Mental Disorders and Illnesses: Part Four
Editing is the correction and condensing of things. Curation is the selection and organizing of things. Protection is the process of keeping something safe from harm.
Editing and Curation of Environment Under 18
In some of the best child and adolescent psychiatric treatment programs, the family is integrated into the treatment and there is much more emphasis on behaviour replacements and healing beyond stabilization. However, even with the occasional inclusion of perhaps the patients’ best friends here and there, the involvement of family is perhaps the lesser piece when it comes to the patient’s full environment of existence.
Even for these treatment programs that fully integrate behavioural change and techniques, remission remains unavailable to more than half of all adolescent eating disorder cases even when they have access to family-based treatment. 1 And as with many other psychiatric conditions for both children and adults alike, identification of remission also remains either undefined or poorly defined.
Our society is particularly class-focused on thinness and so-called wellness or health and this muddies our ability to objectively assess what constitutes remission from an eating disorder as well. If a young 11-year-old girl develops an acute eating disorder, enters family-based treatment, comes out with the requisite successful score on recovered body mass index and the eating disorder screening tool, then no one is too concerned if she subsequently expresses her remission with redoubled focus on her passion for running or lean-focused athletics.
And the catch is that a pivot to athletics may or may not constitute remission for that particular individual. Yes, it is true that I have written plenty of material on the narrowing chance that remission could be defined through athletics once an eating disorder set of behaviours has been activated. It is therefore far more likely this girl in question has swapped out avoidance behaviours, but in the right treatment circumstances there is a (albeit much less likely) chance that she was able to fully swap out maladaptive coping with adaptive coping.
Carefully Edit and Curate Peers
The debate on this topic will never end in psychology circles, but I am firmly in the camp of Judith Rich Harris on this topic so you know where I stand. In Harris’ research over the years and in her book The Nurture Assumption, she posits that it is peers, and not parents, who are most influential in shaping how children become the adults they become.
The reason I find this position compelling is that from a biological standpoint, developing relationships with peers is life protective. Establishing close relationships with peers is inevitably going to be beneficial to survival, as parents will usually stop being part of your close circle many years before you are at the end of your own life.
What this will mean for parents with children, and particularly adolescents, struggling with the onset of any coping continuum conditions it will be good to cast an eye beyond both the nuclear and extended family towards the peers who surround your child.
It will almost assuredly fail if you choose a dictatorial approach and prohibit your child from interacting with friends. But there are two options, depending on your child’s current level of self-awareness. For the first option, you must wait until your child comes to you. At any point if they actually express ambivalence or even frustration with their friends, that is the point at which you respond with motivational interviewing-level questions. When a child shares that their friendships may not align with their goals, then motivational interviewing is the best technique for helping them to further probe and investigate their own options. There is quite an age range for which this self-awareness might reveal itself, but somewhere between ages 7 and up and a conversation or two might be able to be had.
The second is an option that tends to be available to families that have more resources at their disposal, nonetheless it is even possible for families with very limited budgets and options to undertake it to a certain extent as well. It is about how (or if) to edit your child’s friendships in the event that coping continuum behaviours are being reinforced through current friendships.
We all develop our friendships proximally — in fact we do this throughout life. If we are around these people a lot, then we develop friendships with these people.
Possibilities and Provisos
For those with a lot of resources, it is possible to simply move the entire family so that the child is immersed in a brand-new environment that has a very different mix of nearby opportunities for friendships. Extracting your child from a friend circle that tends to reinforce their coping continuum issues is nonetheless a high-risk maneuver as the child could easily end up feeling terribly isolated in the new surroundings and it ratchets the coping behaviours even more.
There are additional provisos for attempting this approach:
If your child is particularly connected online, then short of moving off grid you may not be able to have them set shift into a new physical environment that gives them the opportunity to disconnect from their coping continuum behaviours as they can continue to identify within the virtual friendset they have already developed.
It removes the possibility that the current friend circle will all develop and grow in ways that are currently not predictable. This is not as unusual as it might seem and the current friend circle will be the most protective and supportive place for your child to swap out coping continuum behaviours in favour of adaptive and resilient responses over time alongside their cohort.
Some coping continuum behaviours (for example, dieting) are so ubiquitous that again, short of an off-grid option or part of the world somehow miraculously not touched by western cultural sensibilities, your child will not be given any space to develop outside of those behavioural norms no matter the friends who might encircle them.
The family still generates a core environment for your child and that old adage is very true: “no matter where you go, there you are.”—meaning if the child is struggling with contentious interfaces with parents and siblings, a move with that same core group will not change much.
I am not a fan of binary approaches to much of anything and it is no more helpful to have treatment programs that reinforce that the parents are not to blame than it is to have treatment programs that reinforce the parents are to blame (particularly mothers). It is important to move beyond the blame/blameless focus altogether.
Human terroir is a highly complex regime of existence (as discussed in more depth in the Envirakido series). The subtle dynamics of partners/parents and siblings/child in a nuclear family will mean that it is a quantum experiment of everyone being both blame-filled and blameless all at once and not at all. It is far better to focus on the here and now of how to improve things.
In Part Five, I will be looking at trauma-informed care in brief and what options there are with limited time and resources.
Lock J, Le Grange D. Family‐based treatment: Where are we and where should we be going to improve recovery in child and adolescent eating disorders. International Journal of Eating Disorders. 2019 Apr;52(4):481-7.
