How are Families and Friends Affected?

•  Parents' Views of Anorexia Nervosa
The author (Maryann MacDonald) bases her text on her own experience, but includes the views of a number of other parents whose children received treatment for an eating disorder from a wide range of different resources around the country. Together these parents are at times highly critical of current clinical practice, yet they offer many constructive suggestions for improvement.

•  Parent's views of Anorexia Nervosa
What is it like to be the parent of a child with anorexia nervosa? It is to ask yourself all day and half the night what went wrong. It is to read everything you can find on anorexia nervosa to try to understand and help your child and to learn from your reading that it is your fault that your child is ill. It is to be blamed by no one more than yourself.

It is to reach out for life when you want to die, knowing that you do so to survive and help your child survive, but knowing also that for doing so you will probably be accused of being callous and uncaring. It is to have everything about you rejected by your child - your food, your body, your personality, your achievements. It is to wonder long after your child is 'well' if you have caused her harm in some way that is so grievous that she will never recover.

These are some of the descriptions of the experience I have gathered from parents of anorectic children. After all, it is parents who have lived with and observed the anorectic child from birth, and who have had to deal with the anorectic child's problems first-hand, 24 hours a day. So I met with several parents of former anorectics to obtain their ideas. We decided the most useful course of action would be to gather as much reaction from other parents as possible. Together we prepared a questionnaire. It was mailed to parents who responded to an advertisement in the Eating Disorders Association newsletter, and given directly to parents of anorectics known personally. Altogether, responses were obtained from 30 families.

These responses were heartbreaking. I found myself reading them with tears rolling down my face. I feel a tremendous responsibility to speak for these varied parents, most of whom put much time and thought into their answers. It is clear that these people feel they need to be heard and have never before been asked. Many had covered every available space on the questionnaire with lengthy answers to the questions asked, striving to express every detail of their experience. Wherever possible I will try to quote the parents' own words, and allow them to speak for themselves.

•  Mothers and their Daughters
First of all, I think it is significant that not a single questionnaire was returned by a father. They were without exception completed by mothers. Mothers are those most intimately involved in the day-to-day difficulties of living with an anorectic child. Mothers feed children, from birth onwards, and anorexia nervosa is a refusal to be fed. The mother of an anorectic has the bitter, experience of having her love and nurturing, symbolically herself, rejected. In the great majority of cases, anorexia nervosa is an illness that affects girls, often at the onset of adolescence. Why is this so? Why do these girls feel such a strong need to reject their mothers and their own female bodies?

I am convinced that the answer to this question lies in society's view of women. Women are the 'second-best' sex. They are no longer respected in their traditional roles as housewives and mothers, and often find it difficult to succeed in pursuits outside the home, partly because of discrimination and partly because of the difficulties of balancing their work with their domestic responsibilities. If they do work, they are most often expected to fulfil all their traditional functions as well.

One of the most constant of a mother's responsibilities is to make sure that her family is fed. She must shop, cook and wash up every day of her life. But at the same time, she must be careful not to overeat herself. She must not get fat, for above all, society despises a fat woman. A woman can be forgiven for being 'just a housewife', but she cannot be forgiven for being fat. Her obligation is to be slim and attractive to men. So she must take care of and feed everyone but herself.

This imposes a strain on a woman's life. A little girl growing up, playing with her impossibly-proportioned Barbie doll, may not see this strain. But as she moves into adolescence, she begins to look her biological destiny in the face, and what does she see? Her mother. Her mother, whom she may always have loved, she now sees with new eyes. She may, because of her love, be unable to bear the sight.

Most probably, her mother's attractiveness has begun to fade. She may, in middle age, have become somewhat overweight. She may or may not work outside the home. If she does not, her daughter, like the rest of society, cannot respect her. If she does, she no doubt experiences a greater or lesser degree of difficulty in balancing her career with her continuing need to look after her family.

