Family Members of the Eating Disordered Patient

For Family Members And Those Who Treat Them

Individuals with eating disorders directly or indirectly affect those with whom they live or who love and care about them. Family patterns of socializing, preparing food, going out to restaurants, and just plain talking to each other are all disrupted by an eating disorder. Everything from finances to vacations seems jeopardized, and the person with the eating disorder is often resented for an illness she cannot control.

A family member with an eating disorder is most likely not the only member of the family with problems. It is common to find problems with mood or behavior control in other family members, and the level of functioning and boundary setting among parents and siblings should be evaluated. In many families there is a history of excessive reliance on external achievement as an indicator of self-worth, which ultimately or repeatedly fails. Fluctuations between overinvolvement and abandonment may have been occurring for some time, leaving family members feeling lost, isolated, insecure, or rebellious, and without a sense of self.

Parents, who have their own issues both from the past and in the present, are often frustrated, fighting between themselves, and unhappy. Overinvolvement with the eating disordered child is often a first reaction in trying to gain control of an out-of-control situation. Futile attempts at control are exerted at a time when understanding and supportive direction would be more helpful.

In a marriage where one partner has an eating disorder, the spouse's concerns are often overshadowed by anger and feelings of helplessness. Spouses often report a decrease of intimacy in their relationships, sometimes describing their loved ones as preferring or choosing the eating disorder over them.

Individuals with eating disorders need help in communicating to their family members and loved ones. Family members and loved ones need help as they experience a variety of emotions, from denial and anger to panic or despair. In the book, Eating Disorders: Nutrition Therapy in the Recovery Process, by Dan and Kim Reiff, six stages that parents, spouses, and siblings go through are delineated.

STAGES OF GROWTH EXPERIENCED BY FAMILY MEMBERS AFTER BECOMING AWARE THAT A PERSON THEY LOVE HAS AN EATING DISORDER

Stage 1: Denial

Stage 2: Fear, ignorance, and panic

• Why can't she stop?
• What kind of treatment should he have?
• The measure of recovery is behavior change, isn't it?
• How do I respond to her behaviors?

Stage 3: Increasing realization of the psychological basis for the eating disorder

• Family members question their roles in the development of the eating disorder.
• There is increased understanding that the process of recovery takes time and that there is no quick fix.
• Parents/spouses are increasingly involved in therapy.
• Appropriate responses to the food- and weight-related behavior are learned.

Stage 4: Impatience/despair

• Progress seems too slow.
• The focus shifts from trying to change or control the person with the eating disorder to working on oneself.
• Parents/spouses need support.
• Anger/detachment is felt.
• Parents/spouses let go.

Stage 5: Hope

• Signs of progress are noticed in the person with the eating disorder and oneself.
• It becomes possible to develop a healthier relationship with the person with the eating disorder.

Stage 6: Acceptance/peace

To help family and friends understand, accept, and work through all the problems a loved one with an eating disorder presents, successful treatment of eating disorders often mandates therapeutic involvement with the patient's significant others and/or family, even when the patient is no longer living at home or a dependent.

Family therapy (this term will be used to include therapy with significant others) involves the creation of a powerful therapeutic system consisting of the family members plus the therapist. Family therapy emphasizes responsibility, relationships, conflict resolution, individuation (each person's developing an individual identity), and behavior change among all family members. The therapist assumes an active and highly responsive role within this system, altering the family rules and patterns in a significant way. If the therapist appreciates the vulnerability, pain, and sense of caring within the family, he can provide initial support for all family members. Supportive, guided therapy can relieve some of the tension created by tenuous and previously disappointing family relationships.

One goal in family therapy involves helping the family learn to do what the therapist has been trained to do for the patient (i.e., empathize, understand, guide without controlling, step in when necessary, foster self-esteem, and facilitate independence). If the therapist can help the family and significant others to provide for the patient what a healing therapeutic relationship provides, the length of therapy may be reduced.

In doing family work, the patient's age and developmental status are important in outlining the course of treatment as well as highlighting the responsibility of family members. The younger the patient is, both chronologically and developmentally, the more responsibility and control the parents will have. On the other hand, patients who are developmentally more advanced require parental involvement that is more collaborative and supportive and less controlling.

