Hello! So in this video I’m going to assume that your
child or teen suffers from a restrictive eating disorder like anorexia, and that you are working
very hard at helping him or her to eat, and that you want to know what to do when
after a while your child seems stuck. How long should you help him or her at the table?
What are your options? You might be at the re-feeding stage, where
you’re requiring your child to eat what you’re putting on their plate, and you’re
aiming for rapid weight gain if your child is underweight.
Or you might be at another stage where you’re doing exposure and desensitisation work on
foods which your child used to eat but has been avoiding for a while.
I have lots of tips to help you support your child to eat when it seems completely impossible,
and I’m assuming you’ve seen these or you’re going to check them out later. This
video is specifically on when your child gets stuck.
I’m Eva Musby. I’m a parent and the author of a book and videos for parents.
If you haven’t yet come across concepts like re-feeding and exposure to fear foods,
and if you’d like to learn more about family-based treatment and the role of parents, check out
some of my other videos, my book or website. Follow the links.
So let’s get going. Before I go into specific tips, let’s consider:
how is your life – and your child’s life — organised to support meals? You need to
appreciate quite how much dedication it takes you, the parent, to help your child to eat,
meal after meal (and perhaps stopping exercising, purging, or self-harm). Most of us have to
make changes to our life for a few weeks or months.
The risk with this is that we end up with so many unmet needs that we can’t be the
person we want to be for our children. We lose touch with compassion, and as I show
in my other resources, compassion is absolutely key to getting results (and
keeping yourself sane and perhaps even helping you have a good life in spite of everything).
So keep checking with yourself: what help do you need? Do you need a friend or family
member to take over some of what you normally normally do? Do you need some evenings off to relax
and have fun? Do you need emotional support from a friend or professional?
Our child’s normal life can be on hold too for a few weeks or months. When my daughter
was well enough to sit in school but weight gain was a priority, breakfast was non-negotiable.
This meant that sometimes she was late to school and sometimes she didn’t make it
at all because I wouldn’t let her go on an empty stomach.
One more generality: it helps to try and understand what’s going on for our children, and with
an eating disorder what’s most probably happening is that because of malnourishment
and the way their brains are wired to respond to food and hunger cues, much of the time our children’s
experience is that eating is extremely scary. They may even have a bullying voice in their
head telling them not to eat ‘or else’. Our children may feel disgust or fear in front
of food even when they’re very hungry. So let’s bear in mind that when they
stop part way through their meal, it may be to avoid some pretty awful suffering.
Now lets leave the generalities and get specific. In this video, we’re looking at the situation
where we’re sitting next to our child at the dinner table, and we’ve done this for quite a while, and they’re stuck. Perhaps they haven’t eaten any of the meal, or perhaps they’ve eaten a small
or major part of it. Or the issue might be over the last two grapes. We’ve already
done our very best to get all the food eaten – let’s call that Plan A. Eating disorders
being what they are, it’s pretty normal for Plan A to fail some of the time. It could
even be a good sign: it could show you’re doing a great job of working on rapid weight
gain or on tackling fear foods. So you need a Plan B.
There is not a single Plan B. There is no magic, no right or wrong way, and there’s
no research, to tell us how to deal with an unfinished meal. This means that what worked
for other families, or what works in a treatment centre, may not serve your family very well, and
vice-versa. And what works for you this week may not be the best approach in a month’s
time. What’s on your Plan B at any time depends
on what matters to you at this moment – and there may be several factors in play:
It might that it’s the calories and nutritional content of the food matter, because of the state of
your child’s health. So then you might act differently if your child has stalled on a
whole plateful of pasta, compared to if he or she is not eating the last 2 grapes of
a good-sized meal. Perhaps what matters right now in your situation
is being consistent and that you don’t create an unhelpful precedent, because you need to support
your child meal after meal after meal. The last 2 grapes might matter because they’re
a way for you to show you mean business. And you might also take into account your
own resources: are you still able to support your child in a productive way, or are you
about to explode with anger and blame or break down in tears?
Let’s see what Plan B might look like in practice. If your main concern is
medical safety and calories, you’ll try and get your child to eat for
as long as seems reasonable, then you’ll signal the end of the meal and insist on rest.
You will cancel activities that stretch your child’s limited, precious resources. Or
you’ll take your child to hospital. Your child may jump to the conclusion you’re
angry and want to punish him or her, so be clear about the safety aspect.
Another option, which doesn’t work for everyone, is your child may manage an energy drink to
make up for lost calories. That’s just the missing calories. I know a treatment centre
where they provide an energy drink equivalent to the whole meal, even if the person has
managed part of the meal – if you do this be aware you’re moving into a carrot-and-stick
approach. Another option you can use if your child is
usually fine eating something different: you’ll need to see if swapping one food for another
works for you or if creates extra bargaining and anxiety.
Another option is you’ll add the missing calories to the next meal, and you’ll learn
from experience if it’s helpful to tell your child you’re doing this, or not.
And another option is you could give both of you a break, after which you will call
your child back to the table to continue with the meal. If your child is not used to eating
and his or her tummy is sore, you could use the break to make a hot water bottle.
