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Attacks on linking: stressors and

identity challenges for mothers of
daughters with long lasting anorexia
nervosa
ab a a
Rivka Tuval-Mashiach , Ilanit Hasson-Ohayon & Adi Ilan
a
Department of Psychology, Bar-Ilan University, Ramat Gan, Israel
b
The Gender Program, Bar-Ilan University, Ramat Gan, Israel
Accepted author version posted online: 03 Jan 2014.Published
online: 28 Jan 2014.

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To cite this article: Rivka Tuval-Mashiach, Ilanit Hasson-Ohayon & Adi Ilan (2014) Attacks on
linking: stressors and identity challenges for mothers of daughters with long lasting anorexia
nervosa, Psychology & Health, 29:6, 613-631, DOI: 10.1080/08870446.2013.879135

To link to this article: http://dx.doi.org/10.1080/08870446.2013.879135

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 Psychology & Health, 2014
Vol. 29, No. 6, 613631, http://dx.doi.org/10.1080/08870446.2013.879135

Attacks on linking: stressors and identity challenges for mothers of

daughters with long lasting anorexia nervosa
Rivka Tuval-Mashiacha,b*, Ilanit Hasson-Ohayona and Adi Ilana
a
Department of Psychology, Bar-Ilan University, Ramat Gan, Israel; bThe Gender Program,
Bar-Ilan University, Ramat Gan, Israel
(Received 24 September 2012; accepted 21 December 2013)

The purpose of the current study was to focus on the subjective experience of
mothers of daughters with ongoing anorexia nervosa. Specically, we
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explored the stressors faced by these mothers while coping with their
daughters illnesses; we also looked at how they experienced their maternal
selves and roles, and their perceived competence in coping with their
daughters illnesses. Two related aspects were found to be central in the
participants experiences. One aspect was their network of relationships and
how these relationships were challenged or compromised as a result of their
daughters illnesses. This aspect included the mothers relationships with their
daughters, the mothers relationships with other family members and with
their spouses/partners, the mothers relationships with the professionals
treating their daughters, and the mothers relationships with themselves. The
second related aspect was the challenge presented to the participants
self-perception as good mothers by their daughters illnesses. The ndings
showed that coping with a daughters eating disorder (ED) posed a signicant
obstacle to the mothers ability to maintain a satisfying relationship with her
daughter and her environment, as well as to maintain a positive maternal
self-perception. The implications of these ndings for professionals working
with caregivers are discussed, and a more nuanced, gender-specic attitude is
suggested in working with mothers caring for daughters with EDs.
Keywords: motherdaughter relationship; eating disorders; family burden;
childs illness

Anorexia nervosa is an eating disorder (ED) that usually begins during adolescence,
and is more frequent in women than in men (95% are women). It is characterised by a
very low body weight (85% of what is considered normal for a specic individuals age
and height), an intense fear of putting on weight despite the individuals being severely
underweight, amenorrhea and distorted body image (American Psychiatric Association,
2000). Anorexia is both a physical and mental illness: the patient suffers serious and
life-threatening physical symptoms, as well as a signicant misreading of reality in rela-
tion to weight, body image and food intake. Furthermore, patients with anorexia do not
perceive themselves as being ill and therefore tend to refuse treatment and help from
parents and professionals (Polivy & Herman, 2002). About one-third of those diagnosed
with anorexia remain sick ve years following their initial diagnosis, and fewer than

*Corresponding author. Email: tuvalmr@mail.biu.ac.il

2014 Taylor & Francis

 614 R. Tuval-Mashiach et al.

half of those aficted with an ED (both anorexia and bulimia) ever fully recover
(Steinhousen, 2002; Steinhausen & Weber, 2009). The chronic nature of the illness
leads on many occasions to medical complications and sometimes results in death
(Taylor, Bagby, & Parker, 1997), creating challenges and a heavy, ongoing burden for
caregivers, especially within the family (Highet, Thompson, & King, 2005).
The caretaking burden on parents of children with severe mental illness
is documented extensively in the mental health literature (e.g. Baronet, 1999;
Hasson-Ohayon, Levy, Kravetz, Vollanski-Narkis, & Roe, 2011; Tsang, Tam, Chan, &
Chang, 2003) and is traditionally conceptualised as having both objective and subjective
components (Hoenig & Hamilton, 1966). Several attempts have been made to assess
the experience of parents of children with anorexia. In many of these studies, however,
the focus has been on caregivers in general, and no attempt has been made to
differentiate between parents and other caregivers, or for that matter, between fathers
and mothers. Caregivers of patients with EDs have been found to experience high levels
of both objective burden (as measured by the extent of disruption or change to caregiv-
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ers lives) and subjective burden (emotional costs). This subjective burden has been
experienced as higher with anorexia than with other EDs (Santonastaso, Saccon, &
Favaro, 1997) and higher also with anorexia than with other chronic disorders such as
schizophrenia (Treasure et al., 2001). Recently, in the EDs arena, family therapies (e.g.
Robinson, Dolhanty, & Greenberg, 2013) and interventions for informal caregivers were
developed to specically address the burden on parents who cope with the illness of
their child (e.g. Grover et al., 2011; Hoyle, Slater, Williams, Schmidt, & Wade, 2013).
While most of the studies on parents of children with anorexia have focused
specically on how the parents coped with their childs illness (Honey & Halse, 2006;
Sharkey-Orgnero, 1999; Tierney, 2005), less empirical and theoretical attention have
been given to their broader subjective experience (i.e. the special challenges faced by
these parents in terms of their identity and perceived roles within the family). Further-
more, very little research has been done regarding the differences between maternal and
paternal experiences when dealing with a childs ED. However, given the differing roles
and functions played by mothers and fathers in general, and when coping with a childs
illness in particular (e.g. Waters et al., 2000), there is reason to assume that mothers
and fathers experience their daughters eating behaviours differently, and cope in differ-
ent ways. This idea is in accord with other studies on mothers of children with a variety
of different illnesses or disabilities that assume the unique sociocultural construction of
motherhood and focus on the maternal experience (e.g. Hassall, Rose, & McDonald,
2005; Young, Dixon-Woods, Findlay, & Heney, 2002).
In western societies, mothers are held more accountable than fathers for their childs
health and well-being and are culturally considered responsible for their childs
developmental or psychological difculties (Caplan, 2007; Lee, 1999, Ruddick, 1989),
including their EDs (e.g. Cooper, Whelan, Woolgar, Morrell, & Murray, 2004; Hoskins
& Lam, 2001). In addition, theoretical (i.e. mainly psychoanalytic) and clinical attention
has historically focused on problematic aspects of the motherdaughter relationship in
order to account for the daughters ED (Bruch, 1973; Masterson, 1995; Palazzoli,
1985). This historical stance, which has contributed to the stigmatisation of these moth-
ers, has perhaps resulted in a parenting experience that is quite different for mothers
than it is for fathers. Another rationale for focusing on the maternal experience of
coping with a childs ED stems from studies in the mental health eld showing that
 Psychology & Health 615

