A talk I heard by Dr. Janet Treasure, PhD, last fall at the National Eating Disorders conference in New York City was so insightful I thought it worth sharing again here. One of the giants of the eating disorders research field, Dr. Treasure works out of the Maudsley Hospital in London, and exudes an authoritative yet reassuring tone that must go over very well with her patients.
Dr. Treasure's talk, "Cultivating Hope for Recover" was about caregivers. First, she gave an overview of eating disorders, describing the "vicious circle" that begins with a person feeling overweight or ashamed of her or his size; the fear and then avoidance of food that results; the way brain function is disturbed by poor nutrition, which in turn leads to rigid behavior and an impaired ability to control emotions. A sense of social isolation, severe anxiety, and an increase in either impulsivity or inhibition (depending on the patient's genetic inheritance) follows.
The role of family members, Dr. Treasure said, is to "provide an escape route" for their eating-disordered loved one, to "pull them out of the hole" that they have dug themselves into. Along with fathers, siblings can be especially effective, she noted, because they will have lifelong relationships with the eating-disordered person.
The doctor's descriptions and hand-drawn sketches of the different classes of caregiver were both humorous and spot-on. There are "The Jellyfish," who become so anxious and angry that they are not able to regulate their emotions. They reach a stage of clinical anxiety and depression, which the doctor dryly noted, "is unhelpful" to the situation at hand.
"The Ostrich" avoids all emotional reaction, and channel his or her energies into supporting the family practically. The vicious circle that can arise here is one in which the anorexic child mirrors the example of the parent's anxiety, anger and avoidance, which leads to an exaggeration of these emotions in herself. To make matters worse, the patient is unable to naturally self-regulate her emotions because the effects of starvation have made such complex tasks difficult or impossible. While the Jellyfish is too emotional, the Ostrich is not emotional enough; the ideal would be the midpoint of being interested, supportive, and affirmative.
The next archetypes Dr. Treasure described were "The Terrier," a nagging, micro-managing caregiver who won't let up, and "The Rhino," who is controlling, constantly giving advice and arguments for change, charging the eating-disordered person in "coercive circles" and ultimately provoking defiance from the patient.
These patterns arise, the doctor explained, because of a mismatch between the patient's motivation to change and the caregiver's. The eating-disordered person is still in the stage where the disorder is a solution to her or him. The more the caregiver argues for change, the more the patient argues against change. "The great danger," said Dr. Treasure, "is that if you put a person in a position of ‘not going to change,' it embeds that resistance." Instead, you "have to elicit from them arguments for change." See our many posts on Stages of Change and Motivational Interviewing for more information on this topic.
Another commonly seen model is the overprotective "Kangaroo" caregiver, who puts the eating-disordered person in his or her pouch. This infantilizes the patient and offers "no opportunities for self-care" which ultimately lowers the patient's self-esteem.
The ideal caregiver type, Dr. Treasure explained, is "The Dolphin." This caregiver offers "gentle guidance," keeps charges safe, models good coping behaviors, sticks to a non-negotiable bottom line of accepted behaviors, but "goes easier on the rest." It's so easy for caregivers to be bullied by the eating disorders, or to martyr oneself for the family, the doctor noted, or in the case of bulimia nervosa patients, enabling the disorder by covering up the problem.
They key to becoming a gentle Dolphin caregiver, said Dr. Treasure, is to get the kind of education and skills that her program and many other good eating disorders programs teach. For more information a good place to start is the online resources page of NEDA's Web site.