Families and Eating Disorders
D. Blake Woodside, MD FRCP(C) and L. Shekter-Wolfson, MSW, C.S.W.
The role of the family in the development and perpetuation of eating disorders has been an issue of considerable controversy. Historically, mothers, fathers, or both together have been variously blamed- either for doing something (everything) wrong or for not doing enough. The eating disorder was often held to be nothing more than a symptom of underlying family problems. Consequently, family therapy was often advocated as the treatment of choice for all clients with anorexia nervosa or bulimia nervosa, with the explicit promise that the eating symptoms would disappear once the underlying family conflicts were resolved.
A more balanced view
Currently, most family researchers view the role of families in the development of anorexia and bulimia nervosa in a much different fashion. Families are not so much held responsible, but rather viewed as unwittingly caught up in a complex, frightening disorder which they do not understand and often feel helpless to influence. Because of this lack of understanding, families may attempt to help the client with her issues in ways that, while well intentioned, may in fact serve to perpetuate the eating disorder.
The role of the family as precipitator of anorexia nervosa and bulimia nervosa must be viewed in a different way as well. It is clear that individuals with anorexia nervosa and bulimia nervosa are often affected by significant family events, such as deaths, divorces, and other life-cycle changes. It is also clear that individuals with a family history of alcoholism, major depression, and sexual and physical abuse are at increased risk for developing eating problems. However, how cultural, familial and individual factors interact to cause someone to develop an eating disorder is unique to the individual.
Levels of family involvement in treatment
Families will require different levels of support and intervention depending on their specific circumstances. Families often need and benefit from education and support while clients are resolving issues around food, weight and shape. Education involves providing family members with accurate, adequate information about the symptoms and treatment of the disorder. The amount of information provided will vary depending on the degree of involvement the client has with the family. Families may benefit from being referred to family support groups, providing an opportunity to share information with other families in similar situations. Supporting such families does not involve telling them to ignore their struggling family member, but rather encouraging them to be realistic about the degree to which they will be able to affect the process of recovery. Some clients express a wish to obtain significant amounts of support from one or more members of their family, or may wish no support from the family. The role of the health care worker is to help the family clarify the needs and resources of different family members, while facilitating a realistic attitude about what would be helpful.
For families of a younger client, specific attention may need to be paid to issues currently active in the family. These may include life-cycle changes, such as older children leaving home, or unfortunate circumstances such as parental marital difficulties or illness in other family members. The focus of attention will not be to blame other family members, but rather to examine how these events are affecting everyone in the family, including the individual with issues around food, weight and shape.
Assessing family strengths
A family assessment is helpful in order to decide how the family might meaningfully participate in the client’s treatment and process of recovery. This should be, whenever possible, a mandatory part of the assessment of any client under the age of 18 or who is still living at home, and we recommend it strongly for all clients, regardless of their age. Such an assessment can be carried out by the primary therapist, or the family can be referred to a family therapist. For married adult clients, their current family should be assessed, as well as their family of origin. Such an assessment should include at least the following components: how much does the family know about the eating disorder; how do they understand it; when did they find out; who has been the most involved; and what have they heard about treatment and outcome?
Some families are very knowledgeable about eating problems, and the assessor can then focus quickly on suggestions about how the family can be helpful. For other families, education and information is the main priority, and if this is the case it should be provided, either by the therapist or in the form of reading material.
A family assessment of this type is not an assessment for family therapy. Some families will express the feeling that their distress is so great they wish to have some ongoing form of family involvement. Other families may express such a desire only after eating is normalized. A very few families will feel so threatened by the entire experience that they will refuse to be involved or will be hostile to the assessor. Clients will also occasionally block family involvement, usually out of fear of what form the involvement will take.
In summary, families remain an important part of the assessment and treatment of clients with eating disorders. Wherever possible, family assessments should be routine, with the focus being psychoeducational and supportive. The degree and nature of further family involvement will be determined by the nature of the family and the setting in which the therapy is taking place.
Coping with a family member suffering from an eating disorder
- Be patient. Eating disorders can be a long-term illness. You cannot expect over-night recovery, even if the person is in therapy.
- Encourage the person to seek professional help. If the individual is truly endangering their life by their eating habits, be insistent.
- Seek outside help for yourself. Find a family/friend support group, a counsellor, or other professional who has experience in helping families and friends cope with an eating disorder sufferer.
- When discussing the problem with a person you suspect has an eating disorder (especially if it is for the first time), don’t be surprised if the reaction is one of denial or perhaps even hostility.
- Don’t lay blame. This only reinforces the person’s feelings of failure.
- Try to ensure that you don’t allow the person’s problems to interfere with your routine functioning. Let the person know that he/she is important to the family, but not more so than any other family member.
- Don’t dwell on food related discussions. Encourage the person to get involved with non-food related activities.
- Avoid commenting on the person’s weight or appearance- your comments may not be taken in the proper context.
- The person with an eating disorder must feel that they have control over their daily routine. This can be very frustrating for those around the individual, but the situation often only becomes worse when it is perceived that someone else is trying to take that control away.
- Be aware that low self-esteem is often a problem for those with eating disorders. Be careful not to make comparisons.
- Learn about eating disorders. Understanding is a key to coping.
© NEDIC 1988; Reviewed 2003 www.nedic.ca