Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

When Books are Wrong

A new book on eating disorder treatment entitled When Food is Family will be published later this year. The book is written by a therapist with over 25 years of experience treating eating disorders who is also the founder and director of an eating disorder clinic.

The premise of When Food is Family is that early childhood relationships play a significant role in the development of an eating disorder. The book is based on attachment theory, which posits that “emotional support, understanding, empathy, and acceptance during a child’s development are the foundation of self-esteem and self-worth throughout life.” The author asserts that children develop eating disorders in part because they do not receive the emotional support and nurturing they need from their families, so they develop a “relationship with food” as a substitute for the intimate familial relationships they crave.

According to the online synopsis, When Food is Family “provides family members a step-by-step approach to understanding what attachment means, why connection to each other is important, how relationship breakdowns can lead to an eating disorder, how food becomes the relationship of choice, and how to go about repairing these relationships so that food (and the eating disorder) is replaced by healthy relationships within the family.”

My primary concern with this book is that it seems to set our field back about 20 years. There is no reliable scientific evidence to support the theory that disrupted attachments or dysfunctional family relationships lead to eating disorders. Nor is there any reliable evidence that treatment approaches predicated on these attachment theories help patients achieve recovery.

I absolutely agree that “emotional support, understanding, empathy, and acceptance during a child’s development are the foundation of self-esteem and self-worth throughout life.” Of course childhood environment is important in the development of self-esteem and emotional well-being. Of course “relationship breakdowns” within a family cause emotional suffering for everyone. Disrupted attachments are bad. Healthy attachments are good. But I am not aware of any evidence that disrupted attachments can lead to eating disorders.

The fact that some eating disorder patients come from dysfunctional families does not indicate that said family dysfunction caused their eating disorder. Correlation does not equal causation. Despite decades of research and millions of dollars spent on cross-sectional and longitudinal studies, researchers have not been able to identify anything that parents do, or don’t do, to cause eating disorders in their children.

The theories espoused by this book are not only unfounded and incongruent with our modern scientific understanding of eating disorders, but also potentially harmful to young patients and their families who are seeking treatment for these life-threatening illnesses.

When parents have a child with a poorly-understood, stigmatized, confusing, life-threatening illness such as anorexia nervosa or bulimia nervosa, they do not need to be told by an expert that family dysfunction is at the root of her illness. The family unit is not well-served when parents are told by an expert that they have failed to bond properly with their children, and this failure to bond has resulted in their child developing a serious illness. Parents with an anorexic or bulimic child do not need to be taught skills to develop healthy attachments with their children. They need well-informed professional support which empowers them to take aggressive action to help restore their child to health.

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7 Responses to When Books are Wrong

  1. Tom Blaschko says:

    I have attached the discussion section from the article Dr Ravin cites (Academy for Eating Disorders Position Paper:
    The Role of the Family in Eating Disorders, International Journal of Eating Disorders, http://www.drsarahravin.com/web/pdf/AED.Role_of_Families.pdf).

    As the role of family life in a child’s emotional and psychological well-being is uncontested, so too is the potential value of including families in the treatment of children and adolescents, and in identifying resources within the family that can hasten recovery. Just the same, although no evidence exists supporting the concept of ‘‘anorexogenic’’ parents or families, in certain cases involvement of the family may be clinically contraindicated (e.g., severe parental psychopathology). Thus, the assessment of families requires close attention to the parents’ competencies, motivation, and history of adverse or traumatizing events. But even when such adverse circumstances are present, the development of a play to help and support sufferers and how to ease family burdens should take precedence over accusation and blame. Thus, it is our position that families should be involved routinely in the treatment of most young people with an eating disorder. Exactly how such involvement should be structured, and how it will be most helpful will vary from family to family.

    The authors of the article state that parents should be given a role in the treatment. When Food Is Family offers a model (successfully used for 25 years and supported by Kathryn Zerbe, among others) of what parents can do to help their child. The suggestions about this aspect of the problem from someone with Dr. Scheel’s experience are worth considering, at least in clinical practice.

  2. PTC says:

    Sounds like a book I won’t be reading. My family was far from dysfunctional, and guess what, we ate dinner together as a family most every night. Guess what? I still developed an ED. I think you’re probably right, though I have not, and probably won’t read the book, that it sets things back about 20 yrs.

  3. It’s interesting what you’re saying. Which came first the chicken or the egg? I hear what your saying but I do find that poor attachments and unhealthy family communication styles more than usually appear with an eating disorder. http://www.eatingdisordersgroup.com

    I think the rationale of replacing family with food is very elemenatry thinking. The use of or restritiction of food is a symptom and coping skill .

