By Kay Gittins, Family Therapist, Newbridge House

Towards the end of eating disorders treatment programmes, there is a focus on recovery and how to protect against an eating disorders relapse. The framework for this is often individual: how do I recognise the signs of a possible relapse? What are the possible triggers for me and what can I do to maintain my recovery.

As a Family and Systemic Psychotherapist, my focus is on the family system and the individual within those close relationships: what can parents, carers and significant others do to support recovery and reduce the risk of an eating disorders relapse?

Equally, what support do others in the family require for themselves to best help maintain a continued recovery?

It is very helpful for the family as a group to consider and prepare for eating disorders relapse prevention before the treatment programme ends. For example, if parents have a concern about an increase in exercise without a compensatory increase in food intake, how should they raise their concerns?

We can consider the dynamics in the family group: parents may have enduring guilt from the time the eating disorder first developed around not identifying it or seeking help sooner. The experience of caring for a child with an eating disorder is challenging and traumatic, often leaving parents feeling anxious and fearful.

Equally, within this dynamic, the young person who is back at home after an inpatient treatment programme might say: “I don’t like it when I am constantly being questioned.” Or perhaps: “Mum is so stressed she doesn’t believe me or trust me.”

In this situation, thinking about eating disorders relapse prevention, parents need to be able to raise their concerns in a way that doesn’t escalate into conflict and undermine trust. It is helpful to prepare for this before discharge (or the end of a community-based treatment programme) so there is acknowledgement from everyone that parents need to be able to raise concerns and that equally, parents will try to raise their concerns in a way that doesn’t escalate into conflict.

For example, the parent might say: “I have noticed you went to the gym again yesterday and didn’t have a snack when you returned home. I just want you to know that I have concerns about that and I’m going to leave it with you to consider this.” We call this relational relapse prevention: considering the different relationships an individual has and how those relationships might support recovery.

One of the first things I talk to parents and carers about when we are thinking about relapse prevention is self-care. Looking after a child with an eating disorder is an exhausting, traumatic process which impacts on parents physically, psychologically and socially. They feel unable to look after themselves because the challenge of looking after their child is so overwhelming. But we say to parents and carers very clearly: it is important that you look after yourself because when we aren’t able to do this, our capacity to look after others is depleted. Showing your child that you are taking care of yourself also helps your child to see the importance of self-care.

To return to relational relapse prevention: what does your child do if they are concerned about anorexic thoughts and feelings returning? Effective relapse prevention is dependent upon your child being able to be open and honest about these sorts of concerns and to quickly take them to an adult, most likely the parent.

However, many of the young people I work with are acutely aware of the impact their eating disorder has had on their parents. They say things like: “I can’t talk to Mum about how I’m really feeling because she has been through so much and I don’t think she can take any more.” Consequently, the young person hides their feelings and concerns, which creates a significant risk in terms of recovery and relapse.

There are two main messages from my perspective as a family therapist: first, that relapse prevention needs to be framed in a relational way, considering all significant individuals, how those relationships are functioning and how they can support recovery. Secondly, that relational relapse prevention needs careful preparation and consideration in advance: concerns about a possible missed lunch raised by an emotional, anxious parent can quickly escalate into conflict and harm relationships.

The relational plans account for past patterns of interaction that the family feel have been unhelpful; that they do not wish to return to. Relational plans also highlight interactions that are supportive, which they wish to continue with and strengthen over time.

I extend this to include the professional network around the family: even with the best of intentions our interactions as professionals may not fit with the family and we should be open to feedback with a willingness to alter our practice to further strengthen and support the ongoing recovery process.

The relational relapse prevention plans are intended to be ongoing, evolving document and should be reviewed with those involved in the ongoing care of the individual and their family.

Every family and support system is different and there is no single approach that will be appropriate for everyone. However, the overall principle is helpful: if there can be a full and open discussion about the need to raise concerns, broad agreement on how to do so, with understanding of the different to perspectives involved, this will support everyone working together in the eating disorders relapse prevention and recovery process.