Understanding your loved one’s avoidance

by Zuzanna Gajowiec, CEDS-C

For us as caregivers, some eating disorder behaviours can be very hard to understand.

And that means that it can be  even harder to try to CALMLY and effectively support someone in recovery.

One of the issues that families (and treatment teams) face is Avoidance.

For most of us, it is simple: we decide to do something, and we just do it.

Even when the action we decide on is anxiety provoking, we either want to do it more than we are scared of it, we can gently “nudge” ourselves to still do it, despite our anxiety, or we can focus on the gratification of achieving what we want and endure some pain (i.e., anxiety) in order to achieve the reward.

Why it is so simple for some of us – and not for others?

It is not because those of us who can are ‘superior, smarter or know better’. Some of us can do it, because our brains have not been scared so much as to “install” an inner phobia of something that started the avoidance behaviours in the first place.

Inner phobia is not something that is installed easily – it needs some overwhelming and unescapable events where we feel unsupported and therefore  completely alone. Avoidance is an adaptive strategy, there to ensure safety and survival.

What could have scared your loved one to have developed so many avoidance behaviours?

Eating disorder cognitions and beliefs, which for some are experienced as the eating disorder voice, are usually wired as survival strategies “If you gain any weight at all you will be unlovable” Once you eat …. you become disgusting”, “Everyone can see how much you have eaten and that you are a disgusting, gluttonous pig and will be repulsed by you”.

Also, people who suffer from an eating disorder are still largely let down by our health system. They are often  seen by health professionals who have zero training and zero understanding of eating disorders. As a result, they may  say things that only make the eating disorder cognitions worse “You don’t look like you have an eating disorder” … “Why do you do it to your family? Can’t you  see how your family is suffering because of you?”, “your BMI is too high to receive treatment” etc.

Many people are treated this way, especially when they have had to be hospitalized in a general or a psychiatric hospital (where sadly people are still treated instead of being treated in specialised centres). Even in residential treatment people can be traumatised, for example, held down  so that an NG tube is put into their stomachs, shamed and blamed, threatened, subjected to different restrictions without any explanations being offered so that  it feels to them like a punishment.

I can imagine a lot of eye rolling when I use the word trauma… and yes, there is a lot of trauma amongst eating disorder populations from being in treatment.

We have to acknowledge that and treat these individuals properly, because – through the later acquired adaptations like avoidance – people with eating disorders are further blamed, shamed and traumatised when we expect them to “just do it”, when they really can’t due to trauma.

To bring this to life a bit more, let’s list the different adaptive ways people learn to use to protect themselves from what was painful and unbearable:

• Denial: Becoming distressed or even defensive when painful issues from the past are brought up. “I don’t know”; “I don’t remember”; “I don’t want to talk about it”; “I don’t want to go to therapy”.

• Perfectionism: focusing on achieving high standards of performance to avoid punishment or rejection; “I have to be productive all the time to deserve basic things like rest”; “As long as my weight is…. I am safe.”

• Avoidance of unpleasant feelings: not being able to express vulnerability; bottling up feelings, not being able to seek support from others. Feeling unable to feel some feelings, needing to escape some feelings by using eating disorder behaviours.

• Minimizing – not being able to fully understand how unwell they are, how traumatised they are or how strong the eating disorder is. This is a hard one for carers. Carers sometimes fall into this eating disorder trap and believe what their loved ones are saying – therefore enable the eating disorder.

• Over intellectualization: Preferring intellectual understanding, but not being able to connect emotionally. Sometimes when therapy encourages people to feel more than just think they may want to avoid it. “I don’t want to go to therapy”. “I hate art therapy, dance therapy, yoga”.

• Withdrawing: Intellectualization and obsessive nature of the eating disorder thoughts which can lead to emotional distancing and difficulties in keeping existing connections and forming new ones.

An eating disorder is a sneaky disorder, so for a long period of time, (largely due to how convincing the eating disorder cognitions are) – people are at first against recovery or at least ambivalent about it (“ I want to get better, but I can’t eat normally because I can’t get fat”; “I like therapy, but I won’t see the dietitian, they make me feel very anxious”).

It usually takes quite some time, and not by scaring and shaming, but properly exploring what their real goals are in life. Helping people understand how the brain works and how the eating disorder is manipulating their brains is an important part of recovery. It also takes a long time to build a strong and safe relationship that feels safer than the eating disorder punishment and reward system.

So even after people do all this hard work of (i) building their motivation to recover and (ii) understanding their brain, they find themselves stuck in the avoidance traps.

