What Is Helping? Youth & Recovery

What Is Helping? Youth & Recovery

Joanne Gusella, Ph.D

When girls who have recovered from an eating disorder were asked their opinions, they told us that helpers need to be patient, and to understand that it takes time and a readiness to change. They talked about having to: make major changes in eating and activity patterns, eliminate weight control methods, view their bodies differently, and learn how
to express their emotions assertively. For others, it also meant learning how to take on responsibility and face their fears. Some had a life to return to, while others needed to carve out a new life.

Motivational stages of change

Clearly, the tasks of recovery can be monumental. So, how then does a young person find the motivation to face these changes? It is summed up nicely by one girl who recovered after a 5-year struggle with bulimia: “You have to be ready...It’s like you weigh the pros and cons until you get to the point that it makes more sense to change than to stay the same.”

Her description of the change process, along with that of other youth interviewed, is consistent with the “stages of change” framework. Psychologist James Prochaska and his colleagues discovered that when people manage to make positive changes in behaviours that pose a risk to their health, they go through distinct stages. Their readiness to take action depends on where they are along the path to change. Self-change is rarely a straight route, and people generally cycle through the stages more than once before they achieve more permanent change.

Clinical interviews at the Eating Disorders Clinic at the IWK Grace Health Centre in Halifax, Nova Scotia, suggest that this model provides youth and their helpers with a framework for understanding the course of the disorder. When asked what helped them to move forward or to get ready for change, they indicated that their helpers (including parents, friends, teachers and health professionals) played a key role in recognizing their need for treatment, and providing them with the structure and tools for recovery. I will highlight some helping tools and suggest the stage at which they may be particularly important.

Pre-contemplation stage

“Leave me alone!”
Youth who say, “I don’t have an eating disorder” when their physical state and behaviour clearly indicate otherwise, are in the pre-contemplation stage. They are so immersed in the eating disorder and obsessive thoughts about their weight, shape and food that they are unaware of the difference between reality and their distorted thoughts. Youth may be convinced that others are trying to “make them fat” and “can’t be trusted,” making it particularly difficult to help them.

Helping Tool #1: Being Informed and Addressing Specific Concerns and Behaviours

Becoming well informed about the signs and symptoms of eating disorders and where to obtain treatment in your community is a first step. Parents play a greater role in the treatment of a child or adolescent. They can help by addressing specific concerns, e.g., “you’re losing too much weight; I heard you vomiting after your meals, and I’m
concerned”, and initiating a medical evaluation. The young person may try to make light of, or justify their behaviours as part of their denial, but it is best not to make seeking help a choice, because young people are unlikely to become more insightful about having a problem as they lose more weight. It can, however, be phrased positively, e.g., "A visit to the doctor will help establish if there is a problem we need to deal with."

Helping Tool #2: Separate the Youth from the Eating Disorder

Supporting the youth without “enabling” the eating disorder (see Table 1) requires a great deal of emotional strength, and an understanding of how an eating disorder works. Young people will appeal to their parents to go along with the obsessive thoughts and rituals aimed at avoiding their fear of weight gain. A girl might insist that her parents buy only
diet foods, or she may demand a membership to a local gym to satisfy her drive to exercise. Parents may innocently concede to her demands because they want to ease her distress. It is very easy for parents with good intentions to become trapped with their daughter in the grips of the eating disorder. Youth may be upset when their helpers do not collude with them. This anger decreases once they recognize that they have an eating disorder. A Parent Support Group can help parents to handle these difficult situations.

Helping Tool #3: Don’t Ignore Danger Signals

Regular medical checkups are important. If the youth’s health is deteriorating in outpatient treatment, this needs to be addressed and a more structured treatment environment considered to help break the cycle of disordered eating. Helpers who ignore these danger signals may inadvertently contribute to the young person’s denial.

