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Parental Alignment in FBT

by Abby Sarrett-Cooper

It is a myth that opposites attract. Research has revealed that people with similar values will have the most successful relationships. However, no two people agree on everything and differences can help balance and strengthen a relationship. In Family Based Treatment (FBT) I often find myself reminding parents of what they have most in common, while simultaneously calling on their unique individual differences.

It is a common metaphor in FBT to tell parents that “they need to be not just on the same page, but the same paragraph, sentence and word.” This is easier said than done, especially when extreme behaviors and emotions polarize parents into opposing camps of what the “right” thing to do is. In those moments, I repeat the most basic of truths: that the one thing they (and every two parents or caregivers) have MOST in common is their love for their child. I say this as a way to push an imaginary reset button when they find themselves disagreeing about how to approach any one of the many concrete decisions they need to make in the treatment process.

In parenting, differences in style or approach are routine. A common dynamic holds one parent as the more flexible nurturer and one parent as the more effective limit setter. Both roles are crucial for raising children. And these roles are most effective when held together in a dialectic rather than swinging from one extreme to the other creating inconsistency and confusion. Children need structure and rules and consistent, strong, loving parents to create a feeling of safety. Nothing feels more dangerous for a child or teen than knowing they hold more power in the family than the adults. Except, perhaps, the other end of the dialectic where rigidity reigns and limits are harshly imposed with anger or aggression. This dynamic will also result in an environment that feels unsafe. Finding the balance is way easier to talk about than to find in the midst of a meal where a raging eating disorder has just forced your kid to fling a plate of pasta across the room

If we can lay out plainly, on the table, what pushes us into one extreme or the other, we can often bring the two ends into synthesis.

Parents can become “too flexible” when they feel intense empathy for their child’s suffering and/or doubt their own judgment out of fear. It’s easy to doubt our own judgment after learning the scary truth that your child has a life-threatening disease. Parents often recall permitting changes like eliminating meat, sweets, or carbohydrates only to learn later that these were steps on the path to a full-blown eating disorder. It is also easy to see and empathize with the misery of a child who can no longer attend school or play a beloved sport and misses the social opportunities that came with it. Yet, treatment requires a wide variety of foods and in quantities that are difficult to consume. And treatment is less likely to succeed if your child has eliminated basic food groups and has not decreased their activity levels significantly. Many FBT therapists use the metaphor of cancer treatment. When cancer is detected at any stage, it is a waste of precious time to beat ourselves up about what we didn’t do before. We attack the cancer now, in whatever stage we find it. Chemotherapy can be cruel, resulting in hair loss and nausea. Those are side effects that no one wants and are hard to watch. Yet we know these are temporary and will disappear with successful treatment. The sooner and harder we hit that eating disorder – side effects and all – the greater the likelihood for full recovery. Parents can lean into that knowledge when their child is withdrawn, anxious, or furious.

At the other end of the dialectic, parents can often become rigid and even angry as their fear and frustration build. A smart and once sensible young person is now argumentative, reactive, and irrational as the eating disorder controls their brain. It is such a marked contrast from the kid we once knew or who still shows up when it comes to academics, hobbies, or passions. It would help if we could walk around with a window into that brain revealing where it is not functioning. I provide parents at the beginning of treatment with just such a “window” in the form of images taken from fMRIs showing stark differences between the brains of healthy kids and malnourished ones. I suggest they look at it whenever they are tempted by anger. You see, anger is often a stand-in emotion, functioning as both a release valve and protector for the softer emotions. When a child or teenager becomes oppositional, it is common to feel disrespected and then fear can push us over the edge. These brain images remind us that what we see on the outside may resemble our beloved child, yet their eating disordered brain in no way resembles their brain when healthy. I then remind parents to direct their anger toward the eating disorder and not their anxious, terrified child.

When parents find themselves in opposite roles, whether that is long-standing or a new dynamic in the face of the eating disorder, I ask them to lean into each other. The differences in style that have taken them this far together can be their greatest asset in defeating the eating disorder. Respect what your partner in parenting brings to your family and to you. If you cannot stand firm in the face of an eating disorder demand channeled through your child’s voice, then bring in your partner who has the ability to stay firm. If your partner’s firmness threatens to cross the line into anger, then remind your partner that your child is suffering, and what your partner is interpreting as disrespect is in fact terror, attempting to push you both back. Hear each other’s exhaustion and provide validation. When you are on an extreme end of the dialectic, step aside and allow your partner to step in.

You and your partner are each other’s greatest assets in helping your child overcome their eating disorder. Use each other’s strengths and shore up each other’s weaknesses. Have compassion for your child and for each other. And stay focused on the ultimate goal of your child’s recovery.

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