This coincides with her daughter's growing awareness that she, too, will be expected to be both successful in the world and, simultaneously, feminine, sexual, and a self-denying mother. It is all too much. The daughter feels pain for her mother's life and anger that the same will be expected of her. She resolves never to be 'stuck' like her mother. And the stage is set for her to begin to work compulsively to achieve in the world and to keep her body as thin and non-maternal as possible.

But what is it that makes the difference between the girl who is prepared to diet to be slim and to outstrip her mother's achievements and the girl who is prepared to starve herself to the point of emaciation and to work obsessively for success, never satisfied with her accomplishments?

Some mothers remarked on worrying characteristics in their children which pre-dated their eating disorders. My own daughter was always extremely anxious. As a baby, she never wanted to be held and cuddled. She would squirm out of my arms, seemingly restless and impatient for activity. As she was my first child, this was disappointing for me. I found myself taking her for endless walks to keep her happy and amused. She seemed always to be anxious and unsettled. Her father and I hoped that when she started school she would be busier and therefore happier, but she didn't seem to like school much at first, and often cried and did not want to go. Although she was very bright, we deliberately made a point of not making demands on her to achieve any particular grades, and in fact changed her school after several years to one that was more relaxed in the hope that she would feel less pressured. But no matter what we did, she remained nervous, constantly sucking her thumb and biting her nails. When I once discussed this with a wise and experienced teacher of hers, he remarked: 'Your daughter may not be pressured by what you do or say but by who you are', implying that perhaps my child felt her parents' success in life was a hard act to follow.

Another mother, in listing factors that may have contributed to the development of anorexia nervosa in her daughter, also mentioned severe anxiety.

(She had) irrational and unexplained fears: fear of being poisoned, fear of death, fears that she was not a perfect Christian (she had become fanatical about religion although we are not religious ourselves).

Another whose 'socially precocious' daughter became anorectic at the age of eight and a half remarked

She was very high-strung and became jealous and aggressive when her sister was born. We probably didn't handle it very well, but the constant tantrums and rebellious behaviour were exhausting. Her domineering personality seemed to manipulate the entire family. By the time she was five years old, she refused to get dressed for school and said that voices told her not to do what we asked her to do. Her behaviour became disturbed and obsessional and I took her to see a child psychiatrist. Behavioural therapy was all that was offered, so I tried to reward her for good behaviour and ignore the bad ... It didn't work, and I think confirmed her darkest fears that she wasn't as good or lovable as her little sister.

Intense jealousy of siblings was a common element mentioned by parent's in discussing factors that may have led to their children's illness. A mother of six said

I realize that she was crying out for attention ... Her eldest sister was only 18 months older than her, tall, naturally slim, and has plenty of confidence in herself, she is multi-talented, and had plenty of boy friends when they were both younger. All my anorectic daughter wanted to do was to fit into her eldest sister's clothes.

Another remarked

My daughter is very reliant on me and always has been since she was a baby. (She) seems to want all my attention.

Mothers are likely to feel ambivalent about their anorectic daughters. They may want to nurture them, but may be worried about their lack of autonomy and feel tyrannised by their demands. Of course, an anorectic child effectively steals the limelight from her brothers and sisters for the duration of her illness. Parents repeatedly commented on this, remarking that other children had become rightfully resentful, although in certain cases brothers and sisters were exceptionally understanding of and helpful to their anorectic siblings.

•  Hope: Lost and Found
Parents speak of the terrible burden of guilt that almost overwhelms them, of the necessity of having to live with constant violent and abusive behaviour for months and even years on end, and of the unspeakable grief of watching their beloved children committing long, slow suicide before their eyes. They feel like prisoners in their own homes, afraid to go out because of what might happen while they are gone, yet feeling they must take care of themselves, if only to set an example for their children. They walk a daily tightrope, trying to know when to be firm and when to be flexible, trying to do everything they can but often feeling that their efforts are worthless.

I feel miserable and trapped in an impossible situation. I've lost a lot of weight and my hair is turning white. I saw a therapist once. She told me to go off around the world, have an affair and leave Kate to herself.