women as caregivers tend to be more vulnerable than men (Lee, 1999, 2001;
Zendjidjian et al., 2012), that gender differences are stronger than role differences
(patient/caregiver), and that women experience more distress as caregivers than men do
(i.e. Hagedoorn, Sanderman, Bolks, Tuinstra, & Coyne, 2008).
The aforementioned challenges to the coping abilities of mothers of daughters with
EDs relates to their perceived parental efcacy, which could be dened as the beliefs
or judgments a parent holds of their capabilities to organise and execute a set of tasks
related to parenting a child (de-Montigny & Lacharite, 2005, p. 390). Bandura (1997)
suggested that there are four major sources for the development and maintenance of
parental self-efcacy (de-Montigny & Lacharite, 2005). These sources are: enactive
mastery experience (childcare experience prior to becoming a mother); vicarious
experiences (learning from observation and modelling); verbal persuasion (signicant
others beliefs regarding the maternal capacities of the mother); and physiological and
affective states. In addition, the childs characteristics also affect the parental sense of
efcacy (de-Montigny & Lacharite, 2005; Teti, OConell, & Reiner, 1996). Thus, estab-
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lishing and maintaining a sense of maternal efcacy is based on sources that are related
to the mothers relationship with herself, with her daughter and with the environment.
Since it can be assumed that all of these relationships are at risk while coping with a
daughter who has an ED, the sense of maternal self-efcacy might also be challenged.
Nevertheless, a review of the literature shows that there has only been one
published study specically addressing the challenges faced by mothers of daughters
with anorexia. In that study, it appeared that mothers who were coping with a daugh-
ters ED felt shame and guilt, and as if they were carrying around an embarrassing
family secret. These mothers not only blamed themselves for their childs anorexia, but
also described feelings of being blamed by professionals in the eld as well (Hoskins
& Lam, 2001).
In the current study, we wished to look into these matters more deeply and address
the subjective experience of mothers of daughters with chronic anorexia, their
perceptions about themselves and their maternal efcacy. In doing so, we hoped to
better understand the sources of stressors that these mothers experienced when coping
with their childs illness, both in relation to their own identities as women and to their
roles as mothers.

Method
Participants
The data analysed for this paper were extracted from in-depth interviews conducted
with 10 mothers (aged 4365) of daughters who either had a chronic ED at the time of
the study (four mothers) or had since recovered (six mothers). The range of EDs was
between 38 years in duration. All daughters were originally diagnosed as suffering
from a chronic sequel of anorexia nervosa, and all were hospitalised at least once in
ED units for the purpose of treatment. As we wished to understand the mothers
experiences in the chronic phase from the widest possible perspective (both
retrospective and current), we chose mothers whose daughters EDs had gone on for at
least three years prior to the time of the study, and also mothers whose daughters had
eventually recovered.
 616 R. Tuval-Mashiach et al.

