Case Scenario

A 14-year-old patient arrived for her appointment accompanied by her mother. She indicated that it was fine for her mother to stay in the room during the visit. However, when I questioned the patient, her mother interrupted with her own opinions. The mother told me that her daughter was bulimic and did not want me to know. What should I have said next? I cannot help but feel that this patient's eating disorder is related to her relationship dynamic with her mother. How should I handle a controlling parent, and how do I gain the trust of my patient in a situation like this?

Commentary

It can be challenging to work with adolescents and their parents when eating disorders are involved. This is why it is important to work within a multidisciplinary team to treat these patients. It is common for parents to take their children to the physician when they suspect an eating disorder. Often, patients are reluctant to discuss eating disorders with their physician. Even though observing child-parent interactions may provide you information, it is important to remember that eating disorders develop for multifaceted reasons; no one variable is a singular predictor.^1,2 Family dynamics often have a significant role in the development and maintenance of an eating disorder.³ However, this does not mean the parents are to blame; in fact, they often have no idea that their behavior may be encouraging or reinforcing the eating disorder.

WHAT TO SAY WHEN PARENTS AND CHILD ARE PRESENT

Initially, the family physician should meet with the patient and the parents (or, as in this scenario, one parent) together, and then ask permission to speak with the patient alone. Observing the interaction between an adolescent and his or her parents helps to gain understanding of what their home life may be like. As the family physician, you can gather information on what type of feedback is likely to be most beneficial for the parents. For example, you may observe that the parents make statements that encourage the patient to lose weight, but then warn not to become “too thin;” or the parents and patient may argue with each other about food issues. If the parents monopolize the discussion, you can politely ask that the patient be allowed to answer the questions. For example, you might say, “Thank you for providing additional information; however, I would like Julie to answer the questions by herself first.” Direct your questions to the patient and make continual eye contact to give the message that you would like her to answer your questions initially. It is also important to remember that you are going to need the parents' help in providing information on the patient's eating and weight-loss behaviors because most patients with eating disorders in the early diagnostic stage are not completely forthcoming about their symptoms.

WHAT TO SAY WHEN YOU ARE ALONE WITH THE PATIENT

Children and adolescents may be more likely to give an honest report of eating behaviors, sexual activity, or substance abuse without the presence of their parents. If the parents allow you to speak privately with the patient, you can build trust by listening and being nonjudgmental. Ask the patient direct questions about daily eating patterns, bingeing and purging behaviors, and excessive use of exercise. You might ask the following questions: “Can you tell me what you eat on a typical day?”; “Are there times you feel you eat large amounts of food with a feeling of being out of control?”; “Do you get rid of food by throwing up or using laxatives? How often do you do this?” This will give you an idea of the patient's eating-disordered behaviors. You should also ask questions to assess the patient's self-esteem and body image, such as: “How do you feel about your body?”; “How much weight are you trying to lose?” “Why is losing this much weight important to you?”; “In what ways do you feel good about yourself?”; “What do you wish you could change?”

Individuals with eating disorders often have poor self-esteem and focus excessively on their bodies as mechanisms to feel better about themselves. Over time, you can challenge some of the patient's eating-disordered thoughts, but initially you should simply listen and not be directive (e.g., do not immediately begin talking about the food pyramid or suggest that they should just like themselves). Also, the physician should keep in mind that individuals with bulimia are often ashamed and embarrassed of their behavior, so it is important to reassure them. The physician should use active listening and empathy. For example, “So you are throwing up after you eat a lot of food, and this is happening at least once a day. It must be really hard to be so scared of gaining weight. This must be really tough to hide your secret from everyone. How are you feeling?”

Physicians often feel frustrated with patients who have eating disorders because their behavior is so self-destructive. One mistake that many physicians may make is to say, “Just eat healthy.” If patients could do this successfully they would not have a problem; suggesting this makes them feel as though their physicians do not understand what they are experiencing. Remember that patients with eating disorders are often ambivalent about getting better, and they need a gentle, supportive approach. Eating disorders are far more complex than merely eating or dieting behaviors. Sometimes the child or adolescent is not willing to say much or offer any insight to their experiences. Do not push these patients initially; try to get them to talk about their friends or other aspects of their lives. It may be necessary to spend several session hours with some patients before they develop enough trust to talk about their eating disorders. Also, they are often in denial that a problem exists (although this is more common with individuals who have anorexia nervosa). Try to have a discussion about what is going on at home and school, and screen for psychological distress. Focusing on the psychological issues as much as the dysfunctional behavior will earn the patient's trust.

TALKING TO THE PARENTS IN PRIVATE

It is often helpful to also meet with the parents alone. This is an opportunity to educate parents on the eating disorder, form a trusting relationship with them, provide some gentle feedback, and discuss their observations of their child's behavior. I explain to patients my purpose for meeting with their parents. Patients often ask me to talk to their parents because they do not believe their parents understand what they are experiencing, or their parents may be aggravating the situation by making unhealthy suggestions. The parents often are frightened and confused, or even angry with their child, and need a basic understanding of an eating disorder. Explaining that their child feels controlled by an eating disorder reduces the parents' perceptions that the problem would simply go away if their child would just listen to them.

The issue of the parents and the patient arguing over food may need to be discussed with the parents. Food-related arguments can quickly become a power issue between the patient and the parents, and the patient almost always wins. Meal times can become a battleground, and this should be avoided. Advise parents to support their children to eat a variety of foods in moderation and to avoid arguing with the patient in situations where they may feel the patient ate too little or too much. (These issues will be addressed as the patient progresses in treatment with a therapist and nutritionist, taking some of the strain off the parent-child interaction with regard to food.)

Unfortunately, some parents may have their own body-image problems that they project onto their children. It is not unusual for parents to encourage individuals with eating disorders, but who have a healthy body mass index (BMI), to lose weight. The parents might need education that their child is in a healthy weight range and that supporting weight loss is unhealthy. Some individuals with bulimia do have a higher BMI, but the focus for each patient should be on health and activity level rather than weight loss. For example, a common mistake parents make is telling their child to “cut out fattening foods” because they believe this is healthy advice, or they believe their child is overweight. Many adolescents do not eat during the day, in an effort to lose weight, and then binge toward the end of the day because they feel psychologically deprived and physically hungry. Describing foods as fattening only serves to reinforce the adolescent's belief that food is either good or bad. Parents should learn to talk about food in terms other than ‘good’ or ‘bad’ because this type of thinking tends to encourage binge eating. Educating the parents and adolescents on eating all types of foods in moderation is important. It might also be appropriate to ask the parents to refrain from making negative comments about their own bodies or other peoples' bodies. These discussions might not change the parents' beliefs or body image, but you may get the parents to change specific behaviors.

It is important to remember that, as the physician, you are not likely to resolve the interpersonal issues between parents and their children because the dynamics of their relationship have been developing over many years. Addressing and changing relationship and communication problems takes considerable time in therapy. However, your role is very important in the ongoing treatment process. Patients and families listen to their family physician; they respect your opinions and knowledge. You can jump-start treatment for the eating disorder, stay involved, and continue to address each patient's primary care needs. Although eating disorders are difficult to manage, counseling principles are useful to family physicians when family dynamics contribute to the underlying problem.

Finally, keep in mind that patients with an eating disorder are not your responsibility alone. These patients need a multidisciplinary team, often consisting of a physician, a psychologist or other mental health provider, and a dietitian. To develop a multidisciplinary team, ask around and find professionals that have some experience treating patients with eating disorders.