When approaching the important and humbling task of treating teenagers with eating disorders, it is important to understand:
The urgency about this adolescent epidemic,
The basic developmental needs which are the foundation of treatment,
The differences in treating adolescent vs. adult populations, and
General and basic principles for treating eating-disordered youth
The Urgency about this Adolescent Epidemic:
In an attempt to increase our understanding of the role we all play in this eating disorder epidemic among our young people, I share the following story – a parable by Leo Tolstoy:
The grandfather had become very old. His legs would not carry him, his eyes could not see, his ears could not hear and he was toothless. When he ate, bits of food sometimes dropped out of his mouth. His son and his son’s wife no longer allowed him to eat with them at the table. He had to eat his meals in the corner near the stove.
One day they gave him his food in a bowl. He tried to move the bowl closer, it fell to the floor and broke. His daughter-in-law scolded him. She told him that he spoiled everything in the house and broke their dishes, and she said that from now on he would get his food in a wooden dish. The old man sighed and said nothing.
A few days later, the old man’s son and his wife were sitting in their hut, resting and watching their little boy playing on the floor. They saw him putting together something out of small pieces of wood. His father asked him, “What are you making Misha?” The grandson said “I’m making a wooden bucket. When you and mama get old, I’ll feed you out of this wooden dish.”
The culture we are a part of – the culture that we are bringing to and leaving our children – is a culture which hurts them. It hurts them because it does not teach them that they are good, worthy, valuable, and important. It does not adequately teach them that their value comes from who they are, rather than the external “what they do.” We owe it to our children to do everything we can to correct the cultural messages which equate success, beauty, and goodness only with external appearance and accomplishment.
Our children are our most precious resource. It falls to each of us to leave them a legacy which, in turn, will allow them to teach their children even more effectively about their inherent worth. It would be a wonderful gift if each generation could have more self-respect and a better sense of inherent personal worth than the preceding generation.
In our fast-paced, technological, affluent, adult-focused, and media-driven culture, children are too quickly given adult clothing, adult appearances, adult status, adult entertainment, adult pressures, and adult decisions. There is a substantial and damaging trend called by researchers and clinicians, “The sexualization of Girls”, which further robs children and adolescents of a healthy sense of self. Our children receive too little time, care, involvement, and nurturing. Even in the best of homes, our young people, I fear, do not receive the attentiveness and investment which they so need and deserve. In this culture where traditional childhood cannot take place in a normal manner, eating disorders and other addictive and unhealthy coping strategies will likely show up at an earlier and earlier age. We must begin to turn and change the course of this rapidly growing trend.
One prolific symptom of this trend is the escalating incidence of eating disorders in our youth. In a recent study of high school students in the Intermountain West it was found that 8% of adolescent girls had already developed a diagnosable eating disorder and that an additional 18 % of high-school-aged girls had beliefs and attitudes about food and their bodies that put them at high risk for developing an eating disorder (Hardman and Richards).
Our adolescents have critical, and all too often, unmet needs. These needs have been delineated and defined in various ways by different writers and youth experts. Benson, Galbraith, and Espeland (2000) suggest that in order for these youth to succeed, they need help and support in building “external and internal assets.” The writers delineate 43 specific assets that are needed. Helping our youth build these assets takes concerted effort, time, and dedication, not only on the part of parents, but the entire community.
Mary Pipher (1994) in her landmark book, Reviving Ophelia, articulates well the difficulties adolescent girls living in our culture face. She suggests that adolescent girls most need the support of their parents within that very time when they seem to be distancing themselves from their parents. While we need to give room for growth, independence, and a growing sense of autonomy to our youth, we also need to stay more involved and closer to them than we naturally tend to.
Stephen Glenn (1989) has taught us well over the years that adolescents need to feel “that they matter,” that they are important, that they belong, make a difference, are wanted, and that their absence is definitely noticed and felt. He further describes seven significant tools of the “Learner,” that is, one on the journey of growing up. These tools include ever-important intrapersonal skills as well as interpersonal skills. He also teaches us that the way we handle difficult situations with our adolescents makes a big difference, and can help them to learn from their own experience in beneficial ways.