SUMMARY OF IMPORTANT TASKS FOR SUCCESSFUL FAMILY THERAPY

The multidimensional task of the therapist in family therapy is extensive. The therapist must work on correcting any dysfunction occurring in the various relationships, for this may be where the underlying causal issues have partly developed or at least are sustained. Family members, spouses, and significant others need to be educated about eating disorders and, particularly, the patient's unique manifestation of symptoms. All loved ones need help in learning how to respond appropriately to various situations they will encounter. Any serious conflicts between family members, which contribute highly to the development or perpetuation of eating disorder behaviors, must be addressed.

For example, one parent may be stricter than the other and have different values, which may develop into serious confrontations over the raising of the children. Parents may need to learn how to solve conflicts between themselves and nurture each other, which will then enable them to better nurture their child. Faulty organizational structure in the family, such as too much intrusiveness on the part of the parents, too much rigidity, or fused boundary issues, must be pointed out and corrected. Expectations of family members and how they communicate and get their needs met may be underhanded and/or destructive. Individual members of the family may have problems that need to be resolved separately, such as depression or alcoholism, and the family therapist should facilitate this happening. The task of family therapy is so complex and at times overwhelming that therapists often shy away from it, preferring to work solely with individual patients. This can be a grave mistake. Whenever possible, family members and/or significant others should be a part of overall treatment.

The following is an excerpt from a session where an extremely upset father was complaining about the fact that the family had to be in therapy. He felt that there were no family problems except that his daughter, Carla, was sick. Allowing this kind of thinking is detrimental. In fact, for teens and younger patients, statistics show that family therapy is necessary for recovery.

Father: Why should I listen to this? She is the one with this disgusting sickness. She's the one screwed up in the head. She's the one who is wrong here.

Therapist: It is not a matter of right or wrong, or of blame. It is not just something wrong with Carla's personality. Carla is suffering from an illness that affects you and the rest of the family. Furthermore, there may be certain things in her development that got in the way of her being able to express her feelings or cope with stressful situations. Parents can't be blamed for creating eating disordered children, but how a family deals with feelings or anger or disappointment can have an effect on how someone turns to an eating disorder.

Yelling and punishing Carla have not worked to help resolve her problem, and in fact things have been getting worse. I need you all here if Carla is to get better, and if all of you are to get along better. When you try to force Carla to eat, she just finds a way to throw up afterward - so what you're doing isn't working. Also, everyone is angry and frustrated. For example, you disagree on things like curfew, dating, clothing, and even going to church. If you want Carla to get better and not just follow your rules, I need to help you find compromises.

The therapist creates an experience of continuity for the treatment and remains its guiding force until the family as a whole trusts both the therapist and the changes that are asked for and slowly taking place in treatment. It is important for the therapist to show patience, continuity, support, and a sense of humor within the context of optimism about the possibilities of all family members for the future. It is best if the family experiences therapy as a welcomed and desired situation that can help foster change and growth. Even though the therapist takes responsibility for the course and pacing of treatment, she can share this responsibility with family members by expecting them to identify issues for resolution and to demonstrate greater flexibility and more mutual concern.

ESTABLISHING RAPPORT AND GETTING STARTED

Families with eating disordered individuals often seem guarded, anxious, and highly vulnerable. Therapists must work at establishing rapport to make the family feel comfortable with the therapist and the therapy process. It is important to lessen the anxiety, hostility, and frustration that often permeate the first few sessions. When beginning treatment, the therapist needs to create a strong relationship with each family member and imposes himself as a boundary between individuals as well as between generations. It's important for everyone to express their feelings and viewpoint as thoroughly as possible.

It may be necessary to see each family member alone to establish a good therapeutic relationship with each one. Family members must be recognized in all their roles (i.e., the father as husband, man, father, and son; the mother as wife, woman, mother, and daughter). In order to do this, the therapist obtains background information about each family member early in treatment. Then, the therapist provides recognition of each individual's strength, caring, and passion while also identifying and elaborating on individual difficulties, weaknesses, and resentments.

If the individual family members trust the therapist, the family can come together more at ease, less defensive, and much more willing to "work" at therapy. Treatment becomes a collaborative effort where the family and therapist begin to define problems to be solved and to create shared approaches to these problems. The therapist's responsibility is to provide the proper balance between stirring up controversy and crises in order to bring about change, while at the same time making the therapeutic process safe for family members. Family therapists are like directors and need trust and cooperation in order to direct the characters. Family therapy for eating disorders, like individual therapy, is highly directive and involves a lot of "teaching style" therapy.

