Dr. Michel is clinical assistant professor in the Department of Psychiatry and Neurology at the Tulane University School of Medicine in New Orleans, Louisianna.
Dr. Willard is professor in the Departments of Psychiatry, and Neurology and Pediatrics at the Tulane University School of Medicine.
Disclosure: The authors report no financial, academic, or other support of this work.
Please direct all correspondence to: Deborah M. Michel, PhD, 824 Amethyst St, New Orleans, LA 70124; Tel: 504-282-7191; Fax: 504-282-7196; E-mail: firstname.lastname@example.org
• The role that family dynamics can potentially play in the development and maintenance of eating disorders is delineated.
• Areas of inquiry for the assessment of family dynamics are presented.
• The importance of family therapy in multidisciplinary treatment of eating disorders is discussed and a brief literature review of support for family treatment of eating disorders is provided.
• Common issues that arise during the course of family treatment of eating disorders are outlined.
How is family treatment of eating disorders conducted and when is it warranted? This article briefly reviews the important role family dynamics can play in the development and maintenance of eating disorders and summarizes support for family treatment of eating disorders. The review presents areas for inquiry in the assessment of family dynamics and discusses the role of family therapy in multidisciplinary treatment. Common issues that arise in the course of therapy are also delineated.
The family dynamics of those with eating disorders, particularly anorexia, have been of interest to clinicians since the disorders were first described1,2 and well past the time that they were recognized as psychological problems.3 In particular, practitioners have noted the association between eating disorders and difficulty with individuation and separation from the family of origin. Peer relationships are vitally important during the developmental stage that occurs between childhood, during which family is the main source of support, and adulthood, when nonfamilial resources become paramount. During adolescence, it is imperative for friends to become of primary interest and for the family to recede to secondary status. If this phenomenon does not occur, the adolescent’s development of normal peer relationships may be inhibited, thus depriving the youngster of appropriate “growing up” experiences. Without a peer group, it is next to impossible to make the necessary transition from the family to the larger world.
The notion that dysfunctional family characteristics play a part in the development of eating disorders is controversial, as some clinicians believe that the observed family problems are a result rather than the cause of the stress associated with having a child with such a frightening illness.4 There is mounting evidence that genetics contribute to the development of eating disorders, although it is commonly believed that an interaction occurs between genetics and environmental stressors that spawns these disorders.5 What we do know is that the family represents the holding environment for the child and it is always necessary to look at which aspects of the family might relate to the occurrence and maintenance of the disease while remembering that it is never useful or appropriate to blame family members for the disease.3
The ways in which family dynamics may contribute to the development of an eating disorder vary. For example, the family may provide an atmosphere which hinders a youngster from establishing an identity, practicing effective communication skills, and/or learning adaptive coping strategies. Furthermore, within the context of the family, an eating disorder may help an adolescent establish a distinct and separate identity from the family, cope with stressors, distract from negative feelings, or provide what she or he considers to be a means of “safe” self expression in an environment that does not allow open self expression.3
We have noted6 that there have been many clinical accounts of the effectiveness of family therapy in the treatment of eating disorders, yet relatively few controlled studies. However, these few studies clearly show that family therapy is an effective modality for treating eating disorders, particularly in adolescents with anorexia. Investigations with families of bulimics also support the use of family treatment, although fewer studies have been conducted with this population compared to families of anorexics. Taken together, research and clinical experience has convinced us that family therapy is a critical part of treatment within a multidisciplinary team approach, and the need for family therapy from a biopsychosocial stance is now widely accepted.4 A more critical overview of the literature in this area is available in Eating Disorders.6
Assessment of Family Dynamics
The family therapy process begins with an assessment and is a continuous process throughout treatment.6,7 The assessment involves an evaluation of individual family members as well as the family unit as an interrelated system. Thus, the evaluation will necessarily include all family members living within the home. Other extended family members may also be asked to take part in the assessment if they have a significant relationship with the identified patient. The goal of the assessment is to determine if the familial environment played a role in the development and maintenance of the eating disorder and, if so, to identify the extent to which any problematic issues remain.8 The assessment also addresses how the eating disorder functions within the family system. During the evaluation, it is important to identify: (A) how the symptoms stabilize the family; (B) what role the family plays in stabilizing the symptoms; (C) around what themes the problem is organized; (D) what consequences will follow familial change; and (E) the therapeutic problem or dilemma.7
When conducting the evaluation, the practitioner should begin by obtaining standard psychosocial information for each family member including demographic data, current and previous living arrangements, psychiatric history, medical history, educational and occupational history, social history, and trauma history.6 It is also important to inquire about significant family events as well as family traditions. Gathering background information on each parent’s family of origin will promote identification of multigenerational patterns of relating and behaving.