Now as we saw, your Plan B might be about establishing that you are in charge, you’re
determined, and you’re not going to be bullied – so that you can support your child meal
after meal after meal. One way to do this is a zero-tolerance, brick
wall approach. It’s like saying “I won’t accept anything less than 100% nutrition”.
Before I tell you more about this approach, I want to tell you of one other approach.
This approach is the opposite of zero-tolerance, and it might surprise and confuse you so I’ll
come back to it. Basically, you’ll decide the best option is to end the meal even when
everything has not been eaten. This is not about giving up but about acting like a wise,
flexible, compassionate leader. Before I explain more, I want to flag up another
thing for your Plan B, and that’s to give yourself an exit route:
Ideally you should have someone who can take over from you, and a way of signalling that
you need them to take over NOW, before you break down – I know, that’s not always
possible, but if you’re the one everything rests on all the time, it might not be sustainable.
Make teamwork a priority. If at any stage you’re on your own and about to seriously
mess up, you need a way to make a dignified exit, like “Oh dear, is that the time, I’m
afraid I need to deal with an urgent email”. As opposed to, “I can’t bear it any more,
I’m off!” While we’re talking about your emotional
state, I want to offer some reassurance on one point. We parents can convince ourselves
that if our child doesn’t manage one meal, he or she will decide to stop eating altogether.
The all-or-nothing thing is how the eating disorder talks. In practice it’s normal
not to succeed at every meal and still make great progress.
Now let’s get back to what you can do if your priority is to show the eating disorder
you mean business. Let’s start with the approach that is about:
This is where you’re going to do your very best to make sure every last piece of food
goes in. Do you remember how at the beginning of a
new school year, some of your teachers were strict and rule-bound, only to show their
friendly side once they’d established their authority? Many parents use this tactic in
the early days of refeeding. Some parents who insist on 100% nutrition
100% of the time have some kind of time limit for the meal – and they may or may not tell
their child about this. After a certain amount of time they will enforce sanctions. So this
approach is: “You eat everything, and I mean everything, OR ELSE…” The sanctions
that are not necessarily justified on health grounds but are designed to incentivise – typically
removing access to a mobile phone or games. (Now, before you leap into a carrot-and-stick
approach, I’d like you to know it’s a lot more complicated and risky than you might
first think – I have a lot to say about it, so check out my other resources.)
For some, 100% nutrition 100% of the time means that parents require their child to
stay at the table for however long it takes to get every last crumb eaten. There’s a
mantra often quoted on parent forums, which is: ‘Life stops until you eat’. It can
mean all sorts of rather different things, and for many parents, it means, “You’re
not doing anything until you eat”. I know of parents who have kept their child at the
table for many, many hours. For some it’s eventually been successful, and they reckon
that one or more marathon sessions produced an important shift. For some it’s not worked:
their child still didn’t eat and everyone got extra stressed out.
You could decide to keep your child at the table for however long it takes, as long as
you’re able to maintain a compassionate stance. There is so much you can do as long
as you’re not worn out, and I offer lots on suggestions in my book and videos. And
all the same, there will be times when you’ve spent a very long time trying to get 2 grapes
eaten, and you’re going to wonder how much longer you want to keep trying.
The 100% nutrition, zero-tolerance, brick wall approach is normally a short-term tactic
to silence your child’s eating-disorder ‘voice’ by showing it that arguing against
you and manipulating you (and bullying your child) isn’t going to work. It states that
food is medicine and that anything less than the full dose isn’t good enough. Many parents
report that a zero-tolerance stance got their child on the path to recovery.
The zero-tolerance approach can also have a role if your child is generally eating well
but insists on leaving some small thing uneaten. Sometimes our children are secretly relieved
that they have to eat – that there is no choice – but they can’t afford to acknowledge
this because of their internal eating-disorder bully, so they consistently leave a symbolic
bit of food on the plate. Maybe it helps them placate the eating disorder part. Like “See
I’m not really eating everything. I’m doing my best to get around my parents.”
So for a while you might support your child to eat the last grape or two but not get remotely
upset when that doesn’t work. Because your child is really doing quite a clever job of
fooling his or her eating disorder bully. You’re on the same team. But after a while
you might see this as a crutch which your child is now capable of throwing off. At this
stage you might start insisting on the plate being wiped clean, so your child experiences
that nothing bad happens. That’s one more step towards normality.
Because many parents are so grateful that a zero-tolerance, brick wall stance worked,
they can make it sound as though this is the only way, for all situations, for everyone.
We’ve got to be careful about this because I have seen parents give up on family-based
treatment (or deny themselves the support of a parents’ group) because they believe
a hard-line approach is required and they’ve had bad results from it.
In fact different strategies work for different people. The only rule emerging from trials
is that with parents who are very hostile and critical, outcomes are poor (which doesn’t
mean we parents have to be perfect – we all have bad days). Family-based treatment
doesn’t dictate how we feed our children, as long as we show unconditional acceptance
of our children. That means we try not to judge them, whatever their behaviour.