EDUCATING THE FAMILY

It is important to have information for family members to take home to read or at least suggestions of reading material they can buy. Much confusion and misinformation exists about eating disorders. Confusion ranges from the definitions and differences between the disorders to how serious they are, how long therapy takes, what the medical complications are, and so on. These issues will be discussed, but it is useful to give family members something to read that the therapist knows will be correct and helpful. With reading material to review, family members can be collecting information and forming questions when they are not in the session. This is important, as therapy is expensive and family therapy will most likely take place no more than once a week.

Additional sessions are usually not feasible for most families, especially since individual therapy with the patient is also ongoing. Information provided in the form of inexpensive reading material will save valuable therapy time that would otherwise be spent explaining the same information. The therapy time is better spent on other important issues, such as how the family interacts, as well as questions on and clarification of the material read. It's also comforting for family members to read that other people have been through similar experiences. Through reading about others, family members can see that there is hope for recovery and can begin to look at what issues in the reading material relate to their own situation.

Literature on eating disorders helps to validate and reinforce information the therapist will be presenting, such as the length of time therapy is going to take. The new studies indicate that recovery is possible in about 75 percent of cases but that the length of time necessary to achieve recovery is four and a half to six and a half years (Strober et al. 1997; Fichter 1997). Families may be inclined to be suspicious and wonder if the therapist is simply trying to get several years of income.

After reading various material on eating disorders, family members are more likely to understand and accept the possibility of lengthy therapy. It is important to note that the therapist should not doom a patient or her family into thinking it will absolutely take several years to recover. There are patients who have recovered in much less time, such as six or eight months, but it should be made clear that the longer time period is more likely. Being realistic about the usual lengthy time necessary for treatment is important so that family members don't have unrealistic expectations for recovery.

EXPLORING THE IMPACT OF THE ILLNESS ON THE FAMILY

It is necessary for the family therapist to assess how much the eating disorder has interfered with the feelings and functioning of the family. Is the father or mother missing work? Has everything else been put secondary to the eating disorder? Are the other children's needs and problems being neglected? Are the parents depressed or overly anxious or hostile due to the eating disorder, or were they like this before the problem started? This information helps the therapist and family begin to identify whether certain things are the cause or result of the eating disorder. Families need help learning what is appropriate behavior and how to respond (e.g., guidelines for how to minimize the influence of the eating disorder over family life).

The therapist will need to find out if other children in the family are affected. Sometimes other children are suffering silently for fear of being "another bad child" or "disappointing my parents more," or just simply because their concerns were ignored and they were never asked how they were feeling. In exploring this issue, the therapist is making therapeutic interventions from the very beginning by (1) allowing all family members to express their feelings, (2) helping the family examine and change dysfunctional patterns, (3) dealing with individual problems, and (4) simply providing an opportunity for the family to come together, talk together, and work together on solving the problem.

Reassuring family members that the eating disorder is not their fault is crucial. Family members may feel abused and perhaps even victimized by the patient and need someone to understand their feelings and see their sides. However, even though the focus stays off blame, it is important that everyone recognizes and takes responsibility for their own actions that contribute to family problems.

The therapist also addresses the quality of the patient's relationship with each of her parents and assists in developing an effective, but different, relationship with both of them. These relationships should be based on mutual respect, with opportunities for individual assertiveness and clear communication on the part of everyone involved. This depends on a more respectful and mutually supportive relationship between the parents. As treatment progresses there should be a greater ability on the part of all family members to respect each other's differences and separateness and enhanced mutual respect within the family.

Sessions should be planned to include appropriate family members according to the issues being worked on at that time. Occasionally, individual sessions for family members, sessions for one family member with the patient, or sessions for both parents may be necessary.

In situations where chronic illness and treatment failure have led to marked helplessness on the part of all family members, it is often helpful for the therapist to begin with a somewhat detached, inquisitive approach, letting the family know that this treatment will only be effective if it includes all members in an active way. The therapist can define everyone's participation in ways that are different from previous treatments and thus avoid earlier pitfalls. It is common for families who have been faced with chronic symptoms to be impatient and impulsive in their approach to the therapeutic process.