Procedure and interviews

The Bar Ilan University Ethics Review Committee approved this research study.
Mothers were then recruited via contact with several clinics for the treatment of EDs,
advertisements in internet forums and the use of the snowball method, whereby
participants told other potential participants (i.e. mothers with anorexic daughters) about
the study. Mothers who agreed to participate were informed of the research purpose and
gave their signed consent.
Each participant took part in one interview, which was comprised of two stages.
During the rst stage, mothers were asked to describe their experiences of coping with
their childs ED in an open-ended narrative, from the initial onset of the illness to the
current time. During the second stage, several key questions were asked in order to gain
a better scope of the stressors and challenges faced by these mothers and their strategies
for coping. The main questions during this second stage were: What was difcult for
you during the time of the illness? What were the sources of stress for you? What
helped you cope? Can you describe your feelings and thoughts from this time?
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Interviews were conducted in the participants own homes, except for two which were
conducted in ED clinics, as per the participants requests. Both stages of the interview
were conducted in one session and the length of the interview was between one and a
half and two hours each. All interviews were recorded on audiotape and transcribed.
Two raters individually coded each transcript and then cross-checked their codes.
The interviews were carried out by a clinical psychologist who had a basic
knowledge of EDs, and the research was conducted as part of her MA dissertation. She
had no prior acquaintance with any of the interviewed mothers, and was closer in age
to the daughters than to the mothers. This information was openly disclosed to
participants during the rst telephone call in which participation was requested. It was
our impression that because the interviewer was not afliated with any hospital or
formal ED centre, the mothers who were initially suspicious regarding the purpose of
the research and the initiative behind it felt a greater willingness to participate in the
study, an impression that several of the mothers conrmed quite clearly. It should be
said that the interviewers age, being closer to that of the daughters than the mothers,
might have impacted the narratives in a way which emphasised the relational aspects of
the mothers experience, especially in regard to the motherchild relationship. The two
other authors, who took an active part in the analysis of the ndings, are the supervisor
of the MA dissertation (Rivka Tuval-Mashiach), a clinical psychologist with extensive
clinical experience with women with EDs, and Ilanit Hasson-Ohayon, a rehabilitative
psychologist who is an expert in the eld of mental illness and has long worked with
patients and their families.

Analysis
Transcripts of the interviews were analysed for categorical content analysis on the basis
of the model of narrative analysis proposed by Lieblich, Tuval-Mashiach and Zilber
(1998). According to this model, textual analysis focuses on the dimensions of content
and/or structure and on the unit of analysis, with the choice of using the unit of the text
as a whole (holistic analysis) or only parts of the text (categorical analysis).
As is common in qualitative research, we employed both conrmatory and
exploratory analyses. In conrmatory analysis, the researcher tries to conrm or validate
 Psychology & Health 617

prior theoretical notions, while exploratory analysis aims at opening up new hypotheses
and theoretical concepts (Patton, 2002). In the rst stage of this study, the existing
literature on parents experiences when coping with a childs ED guided our initial anal-
ysis of the main themes. While we were searching for the factors and contents leading
to the mothers distress, however, it appeared that rather than describing specic stress-
ors, the participants emphasised the ways in which the ED interfered with their relation-
ship networks. Therefore, we decided to focus on relationships as the main overarching
theme, and to map the types of relationships the mothers described and how they
related to the mothers experience of their daughters ED. This inquiry resulted in the
conceptualisation of four domains of relationships, which are presented in the Results.

Results
General ndings
All of the mothers described the onset of their childs ED as a traumatic, life-changing
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event, which derailed their lives from their natural paths. The mothers narratives
revealed that they were intensely absorbed by and involved in the management of their
daughters illnesses on both practical and emotional levels. Although mothers described
the various difculties they confronted in coping with their daughters including those
which they experienced on a daily basis what they emphasised most were the
relational aspects of their experience, i.e. the relationships seemed to determine or at
least heavily inuence the participants feelings of competence regarding their percep-
tion of themselves as mothers, and their own mothering skills. Therefore, an overarch-
ing theme of relationships emerged, and we have framed the results of this study
within this overarching theme.1 Table 1 summarises the themes which emerged.
Four types of relationships emerged from the narratives: the relationship with ones
daughter, the relationship with ones spouse/partner and other family members, the
relationship with the greater community, and the relationship with oneself. It appears
that in their narratives of relationships, mothers described a subtle process of evaluating
their own mothering abilities against an implicit cultural model of a maternal ideal,
which constitutes who and what a good mother is. Furthermore, in regard to each type
of relational stressor, a different aspect of the maternal ideal was highlighted and
perceived to be missing or lacking in the mothers perceptions of themselves and their
mothering abilities. In what follows, we will present the four relational domains,
illustrate them and interpret our ndings in relation to the mothers maternal identities,
as compared to their perceptions of the maternal ideal.

Domain I: the motherdaughter relationship: threats to the image of the good

mother as connected to her daughter
All of the mothers described their relationships with their ill daughters as a primary
source of stress, worry and emotional turmoil, beginning with the rst time they
suspected their daughter was ill, peaking upon their daughters formal diagnosis and
uctuating thereafter, in accordance with their daughters illness status.
A recurrent theme, emerging in all of the interviews, was that of the mothers
inability to communicate with her daughter. As a result, the mother often worried that
the relationship between the two was in jeopardy:
 618 R. Tuval-Mashiach et al.

Table 1. Themes of relationships in the maternal experience.

