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College Mental Health Eating Disorders Family based treatment

Eating Disorder College Contracts

Eating Disorder College ContractIf you are sending a young adult with a history of an eating disorder to college (or seminary or another away program), it is a good idea to have a college contract in place. This is our recommendation for young adults with anorexia, bulimia, binge eating disorder, ARFID, and OSFED.

College and living away from home for the first time brings novel stressors and recovery challenges. Any transition can challenge the most stable of recoveries. The freedom and independence can provide a breeding ground for an eating disorder. Your young adult will be eating in an entirely different context than the one they have practiced recovery in. Relapses during college or the first period of independence are not uncommon.

Prior to sending your young adult with an eating disorder off to college or a similar independent experience you will want to ensure that your young adult is ready for the challenge of being away from home. A contract is NOT a substitute for readiness. Read more about our criteria for readiness in our post about college readiness. If you deem them ready, a college contract can be very helpful.

A contract is an agreement between the parents and the student—obviously not a legally binding document. Treatment professionals may help develop the contract or play a role in supporting the contract, but they are not parties thereto. I think about a contract as a safety net rather than something adversarial. Parents are on the side of their young adult—and are merely saying, “We want you to be in college, but we want to ensure that you are healthy enough to stay there in order to fully benefit from the college experience.” They then use the contract to specify the criteria required for the student to stay in college, as well as the consequences if those criteria are not met.

As long as you are paying for some of your young adult’s school or living expenses, you have leverage and can require a contract. I do not advise counting on the school to ensure your young adult stays well. No college, even those with excellent mental and physical health resources, is able to provide the level of oversight that parents do.

A contract should include the following:

  • A minimum healthy weight for your student based on optimal physical and psychological recovery and historic weight patterns, ideally developed with a treatment team and taking into account that young people are expected to gain weight until about age 20
  • A release of information signed by your student, allowing treatment professionals to communicate with you
  • A plan and cadence for your student to get weighed and have their vitals checked
    • Some families are able to set this up with the college health center; others with private practice professionals (MD, RDN, or therapist)
    • The frequency of weighings and vitals will be determined based on length in recovery and stability
  • A plan for consistent communication of the above weights and vitals information (i.e., each time it’s checked, or only if concerning; to whom on the team and when to parents).
  • Recommended treatment follow-up with various professionals. This ideally follows the recommendation of the prior treatment team and may include as many team members as necessary. Some individuals may need a full team; others may just need weights and vitals.
  • An expectation regarding behaviors:
    • Meals—how many meals and snacks the student is expected to have and any associated guidelines, such as a meal plan.
    • Exercise—any appropriate restrictions.
    • Any other behaviors of concern, such as purging
  • The specific steps parents will take if there is a lapse including weight loss or an increase in eating disorder behaviors.
    • For smaller lapses, parents may give the young adult some time to self-correct or regain weight independently and maybe increase sessions with team members before initiating other steps.
    • Some parents specify that they will come to school and stay with the student and try to help them for a time to get on track while staying in school.
    • If these steps are not working and for more significant lapses, parents may require the student to come live at home or go to residential treatment.

As with any consequence, parents should not include anything in the contract on which they are unwilling or unable to follow through.

I recommend that parents and their students start talking about the college contract and college readiness at least six months before the start of college, so the young adult is not surprised by the idea of a contract. I suggest parents write the first draft and then share it with their treatment team and their young adults and then incorporate feedback. The agreement should be signed by the parents and the student and the current treatment team members may also sign it showing their endorsement.

Sample College Contract:

In order for Mary to be successful at college, we agree to all the terms set out in this agreement and will not take action beyond what is prescribed in the agreement without a review with Mary and her team first.

  • We will treat Mary like a responsible adult.
  • We will not show up at college unannounced.
  • We will give 24 hours’ notice before visiting.

In order to remain at college:

  • Mary will be weighed weekly at her counseling sessions with Dr. Freud. Dr. Freud will communicate her weight to her parents each week.
  • Mary will attend weekly counseling sessions with Dr. Freud and bi-weekly appointments with dietitian Nancy.
  • Mary will eat 3 meals in the dining hall and 3 snacks daily containing appropriate amounts of fats, carbs, and protein in order to maintain her weight. She will eat a dessert daily.
  • Mary will not become a vegetarian.
  • Mary will maintain a minimum weight of 140 pounds.
  • If Mary binges/purges, she will discuss it with Dr. Freud and Nancy and develop a plan.
  • Mary agrees that physical and emotional health and safety are a higher priority than educational progress or participation.
  • Mary will be mindful of exercise as a potential trigger and will limit exercise to no more than 3 times a week for 30 minutes. Mary agrees she needs to consume sufficient food to fuel her level of exercise.

The following backup plan is not a punishment but a safety net to facilitate ongoing progress:

  • If Mary’s weight drops below 140 pounds, she has 2 weeks to regain the lost weight. Her parents and dietitian will help with suggestions and provide more snacks.
  • If lost weight is not regained by the 2-week mark, one of her parents will come to college at the end of classes for the week and all meals and snacks will be supervised by her parents for the weekend, even if Mary has to cancel something. Mary can return to classes after the weekend after the Sunday evening snack. Supervised weekends will continue until weight is back above 140 pounds. Once the weight is regained, Mary can remain at school without parental supervision.
  • If supervised weekends do not result in expected weight regain in 2 weeks, Mary will return home until weight is regained.
  • If Mary fails to comply with any of this agreement, she will need to withdraw and either enter residential treatment or seek employment.