In these situations, therapists need to gently probe family relationships and the role of the eating disorder within the family, pointing out any positive adaptive functions that the eating disorder behaviors serve. This often highlights difficulties in family relationships and offers avenues for intervention in highly resistant families. In order to gain the family's participation in the desired fashion, the therapist must resist the family's attempt to get her to take full responsibility for the patient's recovery.

DISCOVERING PARENTAL EXPECTATIONS/ASPIRATIONS

What messages do the parents give the children? What pressures are on the children to be or to do certain things? Are the parents asking too much or too little, based on the age and ability of each child or simply on what is appropriate in a healthy family?

Sarah, a sixteen-year-old with anorexia nervosa, came from a nice family who had the appearance of having things very much "together." The father and mother both had good jobs, the two daughters were attractive, good in school, active, and healthy. However, there was significant conflict and constant tension between the parents regarding the disciplining of and expectations for the children.

As the eldest child got into the teenage years, where there is a normal struggle for independence and autonomy, the conflict between the parents became a war. First of all, the mother and father had different expectations regarding the daughter's behavior and found it impossible to compromise. The father saw nothing wrong with letting the girl wear the color black to school while the mother insisted that the girl was too young to wear black and would not allow it. The mother had certain standards for having a clean house and imposed them on the family even though the father felt that the standards were excessive and complained in front of the children about it. These parents didn't agree on rules regarding curfews or dating, either. Obviously this caused a great deal of friction between the parents, and their daughter, sensing a weak link, would push every issue.

Two of the problems regarding expectations addressed in this family were (a) the parent's conflicting values and aspirations, which necessitated couple therapy, and (b) the mother's excessive expectations for everyone, especially the oldest daughter, to be like herself. The mother would constantly make statements such as "If I did that when I was in school . . . ," or "I would have never said that to my mother." The mother would also overgeneralize, "all my friends . . . ," "all men . . . ," and "other kids," for validation of rightness.

What she was doing was using her past or other people she knew to justify the expectations she had for her own children instead of recognizing her children's own personalities and needs in the present. This mother was wonderful at fulfilling her motherly obligations like buying clothes, furnishing rooms, transporting her daughters to the places they needed to go, but only as long as the clothes, the room furnishings, and the places were those that she would have chosen for herself. Her heart was good, but her expectations for her children to be and think and feel like her or her "friends or sister's kids" were unrealistic and oppressive, and one way her daughter rebelled against them was through her eating disorder behavior: "Mom cannot control this."

Unrealistic expectations for achievement or independence also cause problems. Consciously or unconsciously children may get rewarded, particularly by their fathers, only for what they "do" as opposed to who they are. These children may learn to depend only on external rather than internal validation.

Children who get rewards for being self-sufficient or independent may feel afraid to ask for help or attention because they have always been praised for not needing it. These children often set their own high expectations. In our society, with the cultural standard of thinness, weight loss often becomes another perfectionistic pursuit, one more thing at which to be successful or "the best." Steven Levenkron's book, The Best Little Girl in the World, earned its title for this reason. Unfortunately, once successful at the dieting, it may be very hard to give it up. In our society, all individuals are praised by their peers and reinforced for an ability to diet. Once individuals feel so "in control," they may find they are unable to break the rules they set for themselves. The attention for being thin, even for being too thin, feels good, and too often people just do not want to give it up, at least not until they can replace it with something better.

Individuals with bulimia nervosa are usually trying to be overcontrolled with their food half the time, like anorexics, and the other half of the time they lose control and binge. Some individuals may place so many expectations on themselves to be successful and perfect at everything that their bulimic behaviors become the one area where they "go wild," "lose control," "rebel," "get away with something." The loss of control usually leads to shame and more self-imposed rules (i.e., purging or starving or other anorexic behaviors, thus starting the cycle over again).

There are several other ways in which I have seen faulty expectations contribute to the development of an eating disorder. The therapist needs to uncover these and work with the patient and the family to set realistic alternatives.

