What would you do if your partner started restricting caloric intake or bingeing and purging? Would you know how to approach your partner, how to offer support? And what about your own mental health?
Coping with an eating disorder in the context of any relationship can be tricky. There is a growing body of literature that addresses ways to bolster support for caregivers. While this is encouraging, a number of these studies explore the experiences of “caregivers” as a generic category encompassing parents, spouses, and other relatives. Few studies focus on the experiences of spouses and significant others in particular.
Dick, Renes, Morotti & Strange (2013) looked at literature exploring eating disorders in the couple context in an effort to devise recommendations for clinicians working with couples. For their review, the authors honed in on the experiences of heterosexual couples where the female partner was diagnosed with anorexia nervosa or bulimia nervosa.
I suspect that these decisions were largely pragmatic: it would be more difficult to compare across studies highlighting the experiences of a more diverse sample. Nonetheless, I think that looking at the experiences of more diverse couples would be an incredibly interesting study… any takers?
But I digress. The authors highlight key themes in this relatively limited literature and indicate potential areas for increasing or improving support for both partners.
Obviously, intimate relationships can be complicated at the best of times (understatement of the year?). The literature suggests that in relationships where one partner has an eating disorder a number of relational problems can emerge.
MALE PARTNERS: ROLE AND PSYCHOLOGICAL STATE
I was admittedly on my guard when the authors suggested that “a major topic in the literature on eating disorders and couples is the role a male partner may play in the development of or perpetuation of an eating disorder in his female partner” (p. 233). This struck me as finger-pointing, or at least an oversimplification of the causes of eating disorders.
It is worth noting, however, that any kind of stressor could potentially exacerbate an existing or underlying eating disorder. So, the suggestion that marital distress could be detrimental to one’s mental health is understandable, an assertion that I would argue is not unique to eating disorders.
Some other assertions about the male partner’s potential role in the development or perpetuation of an eating disorder seem a little stranger: for instance, that that “a man may be attracted to a woman with an eating disorder due to his desire to fulfill fantasies of being a rescuer” (p. 233) or that this decision reflects insecurity.
I’m sorry, but really? This strikes me as similar to that dreadful article about reasons to date a woman with an eating disorder that went viral not too long ago, not as something I’d find in a peer-reviewed journal. It all seems a little to Freudian for my liking.
To clarify:I am not saying that this could never be the case. Certainly, it would be worth looking closely at whether this is a common phenomenon among men engaged in relationships with women with eating disorders. What I’m taking issue with is the idea that all (or even most) relationships with individuals with eating disorders would be co-dependent. It strikes me as incredibly similar to some earlier work on family relationships in the eating disorder context, which situated the blame solely on “dysfunctional” families.
The focus of the article, however, is on how partners cope, rather than how they might contribute to the development of the disorder.
So, how do partners cope?
The literature reveals potentially problematic patterns around conflict resolution in particular, including:
- Conflict avoidance
- Conflict over a wide variety of topics including (but not limited to) the eating disorder, sexual intimacy, moods, and affection
Conversations around the eating disorder may also be loaded: issues of secrecy and fear of disclosure may complicate couples’ ability to be open about individual or mutual struggles. This, in turn, can disrupt feelings of “couple-hood.”
If there is any area of the couple experience of an eating disorder that has received attention, it is sexual relationships. In terms of sexual functioning, studies have suggested that women with anorexia in particular may experience low sex drives. The authors also highlight literature arguing that women with eating disorders may also avoid sexual encounters due to psycho-social factors including self-consciousness and/or anxiety, body shame, and low sexual satisfaction. Perceptions of sexual intimacy may be lower for women with anorexia and bulimia, and while this may improve with recovery, sexual difficulties may persist.
Another key area that has been explored in the couples literature is the idea of “relational boundaries,” which are norms or rules partners use to negotiate relationships. Drawing on a developmental and attachment theory approach, the authors suggest that problems with boundaries that arise in the couple context may stem from “boundary issues that occurred in one’s family-of-origin” (p. 236).
Stepping out of this article for a minute, a little background information on attachment theory. Some “big names” in attachment theory research are Bowlsby and Ainsworth. I am going to oversimplify quite a bit in the interest of not having an epically long blog post, so if you are an attachment theorist, please bear with me.
I’d also like to point out that however critical I might be of attachment-based theories, I admit there is some truth and logic in the theory, and I acknowledge the promising research with attachment theory leanings, particularly in terms of understanding and establishing interventions for those “with poor attachments.”
What is a “poor attachment,” you might ask? Well, I’m glad you asked. According to attachment theory, the relationships that individuals form over the course of their lives are largely influenced by their early “attachments” to caregivers. There are a number of different attachments that infants can form with their caregivers, including:
These types of attachment are usually observed in children, for example by seeing how an infant reacts to a caregiver leaving a room and then returning. The “secure” attachment style would be characterized by the child feeling secure enough to explore (i.e., being able to be apart from a caregiver and knowing that the caregiver will return).
Notably, though attachment patterns are observed in childhood and are said to influence future relationships, they are not “set in stone.” Life events can alter the attachment, though the stability of attachments is noted to be higher earlier in life and decrease with age.