Organizing theme:

Relationships
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Relationships with Relationships with Relationships with Relationships with

daughter other family the environment: oneself:
members:
Difficulties in Relationships with ED Reflection and
Relationships with
communication professionals: rumination on ones
other children:
behavior
Being blamed The need to maneuver Being left out of
between the different treatment Self doubt as a mother
Mothers feelings: needs
pain, guilt, Conflicts with (am I a good mother?)
helplessness The impact of ED on professionals
siblings Mothers feelings:
Feeling blamed pain, despair, guilt
The threat of falling
apart

Relationships with
husband:

Loneliness,

Lack of division of
responsibility
 Psychology & Health 619

She was always locked in her room, always in the dark. And you didnt know if she was
in there or not. And sometimes I would knock on the door- Gail, open up! Gail, open
up! (crying). It was always locked. And in our house the doors had never been locked
before. She locked herself in there with a key I didnt know how to speak to her. I still
dont know how to speak to her, even today. We ght all the time. (Sharon)

This mother describes both the physical and emotional barriers that come between her
daughter and herself. The locked door also symbolises for the mother her daughters
hidden needs and feelings, which she will no longer share with her mother.
Expressions such as I cant reach my daughter, she doesnt talk to me and she
wouldnt listen to anything I tried to say were at the core of the mothers frustration
and pain, especially as these feelings marked a major departure from the relationship
that existed prior to the onset of the disorder.
For some of the mothers, this rupture in the relationship is so painful that they
would prefer anything to their daughters silence even being blamed by their
daughters for their problems:
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She has a million complaints for us as her parents, but she hasnt voiced them yet. I wish
she would just come to me and explode and say: You were not a good mother; you were ter-
rible all these years. At least then I would know what to I mean, she doesnt even dare
to come and yell at me. All she says is: everything is ne, just leave me alone. (Dafna)

This unexplained rupture in the relationship results in two parallel processes. The
mother makes greater and greater efforts to initiate a connection with the child who is
pulling away, efforts which in most cases prove futile and are eventually abandoned.
The other result is an internal emotional-cognitive process of checking what and where
did I go wrong, a theme we will elaborate on in greater detail in the last section.
Several mothers said that when their daughters did eventually speak to them, they
were shocked by the intensity of the anger and blame targeted at them. Blaming was in
some cases targeted towards both parents, but in most cases it was aimed at the mother,
both because of her active involvement in the treatment or in a few cases because
she was held responsible for the disorder. Ann says:

One day we watched TV and saw a baby whose parents burned him with cigarettes. I said:
What parents could do such a horrible thing to their child? So my daughter said: I know
parents who did an even worse thing to their child. I said: What? She goes: They forced
their child to be hospitalised. It was very painful for me to hear.

Mothers emotions in the context of their relationships with their daughters included
confusion, frustration, guilt, helplessness and despair, as well as anger and disgust. It is
important to note that positive emotions and moments of closeness were also
experienced by the mothers at times, but since our focus in the current paper is on the
stressors, we dont refer to them. In addition, although a few of the mothers described
some areas in which their relationships with their daughters had improved over the
years, all of them stated that they were never able to recapture the same
motherdaughter bond that had existed between them prior to the illness.
 620 R. Tuval-Mashiach et al.

All you want is for your child to be happy and blessed and you dont know how to do
those things for her. You dont know how to help and you dont know what to do for her
this frustration is with me all the time, at this very moment. (Lee)

The relationship with the daughter was described as the most painful relational aspect
of the mothers experience. Since it was the daughter whose illness required the
mothers focus and attention, it is not surprising that the childs situation created such a
primary stressor. Nevertheless, we claim that in addition to the objective stress of the
daughters illness, another source of sorrow and pain for the mother was the impact that
the illness had on the motherdaughter relationship. The difculty the mothers had in
understanding their daughters and why they behaved as they did, and the deterioration
of their relationships, added to their feelings of inadequacy as mothers. Because one of
the primary characteristics of the good mother is a strong, affectionate bond,
especially with her daughter (Chodorow, 1978; Miller, 1991) one which includes
empathy, identication and proximity these mothers felt ill-qualied in this aspect of
their maternal identity. Since they didnt understand why their daughters became ill in
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the rst place, nor could they empathise with their daughters disorder, these mothers
found themselves feeling disconnected from their daughters, unable to help them
recover or protect them from the deterioration that accompanies the disorder. The
position of not being able to help and protect their daughters reinforced the mothers
feelings of impotence and incompetence, leading them to feel that they were the
antithesis of the nurturing and caring good mother.

Domain II: relationships with other family members: threats to the good mother as
the keeper of the family
Another source of self-doubt was the mothers relationship with other family members.
Despite the signicant disruption created by their daughters EDs, mothers struggled to
maintain family life and routine as smoothly as possible. Coping with the illness
demanded time and energy that inevitably came at the expense of other family
members, especially younger brothers and sisters:

You are only busy with her (the daughter). Its not that you neglect the others, but lets say
that it was 90% with her, and 10% with the others, and you do have other children. They
were very hurt, and they would come to me and say: Youre always with her; when will it
be over? We tried so hard, but the situation was so difcult. I dont know how I stayed
sane. (Melanie)

The difcult task of maneuvering between the different needs of their children was only
one of the mothers tasks associated with family life. The more painful aspect was the
feeling that the family is falling apart, as one mother put it. All of the mothers
described how the atmosphere at home radically deteriorated and became frightening
and anxiety-ridden, as constant ghts and arguing with the ill daughter became routine.
The situation often resulted in the other children acting out, and one way of their doing
this was by joining in the efforts to take care of their sick sister. These efforts included
watching over their sisters eating, and making sure she didnt hide food. It is important
to note here that the mothers in our sample did not ask for this kind of help.
Nevertheless, family members naturally took these caretaking roles upon themselves, a
 Psychology & Health 621

reality that despite being helpful was also difcult for the mothers to accept
emotionally.
The other way in which some of the ill childs siblings acted out was by staying
away from home, looking for other places to spend time and avoiding the tense
atmosphere in the house. Sheila said:

Being anorexic is being half dead and of course it affects everybody, so the younger kids
stopped staying at home. They went to the neighbors house, saying they were not comfort-
able in ours. And they were right; it was not comfortable at home.