GOAL SETTING

Parents don't know what to expect from treatment or what they should be asking of their sons or daughters who are being treated. Therapists help families set realistic goals. For example, with underweight anorexics, the therapist helps the parents to expect that weight gain will take time, and when it begins, no more than a steady, slow weight gain of as little as one pound per week should be expected. In order to meet the weekly weight goal, parents (depending on the patient's age) are usually advised to provide various foods but avoid power struggles by leaving the issue of determining what and how much to eat up to the patient and therapist or dietitian. Setting goals in a family session helps guide parents in assisting their sons or daughters to meet weight goals while limiting the parents' intrusiveness and ineffective attempts to control food intake. An agreement will also need to be made regarding an appropriate, realistic response should lack of weight gain occur.

An example of goal setting for bulimia would be symptom reduction, as there may be an expectation on the part of the family that, since the patient is in treatment, she should be able to stop bingeing or purging right away. Another example would be setting goals for using alternative means of responding to stress and emotional upset (without resorting to bingeing and purging). Together the therapist and family help the patient discuss goals of eating when physically hungry and managing her diet appropriately to reduce episodes of weight gain and periods of anxiety leading to purging behavior.

For bulimics and binge eaters, a first goal may be to eliminate the goal of weight loss. Weight loss considerations should be set aside while trying to reduce binge eating behavior and purgings. It is difficult to focus on both tasks at once. I point this out to patients by asking them what they will do if they overeat; since when weight loss and overcoming bulimia are simultaneous goals. If stopping bulimia is a priority, you will deal with having eaten the food. If weight loss is a priority, chances are you will purge it.

The usual focus on the need to lose weight may be a big factor in sustaining the binge eating, since bingeing often precedes restrictive dieting. For a further discussion of this, refer to chapter 13, "Nutrition Education and Therapy."

ROLE OF THE PATIENT IN THE FAMILY

A family therapist learns to look for a reason or adaptive function that a certain "destructive" or "inappropriate" behavior serves in the family system. This "functional" behavior may be acted out on an unconscious level. Research on families of alcoholics or drug abusers have identified various roles that the children take on in order to cope. I will list these various roles below, as they can be applied to working with individuals with eating disorders.

Scapegoat. In the case of parental disharmony, the eating disorder may serve as a mechanism to focus the parents' attention onto the child with the eating disorder and away from their own problems. In this way the parents can actually work together on something, their son or daughter's eating disorder. This child is the scapegoat for the family pain and may often end up feeling hostile and aggressive, having learned to get attention negatively.

Often, as an eating disordered patient begins to get better, the relationship between her parents gets worse. When not sick herself, she ceases to provide her parents with a distraction from their own unhappy lives. This certainly must be pointed out, however carefully, and dealt with in therapy.

The Caretaker or Family Hero. This is the child who takes on too much responsibility and becomes the perfectionist and overachiever. As mentioned under the issue of parental expectations, this child puts the needs of others first. An anorexic is often the child who "never gave us any problems." "She was always so good, we never had to worry or concern ourselves about her."

There is a careful and gentle technique to uncovering and confronting these issues in a family. Yes, the parents need to see if their child has become the caretaker, but they need to know what to do about it and they need to not feel guilty about the past. In this case, they can learn to take more responsibility themselves. They also can learn to communicate better with and focus more attention on the child with the eating disorder, who has been virtually ignored because she was doing so well.

A caretaker often comes from a household that has a chaotic or weak parental system - the child becomes independent and assumes too much control and self-reliance before being mature enough to handle it. She is given, or takes out of necessity, too much responsibility. The eating disorder occurs as an extension of the child's self-imposed control system. Anorexia nervosa is the ultimate form of control; bulimia nervosa is a combination of overcontrol combined with a sort of loss of control, rebellion, or at least escape from it. A bulimic controls weight by purging; forcing oneself to purge is exerting control over the binge and the body.

The Lost Child. Sometimes there is no way to overcome a combative parent or abusive family situation. Sometimes there are too many children, and the competition for attention and recognition is too tough. Whatever the reason, some kids get lost in a family. The lost child is the child who learns to cope with family pain or problems by avoidance. This child spends a lot of time alone and avoids interaction because she has learned that it is painful. She also wants to be good and not a problem. She cannot discuss her feelings and keeps everything in. Consequently, this individual's self-esteem is low. If she discovers that dieting wins approval from her peers (which it almost always does) and gives her something to be good at and talked to about, then she continues because it is reinforcing. "What else do I have?" she might say, or at least think and feel. Also, I have seen the lost child who takes comfort in night binges as a way to ease loneliness and the inability to reach out and make meaningful relationships.