It is hard not to feel resentful especially when she uses emotional blackmail. If she feels I haven't spent long enough listening to her she will rush into the bathroom and threaten to do 'something stupid' or else rush out of the house and not return for hours causing us tremendous worry. She is also violent and abusive. It is a living nightmare.

I have been changed irrevocably by her illness. I no longer have any ambitions or hope for the future of my children ... I feel I have let her down as a mother. I love her so much, as does her father, but on more than one occasion she has told us that she hates us both and the house also. I tried so hard to make her happy and nurse her through her illness, but I think she blames me, and maybe she is right.

There are times when I feel I am headed for a nervous breakdown. I have nobody to turn to for support. I live in a constant state of fear.

In the beginning I felt I hated my daughter for being so selfish, but now I think I love her more than I could ever tell her and will never give up on her.

Her life is a nightmare, but I see inside the obsessive, darkened child the sunny child I remember and I know we can rescue her. Tonight she told me that she knows it is difficult to be a parent to her now. I looked at her hollow eyes and thin skull and I hugged her and told her that it was alright, and that she would be getting better soon.

Her life is a nightmare, but I see inside the obsessive, darkened child the sunny child I remember and I know we can rescue her. Tonight she told me that she knows it is difficult to be a parent to her now. I looked at her hollow eyes and thin skull and I hugged her and told her that it was alright, and that she would be getting better soon.

•  Family Roles
Roles play an extremely important part in healthy family functioning. Most researchers agree that the establishment of clear roles within a family is directly connected to a family's ability to deal with day-to-day life, unforeseen crises, and the normal changes that occur in families over time. Family Roles are patterns of behaviour by which individuals fulfil family functions and needs.

•  Types of Family Roles
Individual members of families occupy certain roles such as child, sibling, grandchild. Along with roles come certain social and family expectations for how those roles should be fulfilled. For example, parents are expected to teach, discipline, and provide for their children. And children are expected to co-operate and respect their parents. As family members age, they take on additional roles, such as becoming a spouse, parent, or grandparent. A person's role is always expanding or changing, depending upon his or her age and family stage.

•  Instrumental and Affective Roles
Individuals within a family have both instrumental and affective roles to fulfil. Each serves an important function in maintaining healthy family functioning. Instrumental roles are concerned with the provision of physical resources (e.g., food, clothing, and shelter), decision-making and family management. Affective roles exist to provide emotional support and encouragement to family members. Both sets of roles must be present for healthy family functioning. In addition, families must also consider issues of roles allocation and accountability.

There are many roles within a family; however, researchers have identified the following five roles as being essential for a healthy family.

•  Provision of Resources
Providing resources, such as money, food, clothing, and shelter, for all family members is one of the most basic, yet important, roles within a family. This is primarily an instrumental role.

•  Nurturance and Support
Nurturing and supporting other family members is primarily an affective role and includes providing comfort, warmth, and reassurance for family members. Examples of this role are a parent comforting a child after he/she has a bad day at school, or family members supporting one another after the death of a loved one.

•  Life Skills Development
The life skills development role includes the physical emotional, educational, and social development of children and adults. Examples of this role are a parent helping a child make it through school, or a parent helping a young adult child decide on a career path.

•  Maintenance and Management of the Family System
This fourth role involves many tasks, including leadership, decision making, handling family finances, and maintaining appropriate roles with respect to extended family, friends and neighbours. Other responsibilities of this role include maintaining discipline and enforcing behavioural standards.

•  Sexual Gratification of Marital Partners
A satisfying sexual relationship is one of the keys to a quality marital relationship. This role involves meeting sexual needs in a manner that is satisfying to both spouses.

1.  Role Allocation
Role allocation is the assignment of responsibilities within a family that enables the family to function properly.

Families have to make many decisions, often on a daily basis, about who will be responsible for completing a certain task or fulfilling a particular responsibility. For example, families must decide who will take out the trash, who will take the children to school, who will cook dinner, who will watch the children after they return from school, who will work and provide financial support for the family, etc. In healthy families, roles are assigned in such a way that family members are not overburdened. Sharing roles, such as child-care, is an important family task.