Another source of stress for the mothers was the realisation that their other children
were being exposed to the ill daughters dangerous and unacceptable behaviours:
vomiting, lying, yelling and ghting with the parents. One of the mothers described
painfully how at one point she couldnt bear the situation anymore:

There was one time that I threw her out I called my husband and said: I sent her away,
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I dont want her here. I dont care, Im desperate, I cant cope anymore, I dont have the
energy for it. My other daughters see everything, my younger daughter sees it, i dont want
her to learn from her. I just cant; I threw her out. You get to the point where you want to
hit her. Its hard to describe this feeling (Rena)

The huge effect of the daughters ED on other family members contributed to the
mothers feeling that additional life-domains were being affected by the ED. A vicious
cycle thus ensued: the mothers, seeing that the ED had ramications for all their chil-
dren and not only for their ill daughters, experienced anger and disgust towards their
daughters, which then led to their feeling more guilt and pain. They were aware of the
various ways in which their other childrens lives were being harmed and disrupted,
and the price their other children might ultimately have to pay for a disorder that wasnt
even theirs. Realising that their daughters ED had a great impact on the other children,
the mothers were unable to separate their daughters condition from their overall
maternal self by telling themselves that the problem was only with the sick child; rather,
they had to admit that the ED involved and affected the whole family. A greater
challenge to maintaining a positive and competent maternal self as a good mother was
therefore created, because all aspects of the mothers mothering experiences were
affected by the daughters illness.
The heavy burden of dealing with the sick child as well as with the healthy ones
did of course fall on both parents, and the fathers in these families were described to
one degree or another as being involved in the management of the ED (except for one
case, in which the mother was widowed before its onset). Some of the fathers were
very actively involved while others at least served as partners for some of the decisions
that needed to be made along the way. For this reason, we were surprised to learn that
almost all of the mothers in our sample described very strong feelings of
loneliness of coping on their own with their daughters illness.
Marsha said:

My husband would leave the house in the morning and get back in the evening. During all
this time, and even still today, with the millions of psychologists we saw and the millions
of therapies we were in, I will say it again, and Im going to cry now, that Im alone. Im
 622 R. Tuval-Mashiach et al.

very lonely in this, even today. My husband denes himself as belonging to the UN
(United Nations), he never gets involved, he never helps with anything that relates to our
daughters illness Im always coping alone.

Interestingly, even in cases in which the husbands took an active role in caring for their
daughters, the mothers still felt very alone. Loneliness was one of the most intense
feelings disclosed in the interviews and was often accompanied by tears as well as other
non-verbal markers of pain and distress, even in cases where the illness had been
defeated many years earlier. It appeared that the feelings of loneliness were related to
the mothers perception of her maternal role and to her expectations of herself as a
mother:

I felt very bad because I didnt feel I had support. It seemed as if for him, okay, the child
was sick, it really hurt him, it really was important to him, but it was just another task on
his checklist, while for me it was everything. It encompassed me. I slept with it and woke
with it and thought of every tiny detail, of how to put the food on the plate in a certain
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way and whether to put the vegetables here or there, so it wouldnt seem like too much for
her. My thoughts were only about her; she was the rst, and everything else was second-
ary. (Ana)

Tanya spoke of loneliness resulting from her helplessness and inability to intervene with
her childs illness, leaving her only as a powerless observer:

(Crying). Like I told you, its as if you are alone. You alone need to pull your daughter
from the abyss into which she has fallen. She has fallen, and its all on you. You see the
needle on the scale speeding down without stopping. You feel that you are going to lose
her, as if she is disappearing.

In other cases, the mothers feeling of aloneness resulted from experiencing painful
things with her daughter while not being able to thoroughly share or explain these
things to those who werent present:

When I need my husband he is immediately there, he will leave everything and come, and
this was how it was whenever we needed hospitalization. But the burden was on me
because I stayed with her at home. This is why many times I told him: You dont
understand, you dont understand, you are always out of the house. You dont understand
how it is to stay all day with this thing, how it is to see her not eating, or eating and
throwing up, and again, and again, and her never saying a word. This is what is so
difcult. (Shirley)

We interpret these mothers loneliness as part of their dialogue with the good mother
script, one which in western society places sole maintenance of relationships on the
mother, and models womens self-sacrice (Johnston & Swanson, 2006, p. 510). These
mothers clearly felt that the responsibility of addressing and dealing with their daugh-
ters dire situations fell solely on them, and they seemed ashamed to admit that they
had failed to carry out their duties or that the experience had been so difcult for them.
This may be the reason that they didnt share their difculties and emotional burden
with others. A few mothers added their impression that one of the reasons they were so
alone with their daughters disorder and could not count on their husbands/partners
 Psychology & Health 623

involvement was the specic nature of the disorder and its relation to their daughters
body image, self-esteem and issues with diet; namely, that this disorder was a female
disorder and didnt belong to the mens domain. Only two mothers referred to their
husbands as constant sources of support and felt empowered by their help and coopera-
tion. Perhaps a contributing factor to the loneliness, some of these mothers felt was the
fact that at times their husbands/partners not only couldnt help them, but in fact needed
help themselves in coping. One mother said:

It was very difcult for my husband; he didnt cooperate in family therapy. He cried twice
in the meetings, and during the second meeting he just ran away. He couldnt bear it emo-
tionally. At the beginning I pushed him to go with her, and he did, but then later that is
why Id rather do it all alone it got to the point where I not only had to take care of
her, but of him as well. (Sue)

Another woman described how her husbands responses to their daughters disturbed
eating created an additional ashpoint:
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She vomited all the time, ate and threw up, and again, and again. It was horrible, especially
for my husband. I learned to watch and keep silent, but he would shout and explode. It
wasnt simple, and sometimes this was another frontline in the house: he was yelling and
humiliating her and expressing anger in extreme ways towards her. (Nelly)

As shown by these citations, the womens self-perceptions and sense of competence

were threatened not only in relation to their maternal role, but also in relation to their
roles as intimate partners and wives. The efforts to stay attuned to everybodys
needs the ill daughters, the husbands and the other childrens created a heavy
burden on the mothers and led to feelings of loneliness and self-doubt with regard to
their functioning as good mothers.

Domain III: Relationships with people outside the immediate family: threats to the
ability to protect her child, and to being perceived as a good mother
The coping process of the patient and her family was situated within a wider context of
which many people were part, including neighbours, friends and the extended family.
Professionals, of course, including physicians, therapists, nurses and nutritionists, also
played their roles. The impact of the surrounding environment was therefore
complicated and multi-leveled, and it is impossible to cover all of its aspects here.
While it is important to note that in the community at large there were indeed sources
of support (e.g. the extended family) and resources which were helpful to the daughters
and their parents, the focus of our study was on sources of stress, and it emerged that a
major source of stress was the therapists and professional staff in the hospitals and
clinics. There was a great deal of miscommunication between staff and parents. The
mothers in our study often felt misunderstood and experienced a lack of empathy
from the professionals. They also felt excluded and confused, as they were not
consulted regarding treatment plans for their daughters; they were often left feeling
an unbearable ambiguity regarding their daughters situation while in the hospital.
Melanie says:
 624 R. Tuval-Mashiach et al.

Once our child was hospitalized we were not allowed to be in touch. Nothing. No visits,
no phone calls, nothing. They just took the child away from her family. I remember that
we came back home, locked the door, and didnt answer the phones. We sat here for four
days, unable to stop crying. When I went to the hospital, they wouldnt let me in. We
didnt know what to do. And then, on the fth day, my daughter apparently asked a visitor
to use her cell phone, and called us at home. It was terrible; her crying was terrible, she
begged us to discharge her. So we came and discharged her, against medical advice and at
our own risk. And I want to tell you that it took us a very long time to get her to trust us
again, to convince her that we love her, and that we want her at home. We didnt mean to
cause her such pain, but we did it because we were told that that was how we should do
it, that that was the right way.

From this citation and others, it is clear that mothers and parents in general felt it
difcult to identify with the treatment plans for their daughters and in some cases, as in
this one, they even interrupted them. It seems to us that at least part of this difculty
may be attributed to the mothers feeling that they did not understand the logic and
rationale behind the treatment. They felt the rules were cruelly inicted on them and
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their daughters without any guidance or explanation. When confronted with the good
mother script which requires that the mother not only protect her child from being
hurt by others, but also be all-knowing and in control of the situation these mothers
seemed to feel extremely incapable of lling that role, or of being able to mediate the
hospital experience for their daughters. They themselves felt helpless, confused and in
the dark.
It should also be said that at times the parents conict with the professional teams
encompassed even more complex and troubling issues than those surrounding the
treatment plans: Some of the mothers, in fact, expressed the feeling that they were
being directly or indirectly accused of having caused their childs illness:

At the beginning, all the blame was put on me. I mean, in the family it was clear that
because I uttered the famous sentence (that the daughter should watch her diet) then it was
my fault she got sick. And my husband would say: Its because of you, because of your
healthy foods and special diet. (Nelly)

Some of the mothers also felt that they were being blamed by the medical and
psychological professionals, particularly by the therapists treating their daughters. One
mother, Sharon, when asked by an interviewer if this was her feeling, said:

Its not a question of feeling. I was directly told that because my relationship with my
daughter was charged, thats what caused the illness. My daughters psychologist was
always telling her: You have to disengage from your mother; its her fault that youre sick.

Several mothers mentioned that they felt the treatment teams hidden message to them
was that they the parents, and specically the motherdaughter relationship were at
the root of the ED. This perceived or actual accusation, together with the feelings of
guilt and doubt that already existed, resulted in great pain and distress, as well as anger.
It is important to mention here that two mothers didnt share these feelings and were
mostly grateful for the treatment and guidance received from the medical and psycho-
logical professionals.
 Psychology & Health 625

Domain IV: relationship with oneself: threats to the good mother identity
All of the participants described at length their struggles to derive meaning from their
childs illness and to understand why their child became ill. Most of the mothers (8 out
of 10) described an ongoing ruminative and painful process of looking back at every
aspect of their mothering, their daughters past, and their prior relationship with their
daughter in order to give meaning to and understand the reason for their childs present
illness. This process was accompanied by questions such as, Was I wrong? Could/
should I have done things differently as a mother? Mothers spoke of their failure to
understand that something was wrong at the outset, asked themselves if they had said
something that might have caused their daughters to start dieting, and looked back to
nd whether they had made mistakes in the management of the illness. This process
was very active in the rst stages of the disorder and was accompanied by feelings of
sorrow and remorse. Later, these feelings were replaced by a degree of acceptance, or
quiet despair. Mika says:
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When it all begins, you start looking at what went wrong. And this search is difcult; it
causes one to feel bad. So you start to remember: here I yelled at her, here I was angry at
her, and you dont know if thats the and then you say, Well, I also got angry at her sis-
ter, and it didnt end up like that for her its very difcult.