As recommended by Anderson,9 there is a need to investigate other areas as well.6 First, interactional patterns should be evaluated including marital satisfaction, extent of spousal agreement on parenting, family satisfaction and companionship, patterns of communication, and the overall affective atmosphere of the family. Second, it is important to assess degree of flexibility in allowing family members to alter communication patterns and roles in response to situations and stressors. Third, clinicians should evaluate how sensitive family members are toward one another. Are they hypersensitive and overreactive, uninvolved and insensitive, or somewhere in between? Furthermore, it is suggested that supports and stresses be evaluated. More specifically, degree of support, or lack thereof, that family members afford one another should be assessed in addition to any significant sources of strengths and stressors both within and outside of the family.
Practitioners must also assess the age-appropriateness of rules and responsibilities that are assigned to family members, especially children and adolescents. Lastly, family knowledge of the eating disorder is a critical area of inquiry in terms of etiology, treatment, and recovery in addition to thoughts, feelings, and behaviors associated with it. Family attitudes and behaviors that may impede recovery need to be identified and resolved quickly,8 particularly preoccupations with weight and appearance which may undermine the identified patient’s efforts at recovery.10 Relatedly, it is important to obtain a family history of dieting, exercise, and eating disorders.3
To assist clinicians in family assessment, standardized, self-report measures are available such as the Family Adaptation and Cohesion Evaluation Scale11 and the Family Assessment Measure.12 These instruments examine the quality of familial relationships and familial interactions from an individual family members’ perspective.6 Although these instruments are subject to self-reporting bias, they can nevertheless be helpful secondary sources of information.
Treatment: A Multidisciplinary Approach
As we have written previously,6 recognition of the complexity of eating disorders, combined with the realization that no single healthcare professional can provide comprehensive care for these patients, led to the evolution of a multidisciplinary team approach.3 Family therapy is one arm of this approach. It is based on the tenet that the family is a system, or a group of interconnected parts which affect one another in a stable manner.13 Consequently, the psychotherapeutic focus is on the family system as a whole, instead of any individual member.6 We have stated3 that the family is the context out of which an eating disorder typically arises, and accordingly, necessitates change if an adolescent is to overcome the eating disorder in that environment. As a result, family therapy is often geared toward understanding the role that the identified patient has characteristically played within the family system and how he or she has contributed to maintaining whatever homeostasis has been achieved.