2.  Role Accountability
Role accountability refers to a family member's sense of responsibility for completing the tasks of an assigned role. In healthy families, there are procedures in place, which ensure that necessary family functions are fulfilled. For example, parents in healthy families understand that they are responsible for disciplining their children. When discipline is needed, they do not hesitate. These parents know that a failure to fulfil this role properly will result in child behaviour problems which will disrupt the family's ability to function.

3.  Suggestions for Developing Healthy Family Roles
The assigning and carrying out of family roles can be a difficult task, requiring tremendous effort on the part of individual family members. However, listed below are some guidelines that can help families make this process easier, leading to healthier functioning.

•  Establish Clear Roles
Roles should be clearly identifiable. Individual family members must know and acknowledge their roles and responsibilities. For example, in healthy families, mothers and fathers have a clear understanding of their role as parents. They are to provide physical resources (e.g., food, clothing, shelter), discipline, and a supportive, nurturing environment that facilitates their children's physical and emotional development. Families that are having difficulties often find that their family roles are not well defined and individual members do not understand what is expected of them. Establishing clear roles helps a family function more effectively because each member knows what he/she is expected to accomplish. If these individuals fail to fulfil their roles then other family members might have to do extra work, making them feel resentful and overburdened, thus hurting the functioning of the family.

•  Allow for Flexibility
Flexibility in roles is essential in a healthy family. Family roles naturally change over time. They also may change during times of crisis, such as when a family member becomes seriously ill or unexpectedly dies. The difference between healthy and unhealthy families in these situations is the healthy family's ability to adjust and adapt, which often requires a temporary or permanent shift in roles. In the case of illness or death, it is sometimes necessary for other family members to take on additional roles (e.g., becoming a financial provider). Flexibility in roles is essential in a healthy family.

•  Allocate Roles Fairly
In healthy families, every member is responsible for fulfilling certain roles. These roles are spread among the various members so that no one is asked to take on too many responsibilities. Problems arise if one family member is forced to fulfil too many roles. An example of this is when full-time working mothers are expected to take care of the children and complete the majority of household tasks with little assistance from other family members. It is important to discuss, as a family, each member's understanding of the roles he or she has been assigned. If someone feels overburdened and unable to fulfil that particular role, then changes may be needed. In healthy families, children are required to take on appropriate roles of responsibility within the family.

•  Be Responsible in Fulfilling Family Roles
Families that function well have members who take their roles seriously and do their best to fulfil their duties. Members who fail to take their roles seriously, or who refuse to carry out their roles, can create significant problems for the entire family. An example of failing to fulfil a role is when a parent does not provide adequate physical and emotional support for his/her children. There are many problems that can result from this failure, including behaviour problems, depression, and low self-esteem. Willingness to take responsibility for one's roles contributes to a healthy family.

•  Focus on Family Strengths
Establishing clear, flexible roles is a key to successful family functioning. Research indicates that families who do so will not only be able to deal with everyday family life, but also will be better equipped to handle unexpected family crises. In families where clear, flexible roles exist, individual members will be much more likely to take their responsibilities seriously.

4.  Family Roles
There is no such thing as the perfect family. All families do some things well and some things poorly; have some degree of healthiness and some degree of unhealthiest. Following are some characteristics of family roles which tend to move from healthy to unhealthy as rigid roles develop.

5.  Characteristitc Child Roles

•  Hero
Also known as 'The Little Mother' or 'The Man of the House'. Always does what's right, an over achiever, over responsible, needs everyone's approval. Not much fun. What you 'don't' see inside this child is: the hurt, inadequate, confusion, guilt, fear, low self-esteem. Progressive disease, so never can do enough. They often provide self-worth to the family, someone to be proud of. As an adult without help, this is possible: they are workaholics, never wrong, marry a dependent person, need to control and manipulate, compulsive, can't say no, can't fail. As an adult with help, this is possible: they are competent, organised, responsible, make good managers, become successful and healthy.