  4. Lisa says:

    Julie, this therapist highlights the dangers present in the field of Ed treatment. Her theories are so far from current research. She is using old beliefs much like the theories of schizophrenia and autism were thought off. My own experience has been too many healthy loving well adjusted families experiencing this life threatening illness crush this theory of developmental dysfunctional attachment. My own daughter was very happy, loving, bright well adjusted child who felt very safe within her own family unit. I have heard so many others with similar histories. There will always e a population of dysfunctional families n any sub group. It would be very unscientific to make the leap to causation.
    There is too few clincians who are well versed in the current well documented research and theory regarding Ed and effective treatment. It is, I believe the number one reason for this illness to remain a chronic illness in so many. I really wish we could clone you. We need professionas like you to reach the many others in the field who are still practicing with outdated beliefs and treatment.

  5. It is time for this debate. I’m grateful especially for the clinicians who speak up on this. It is heartbreaking to me that these ideas about parents are out there harming families every day.

    I know it comes from a well-meaning place, but the irrevocable damage it does means we have to all speak up.

  6. KrisB says:

    Thank you, Dr. Ravin, for your comments. Does this author suggest that all ED’s are caused by this lack of attachment? If not, why then do others manifest EDs? If so, our family is the perfect example to disprove her thesis. My 24 yo D received a diagnosis of RAN at age 11. She had always been a bit different from her peers, more sensitive to sensory stimulation, easily frustrated, frequently disappointed – just not comfortable in her own skin. My husband and I love her so much, and we did everything that would make bonding and attachment stronger – not just because that was “right” but because it was what FELT right, and good and wonderful.

    I was a LaLeche League Leader by the time she was 18 months old, took her with me everywhere, considered her feelings, practiced loving guidance, fed her wholesome and delicious foods, all meals were family meals, was a stay-at-home mom and on and on. I ran sessions on self-esteem in children and many other topics, and none of this prevented her from manifesting AN.

    It’s been a long, hard road for her through various EDs and other issues. We had her in constant treatment until she was 18, through several different programs and several different therapists/psychiatrists. She then went off on her own and lived chaotically until, at age 21, she asked for help. She now lives on her own, has a full-time job and is receiving evidence-based care for her EDs and comorbid disorders.

    We also have a son, 3 years younger, who shows no hint of the issues that plague my daughter. She says she was born “without the self-esteem gene.” He has oodles of it, is calm and happy, has a successful life at college 2,000 miles away from home, with excellent grades and jobs tutoring, writing for the school paper and working at the gym.

    So, I’d really like to ask the author, if her theory is true, why did this strike my daughter and not my son? No one could have done a better job parenting both my daughter and son than my husband and I did. Fortunately, I never felt that I had done anything wrong, that I had anything to fix in my attitude. All I needed was the right tools and support to be able to get my D into effective treatment. The only thing I am sorry about is that it took me until she was age 21 to find the right information and support.

    At a minimum, at diagnosis, all parents/carers of those with EDs should be given information about ALL treatments and the results of studies about those treatments. Referrals should be made based on the parents/carers preferences. Sometimes an adult will seek treatment on his/her own, and the same should be done for them. My big complaint right now is that parents/carers are not made aware of all treatment possibilities.

    EDs are notoriously good at ripping apart families and causing huge problems between family members. That is the nature of the beast – sufferers will do everything they can to push away the help that they so desperately need.

    I think that there is so much confusion between what was going on in a family before ED manifests vs. after. Most of the families I know who have a child with an ED are just normal, loving families. I am convinced that for those who are biologically predisposed to getting an ED, any malnourishment for any reason can be the trigger for it to get going. It makes no difference how “attached” the child was or how much “self esteem” the child had.

  7. anne says:

    My daughter said to me, “I don’t know why I’m sick. I don’t have any of the problems some of these others girls seem to have had. They told me there is always a problem in the family. But, I don’t think there has been.” She told me this while hospitalized inpatient for her illness. However, after enduring 9 weeks inpatient in a place that spent a lot of time ‘searching’ for reasons (luckily they did try to refeed her too), she came away feeling that we ‘weren’t’ letting her grow up, that we’d smothered her, that we wanted to ‘keep her a baby’ and that her ED was caused by her father. I would have laughed if I hadn’t felt like crying. I just wanted to keep her alive and safe which I hadn’t seemed to be doing a very good job of at home. This was almost 10 years ago now and NONE of these “reasons” had entered my mind. When I expressed my love by holding or hugging her, it was frowned upon (she was 14 and quite ill–and I simply loved her). I just wanted her to know and feel it. I got odd looks and comments for it. I doubt I would have gotten those looks if she’d been in the hospital with cancer. And I felt like she was dying. She’d lost a third of her body weight. She wasn’t acting rationally or like herself at all. I was just responding to a very sick child and it wasn’t at all helpful to have that natural response in a time of acute stress and crisis made into a pathology. I was very much shut out–not allowed to even see her. Had I not been so desperate to get food in her and keep it there, I would have pulled her out of that place in a nano second. But, I have been living with the psychological damage this did our family ever since–as I feel my daughter views our relationship (and herself) as not quite the same as it once was, a bit damaged as though we’d ‘done’ something to her. It saddens and angers me. No family should ever have to go through this.

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