Larsen and Brendtiro (2000) have described twelve important things each of us must do in order to “reclaim our prodigal” children. These include: recasting all problems as learning opportunities, connecting youth to their cultural and spiritual roots, increasing dosages of nurturing, providing fail-safe relationships, and giving seeds time to grow. Their work is framed in the metaphor of the biblical parable of the prodigal son. Like those parents and care givers of 2,000 years ago, our most enduring joy can come from never giving up on our youth, even the most difficult. Showing unconditional love and forgiveness is important for eating disorder clients who have difficulty asking for help and who have much difficulty with forgiving themselves.
Having reviewed the ideas of these and other great writers, thinkers, and experts on the needs of adolescents and from personal and clinical experience, I present the following five needs as a compilation and summary of the most basic and critical needs of our adolescent youth:
A sense of acceptance and belonging in a social sphere
A sense of being important and valued in the family
A sense of spirituality, purpose, and meaning in life which gives hope
A sense of self and identity
A growing set of principles in which one’s life is anchored
If our energies, efforts, and interventions with adolescents are focused around these basic needs, I believe they will have a more enduring benefit, and a more profound effect for good. These needs are universal for all of our youth. They are particularly important for those suffering from eating disorders because these illnesses are so damaging to one’s sense of identity. Identity, after all, is at the core of the adolescent developmental task.
Differences in Treatment Between Adults and Adolescents with Eating Disorders:
In the most general view, those suffering from eating disorders have three major needs in treatment: 1) Structure, 2) Love and Care, and 3) a Safe Place and Safe Relationship. Since the eating disorder most often begins in adolescence, and sometimes in childhood, those suffering are likely to have some emotional developmental delays related to the competing development of an addiction, which slows emotional development. Some believe that many adult eating-disordered clients are in some ways teenagers developmentally, and at the same time, some adolescent eating disordered clients are “parentified children” or premature adults. Despite definite emotional overlap between adolescents and adults with eating disorders, adolescents have more acute developmental needs to be addressed in treatment. Compared to adults, adolescents in treatment need:
more behavioral approaches;
more experiential therapies;
more immediate praise;
more help to create a more positive vision of the future;
more clear end explicit directives, and less “fuzzy messages;”
more help in planning;
more explained maps “this is what we are doing first and then….;”
less formal verbal therapy and more informal non-verbal therapy;
more family involvement;
more consistent messages that they are “important, wonderful, and good enough;”
more short-term, small and achievable goals;
more education and opportunities to learn;
more small assignments and activities between sessions to keep the work going; and,
more “quantity” of time to create opportunities for “quality time;”
General And Basic Principles and Guidelines for Treating Eating Disordered Youth
The following principles, while general and basic in nature, can be clear guides and a reminder of some of the most critical things to remember and embrace in a consistent manner through the process of treatment for adolescents:
Involve the family system. It is important to involve families wherever possible, since they are the primary support system for adolescents. It is important for the client to make emotional connections within the family and learn to understand and utilize the resources available there. Learning to reach out for help is critical for the client, and keeping the family system in mind at all times during treatment is critical for the therapist.
Be more directive and specific. It is important for the therapist to take more responsibility in treatment to be active, to create energy, and to direct the process, helping the adolescent client who has less experience to draw upon and whose life focus has been more approval and peer acceptance based. Directives are important because if they knew what to do and how to do it, they would have already been doing it.
Do more activity-based sessions and less talking ones. Experiential learning is the best teacher. Activity-based sessions allow the therapist to join the client’s world and gives the adolescent the opportunity to learn from their own experience, which is what they want. Activity creates true participation rather than simple observation of life. It allows the client to “do” rather than “talk about.”
Provide structures in therapy that help them feel secure. Adolescents already carry much confusion and feelings of insecurity. Nebulous and unguided therapy can accentuate these already unpleasant emotional states. Giving the adolescent information on the process of therapy, the prediction of struggles, what to anticipate, and reasons for interventions can help them feel more in control, more included, more mature, and eventually more invested. Accurate prediction and client inclusion in treatment direction also increases trust in the therapist, which is crucial.
Provide much immediate encouragement and reinforcement. Without hope for overcoming these devastating illnesses, movement in recovery is minimal. Adolescents have difficulty seeing past the current moment, day, or week. They need help in nurturing hope, in remembering that their adversity is temporary, and that small steps are good and will eventually “add up.” They need their progress pointed out and processed, and they need us to share our vision about their positive futures when they can’t see it themselves.
