I'm a mom supporting a young adult daughter who has been dealing with anorexia for 7 years. We used FBT when she was younger with only partial success, despite years of trying. We're now finding that she does better with her taking full responsibility for her recovery and with us in support roles. There has been a learning curve for me to figure out how to support her without undermining her ownership of her recovery. I hope some of my observations might be relevant to you and your sister.
My first recommendation would be to watch Tabitha Farrar's YouTube channel. She's a recovery coach who recovered on her own as an adult after years and years of anorexia, and she touches on a lot of the issues that come up especially for people who are trying to recover after a long time. Now that I've been following Tabitha for a while, I find that I'm less often totally blindsided by what's going on for my daughter. (It used to be that whatever I thought she was struggling with at a particular moment, it was almost certainly something entirely different I had never thought of. Now that doesn't happen so often.) Tabitha has a few videos relevant to your situation:
- How can I best support my partner with an eating disorder?
- Parents calling you out on restriction
- Using my brother for FBT?
- Asking for help from family
What's going to be an effective way of supporting your sister really depends on your sister. Tabitha has a section in her book Rehabilitate, Rewire, Recover
that walks individuals in recovery through the process of lining up their supports and deciding who they want in what roles. You might want to take a look at this for some ideas.
Lots of people talk about meal support as a way to help. Don't be surprised if your sister does not find that helpful. When there is a long history, it can be difficult not to fall back into old patterns around the people we know best. For instance, maybe your sister has been pretending to eat well, but actually piling a heap of salad under her other foods to make it look like more, or getting rid of part of her food, or purging, or exercising more in the days leading up to a meal she has with you, or eating less than usual in advance. In this case, she's probably better off turning to someone else for meal support. My daughter has found it's easier to eat well with people she doesn't know as well, especially at restaurants. (Of course, this can also be used as an excuse not to eat together when not eating enough. Double-edged sword.) The other piece of this is performance eating. The individual in recovery wants so much to please the people in their life, to show how well their doing, to relieve those people of the stress they have put them through over the years. This leads to once again using those tactics to make it look like their eating better than they are. It also leads to thinking of recovery as something they're doing for their loved ones, when they need to be doing it for themselves. As long as they're doing it for someone else, the appearance of recovery is more important than real recovery.
Some people find it helpful to call or text with a friend during a meal, just prior to a meal, or just after a meal. If someone else is fixing a meal, especially a particularly challenging one, it might help to take your sister out somewhere before the event. Go for a drive right before Thanksgiving dinner. Some people also find it helpful to be around someone immediately after eating. Go out for a movie after dinner.
Grocery shopping can be a big issue for adults in recovery. It might be helpful for your sister to leave the shopping and cooking to someone else, like her husband. You might be able to help with that. Or maybe you could be available to her by text or in person to help her if she gets stuck in indecision in the store. My daughter has sometimes used me as a backup for her memory. She would feel clear about her objectives before she faced with a food-related decision, but when the decision point came, she would be in such a state of fear that she couldn't remember what she was doing. When this was happening, she started telling me in advance, then calling me to ask for a reminder.
As someone who knows your sister since before her eating disorder, you can help her reconnect with her true, non-ED self. For people who have had an ED for a long time, the eating disorder has consumed all their thoughts and narrowed their lives during all that time. It can be hard to figure out who you are without the eating disorder, and that feeling of not knowing can engender a lot of fear. My daughter went through a phase when she asked me to reminisce about the days before the ED and help her see how she still has the same strengths she did as a child and she can draw on them to help her recovery and rebuild her life. It can also help to share some open-ended fantasizing about what directions she could go in once she is free from the ED.
Regrets about everything that was lost due to the eating disorder are another double-edged sword. Seeing everything that one has lost to an eating disorder can be disheartening. It's easy to get into an unhelpful, self-denigrating mindset. It's not just the obvious things one didn't get to do, the trips or events or accomplishments. What's harder to see, harder to look at and acknowledge, is the damage to relationships, connections, and personal growth. That can be both very painful and very motivating. Talking honestly and lovingly about the losses and regrets can be healing at the right moment. Letting your sister know that you are open to sharing her pain could be a gift.
At some point you may find yourself in a position where your voice may be one she can hear saying difficult things. Progress can be slow, and you might not be able to see some of the progress she is making, so don't worry if you can't see improvement right away. However, if, after a while, you get a strong feeling that she is spinning her wheels, you might want to bring it up by gently asking whether she
feels she is still making progress or is starting to feel stuck. Her treatment team should be watching out for this, but it's good to have a family member looking out for her, too. Treatment providers can be lovely and kind, but also make mistakes. It's quite common that providers set target weights too low or focus too much on weight restoration as the only marker of recovery. Parents doing FBT often have to fight for higher target weights and don't see full restoration of a healthy mental state until their child goes well above the original target weight. When that happens with adults, they can wind only partially recovered and feeling stuck. Providers also don't always see some of the signs that anorexia has not left the mind: difficulty making decisions around food, planning everything around how she will work in her eating, standing all the time, strict routines that must be followed before eating, linking eating to what others are eating or exercise to others' exercise, feeding family members treats without eating any, hoarding/unwillingness to spend money, not sleeping enough/requiring self to be productive all the time. As a family member, you're likely to see the ways in which the ED is still ruling her life. The time may come when you can save your sister from a half-life of semi-recovery by calling her out on this type of stuff and asking her whether this is really the way she wants to live. In the mean time, try to respect her request not to ask her how it's going all the time. She will need to figure out a lot of difficult stuff, and it will take time and space without the feeling that her loved ones are constantly judging her progress.