggered the anorexia rather than some supposed flaw in the family.

There are certain things the human body is programmed to do to sustain life: eating, drinking, breathing and sleeping being the ones we’re most aware of. That we have to do these things to stay alive is written into our DNA, and to fight any of these things is, for most of us, impossible. Okay, we might be able to stay up and party for a night, but sleep is going to hit us eventually; we can’t stay awake forever. And for most of us, if we deny ourselves food, eventually we will just have to eat. The survival instinct will override any other feelings we might have. That isn’t true for someone with anorexia. A person with anorexia nervosa can function for a surprising length of time on very little food. So there must be something within their biology that is different from the rest of us. Suggesting that a misstep in the way a parent brought up their child could result in the child developing an ability to go without sustenance is fanciful. Yes, we know that sadly some parents abuse their children, and that may be a factor in the development of the disorder in some. But even then I don’t think it would be possible to go against nature for a sustained period to the extent where your life is in danger without something in your personal biology having a fundamentally different structure. Imagine that a mother didn’t pay her son enough attention when he was a child, and the result was that, as an adult, he’s able to stay awake for weeks at a time. The human body just doesn’t work like that.

To be fair to Hilde Bruch, many before her also suggested that families were behind the development of anorexia nervosa. But since The Golden Cage was published, there have been a number of developments in the field of eating disorders research that have shown this theory to be false. For example, we now know without doubt that genetics often plays a part in the development of anorexia nervosa. We know that it is likely that the way a person’s metabolism works is significant. And there is the possibility that an individual’s gut microbiota may be linked to the development of the disorder.

No parent would wish this illness to befall their family, but to be blamed for its development as well seems like a very special type of cruelty. I weep for all the parents in generations before ours who were accused of doing something to make this happen, particularly those who watched their children lose their lives and thought it was their fault.

For a parent, anorexia often feels like someone has lit a match under your home and now the fire is raging out of control. So what do you do when your world is ablaze? Well, one of the first things you can do is stop blaming yourself. Stop asking where did I go wrong? What did I do that caused this thing to happen?

This is not your fault.

And it’s also important to know that it is not your child’s fault either. They are not deliberately trying to hurt you, or inflict worry and pain. They have an illness, like any other. It’s just bad luck that they have an illness as complicated and difficult to treat as anorexia nervosa.

One thing you can do is speak to them with compassion and kindness and love. The phrases at the top of this piece might help, but I’d add to them, to transform them from platitudes into sentences you can use to help your child do the most important thing right now — eat:

“I’m sorry that you’re hurting right now, but we’re not going to leave the table until you’ve finished that plate of food.”
“I love you and care about you, and I’m going to sit with you while you drink all of your milkshake.”
“Let’s do this puzzle together, while you eat up that bowl of apple crumble and ice cream.”
“I know this is hard but I believe in you, and I know that you can eat all of the lasagna on your plate.”
“I might not understand but I’m here for you and I will sit with you while you eat, for as long as it takes.”

This approach won’t work for everybody all of the time. When I tried something similar with my daughter, she said: “I see you’ve been reading about how to talk to someone with an eating disorder.” Our children aren’t stupid, and if we suddenly entirely change the way we speak to them, they will spot it a mile off. You don’t need to alter who you are or speak in an artificial way to your child, but anger and rage won’t help them to eat, and kindness and patience just might. It won’t always be easy to keep your cool. After all, you’re only human. But you can help your child eat, and you can help your child recover. You’re a parent. It’s what you do.

Because parenting is putting out fires.

And love.