Thursday, October 23, 2008

We STILL don't get it

I was saddened to read today of a woman in York, England, who died of complications from anorexia. Carole Patrick had struggled with anorexia for 30 years, according to this article. Chronic malnutrition led to osteoporosis, which led to a fall that broke her hip and made it impossible for her to recover when complications developed.

But I was shocked to read this line, buried in the article:

York Coroner Donald Coverdale, recording a verdict of death by misadventure, said her death was the “unfortunate and unintended consequence of a medical condition arguably under her control."

You would think medical people, at least, would understand that anorexia is not a choice. Anyone who's ever watched someone they love suffer with an eating disorder understands this basic fact; why can't the medical profession get it?

A few paragraphs down, a spokeswoman for BEAT, a UK-based organization supporting people with eating disorders, had this to say about anorexia:

. . . disorders such as anorexia were not a “diet gone wrong” or a fad or a fashion. “They are a way of coping with difficult thoughts, emotions or experiences,” she said.

In some ways, this shocked me even more. This is the old psychodynamic perspective on eating disorders, one that has been in vogue for 50+ years. Only thing is, there's absolutely no evidence that it's true.

The latest research points to genetics and heritability as primary factors in eating disorders. EDs run in families. They're associated with clinical levels of anxiety. Many people have difficult thoughts, emotions, and experiences; very few of them develop eating disorders.

I don't expect most people to understand anorexia; we have a lot of educating to do. But I do expect medical people and organizations like BEAT to know better--or to stop speaking for all those with eating disorders.

Tuesday, October 21, 2008

Of parents, health, and eating

This semester I teach mainly seniors, and today I was asked by some folks in another part of the university to administer a health survey to my classes, to gauge the effectiveness of some "healthy living" efforts they've been working on for the last few years. I couldn't help noticing, as I collected the surveys, one line in particular. It was one of a series of questions about where these 22-year-olds get their health information. There were many choices (the internet, magazines, newspapers, classes, health initiatives on campus, etc.), and many of the students indicated that they didn't get health info from very many sources. The one source that almost unfailingly scored high: their parents.

That's right. Their parents. These young women (and a few men) have been living away from home for the last four years. They've been independent. They've traveled to Europe, many of them; they're close to starting their own adult lives. And yet they trust their parents more than almost any other source of health information.

I must admit that tears came to my eyes as I looked at survey after survey (just that one line, honest!).

This was especially moving and poignant given what I'd been reading earlier in the day: A book called Psychosomatic Families by Salvatore Minuchin, one of the founders of family systems therapy. Minuchin's work with families is often cited as one of the inspirations for family-based treatment of anorexia and bulimia. Until Minuchin's work, patients were routinely separated from their parents and treated (usually ineffectively) individually. Minuchin was one of the first to see patients as part of a bigger family system.

Unfortunately, his view of families was anything but positive. The title says it all: Instead of psychosomatic patients, he believed in psychosomatic families--families that through enmeshment, conflict avoidance, triangulation, and other unlovely psychodynamics created children who expressed their emotions through illness. Interestingly, Minuchin writes that he developed the idea of psychosomatic families after treating diabetic children who managed their blood sugar fine in the hospital but who had crisis after crisis when they were at home. His theory was that emotional stress at home was affecting the kids' blood sugar levels.

It's an interesting theory, and I think there's some merit in it, but not for the reasons Minuchin believed. As this rather technical article discusses, stress early in life can lead to permanent changes in physiology--in this case, rats' guts became more permeable, leading to more gastrointestinal symptoms. The idea is that some of us (rats or humans) may be more genetically predisposed to such stress mediation than others. Genes load the gun, environment pull the trigger.

For Minuchin, though, it was all environment. He blames parents for pretty much everything. For those of us who have parented children with eating disorders, his book is painful reading. For instance, Minuchin describes a family at the table with their anorexic daughter. Each parent tries to cajole, threaten, and inspire the child to eat. The child does not eat. Minuchin deconstructs the parents' behaviors as "enmeshment."

He was way off base on that one. By the time a child is in that kind of trouble with anorexia, of course parents are going to be trying to get her to eat. And of course they're going to be unsuccessful, unless they're empowered or supported by the treatment and/or professionals. Sitting in a room with a one-way mirror, pleading with their child to eat, most parents will look enmeshed and ineffectual.

Which is why I was so moved to see those answers on the surveys today. One of the fundamental principles of the Maudsley approach is that families love their children and are best positioned to support and help them through one of the most devastating experiences of their lives. Critics of Maudsley say the treatment fosters an inappropriate "enmeshment" (that word again) between parents and children. Proponents say Maudsley leverages the asset that already exists: the strong and loving relationship between parent and child.

Not all families are healthy. Not all families are functional. Not all parents love their children. But most do. And if those surveys are correct, for many adolescents and young people, parents are still an important part of the picture. And not in the way Minuchin imagined.