Their phobia of exploring inner states, sensations, emotions and body sensations creates an enormous obstacle to healing and progressing in recovery. In other words, now they know why they want to recover and that they really, really, want to recover, but when they are asked to “do it “, they face an enormous fear.

Avoidance is not being difficult and stubborn. It is a survival mechanism; therefore, it is wired into a part of the brain that is “stronger” than logical thinking (or at least it is  until we support the person).

Therapists and dietitians encourage people to eat the foods they fear, confront scary memories, lean into their emotions, not use compensatory behaviours and sit with the fear, shame and guilt that may arise. Parents are instructed to support all this exposure work, however, we often get blocked by our loved one’s inability to ‘go there’ or ‘just do it’.

So how do we deal with those impediments that do exist, even years later, even when our loved ones have clear goals in recovery and have good motivation for recovery?

Let’s start with what we know is all parents superpower – connection and time.

This superpower is based on the fact you have such a deep connection with them. They care and love you, so you don’t have to build a relationship with them from scratch, like therapists and other people on their team have to.

Even if you feel that your relationship is not great, probably due to the eating disorder making your loved one push people away and the complex and exhausting recovery process, when you learn new skills and change even a little something, this will be more impactful than anything else and anyone from the team.

This superpower is also based on how you view them, which can either be shaming or healing. Let me explain:

Even when we don’t say a word,  people can sense how we view them. We are social creatures and, to survive, we must be able to read other people. When others view us as broken, faulty or difficult and annoying, this will make us more defensive. We will respond from the survival part of the brain.

When people view us as good and making sense, we feel safer.

This may sound simple but is not.

You can start by recognizing that avoidance serves a survival function. Then we can begin to understand the reluctance or even the inability to “just do it”.

Once you can fully see that avoidance is a valid, smart mechanism, we are able to view our loved one as wonderful, adaptive, smart and careful. That in turn makes them feel safe with you.

Validation of their understandable fears and respect for their need to go slowly (but, as caregivers still not being fooled by eating disorder tricks) is key to helping your loved one effectively.

This does not mean that you give in to the eating disorder. But it means that you can empathise and validate with them that it is hard and scary and, at the same time, provide them with comfort,  encouragement and an unbreakable faith that they can and will recover, because deep down they are smart and can adapt.

Previously they adapted by becoming avoidant (remember why? – because they were alone with an overwhelming feeling),so now with your support and attention they will be able to face more and therefore become a little less avoidant.

As caregivers,you want to help your loved one learn strategies to tolerate more and more of the avoided discomfort. And you  can do this by being there and by supporting them emotionally. Our favourite way to teach families and carers to provide emotional support is emotional coaching created by Dr. Adele la France, founder of the Emotionally Focused Family Therapy. (insert link here).Here’s how this can look:

Let’s say the dietitian’s recommendation was to eat ice cream this week (ok, maybe that is a bit of an advanced one  so you can say instead perhaps add one tablespoon of milk to tea or something).

You try to support your loved one in doing so, and when the task is far away into the future (e.g., next week), they seem to be on board, even enthusiastic. However, once the ice cream is in front of them, you can see that they start to panic, tense up, stare fixedly at one particular point etc.

While you might be tempted, don’t appeal to their logic, shame or blame saying “you promised. You just said you will do it… Remember that the dietitian said it is good for you”. Doing this makes them think that you think they’re not making sense, that you’re frustrated with them. And, above all, it may feel to them that you are pressuring them.

Instead, be there in a supportive way, saying something like:

“Oh.. that feels scary … I can understand that the eating disorder is probably screaming in your head right now, and that you are now scared of how guilty you may feel after” (note: we usually try at least 3 validations – trying to guess how they feel).

When you  can really feel that you are making them feel that they are not alone, that someone sees them and understands them, (and not just saying validating things three times!),  you can try some emotional support:

“I am here with you, we can take time (even with ice-cream😊)

I know you can do it, I am here with you and will support you after too.”

And only if you can see that something is shifting, that they are a bit less stressed, you can then also offer  some practical solutions:

“If you want, you can put the ice cream into a cup and take your time (if it was in a cone). We have lots of time.”

We recommend that you watch this video with Dr Adele La France (whom we love!) https://www.youtube.com/watch?v=-q3V_gkJoXE

or book sessions with Deirdre (https://supportedfamilies.ie/calmly-connecting-for-change/) to learn how best to support your loved one when you can see that they really want to face their fears, but on the other hand are facing this invisible wall of “not being able to…”

We hope that you found this blog helpful – please email us at info@supportedfamilies.ie with your thoughts – or leave a comment below!