Within this context, guilt was one of the main feelings described. It was an inclusive
experience, sometimes related to a specic event or mistake, and sometimes vaguely
related to mothering in general.

I cant rid myself of it, the feeling that Im guilty for her illness (crying). Because of the
ghts we had. Maybe I shouldnt have argued with her over what time she came home at
night, maybe I should have argued differently sometimes she would come home at ve
or six in the morning, without letting me know where she was. (Sharon)

And Nelly says:

Im guilty. Im guilty for not being a good enough mother. I probably didnt give her, I
dont even know what, but youre always wrong, whatever you do, it is wrong.

Along with guilt, these women experienced a great deal of self-doubt and a loss of self-
condence as mothers. Everything they had previously taken for granted about them-
selves that they were good mothers raising healthy normal children now felt tenu-
ous. The fact that their daughters developed EDs and that their illnesses became
chronic or long-lasting was automatically perceived by them as implying that there was
something missing or inadequate in their mothering. The psychological climate, in
which mothers are still held solely responsible for their childs mental and physical
health, serves as the backdrop for such feelings of guilt, self-doubt and loss of maternal
efcacy. Even many years after the onset of the illness, Ann, another mother, says:

You never know any more if what you decide is right, and it tortures you, it never leaves
you. So there are things that Im glad I did, like leaving that doctor, and other things I did
that I dont know if I did right, like hospitalizing her you just dont know what is right
and what is not.
 626 R. Tuval-Mashiach et al.

With such guilt, disruption of ones self-condence, and self-doubt, it was not uncom-
mon to hear notes of despair and helplessness in several narratives:

Life takes you to places you dont expect. Youre like a wandering leaf. Who are you at all?
You cant control anything; you can hardly control your own life. So I said to myself: Give
up, you cant do anything anyway, at least not more than youve already done. (Shirley)

Interestingly, there was no difference in maternal self-perception between mothers whose

daughters recovered and mothers whose daughters were still coping with anorexia at the
time of the interview. It would not have been surprising to nd that mothers of daughters
who recovered felt better about themselves as mothers and about their relationships with
their daughters than mothers of daughters who did not recover. We interpret the fact that
this did not turn out to be the case in three ways. First, the focus of the interview for
all of the mothers was on the difcult times, not on the times marked by improvement.
Second, even in regard to those daughters who recovered, mothers described a fragile
state of wellness rather than a full recovery; the recovery they saw was a tenuous one,
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and one which they were afraid to trust even after several years had passed. And nally,
these mothers did not credit themselves with contributing to or being responsible for
their daughters recovery. When the daughters recovered, this recovery was attributed
solely to the daughters will-power and decision to get better.
It seems as if the mothers in our study evaluated themselves against the cultural
norm of the good mother (Lupton, 2000) and felt that they failed to live up to it. This
norm implicitly denes the good mother as one who is always in touch with her chil-
drens needs and responds with only a certain measure of sensitivity: never too much to
obstruct development, but just enough to allow them to practise being autonomous
(Lawler, 2000; Winnicot, 1988). The good mother is held responsible for the nurturing
and development of her children, and their needs always take precedence over her per-
sonal needs (Hays, 1996).
We termed this category relationships with oneself because mothers devoted a sig-
nicant portion of their narratives to describing their feelings about themselves and their
internal dialogues. Within this category, we included stressors which were personally
and individually felt from within, not directly evoked by interactions with others. These
mothers feelings about the mistakes they believed they made, and about not being a
good enough mother, were directly related to their difculties in their relationships
with their daughters.

Discussion
The ndings of this study showed that daughters EDs signicantly interfered with
mothers abilities to maintain satisfying relationships. This interference emerged as one
of the most difcult burdens for the mothers to bear, as it challenged their identities
and experiences of themselves as good mothers. The four types of relationships which
were affected by the ED and which emerged from the mothers narratives were: the one
with their daughters; the one with other family members and with their spouses/part-
ners; the one with the professionals treating their daughters; and the one with
themselves. The combination of a forced emotional rift from their daughters, a feeling
of being disrespected, blamed or misunderstood by the medical professionals, and a
 Psychology & Health 627

lack of emotional support from their spouses/partners resulted in profound feelings of