Super Responsible
High Achiever
Follows Rules
Seeks Approval Caretaker

•  Scapegoat
This child has a lot of hostility and defiance, withdrawn and sullen. Gets negative attention. A troublemaker. What you don't see inside this child is: the hurt and abandoned feelings. Often has a lot of anger and rejection, feels totally inadequate and no or low self-worth. They often take the focus of the family, takes the heat, 'see what he/she's done' - 'Leave me alone'. As an adult without help may have alcoholic tendencies or addict, unplanned pregnancy, trouble with the law, legal trouble. As an adult with help, recovery, has courage, good under pressure, can see reality, can help others, Can take risks.

Hostile
Defiant
Breaks the Rules
In Trouble
Angry

•  Lost Child
This child is a loner, a day dreamer, solitary (alone rewards, ie: food, withdrawn, drifts and floats through life, not missed for days, quiet, shy and ignored. What you don't see inside this child is: Unimportant, not allowed to have feelings, loneliness, hurt and abandoned, defeated, low self-esteem. They often bring 'relief' to the family, 'at least one kid no one worries about'. As an adult without help; may be indecisive, no zest, little fun, stays the same, alone or promiscuous, dies early, can't say no. As an adult with help, may be independent talented and creative. Imaginative, assertive and resourceful.

Shy, Quiet
Fantasy Life
Solitary
Attaches to Things, Not People
Feels Rejected

•  Mascot
This child is super cute, immature and anything for a laugh or attention. They are fragile and needful of protection, hyperactive, short attention span, learning disabilities, anxious. What you don't see inside this child is low self-esteem, terror, lonely, inadequate and unimportant. This child brings comic relief, fun and humour to the family. As an adult without help, may be compulsive clown, lampshade on head, etc. Can't handle stress, marries a 'Hero', always on the verge of hysterics. As an adult with help, may be charming host and person, good with company, quick wit, good sense of humour, independent, helpful.

Immature, Cute
Hyperactive
Distracting
Feels Insecure
Funny - Clown

•  The Adjuster
These children find it easier to shrug their shoulders and withdraw ... to the bedroom, or slip out to a friend's house. The adjuster usually continues these survival patterns into their adult years. Adult adjusters find it easier to avoid positions where they need to take control. They function better if they take whatever occurs in stride. They become adept at adjusting, being flexible and spontaneous, and they find pride in these traits.

What happened for these children who adopted the adjusting pattern is that they had neither the opportunity to develop trust on an ongoing basis, nor were they able to develop healthy relationships. All their lives, they seemed to be jumping in in the middle. It was difficult for them to identify a beginning, and they never knew how long a particular phase, or situation, would last. These individuals, now adults, who as kids never knew how long they would be living in one place, or how long mom would be sober this time, or how long dad would be staying away, learned how to handle (or adjust to) whatever situation they were currently in.

The adult adjusters often have neither a sense of direction, nor do they have a sense of taking responsibility for the direction they would like their lives to take. They feel no sense of choice, and no sense of power over their own lives. While the more responsible have developed a sense of being able to affect the events in their lives, adjusters usually do not have a sense of control.

For adjusting children, life is a perpetual roller coaster (not because they like living that way, but because they feel they have no other options). They perceive themselves as having no alternative; they never learned that choices were available to them. So now, as adults, they don't talk about real issues in their lives, and they certainly do not seriously examine their own feelings. Adjusters find themselves associating with others who are as emotionally closed as they are. To them, this limited association is the only type of relationship which is safe.

Based on this behaviour pattern, it is easy to see how adjusters find mates who cause uproar. The state of living in constant agitation becomes their comfort zone because they are perpetuating childhood roles of adapting to inconsistent and/or untrustworthy and/or abusing people. They know how to handle chaotic situations (by adjusting). Yet, this kind of self-negating adjusting results in the person becoming depressed, isolated, and lonely.