Help them to explore love and acceptance over approval. Those suffering with eating disorders, especially adolescents, often have incorrectly learned that “approval is everything and disapproval is the end of everything.” They need to know that their external appearance and their external accomplishments are not “who they are.” They need help in noticing, accepting, and giving love, and in ending the never-fulfilling search for others’ approval.
Emphasize having their feelings without self-judgment. Helping the adolescent client feel, label, understand, accept, and express their emotion without making emotional judgments about themselves for the emotions they feel is very important. They are frightened of intense emotion and therefore tend to avoid it. They need help to understand feelings are instructive and can be embraced rather than feared. Help these clients with their emotion secondary to their original feelings. These secondary or “self-judgmental” emotions often include guilt, shame, selfishness, or embarrassment for the feelings they feel.
Make honesty and congruence an ongoing theme. Helping clients become more honest and congruent without self-criticism or self-punishment is necessary for recovery. This honesty includes openness, sharing unhealthy “secrets,” telling the truth, admitting to mistakes, and decreasing “selectivity” in things shared in session. Telling the truth is freeing and helps to overcome intense feelings of shame and guilt for past behaviors and experiences.
Teach them to avoid mainly one thing in life – avoidance. Eating disorders are disorders of avoidance. Help adolescent clients understand their fears and face them, help them pay attention to their internal “moral imperatives” and follow them. Help them learn to “feel the fear and do it anyway” rather than attempting to get rid of all fear or becoming handicapped by it. Help them learn through “pointed-out experience” that avoidance keeps low self-esteem alive and well.
Persistently show nurturance, kindness, and caring. It has been said, “People don’t care how much you know until they know how much you care.” So it is with our adolescents. Many with eating disorders have received too little nurturing. Others have received it, yet were unable to accept, believe, feel, or internalize it. Help them see and feel the love, caring, nurturance, and acceptance in their lives. Since they are not used to seeing and feeling it, it is important to point it out and label it for them until they have learned to do this for themselves.
In summary, we see and know many beautiful, bright, kind, and priceless youth out there who have no idea of their value, their goodness, or their potential. We can and should extend ourselves in order to make a difference to these youth. May we have the courage to face our own fears which may at times get in the way of love and service, and may we also have the courage to no longer support or enable those destructive and hurtful messages, trends, and forces in our culture which devalue the soul or the true identity of our youth. We can refuse to participate in those aspects of our culture which are destructive and we can strive to replace them in our own lives with beliefs and practices which are good. We can then share them with our youth through example and active teaching. We can make an appreciated and much needed difference in the lives of our beautiful young people, one that will extend beyond our immediate culture to the world community – one effort and one person at a time, beginning with ourselves.
“Incidence of Eating Disorders in High School Students in Utah and Nevada,” Unpublished Manuscript. September, 2000, Randy K. Hardman Ph.D., and P. Scott Richards, Ph.D., Center for Change, Orem, Utah.
“Structural Guidelines and Creative Interventions for Treating Eating-Disordered Clients,” Unpublished Manuscript, Randy K. Hardman Ph.D. and Michael E. Berrett, Ph.D, November, 2000, Center for Change, Orem, Utah
“Team Up for Teens: Guidelines for Treating Adolescents with Eating Disorders,” Michael E. Berrett, Ph.D and Randy K. Hardman, Ph.D. In Hope for Healing, Center for Change Newsletter, Volume 6, Issue 3, September, 2001. Center for Change, Orem, Utah
“Raising Self Reliant Chilldren in a Self-Indulgent World,” 1989, Stephen H. Glenn, Ph.D. Rocklin, CA, Prima Publishing and Communications
“Reviving Ophelia: Saving the Selves of Adolescent Girls,” 1994, Mary Pipher, Ph.D., New York, Random House/ Ballantine Books.
“Reclaiming our Prodigal Sons and Daughters: A Practical Approach for Connecting with Youth in Conflict,” 2000, Larsen, S. and Brendtro, L., Bloomington, IN, National Education Service.
“What Kids Need To Succeed: Proven, Practical Ways to Raise Good Kids,” 1998, Benson, P., Galbraith, J., and Espeland, P., Minneapolis, MN, Free Spirit Publishing.