The lost child who develops an eating disorder may also discover a sense of power in having some effect on the family. This power is hard to give up. Even though she really may not want to cause family problems, her new special identity is too hard to surrender. It may be the first real one she has had. Some patients, who are conflicted about desperately wanting their disorder but desperately not wanting to cause the family pain, often tell me or write in their journals that they think it would be better if they were dead.

ANALYZING AND ADJUSTING THE ORGANIZATIONAL STRUCTURE OF THE FAMILY

Looking at the family structure can help tie all the other components together. This is the family's system for working. Each family has rules its members live or function by that are unspoken. These rules concern such things as "what can and cannot be talked about in this family," "who sides with whom in this family," "conflicts are solved in this way," and so on. Family structure and organization is explored to answer the question, "What makes it necessary for the patient to go to the extreme of having an eating disorder?"

What are the boundaries that exist in the family? For example, when does the mother stop and the child begin? Much of the early focus in family treatment for eating disorders was on the mother and her overintrusiveness and inability to separate herself from her child. In this scenario the mother dotes on the child but also wants to be in on every decision, feeling, or thought the child has. The mother feels that she has been nurturing and giving and expects it all back from the child, wanting the child to be a certain way because of it. There is also the overpleasing mother who is emotionally weak and is afraid of the child's rejection, so she tends to let the child be in charge. The child is in charge too soon to be able to handle it, and inside actually resents that the mother did not help her enough.

Marta, a twenty-three-year-old bulimic, came to therapy after her mother, with whom she was still living, called for an appointment. Although the mother wanted to come to the first session, Marta insisted on coming alone. In the first visit, she told me that she had been bingeing and purging for five years and that her mother had not said anything to her until a few days before the phone call to me. Marta described how her mother "came into the bathroom when I was throwing up and asked me if I was making myself sick. I thought, 'Thank God, I will now get some help.' " Marta went on to describe her reluctance to share things with her mother: "Whenever I have a problem she cries, breaks down, and falls apart and then I have to take care of her!" One obvious issue in this family was for the mother to become stronger, allowing the daughter to express her needs and not have to be the parentified child.

One sixteen-year-old bulimic, Donna, and her mother Adrienne alternated between being best friends and sleeping in the same bed together, staying up late to talk about boys, to having fist- and hair-pulling fights when Donna did not do her homework or her chores. The mother in this family gave a lot but demanded too much in return. Adrienne wanted Donna to wear the kind of clothes she wanted, date the boys she approved of, and even go on a diet her way. In wanting to be best friends and expecting her daughter to be a best friend yet still obey her as a parent, Adrienne was sending mixed messages to her daughter.

Mothers who get overly invested in getting their needs met from their daughters get uncontrollably upset when their daughters don't react in the "right" way. This same issue may very well exist in the marriage relationship. With Adrienne, this was one factor in breaking up the marriage. The father was not living at home when Donna came into treatment. The end of the marriage had made the mother even more dependent on Donna for her emotional satisfaction, and the fighting was a result of her daughter not giving it to her. Donna felt abandoned by her father. He had left her there to take care of her mother and to fight with her, and he had not stayed to help her out in this situation.

Donna's bulimia was, in part, her struggle to get back at her mother by having something about which her mother could do nothing. It was a call for help, a plea for someone to pay attention to how unhappy she was. It was a struggle to escape a reality where she could not seem to please herself and her mother at the same time. If she pleased her mother, she wasn't happy, and vice versa. Her bulimic behaviors were a way of trying to get control over herself and make herself fit into what she considered the standards for beauty so that she would be accepted and loved, something she did not feel from either of her parents.

One aspect of Donna's treatment was to show her how her bulimia was not serving any of the purposes she consciously or unconsciously wanted it to serve. We discussed all the above aspects of her relationship to her family and how she needed to make it different, but that her bulimic behavior was just making it all worse. Not only was bulimia not helping solve her underlying issues, it wasn't even helping her to be thin, which is true for almost all bulimics as the bingeing gets further and further out of control.

Other ways of dealing with dieting and the family have to be explored. In Donna's case this involved family participation with both the mother and the father. Progress was made when the mother and father discussed their own problems. Solving them helped lead to the solution of the mother-daughter issues (for example, the mother's expectations and demands). Donna benefited greatly from the knowledge of her parents' role in her feelings and thus her behavior. She began to see herself with more self-worth and to see the futility of her bulimia.

