Family Members of the Eating Disordered Patient

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.

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