Homeostasis refers to the balance that occurs when all family members adhere to their given, often unspoken, rules of behavior. These rules can be quite rigid, thereby preventing family members from learning more adaptive, flexible coping mechanisms in response to life stressors. In some cases, patients do well in treatment without family participation, especially if the family exhibits a high degree of negative expressed emotion.14 Older patients who do not live with their families of origin may not need family therapy unless it is determined that the family continues to be a stimulating factor in the illness. These patients may be in family therapy with their spouses and children. When a patient still lives with her family, however, family therapy is usually recommended. Marital therapy may be suggested as an adjunctive treatment for those with spouses.3
Family therapy may evolve into marital therapy for the parents of the identified patient or individual therapy for one or both parents. In other cases, these psychotherapies may be recommended as adjunctive treatments. Furthermore, it is not unusual for one of the parents to be referred for individual therapy at the outset of treatment if it is clear that the primary family problem lies within that particular parent-child relationship.3
We have reported6 that family therapy conducted in conjunction with individual psychotherapy greatly improves prognosis10 and is recommended in the Practice Guideline for the Treatment of Patients with Eating Disorders.15 For theoretical or practical reasons, some practitioners treat both the identified patient and the family. We prefer a model using separate therapists for individual and family therapy on the following grounds3: (A) facilitation of the individuation-separation process; (B) less complicated management of confidentiality issues; and (C) division of therapeutic responsibilities.16 This model also addresses any family dysfunction on both an individual level, where it has been introjected, as well as on the present family level.17 Finally, there are some schools of family therapy that advocate parental control over the child’s eating and a professional, family-based treatment manual is available outlining one such method.6,18 It has been noted, however, that most clinicians do not follow this approach.19 In our experience, having a registered dietician (nutritional counselor) with expertise in eating disorders handle all food issues has been most beneficial. In this manner, the family and identified patient can relinquish battles surrounding food, strengthen familial relationships, and focus on relevant psychotherapeutic issues.6
At times, families may present obstacles to the assessment and treatment process.20 Potential difficulties include denial of a problem, minimization of the eating disorder, and/or denial of the psychological origins of the illness. Treatment resistance and lack of familial motivation to change may also be present. Family refusal to participate in treatment and/or to cooperate with treatment recommendations can have a devastating effect on the course of the illness and the potential for recovery.3 When family members refuse to take part in recommended treatment, the patient often feels that he/she alone is the one with “the problem” and is in some way defective. The aforementioned challenges must be confronted and resolved early in treatment so that a therapeutic alliance can be established, thereby enhancing the probability of a successful outcome.20
In response to familial disagreement with some aspect of treatment or treatment recommendations, the family therapist, and possibly the entire treatment team if appropriate, should meet with the family to work out those differences.3 Dealing with such problems in this manner models adaptive coping skills for the entire family and creates an atmosphere of mutual cooperation and respect in which healing can take place.
Although each case of an eating disorder develops for a variety of individualized reasons, that there are issues commonly encountered in family therapy.3,6 One such issue is difficulty with communication. This problem may be characterized by miscommunication, lack of communication, mixed or double messages, or failure to allow overt expression of feelings, either directly or indirectly. Another typical theme involves problems with the separation-individuation process and difficulties that the family has in allowing the child to become independent. Lack of appropriate parent-child boundaries (eg, failure to respect privacy), enmeshment (emotional overinvolvement), or disengagement (emotional distance), are also frequently seen. As mentioned earlier, the roles that family members play which contribute to the development and maintenance of the eating disorder must also be addressed. For example, a sick child might be the mediator between parents in a strained marriage. In addition, the family often has unrealistic expectations of individual members, such as the “superstar child.” Finally, issues of power and control within the family are likely to surface. For more detailed information on family therapy in the treatment of eating disorders, see the list of suggested readings.
Family therapy is an effective modality of treatment for eating disorders, particularly when used in conjunction with individual psychotherapy and nutritional counseling as part of multidisciplinary treatment. For younger patients still living with their families of origin, it is usually essential for recovery and requires the participation of all family members. If the family is highly defensive and critical, parent counseling or family therapy without the identified patient may be recommended. For older patients, family therapy may not be necessary unless the family is thought to play a role in the maintenance of the illness.
A careful and continuous assessment of family dynamics is warranted in order to ascertain the therapeutic needs of the family and to implement appropriate interventions. Family therapy can then be expected to surround common themes while also addressing individualized family concerns. At times, families may present challenges to the assessment and treatment process. These difficulties must be identified, addressed, and resolved early in treatment in order to increase the potential for a successful outcome. PP
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3. Michel DM, Willard SG. When Dieting Becomes Dangerous: A Guide to Understanding and Treating Anorexia and Bulimia. New Haven, CT: Yale University Press; 2003.
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5. Klump K. A genetic link to anorexia. In: DeAngelis T, ed. Monitor on Psychology. 2002;33:34-36.
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