If you’re interested in learning more, I would suggest reading this article, which provides a plain-language summary of some of the main tenets of attachment theory as articulated in Bowlby (1969), Ainsworth, Blehar, Waters & Wall (1978) and Schaffer & Emerson (1964). Or go right to the original sources, but don’t say I didn’t warn you that they were a little dry…
Getting back to the meat of this article, the authors refer to three studies that use an attachment framework to understand relational dynamics in eating disorders:
- Ward et al. (2000), who found anxious attachment patterns among some women with eating disorders (leading to care-seeking) and avoidant patterns among others (leading to “extreme self-sufficiency”); together, these patterns led to women with eating disorders to “draw others close while simultaneously pushing them away”
- Broberg et al. (2001), who found similar attachment patterns among women with anorexia and bulimia, which they linked to mistrust of others, minimal emotional disclosure, and discomfort and dissatisfaction with close relationships
- Evans & Wertheim (2002), who found that insecure attachment patterns were linked to mistrust, fear of abandonment, and closeness avoidance among women with eating disorders
Despite my reticence about attachment theory, these conclusions are actually quite interesting, and would certainly have implications for establishing and maintaining close relationships. As long as we don’t interpret these results with too broad of a brush, I could see these being clinically significant.
The authors’ strong attachment orientation continues to shine through in their consideration of the emotional health of women with eating disorders and the impact that this may have on close relationships. Similar to findings surrounding relational boundaries, the authors cite studies suggesting that the following factors may get in the way of forming or maintaining intimate relationships:
- Fear of rejection
- Fear of failing
- Feelings of inferiority
- Trouble trusting others
The authors note that partners may feel:
- Unable to cope
- Responsible for their partner’s well-being
I was right there with them until they suggested that “having a partner who is unable to engage in normal social activities such as going out to dinner is likely to contribute to these feelings of isolation” (p. 237). I found this example a little superficial — isolation could just as easily stem from the factors they discussed earlier, for example, a lack of emotional closeness or difficulties disclosing emotions to significant others. While social isolation could certainly result, it seems a bit trite to bring everything down to an activity such as going out for dinner.
HOW TO HELP?
One of the best intervention ideas I’ve read about, UCAN (Bulik, Baucom, Kirby & Pisetsky, 2011), has already been covered by Tetyana (here). This intervention acknowledges that therapy must go beyond simply treating “relationship distress” and work together with couples to provide concrete skills for navigating the eating disorder and recovery.
Other interventions, too, have sought to integrate the partner as a supportive other in the “healing process.” Social support, such as that provided by a significant other, can help to bolster recovery in general, so it makes intuitive sense to foster empathetic relationships in the treatment context.
The authors provide some guidelines for balancing the needs of partners in therapy sessions. These include ensuring that the therapy goes beyond just focusing on aspects of the relationship that are explicitly linked to the eating disorder, but also addressing the needs specific to the woman with the eating disorder. The authors thus suggest that having individual sessions before couple sessions could be helpful.
Other suggestions for providing therapy to clients with eating disorders and their significant others include:
Education: education about the complexity of eating disorders, including debunking common myths, may help to counter self-blame, powerlessness, and hopelessness/helplessness and to encourage partners to take a more active role in treatment. It is equally important to work with partners around appropriate roles they can play in therapy. For example, partners may not be able to directly intervene in eating disorder behaviours, but could instead provide support and empathy.
Sexual Concerns: the authors suggest that therapists should work with both the physical and emotional aspects of a couple’s sexual relationship. This might include education and the development of problem-solving skills in the interest of deepening understanding and connection.
Potentially Harmful Comments: educating partners about the potential impacts of comments, particularly those that might not “seem” harmful, is also noted to be important. Similar to the potential harms associated with telling some individuals in recovery how “healthy” they look, body comments of any kind could be perceived as unhelpful; counseling may help partners to establish strategies for responding.
Feelings of Inferiority: the authors lost me here, a little. While I can see where they are coming from (i.e. that one would need to explore ways of communicating and mitigating feelings of inferiority), they link the lines of communication that individuals have with partners to those they established in childhood, which may or may not be the case. Again, the attachment orientation of the article really shows here: they suggest that a way to navigate feelings of inferiority would be through exploring childhood experiences.
Social Support: social support for both individuals with eating disorders and their partners is evidently important; the authors use the significant literature on caregiver coping in general to bolster their point, here. Caregivers, including partners, may find talking to similar others helpful in reducing feelings of isolation and hopelessness/helplessness (Winn et al. 2004).
In a study of husbands of women with eating disorders in particular, Leichner et al. (1985) found that the men wanted information about the following topic areas:
- Education about eating disorders
- Experiences of negative emotions including guilt, anger, isolation
- Control surrounding food
- Family concerns
- Wives’ personalities
- Sexual concerns
Community Involvement: the authors suggest that becoming involved in political and/or social causes could help partners to develop or foster mutual interests. Again, the authors lost me when they suggested that “community involvement may also encourage a couple to consider the fact that life is about more than one’s appearance” (p. 240); this presumes that eating disorders are primarily/solely about appearances, which I believe we’ve established, they are not.
Potential Medical Emergencies: another component of couple awareness and therapy is education about the emergency situations that can arise in the presence of eating disorders.
Despite some distinctly Freudian undertones and a few over-simplifications, this article does provide a few useful ideas for clinicians to keep in mind when working with these couples. As I mentioned at the beginning, I would be curious to see what research and recommendations could look like among more diverse couples.
The bottom line? An eating disorder can complicate the dynamics of intimate relationships, and in order to attend to the needs of both partners we need to be looking for ways to support individual needs both related and unrelated to the eating disorder. Perhaps my favourite thing about this article was that it did acknowledge that not every issue couples may experience is explicitly linked to the eating disorder. Relationships are complicated things; adding an eating disorder to the equation can exacerbate existing or cause new tensions.
Dick, C.H., Renes, S.L., Moroti, A., & Strange, A.T. (2013). Understanding and Assisting Couples Affected by an Eating Disorder The American Journal of Family Therapy, 43 (3), 232-244 : 10.1080/01926187.2012.677728