Family Members of the Eating Disordered Patient

continued

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 anorexic, 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.

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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."

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