Even though early researchers focused on mothers and mothering, over the last few years there has been more emphasis on the role of fathers in the development of eating disorders. One issue where the effect of the father's role has been discussed is when a father applies his sense of values, achievement, and control to areas where they are misinterpreted or misused. For example, achievement and control should not be values to strive for in the area of weight, body image, and food.

Although children are more biologically dependent on their mothers from birth, fathers can provide the traditional role of being "outside representative" while also offering a non-threatening transition from the natural dependency on the mother. The father can help his daughter confirm her own separateness, enhancing her sense of self. As stated by Kathryn Zerbe in The Body Betrayed, "When a father is unable to help his daughter move out of the maternal orbit, either because he is physically unavailable or not invested emotionally in her, the daughter may turn to food as a substitute. Anorexia and bulimia nervosa have in common inadequate paternal responses for helping the daughter develop a less symbiotic relationship with her mother. When she must separate on her own, she may take on the pathological coping strategies embedded in eating disorders."

Literature on fathers and eating disorders is scarce. Father Hunger by Margo Maine and "Daddy's Girl" a chapter in my book Your Dieting Daughter, both address this too little discussed but important topic. See Appendix B for more information. Other issues in the family structure involve how rigid or flexible the family is and the effectiveness of members' overall communication skills. The therapist needs to explore all the various kinds of communication that exist. Effective teaching on how to communicate is very beneficial to all families. Communication skills affect how families resolve their conflicts and who sides with whom on what issues.

ADDRESSING ABUSE ISSUES

Numerous studies have documented a correlation between eating disorders and a history of physical and/or sexual abuse. Although one study by the Rader Institute on sexual abuse and eating disorder inpatients reported a correlation of 80 percent, most research seems to indicate a much lower rate. It is important to understand that the association is not a simple cause-and-effect relationship. Abuse does not cause an eating disorder but can be one of many contributing factors. Both physical and sexual abuse are boundary violations of the body, thus it makes sense that abused individuals manifest both psychological and physical symptoms including problems with eating, weight, and body image.

Both therapist and family therapist should explore family histories by asking very specific questions regarding any abuse. Individuals who are abused are reluctant to reveal it or perhaps have no recollection of the abuse. Perpetrators of the abuse are, of course, reluctant to admit it. Therefore, therapists must be well trained and experienced in these matters, paying heed to signs and symptoms of possible abuse that need further exploration.

CHALLENGING CURRENT PATTERNS

Whatever is going on, family members will usually at least agree that what they are presently doing is not working. Coming for help means they haven't been able to solve the problem on their own. If they have not already tried several solutions, they at least agree that something in the family is not working correctly and they can't or don't know how to fix it.

Usually the family is trying to do all the things they are sure will help because they have helped before in other circumstances. Many of the standard approaches used with other problems or with other children are inappropriate and simply don't work with the eating disordered child. Grounding, threatening, taking away privileges, rewarding, and so on will not resolve an eating disorder. Taking the eating disordered patient to the family doctor and having all the medical consequences explained to her doesn't work either, nor will planning a diet or guarding the bathroom.

Parents usually have a hard time stopping their own monitoring, punishing, rewarding, and other controlling behaviors in which they are engaging to try to stop the eating disorder even though those methods don't seem to be doing any good. Often many of the methods used to prevent behaviors actually serve to sustain them. Examples of this are: Father yells and screams about the daughter's eating disorder ruining the family, and the daughter's reaction is to go and throw up. The more control a mother exerts over her daughter's life, the more control the daughter exerts with her eating disorder. The more demands for weight gain are made, the thinner the individual gets. If yelling, grounding, threatening, or other punishments worked to control an eating disorder, that would be different - but they don't work, and so there is no use in continuing them.

