Treat the parent, help the child recover from an eating disorder

Alicia knew she had to do something soon. Her daughter Eden had been stuck in a restrictive eating disorder for a few years. Eden was medically stable and in treatment. But Alicia knew that she was still deeply affected by her eating disorder. And the eating disorder was taking up a lot of space in the family and for Alicia personally. Alicia wanted to make sure she was doing everything in her power to keep things from getting worse. 

Alicia started a parent-based treatment called SPACE (Supportive Parenting for Anxious Childhood Emotions). The program included 12 Zoom calls, plus homework and practice in between. Alicia learned ways to support Eden without accommodating anxiety-driven eating disorder behaviors. At the end of the program, Alicia noticed improvements in her daughters’ eating disorder behaviors. And she gained a new perspective on how she was parenting and skills to support Eden’s recovery.

“I was unsure how I could actually do anything to change the eating disorder. Mostly I was afraid to even try. But deep down I had a suspicion (A dream! A fear!) that there was more I could do. In SPACE training I became aware of how much I was accidentally accommodating the disorder. And in fact, it was those moments when I felt like I was being most supportive and loving that I was accidentally making things worse,” says Alicia.

“Now, I am really supportive … even more supportive than before. But I also have really good boundaries and I’m not getting into dangerous waters by accommodating Eden’s anxiety. I no longer avoid the hard things we need to do to get better,” says Alicia. “When I first learned what I had to do I thought it would be harder to parent this way. But in fact, things are running more smoothly now than they were before.”

Parent training for eating disorder recovery

As a parent, you did not cause your child’s eating disorder, but you have a critical role in recovery. New research is revealing that you can help treat your kids’ anxiety-driven eating disorder behaviors, improve your relationship, and boost your child’s flexibility and resilience by participating in SPACE parent-based treatment. These skills will last a lifetime and might change the course of your child’s recovery from their eating disorder.

SPACE is about learning to recognize parental accommodation and establish a new way of responding to anxious behaviors. When applied in eating disorder situations, SPACE can address anxious behaviors like food restriction and rituals, body-checking, and body comments. It teaches you to focus on your behavior rather than your child’s behavior since that is what is within your control. Parent training can be done either as part of a group or one-on-one. The skills taught in SPACE for eating disorders include: 

1. Creating a daily routine of consistent family meals and building family connections.

2. Identifying which eating disorder behaviors are coming from anxiety and how your responses accommodate the anxiety.

3. Creating a plan for which accommodations you want to target and how you will respond differently to anxiety in the future.

4. Implementing your plan and removing your accommodation for one anxiety-driven behavior at a time.

5. Practicing and refining your approach and choosing additional targets.

How SPACE works

The SPACE parent treatment program was developed and validated by scientists at Yale University. Its original use was with kids who have anxiety disorders and obsessive-compulsive disorder (OCD). A more recent version of SPACE was developed specifically for kids with avoidant restrictive feeding intake disorder (ARFID). SPACE has also been evaluated in children who have ASD, ADHD, and challenging behaviors like physical violence and threats of suicide.

The evidence-based parent treatment usually takes place over the course of 8-16 weeks. Parents join one 1-hour meeting per week and complete homework and practice between sessions. The first several sessions focus on parent education, and the additional sessions involve the parents implementing their plans and refining their skills.

Is anxiety a factor?

If anxiety is a factor in your child’s eating disorder behaviors, then SPACE can be appropriate. Many eating disorder behaviors are driven by anxiety, including:

• Food avoidance: eating only at particular times, in particular places, a very limited list of foods, etc.

• Food rituals: measuring, counting, arranging, hiding, mashing, throwing food, etc.

• Body checking: weighing, pinching, measuring, etc.

• Body talk: frequent questions like “am I fat?” “will this make me fat?” “I’m so fat” etc.

If your child is not medically stable and/or is in Stage 1 of family-based treatment (FBT), then your targets will not be food behaviors. But if your child is home with you then it may be appropriate to apply the treatment to body checking, body talk, or other anxious behaviors that are not directly linked to the eating disorder.

Why SPACE?

I provide SPACE parent-based treatment for eating disorders because it gives parents evidence-based skills to treat anxiety-driven eating disorder behaviors. It’s an excellent option for dedicated parents who want to do more.

“There’s a sense of action and empowerment in SPACE, and I found myself feeling more hopeful than I’ve felt since Eden first started showing signs of an eating disorder,” says Alicia. “I felt so powerless so many times in the past few years, and this is the first time I’ve seen real progress in a long time.”

