"But..." we should not have, should not now, and should do all sorts of things.
Begging the question: if we didn't cause it, then how could we have prevented our child's mental illness?
And: "AHA! If it is a brain disorder, why would it matter what parents did or do?" (I've never heard a parent say this, ever, it only seems to come from those who can't bear to let go of blaming parents)
Time to separate:
- and MAINTAINING Factors
Predisposition is what I'm talking about when I say "cause." I mean there is something about this person's brain that is different and will respond to the world -- and especially to disordered eating -- in a way that puts them in special peril. This predisposition is largely genetic, brain-based, and is still largely a mystery.
Precipitation is what most people mean when they say "trigger." I'm not a fan of that term because it is used so loosely, but what is generally meant is the "the trigger" part of "genes load the gun and environment pulls..." The problem with this is the importance we then give to The Day a person's predisposition becomes mental illness. The day a young man hears from a wrestling buddy that he vomits to "make weight." The day a dancer's boyfriend breaks up with her and she is too upset to eat lunch. The healthy diet pact in the freshman dorm. Cross-country track season. A bout of flu.
We put tremendous importance on that moment as if a time machine could fix the illness. It won't. Precipitating moments are, in my opinion, out there waiting to expose the predisposition. If not that incident it might have been another, or nothing anyone remembers later. Just because something happens on a Tuesday shouldn't make us all Tuesdayitarians.
Maintaining factors, however, are the ones we as parents have a great deal to do with. These are the ones most people confuse with "cause." We ARE in control of many maintaining factors and must address them.
For example, parents on a diet is indeed a problem for someone predisposed to an eating disorder. It is likely to delay diagnosis because dieting behaviors and thinking so closely track with what this mental illness makes the ill brain think and do. It's a mixed message: the topic of weight is a public and highly moral mission for one person, but enforced on another member of the family. Parents on a diet also makes food and normal eating into a joyless, punitive, weight-based activity at the very time a patient deserves normal and socially supportive modeling around food and activity. Picture an alcoholic child staying sober in a bar of not-alcoholic but happily imbibing family. Uncool.
Families unable to reorient their lives toward caregiving -- too busy, too frightened, too scattered, too uninformed, too rigid -- can form a tidy cordon of safety around this mental illness just as a family may do around drug use. We can also do the opposite and be the safety net.
Families under the strain of marital discord, illness in another family member, extremely busy schedules, experiencing a natural disaster, or any of an infinite number of strains can all be "maintaining" to a mental illness that involves enormous anxiety and requires heroic parenting. Just as any major illness or accident requires reorienting and different priorities, so does this crisis.
So, when I blather on about what families need to do and stop doing when a loved one has an eating disorder I'm not talking about us causing or triggering the problem. I'm talking about how necessary it is that we provide an environment that is not maintaining to that illness. We need normal meals, good relationships and communication, supportive clinical teams, authoritative parenting, adults in collaborative harmony, siblings with their needs met. We need, if present, to deal with problems in the family that pull away from good caregiving.
We cannot afford, with ED in the house, the luxury of hiding from issues and discord that might otherwise have waited. This is not "blaming" parents. It is not saying that our actions or inactions could have prevented the illness. It is acknowledging the reality of facing a potentially fatal and invariably grueling mental illness.
If my colleagues in the ED world could stop confusing these different factors -- as we have learned to do with autism and asthma, by the way -- I predict a far more effective relationship with families. We tend to feel "blamed" (and thereby alienated) by the implication that we caused or could have prevented our loved one's terrifying diagnosis. We tend to feel empowered by understanding the power we have to create a non-maintaining environment at home.