The Price of Assumption

Recently, there have been heated debates between clinicians and parent advocates regarding the role of environmental and family issues in eating disorders. Some people insist that family dynamics and environmental factors play a role in the development of an eating disorder. Others bristle at the possibility. Some people say “families don’t cause eating disorders, BUT…” Others fixate on the “but” and disregard everything else.

My views on this issue are complex. Thankfully, my views became much clearer to me as I was watching an episode of the E! True Hollywood Story entitled Britney Spears: The Price of Fame. Now I am able to articulate my views on this topic in a way that most people can understand.

Numerous magazine and newspaper articles have reported that Britney Spears has been diagnosed with bipolar disorder. According to unnamed “sources close to the pop star,” Spears was suffering from untreated bipolar disorder during her public meltdown and psychiatric hospitalization in 2008. While I have not treated Britney and thus cannot ethically make a diagnosis, I will say that her erratic behavior circa 2006-2008 could be explained by a bipolar diagnosis, and that the rate of bipolar disorder is thought to be quite high amongst people in the creative and performing arts.

Scientists now know that bipolar disorder is a neurobiologically-based, genetically transmitted disease. However, rather than focusing on the neurobiology or genetics of bipolar disorder, The E! True Hollywood Story explored various influences in Britney’s life that fueled her self-destructive behavior. Clearly, this type of commentary is far more interesting to the typical E! viewer than neurobiology, my own preferences notwithstanding. Several mental health professionals were interviewed and gave their opinions as to the influence of early stardom, family problems, a stage mom, excessive fame, and extreme wealth on the pop star’s behavior. Sadly, though, the viewer is led to believe that these environmental and family issues are the cause of Britney’s downfall.

Did Britney’s family or environment cause her bipolar disorder? No. Neither family nor environment can cause a brain disorder.

Did her family or environment fuel her bipolar disorder? Yes. And here’s how: Let’s say Britney had taken a different path in life, married a plumber instead of Kevin Federline and worked as a preschool teacher instead of a pop star. Let’s say she stayed in her small Louisiana hometown, never dabbled in drugs or heavy drinking, went to bed every night at a decent hour, and maintained close, age appropriate relationships with her family and good friends, making a decent living but nothing more. Would she still have developed bipolar disorder? Yes, I absolutely believe she would have (remember, most people with bipolar disorder are not pop stars, but regular people). However, her disease would have been much more easily diagnosed and treated if she had been surrounded and supported by normal, loving people who could influence her in a positive way. As it happened, her disease was certainly protracted and exacerbated by the lifestyle of a pop star, which includes late nights, insufficient sleep, excessive amounts of alcohol and drugs, and endless amounts of power and money.

If Britney’s therapist had held a family session with Lynne and Jamie Spears and Kevin Federline in attempts to “explore the family dynamics which contributed to the disorder,” that would be a complete waste of time. The elder Spears’ and Mr. Federline – the very people who are in the best position to help Britney recover – would have felt subtly blamed and marginalized. There is nothing to be gained, and everything to be lost, by approaching a brain disorder in this fashion.

The most ideal situation for Britney would be for her parents and K-Fed (and any other people close to her) to work together to provide family-based support to help her recover and to help eliminate any environmental or family factors which may be fueling her disease. It would be most helpful for her family members to be educated about bipolar disorder and understand that it is a biologically-based brain disease that she did not choose and that they did not cause. The family would also need to know that certain environmental factors, such as pregnancy and childbirth, stress, insufficient sleep, drugs and alcohol, medication non-compliance, or excessive emotional distress, can trigger episodes and exacerbate symptoms. The family would need to learn pro-active ways to help Britney manage her environment in a way that is most conducive to achieving mental and physical wellness.

In considering this example, it is important to bear in mind that people with bipolar disorder run the gamut from pop stars to professors to businessmen to truck drivers to homeless panhandlers. Families of people with bipolar disorder also run the gamut – some are amazing and supportive, others are average, and some are downright abusive. If treatment for bipolar disorder is to be successful, the clinician must perform a thorough evaluation of the patient and family, and the information gleaned from that assessment should be used to guide treatment decisions. A good clinician would not presume that the family of a person with bipolar disorder is dysfunctional or abusive, or that family dynamics caused or contributed to the development of the disorder. Similarly, a good clinician would not presume that the family is healthy or that there is nothing the family needs to change. Quite simply, a good clinician would not assume anything – she would simply perform an assessment and tailor her approach to the strengths, limitations, and realities of that particular patient and family, in line with the most recent evidence-based research.

Eating disorders are also neurobiologically-based, genetically transmitted diseases which patients don’t choose and parents don’t cause. Family issues and environment certainly can fuel eating disorders by encouraging dieting or glorifying thinness, by making diagnosis more difficult or treatment less accessible, or by making recovery harder than it needs to be.

All eating disorder patients have a biological brain disease which most likely would have arisen, at some point in time and to some degree, regardless of family or environment. Some patients have family or environmental issues which are fueling their disorder, and some do not. If such familial or environmental issues exist, they usually become quite obvious if you do a thorough assessment. These family or environmental issues will need to be addressed in treatment, not because they caused the eating disorder, but because they can trigger or exacerbate symptoms and interfere with full recovery.

But if there are no obvious familial or environmental issues fueling the disorder, please don’t waste time searching for them. You aren’t doing the patient or the family any good by “being curious,” or “just exploring.” You are simply satisfying your own voyeuristic drive, as I fulfilled mine by watching the E! True Hollywood Story on Britney Spears.