“I felt really connected to the other parents in my SPACE group,” says Alicia. “It was as if we could all take a collective deep breath and feel less alone in all of this. I think we were all like shaken soda cans in the beginning. We looked fine on the outside but we were ready to burst. By the end, we were sharing our successes and sometimes laughing together. There was a real sense of community and shared safety.”

Setting goals

A key goal of SPACE parent training is seeing a reduction in anxious behaviors. Parents identify the eating disorder behaviors they want to see reduced and then work towards their goals by changing their (the parents’) behavior. You can help treat your kids’ anxiety-driven eating disorder behaviors with this parent-based treatment. Target behaviors might include: 

1. Food refusal goals might include expanding the list of “safe” foods. 

2. Food ritual goals might include eating a meal without hiding food.

3. Weight ritual goals might include not using the bathroom scale.

4. Body talk goals might include fewer meltdowns over body appearance.

5. Treatment resistance goals might include less debate and negotiation about treatment plans and participation.

At the end of SPACE treatment, parents review the goals they are achieving and the goals they still have. The parents’ focus remains on ending their accommodation of anxiety-driven eating disorder behaviors since parental accommodation is a “maintaining factor” in eating disorders. But the results of the treatment will also be apparent in the child. There is good evidence showing that SPACE parent treatment results in a reduction in the quantity and severity of anxious behaviors by the child.

What results can I expect?

Could SPACE parent treatment be what your child needs to get further into their recovery? That depends on many factors, including how entrenched your child’s eating disorder is, your own ability to commit to and follow the treatment, and the consistency with which you practice your new skills at home. 

Kids may need to continue their own treatment even when parents change their behavior. Eating disorders are complex and multi-factorial, so the ongoing involvement of a therapist, dietitian, and physician may be necessary for the foreseeable future. The main opportunity with SPACE parent treatment is for you to know that you are doing everything in your power to support your child’s recovery and nothing that will interfere with recovery.

Some parents who complete SPACE treatment see improvements very quickly, but while things will feel easier and you’ll feel more confident in your own behavior, this is not a miracle treatment. It will take time for you and your child to learn a new way of relating to anxiety-driven eating disorder behaviors.

Facing difficulties

Sometimes your child’s behavior may get worse before you see improvements. This is a known phenomenon called an “extinction burst.” You’ll learn the skills you need to stay steady in the face of anxiety escalations and will work on your own emotional regulation in times of stress. Anxious behaviors are driven by “body-up” sensations and are therefore not intentionally manipulative or coercive, but to parents, that’s exactly what they feel like. 

Your desire to reduce your child’s distress and disruption will feel overwhelming at times, but you’ll have the knowledge and skills you need to respond without accommodation. Being a sturdy, strong parent when your child desperately wants you to accommodate their anxious demands will take time and practice. The SPACE parent-based treatment helps you treat your kids’ eating disorder behaviors and face these difficulties with confidence.

Extinction bursts don’t typically last long, and if you can stay the course, maintain the plan, and practice your skills, both you and your child will feel better soon. The result is fewer anxiety-driven eating disorder behaviors, confidence that you are doing the right thing, and a more connected and relaxed relationship with your child. 

Give it time

Learning to hold yourself steady in the face of a powerful anxiety-driven eating disorder escalation is hard. While every parent wishes for overnight success, SPACE parent-based treatment is more about consistent improvement. You might not see the magic happening every day, but if you stick with the plan you’ll see big changes over time.

A major side effect of SPACE treatment is a reduction of “caregiver burden,” which is significant with eating disorders and can impede recovery. You’ll feel more confident and less overwhelmed and hopeless. And that alone is a major benefit of the SPACE parent-based treatment to treat your kids’ anxious eating disorder behaviors.

That’s what happened with Alicia. The first few weeks of SPACE challenged everything she thought she should be doing to support Eden. But a few weeks later, she could sense a difference in their relationship. “There was a lot less stress at mealtimes and other times we spent together,” she said. “I didn’t even realize the burden I was carrying. But now I see that I was trying to do everything right, and I was constantly walking on eggshells, afraid to make things worse. I worried all the time. But then I learned that my avoidance had actually empowered the eating disorder. Now that I know how to safely stand up to anxiety, I feel stronger and more effective.”

“Eden is still seeing her therapist weekly, but she is firmly in recovery now,” says Alicia. “We still have work to do individually and as a family, but I’m at least sure that I’ve reduced my accommodations and am doing everything in my power to keep Eden healthy through eating disorder treatment.”

For privacy, names and identifying details have been changed in this article.

See Our Eating Disorder Treatment Guide For Parents