Helping Tool #4: Helpers Need to Work as a Team Providing Consistent Messages

It is hard for youth to move beyond this stage if they are getting inconsistent messages. If one parent is concerned and the other feels that there is nothing to worry about, the youth may get a mixed message about the seriousness of her behaviour. If the treatment team is visibly divided in terms of how to best work with her, this will add to her distrust. Parents and professionals need to develop a working relationship. Without it, the chances of engaging and keeping the youth in treatment are diminished.

Helping Tool #5: Provide Opportunities for Consciousness-raising

Helpers can guide youth in making connections between their physical and mental symptoms and the eating disorder; e.g., hair loss, blue hands and feet are signs of a starving body. While she may not be ready to accept that she has an eating disorder, she may be ready to admit to these physical and mental symptoms, some of which may be frightening to her. Involving girls in a treatment group can help. The majority of girls who begin our group therapy believing they don’t have an eating disorder, end the group admitting that they do. They report feeling less isolated in their experience, and more able to talk about it.

Contemplation stage

“I know I have an eating disorder, but I’m not sure I’m ready to change.”

This stage marks a major step forward. While still not self-motivated to change, youth are recognizing that they have a problem, and beginning to question their behaviours. This stage can be prolonged when youth get stuck in a holding pattern of “waiting for the perfect moment” to change, engaging in wishful thinking, e.g.: “If only I could get better without gaining any weight,” or magical thinking, e.g.: “The eating disorder will just go away at some point, it’s not up to me to change.”

Helping Tool #6: Empathy, Warmth and Openness to Listening

Expressing warmth, empathy and a genuine openness to listening will provide the youth with a foundation for building trust. Youth who trust you may reveal life events that influence how they feel about themselves and their bodies. They are more likely to talk with a parent or therapist who shows interest by listening without judging, and can handle what they have to say. By communicating, she will be learning new ways to deal with difficult emotions. Family work, where the family attends sessions with a therapist, has been found to be particularly beneficial for youth under 18.

Helping Tool #7: Raising Awareness by Providing Psycho-educational Experiences

Provide the youth with the opportunities to learn more about eating disorders. Hearing other girls talk about what helped them to deal with restrictive dieting, bingeing, vomiting or laxative abuse, can help contemplators to recognize that getting better will require active change on their part.

Helping Tool #8: Weighing the Pros and Cons of Changing

Youth tend to engage with professionals who adopt a non-judgmental, partnership style at this stage. They can be asked to generate their personal list of “pros” or advantages of taking action against the eating disorder, and a list of the “cons,” or disadvantages of taking action. Over time, the therapist’s role will be to guide the youth in tipping the decision scales in favour of taking action.

Helping Tool #9: Helping Youth to Separate Who They Are From the Eating Disorder

Professionals experienced with Narrative therapies can help youth by having them look at their relationship with the eating disorder. In what way is the eating disorder like a friend to you, and in what ways is it like a foe? Once they have had a good look at its friendship qualities, they will understand why they hold onto it, but when they see how it is a foe, they may begin to question whether it’s worth being friends with. It’s hard to kick a friend out of your life, but when you begin to see the eating disorder as your enemy, the motivation to fight it is increased.

Helping Tool #10: Make the Youth Accountable for their Behaviours

Acknowledge and empathize, but keep reasonable expectations for youth. If she vomits and leaves a mess, remind her in a matter-of-fact tone that she needs to clean up after herself. If she continues to binge on food that was meant for the family, establish an understanding with her that she will need to replace the food. This can increase awareness and motivation to change.

Preparation stage

“I’m getting ready to make small changes.”

As they prepare themselves to make active changes, they will need to arm themselves with the necessary tools to deal with the stress and anxiety they experience as they face their fears. Confidence is gained by small victories. For example, even though they feel the urge to binge, they may choose to delay it by 5-10 minutes. When they’ve had
success going to bed without a binge, this increases their confidence in taking on a bigger challenge. Helpers can focus on their successes and re-label mistakes as “opportunities to learn.” Motivation and commitment increase as the youth gains more confidence in mastering the disorder.