One night early in my career as an eating disorder therapist, I was in a family session when this useful analogy came to me. The father of Candy, a sixteen-year-old anorexic, was attacking her about being anorexic, harassing her, and demanding that she "stop it." The attacks had been going on for weeks prior to their seeking therapy. It was clear that the more attacking the father did, the worse Candy got. The attacking provided distraction for her; thus, she didn't have to face or deal with the real underlying psychological issues that were at the root of her eating disorder. Most of our sessions dealt with the combat that was going on with her father and her mother's ineffectiveness. We were spending most of our time repairing damage that resulted from her parents' attacks concerning what their daughter was or wasn't eating, how much she weighed, why she was doing so and so, and how she was harming the family. Some of these arguments at home ended up in hair-pulling or slapping sessions.

The family was falling apart, and, in fact, the more Candy argued with her parents, the more entrenched she became in her disorder. It was clear from watching Candy that the more she had to defend her position, the more she believed in it herself. It was clear that while being attacked by others, she was distracted from the real issues and had no time to really go inside herself and "clean house" or, in other words, really look inside and deal with her problems. In the middle of more complaints by Candy's father, I thought of the analogy and I said, "While you are guarding the fort, you don't have time to clean house," and then I explained what I meant.

It is important to leave the individual with an eating disorder free from any outside attacks. If the person is too busy guarding themselves against outside intrusion, they will have too much distraction and spend no time going inside themselves and really looking at and working on their own issues. Who has time to work on themselves if they are busy fighting off others? This analogy helped Candy's father see how his behavior was actually making things worse and helped Candy be able to look at her own problem. Candy's father learned a valuable lesson and went on to share this with other parents in a multifamily group.

MULTIFAMILY GROUP

A variation on family therapy involves several families/significant others who have a loved one with an eating disorder meeting together in one large group called a multifamily group. It is a valuable experience for loved ones to see how other people deal with various situations and feelings. It is good for parents, and often less threatening, to listen to and communicate with a daughter or son from another family. It is sometimes easier to listen, be sympathetic, and truly understand when hearing someone else's daughter or son describe problems with eating, fear of weight gain, or what helps versus what sabotages recovery. Patients also can often listen better to what other parents or significant others have to say because they feel too angry or threatened and many times shut out those close to them. Furthermore, siblings can talk to siblings, fathers to other fathers, spouses to other spouses, improving communication and understanding as well as getting support for themselves. Multifamily group needs a skilled therapist and perhaps even two therapists. It's rare to find this challenging but very rewarding type of group in settings other than formal treatment programs. It might prove very useful if more therapists would add this component to their outpatient services.

Family therapists must be careful that no one feels overly blamed. Parents at times feel threatened and annoyed that they are having to change when it is their daughter or son who is "sick and has the problem." Even if family members refuse, are unable, or it is contraindicated for them to attend sessions, family therapy can still occur without them present. Therapists can explore all the various family issues, discover the family roles in the illness, and change family dynamics when working solely with the eating disordered patient. However, when the patient still lives at home, it is essential to have the family come to sessions unless the family is so nonsupportive, hostile, or emotionally troubled as to be counterproductive. In this case, individual therapy and possibly group therapy may very well be enough. In some cases, other arrangements can be made for the family members to get therapy elsewhere. It may be better if the patient has her own individual therapist and some other therapist does the family work.

Treatment for eating disorders, including family therapy, is not a short-term process. There are no magic cures or strategies. Termination of treatment can occur at different times for different family subsystems. When the patient and the entire family are functioning effectively, follow-up sessions are often helpful in assisting family members to experience their own resources in dealing with stresses and transitions. Ultimately, the goal is to create an environment in which the eating disorder behavior is no longer necessary.

It should be noted that although family involvement in the treatment of those with eating disorders, particularly young people, is considered vital, it is not sufficient by itself to produce lasting changes in family members or a lasting cure. Neither will the absence of family involvement doom the eating disordered individual to a lifelong illness. In some instances, family members and loved ones may not be interested in participating in family therapy or their involvement may cause more unnecessary or unresolvable problems than if they were not involved. It is not uncommon to find family members or loved ones who feel that the problem belongs solely to the person with the eating disorder and that, as soon as she is "fixed" and back to normal, things will be fine. In some cases the removal of the eating disordered person from her family or loved ones is the indicated treatment, rather than including the significant others in the therapy process. Each therapist will have to assess the patient and the family and determine the best, most effective way to proceed.

By Carolyn Costin, MA, M.Ed., MFCC - Medical Reference from "The Eating Disorders Sourcebook"

next: Helping a Friend with an Eating Disorder
~ eating disorders library
~ all articles on eating disorders