Nursing a Couple Relationship and an ED
An eating disorder comes into a person’s life as a mechanism to deal with the overflow of emotions that accumulate over teenage. The eating disorder is so effective that initially the young person entertains the magical thought that they have found the solution to living an easy , unencumbered life with a controlled body and controlled feelings. Nobody needs to know how I manage life. No boats are rocked. The person manages general milestones - graduation, moving out , finding a job, travelling. And then a relationship. Most of my clients tell their partner at some point that they have an eating disorder. The partner is “supportive” with little understanding of what they are supporting or agreeing to. However, the couple relationship is too intimate for the distance and secrecy an eating disorder requires. Over some time, managing an eating disorder and a partner’s expectations increases the person’s anxiety and the eating disorder grows because, like any other addiction, it IS the solution to the anxiety. The person turns to the ED more and more and turns away from the partner. Intimacy suffers and dies.
Whether the ED has a place in the home depends on the partner and the relationship. In a typical couple relationship, both partners have expectations of each other. This is a conditional relationship. An adult relationship requires both partners to “show up” with presence to grow themselves and the relationship itself. A partner who is truly present to the relationship will find the one with the ED trying, but absent or secretive. I have seen relationships float along, with or without children, when both partners have ways of checking out. One partner plays video games or goes out while the other exercises or engages in a binge/purge cycle. Sometimes the other partner has an affair. Both partners maintain the status quo till somebody gets tired and pushes for change. Often the partner who is looking for connection will put forward an ultimatum or push for change.
When a couple arrives for counselling. it is important to remember a few points -
While it is our tendency to hone in on the ‘identified patient’ , it is important to wonder how the balance in this relationship is maintained. What makes the other partner stay? Partners who tend to be ‘passive’ are not enough of a barrier to an ED in the home.
Sometimes the relationship was started and relies on one person being “saved” by the other. This keeps the ED in place.
What is the real nature of intimacy in this relationship? What are the expectations? Often both individuals in the relationship have a ‘secret’ side relationship (sports, school, work, gaming addiction, depression) that allows the ED to stay alive. This will be a ‘maintaining’ factor that stalls recovery
The adult client holds the responsibility for their own recovery process. Intervention with the adult still involves family systems work and individual distress-tolerance work. Much of the work with the client involves work with the “maturity fears”, body image and comfort with adult responsibilities. Putting the partner in charge of changes keeps the client in a child-place with the possibility of arguing with the partner about minor decisions. The client gets well for themselves and evolves into the adult partnership.
Work with the partner involves psychoeducation about the disorder and other couple relationship issues. The therapist takes great care to see the partner as an adult partner in an adult relationship. It is ideal to NOT involve the partner as a gatekeeper for the ED. This brings the partner relationship to a parent-child dynamic that leads to animosity and resentment in the relationship and diverts attention away from the client’s work. Partners can learn that behaviours and language that are harmless in ordinary life can have deep meanings in an ED reality. Especially comments about “health” and exercise and food.
The client will do well to rely on their therapist - dietitian team to recover from the ED. This way the partner can simply remain a partner. It is customary for clients to draw the partner into a caretaker role. Therapists must understand that any caregiving that allows a client to not do ordinary adult activities like grocery shopping or cooking or portioning invites the partner into a policing role. For instance , a partner can go along and hang around while the client grocery shops with a list. A partner can help cut vegetables while the client cooks from a recipe. Without engaging in negotiations. All negotiations go to the treatment team.
A final point - An efficient and knowledgeable dietitian is a non-negotiable for treatment. Many of my adult clients are likely to say “I know what I should be eating” as a way to avoid seeing a dietitian. In my experience, this is not helpful. The dietitian has functions beyond telling a person they need to eat two eggs.
In these ways , the partner relationship is protected from sliding into a parent-child, rescuer - helpless victim dynamic. Intimacy returns or in some cases, grows for the first time, as the client recovers and both partners are able to meet each other in an adult place.