Helping Tool #11: Arm Youth With the Tools for Fighting Back Against the Eating Disorder

By this stage, youth are responsive to designing and decorating a recovery box to collect the tools that they are gathering for their recovery. Tools may include pictures of people or pets that motivate them to recover, life-lines (a list of names and numbers of people to call when they need help in coping), top ten ways to distract themselves from obsessive thoughts, a relaxation tape, ways of challenging “anorexic” or “bulimic” thoughts, guidelines on how to be assertive, and a personal journal of insights, poems or stories that inspire them.

Action stage

“I want to stop dieting/bingeing/vomiting/over-exercising.”

This is the busiest period of change, propelled by the youth’s self-motivation to change. As they face real fears, the temptation is strong to slip back into their old, safe ways dictated by the eating disorder. They need the support of helping relationships more than ever.

Helping Tool #12: Provide Active Strategies for Changing Eating Disordered Behaviours

Professionals need to spend less time talking about change and more time providing specific strategies. Youth will be more willing to participate in therapies aimed at making active changes in the beliefs, thoughts and feelings that fuel their disorder. They may also be more willing to take active steps to deal with relationship issues.

Maintenance stage

“I’m trying to keep up the changes I’ve made.”

At this stage, youth need to be prepared for the danger signs which precipitate recycling to an earlier stage, including emotional upsets, boredom, loneliness, frustration and life changes. They also need to know how to access help if they need it.

Helping Tool #13: Build in New Supports and Gradually Remove the Old Ones

Youth will need to have follow-up contacts with professional helpers, but appointments may be less frequent. They may benefit from groups of a general nature (e.g., a girls group aimed at assertiveness) which will give them experience with girls who are not consumed by issues of weight, shape and food.

Helping Tool #14: Recognize the Youths’ Experience by Asking Their Views and Opinions

Youth often want to share what they have learned in the process of getting better. Professionals can ask what advice they would have for helpers, or for other girls, about recovering. Hearing themselves express healthier beliefs and helping others can build their self-esteem. Youth also need to be cautioned about the potential hazards of thehelping role. Seeing other girls who are obsessed with fat can also re-trigger those same feelings in a girl who is not yet fully recovered.

Recovery stage

“The eating disorder is no longer part of my life.”

While we still need better studies to inform us about the course and outcome of eating disorders in children and adolescents, we do know that it takes years for youth to fully or partially recover, and that some youth will carry the eating disorder well into their adult life. The message is that despite their best efforts, helpers cannot “make” a youth recover.

It is best not to take ownership for the youth’s successes, or their setbacks. Recognizing and accepting your limitations, seeking your own support, and taking “time-out” from the helping role, can help caregivers to avoid emotional burnout.

Additional reading

  • Lask, B. and R. Bryant-Waugh. 2000. Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence. 2nd Edition. Hove, UK: Psychology Press.
  • Prochaska, J.O., J. C. Norcross, and C.C. DiClemente. 1994. Changing for Good. N.Y: William Morrow. 

Table 1. The Difference Between Helping the Youth and Enabling the Eating Disorder

Enabling the Eating Disorder Helping the youth
Avoid discussions about eating disordered behaviours (i.e., restricting, bingeing, vomiting, laxative abuse, over-exercising). Address your concerns about specific behaviours.
Minimize the need to follow treatment plans. Minimize the importance of the dieting, bingeing, vomiting or laxative use.
Make excuses for, and defend problem behaviours. Set limits on the eating disorder by reinforcing the need to follow a treatment plan.
Indirectly, or rarely recommend a change in behaviour. Make youth accountable for their own behaviours.
  Gently, but directly talk to youth about your concerns and discuss a plan for helping them to
address the eating disorder.

This table was adapted from Prochaska, Norcross and DiClemente, 1994, p. 97.

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