loneliness. The title we have chosen for this paper, Attacks on linking an allusion to
Bions concept (1959) expresses the emotionally charged experience of mothers
whose multi-layered networks of relationships were challenged.
The ruptures in these relationship networks posed a threat to two central aspects of
these womens identities: as women and as mothers. First, the initiation and
maintenance of signicant relationships are perceived as primary in womens identities
and self-denitions (Josselson, 1996). Women describe and dene themselves through
their relationships with others (Gilligan, 1982; Tuval-Mashiach, 2006), so that
difculties in maintaining these relationships present a challenge to their very identities.
As far as their identities as mothers, we would suggest that the ruptures which
occurred in the four types of relationships in these womens lives were all related to
threats on the idea of their being good mothers. Each relationship rupture challenged
a different aspect of what is generally thought to constitute good mothering: The
relationship with oneself is related to ones identity as a good mother, as one who
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takes good care of her children; the relationship with ones daughter is related to the
role of the good mother, who is deeply connected to her daughter; the relationship
with other family members is related to the concept of the good mother who, like
glue, holds the family together; and the relationship with people outside the family is
related to external perceptions of her as being a good mother. Theoretically, it appears
that the ability of these mothers to engage in maternal practice (Ruddick, 1989) was
profoundly interrupted by the daughters EDs. According to Ruddick, there are three
basic demands placed on mothers: to preserve the life of the child (protection); to foster
the childs growth beyond initial dependency (nurturance); and to ensure the childs
acceptability as a productive and normative member of society (training). For the moth-
ers in our sample, however, mothering was severely compromised in regard to each of
these three demands: they couldnt protect their daughters from the disorder; they had
to watch their daughters risk their lives and cease growing; and they couldnt see or
represent their daughters eating behaviours as normative or culturally acceptable. As a
result, they lost condence in their ability to know how to mother their daughters.
Because mothers are culturally held responsible for their childs healthy
development and well-being (e.g. Hays, 1996; Johnston & Swanson, 2006), the
existence of a mental disorder especially one which is socially perceived as being
under the control of the patient (Roehrig & McLean, 2010) was felt by these mothers
to reect their own problematic inadequate mothering, and led them to doubt their
mothering abilities, not only in regard to their sick daughter, but in regard to their other
children as well. Coupled with the feeling of being held responsible for the well-being
of their families and partners and the difculty in communicating with health profes-
sionals these mothers ended up with a severely depleted sense of maternal compe-
tence, leading to feelings of distress, guilt, shame, loneliness and self-doubt.
While some of the difculties experienced by the mothers in this study may be
common to mothers of children who cope with other illnesses as well, we believe that
coping with ones daughters ED is uniquely difcult and stressful. First, due to the
faulty impression that EDs are self-inicted conditions (Roehrig & McLean, 2010),
there is very little public understanding of or compassion for the familys burden or
for the mothers, in particular when coping with an ED. Second, the stigmatic percep-
tion of EDs as related to the denial of femininity and to poor motherdaughter
 628 R. Tuval-Mashiach et al.

relationships (Cooper et al., 2004) turns the focus, and even the blame, towards the
mother and her misdeeds as a mother. And nally, the very nature of an ED such as
anorexia i.e. the refusal of the daughter to eat or to be fed is in striking contrast to
the most basic maternal motivation: to feed and nurture the child. For these reasons, we
believe that mothers of daughters with an ED are themselves at great risk for major
psychological distress, as is often found among parents of persons with a severe mental
illness (Grandn, Jenaro, & Lemos, 2008; Spaniol, 1987). Thus, the current study adds
to previous qualitative research on parenting and EDs (e.g. Highet et al., 2005; Honey
& Halse, 2005) by highlighting the effect of EDs on the mothers relationships with
herself and with her environment.

Clinical implications
We would like to suggest three ways in which the distress of mothers coping with a
childs ED could be addressed and relieved. One way would be by improving the
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communication between professional staff and family. Mothers (and fathers as well)
should be informed of the treatment rationale and plan for their daughters, and should
be treated with care and respect. Health professionals should be trained to understand
and acknowledge the difculties and stresses experienced by mothers in particular who,
after all, are the main care providers for their child.
The engagement of mothers with other mothers who are coping with similar
situations may also help ease their loneliness. It has been documented that support
groups may improve coping and create a network of support and sharing (Boyd, 2002).
We suggest that mothers be offered the opportunity to engage with other mothers in
clinics and hospitals which treat women with EDs. This support might be provided as
an additional benet for caregivers, one that focuses on helping parents in the guidance
and management of their childs illness (Hoyle et al., 2013; Robinson et al., 2013).
Finally, theoretical perceptions about the origins and development of EDs, about good
mothering and the responsibilities of mothers, should be overhauled. Mothers in the cur-
rent study seemed to internalise the stigma assigned to mental illnesses and EDs, and the
blame for having caused their childs ED. In order to challenge this stigmatic perception
of mothers, professionals also need to develop a more balanced and nuanced perception
which takes into account the complex interactions of family factors, individual factors
regarding the specic child, and other social and cultural factors involved in the onset and
maintenance of EDs (Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004).
Conclusions from this study should be arrived at with caution due to its small
self-selected sample of women who were willing to retrospectively disclose their
experiences and share them with us. It should also be emphasised that there were a few
mothers who spoke about the positive strategies they used to cope with their situations
and overcome the difculties and challenges, thus showing much resilience; our focus
on the relational experiences that are related to challenges to the good mother
perception may therefore have biased the whole picture in a negative way. Also, it may
be that a prospective follow-up of mothers during the process of coping would shed
light on the specic difculties faced at each stage. Still, in accordance with other stud-
ies on parenting a child with a mental illness (Grandn et al., 2008; Hasson-Ohayon
et al., 2011), we believe that the experiences and challenges these mothers dealt with in
their relationships with themselves, their daughters, their families and partners, and the
 Psychology & Health 629

broader environment in general including feelings of shame, guilt and loneliness

may very well reect other mothers experiences. Future studies are needed in order to
further validate the current studys results.

Note
1. Because relationships with others, and threats to them, are at the centre of this paper, we
chose to borrow Bions concept and name the paper Attacks on linking.

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