Let’s move on to something which might look like the opposite of the Brick Wall.
When your child has stalled over the meal for quite a while, your Plan B might be, quite
simply, to end the meal. Now this takes some skill, and you need to
be cautious about when and how you do this, but this can be a really fruitful way of working
with re-feeding or with exposure to fear foods. When it’s not a good option is if you’ve
not done very much to get your child to eat. If you let him or her off the hook too early,
it could make things worse for next time. You don’t want the eating disorder part
of your child to go, “Yippee, my parents have backed off, so next meal I’ll put up
even more resistance and eat even less”. So you’re going to give lots and lots of
compassionate support to try and get the food eaten, and when you declare the meal over,
you need to show you’re a wise parent, a compassionate leader, who is in charge of
treatment, and who is an expert at delivering it. You want your child to trust that you
can do this – that you are doing it. You’re in charge of assessing a situation and working
out the best way forward. You’re giving verbal and non-verbal messages of compassion,
of determination and of confidence. Here’s how it might sound: “Darling, I’m
really pleased you’ve managed three grapes out of five. That’s three more than you
thought were possible! I know it’s a huge challenge and required a lot of courage from
you. You’ve done exactly what needs to be done to make it easier next time.” At this
stage, depending on what matters here, you could replace the 2 uneaten grapes with something
else, do you’d say: “Three grapes out of five is a success! At the same time, you
do need the energy so I’ll get you a biscuit.” And then, you give a clear message that it’s
time to move on, there’s no bad feelings, no blame, no hopelessness, we get on with
life, so that’s when you propose an activity, like “Want to watch a movie?”
So what happens the next day? You put six grapes on the plate, and maybe your child
thinks, “Three grapes is my limit.” That’s quite possible. And maybe he or she is thinking,
“I’ll eat 5 but no way am I eating 6.” Or maybe he or she is thinking, “I wonder
if I can manage them all and be done with it. This is so boring and I do want to be
well enough to go on holiday.” Who knows. We parents deal with uncertainty and get very
confusing feedback. Either way you’re going to work hard at supporting your child to eat
all the grapes on the plate. And your child might say, “But you let me
eat just 3 yesterday” and you’ll say something like, “Yesterday 3 grapes was a huge challenge
and you did really well. I think today you’ll find 6 grapes is quite a bit easier. Go ahead,
and then how about we look on the internet for a present for Grandma?”
Some parents, and some treatment centres, use strict rules of the “You will eat everything
or else…” type, and when you have tube-feeding and even restraint as the ultimate strategy,
than can work. What can also work well is to make decisions
according to a moment-by-moment assessment of the situation. It doesn’t mean that you
look indecisive or that you’re open to manipulation: you can still be in charge, focused on recovery,
confident and compassionate. Given eating disorders, especially anorexia, are so much
about black and white thinking, isn’t it refreshing for parents to keep the ability
to make flexible decisions? You might have been on the receiving end of
this stance when you were in school if you had teachers who could get the best out of
you because they inspired respect and trust, not because they enforced strict rules.
So sometimes you will keep your child at the table to get 100% of the food eaten, and sometimes
you will present alternative foods, and sometimes you will cancel an activity that would take
up too many of your child’s resources, and sometimes you will signal the end of the meal
in an “I’m a wise and caring parent” type of way. And all these possibilities depend
on your assessment of the situation, and you’ll probably decide differently if you’re on
the first day of refeeding or if you’re 3 months down the line, working on desensitising
your child to the fear of ice-cream. You’ll also decide differently depending
on whether your role is to be in charge, or your role is to assist. Elsewhere I explain
how with bulimia or binge-eating disorder or with a young adult or adult sufferer, the
parent’s role may be more collaborative, you may have more teamwork, and that again
will affect what you decide to do when there’s food left on the plate.
How do you decide route to follow, which Plan B is more likely to serve well? There’s
no right or wrong, and the more you can remain in a compassionate state, the more you can
bring your whole intelligence (the rational and the intuitive) to help you out. You’re
looking for subtle indications of your child’s state of mind. So you’re observing body
language and listening for what is said and what is not said, and the tone of voice. From
that you’re weighing up the odds of success if you follow one or the other option. And
if you notice you’re starting to tire, you’re also weighing up your own capabilities and
resources at that moment, to see if you can stretch a little, or if it’s safer to give
yourself a break. So that’s an overview of what you can do
if your child doesn’t eat everything. Do subscribe to my videos and to my website
to find out when I produce new resources, and I do very much appreciate your feedback
– though before you comment on YouTube check out the privacy settings for your child’s
sake. If what I’ve said here leaves you with more questions and some of “yes, buts”, that’s to be expected, there is so much to know about this illness, so do check out
my book where there’s a lot more on this particular issue as well as on the whole business
of helping our children get well. Please remember I don’t know your particular situation,
so do discuss all this with your child’s clinicians to see which bits might be helpful
in your situation and which might not. I really hope this video contributes to you
and your family – if so please tell other parents and clinicians about it, and I’ll
say goodbye no w and wish you so very very well.