We will review this contract at the beginning of each academic semester and revise it as needed to help Mary maintain healthy eating habits.

Signed:______________________                Date:_______________

 

Signed:______________________                Date: _______________

 

 

Witness: ­­­­­­­­­­­­_______________________           Date:­­­­­­­­­­­­­­_______________

Categories
College Mental Health Family based treatment Family-Based Therapy

On Empowering Parents—Not Pathologizing Them

I often write about the importance of including parents in the treatment of adolescents and young adults. My work is informed by my training in Family-based Treatment (FBT), which as a central part of treatment seeks to empower parents to help their ailing children with eating disorders to return to health. When asked why families should be the center of treatment, I usually cite the AED guidelines on the role of the family, The Nine Truths About Eating Disorders, and the vast evidence base underlying FBT. I often discuss how providers who see families with children with eating disorders get a distorted view of the family: they do not have the benefit of having seen how it functioned prior to the eating disorder. Parents’ behaviors are often pathologized when they are actually the normal response of healthy parents to a child in distress.

This post is different—here I will share a more personal perspective.

Recently, one of my children (anonymized here because the story is theirs to tell) stumbled. My child was fighting a mental health issue that was not an eating disorder. The experience of watching my child struggle, and struggling to help my child, has further informed my thinking on this issue.

Sadly, it remains common for parents of children, adolescents, and young adults with mental health problems to be judged, labeled, blamed, and excised from the child’s treatment. This has happened to families with whom I have worked. Parents have sometimes been labeled as “enmeshed” or “overprotective.” This is not productive.

I’m writing this blog to share how beneficial it was personally to be included in my young adult child’s treatment. First, let me give you some background.

For Most of My Parenting Years, I Was Balanced

I care for my children deeply and have chosen a career that has allowed me the flexibility to be present in their lives and to be their primary caretaker. At the same time, I have been anything but a coddler. All three of my children were sleep-trained at less than six months, left at a young age with non-family babysitters, and dropped at preschool on the first day. I shed some tears, but I was not a parent who stayed and watched outside of the classroom for months; I went to work.

I also developed a certain toughness to set limits. During my kids’ early years, I worked at Los Angeles County Jail, where I encountered numerous inmates demanding sleeping medications or “more desirable” housing assignments and then threatening suicide when they didn’t get their way. I became a pro at placing inmates on suicide watch and walking away despite their sometimes yelling at the top of their lungs that they would tell the entire jail, “It’s because of you, Dr. Muhlheim, that I will kill myself.”

I am not a perfect mother, but I am a highly dedicated, devoted one. I have sought to balance my joy in raising my children with time to pursue my own interests and career.

When My Child Started to Struggle I Became Highly Involved

When I work with parents of teens and young adults with eating disorders, I encourage parents to trust their instincts. “Parents know their kids best,” I tell them. During the transition to college, when my child was supposed to be individuating, I knew something was amiss, so I hovered more than usual.

Fortunately, when my child wobbled, I was prepared. I trusted my instincts. I was fully present: watching, standing close, getting my child help. I helped save my child’s life. There are powerful cultural expectations that parents should back off and allow their child to individuate. There is less support for parents who choose to step in at this moment. Observing my behavior at that time, I may have been labeled as overprotective.

Even my child, who recognized the need for parental help, was fighting against it. This was confusing to their therapist, who later wrote in a report, “There is a weird dichotomy between the child and the parents. The child refuses to sign a release of information for the therapist to speak to the parents, but the child appears to reach out to the mother for support.”

Rather than pathologizing hovering parents, we need to recognize that they are doing it for a reason.

Professionals Supporting, Not Blaming Parents

The hardest moments of this whole journey were those times that, on top of his worry for our child and whether they could or would actually recover, my husband blamed himself for causing the problems our child was facing. This tendency of parents—to blame themselves for any problem that befalls a child—is typical, whether or not the problem could be attributed to parenting. I noticed that when my husband started to blame himself, we both became hopeless and lost focus on helping our child. These were dark times—it was hard to have our own faith and be present for our child.

Fortunately, we had the means to seek out high-quality treatment. Our child was treated in a center that specializes in treatment often used for a problem for which parents have historically been blamed. In this program, we as parents were given much-needed support and services as well. Importantly, the clinicians never indicated they believed that we had caused our child’s problems. Instead, we were validated, supported, and given a framework for understanding our child’s problems that did not point the finger at us.

Made/Makes All the Difference

Further, our responses to our struggling child were validated as a reasonable response to experiencing our child’s struggles. We were supported in our child’s recovery, empowered to play a role, included in the treatment, and seen as parents doing our best. This was profound. I think it made all the difference.

Our child worked hard and so did we. With the proper help and our support, our child is now healthy and firmly back on track. My hope for other parents of floundering adolescents and young adults is that they are treated with the same respect that we were.

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