Family Dynamics in the Treatment of Eating Disorders

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Family Dynamics in the Treatment of Eating
Disorders

• James Gerber Ph.D.

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Conceptual/Theory

• Systems Theory Families are systems of
  interconnected and interdependent individuals. To
  understand the person it is necessary to
  understand the family. People cannot be
  understood in isolation

• Structural Family Therapy (Minuchin) Three
  constructs are essential. These are structure,
  boundaries and subsystems.

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• Structure refers to the set of rules (overt or
  covert, idiosyncratic or universal) that guides
  the familys way of interacting.
• Subsystems are the alliances, dyads that develop
  within the family, i.e. mother/son,
  father/daughter, etc.

• Boundaries manifest in how proximity and
  hierarchy are managed in the family. In
  disengaged families, emotional distance is
  excessive and lacks support for the individual.
  In enmeshed families boundaries are diffuse and
  are intrusively intertwined.

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• In theory, behavior disorders develop when
  inflexible family structures cannot adjust to
  maturational or situational changes. Symptoms in
  the individual emerge in response to dysfunction
  in the system.

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• Attachment Theory (Bowlby, J. Ainsworth M.)
  Refers to those parent-infant interactions that
  effect the childs sense of security.

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• Central concepts in attachment theory Attachment
  to caregivers is an innate motivation that
  provides for the survival and safety of the
  infant.
• Secure attachment requires the attunement of the
  caregiver to the infant.

• Infants internalize patterns of interaction in
  internal working models which form the template
  for relationships through the lifespan i.e.
  caregiver/caretaker, abuser/abused.

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• If internalized models are built on the
  experience of reliable and attuned caregivers,
  the child has a secure base from which to explore
  the world.

• Misattunement and unreliability result in
  anxiety, avoidance and dissociation. This then
  has global impact on the a childs development
  (executive functions, self worth), exploration
  and mastery are restricted.

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Internal Family Systems

• Internal Family Systems is based on the theory
  that subpersonalities develop as a way for a
  child to cope with life circumstances. Of
  central focus in the theory and therapy is the
  concept of Self.

• In IFS, the Self is innate, present from birth.
  The Self contains all of the qualities a person
  requires to find satisfaction in life such as
  compassion, creativity, clarity, etc.

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• While parts emerge as a way of coping and is
  adaptive, parts that hold experience that is felt
  to be toxic are disowned. Other parts then emerge
  to manage what is exiled. This creates internal
  polarities between the motivations of the exile
  and the motivations of the manager trying to
  suppress.

• These exiles hold the burdens (shame, secrets,
  trauma) much like the blacksheep of families do
  in the external family.

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• Legacy Burdens Legacy burdens are the residue of
  internalized conflict, be it secrets, trauma or
  shame that pass from one generation to the next.

• Legacy burdens involve the projection of ones
  internal family (parts) onto ones external
  family, especially children who then are disposed
  to pass this to the next generation.

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Clinical Practice

• It would appear that a revision of the overt
  family structure (boundaries, dyads, rules) would
  result in a flexibility that would facilitate the
  growth of the individual.

• However, what we find is that there is an
  intricate interplay between the internalized
  worlds of the individuals and what manifests in
  the world. Without attention to each the
  ingrained patterns are resistant to change.

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Case Example 1

• A twenty year old women is admitted to CW with an
  eating disorder. The family dynamics present as
  an enmeshed relationship between the mother and
  daughter. Then an emotional distance in the
  father-daughter relationship as well as in the
  marital relationship. The woman seems arrested in
  not being able to launch into the world. Though
  bright with past academic success she has
  difficulty in school as well as establishing peer
  relationships. Her relationships with male peers
  are marked by bouts of drinking and brief sexual
  encounters which result in no intimate
  connection.

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• A secure maternal attachment is necessary for
  the infant to explore the world. However, in
  reference to mother-daughter Zerbe writes,To
  grow we must loosen some of the intense powerful
  ties to our mothers thus permitting a new kind of
  connection to form. Mothers must permit this
  evolution to happen. This task is more easily
  said than done. (Zerbe, K. 1993)

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• If not taken to pathological extremes, the
  father-daughter relationship can provide the
  daughter with a sense of specialness and
  lovableness. It also remains important for the
  daughters ineluctable urge to separate from the
  mother. When a father is unable to help his
  daughter move out of the maternal orbitthe
  daughter may turn to food as a substitute
  (Zerbe, K. 1993)

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• In treatment the patient struggled with her
  conflict in launching into the world as an adult.
  As with other patients she described an inability
  to tolerate her emotions and a diminished sense
  of self, especially in regard to her relation
  with men. It is notable that as the therapy
  unfolded she described the tremendous grief
  related to the emotional distance and perceived
  rejection of her father.

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• Overtly, we could invite the two of them to share
  time and learn skills to communicate. But this
  did not alter the shell that restricted the
  fathers empathy and understanding.
• In IFS work with the father he connected with his
  own experience of alienation in childhood and
  lack of guidance in adolescence. This was held in
  his own exiled parts. What he spoke of in his
  experience was identical to what his daughter
  also described.

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• Through the IFS work he was able to acknowledge
  and have compassion for his own injury and
  struggle. This then allowed him to understand and
  relate to his daughter in a way that built
  connection. In addition, the emotional block that
  was removed allowed him to be more open in his
  marriage which fostered the parental dyad.

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Case Example 2

• A twenty six year old woman, six months pregnant
  with a history of episodes of restricting,
  binging and purging since the age of twenty.
  Struggles with alcohol, body image and disordered
  eating were evident earlier in her life. Her
  relationship with her parents was complex and
  helps to highlight the interplay of outward
  systemic dynamics, attachment and the internal
  system.

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• Her relationship with her mother and father
  display seemingly contradictory motivations. She
  stated that she was close to her mother and there
  was an emotional enmeshment evident in both of
  their inability to see the other emote without
  their own distress and need to fix the other.
  However, she also stated that her mother was
  unemotional and felt disconnected from her.

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• On the other hand, she could elaborate on her
  father and their relationship. She felt she was
  identified with him (in personality and body
  type), by others as well as in her own perception
  . This was problematic in that he had suffered
  his own abusive childhood and was prone to
  volatile outbursts. While seldom directed at the
  patient, she viewed his behavior with contempt.
  This then interfered with the availability of her
  father as a source of specialness and support.

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• So while emotionally enmeshed with her mother
  their was a misattunement. Both of these dynamics
  interfered with her sense of security and
  emotional development.
• Her fathers emotional volatility was seen as not
  safe and her contempt for him led her to disown
  her own emotions especially anger.

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• In therapy a number of statements did highlight
  her experience. For example she stated that from
  mid childhood she had fantasies of being
  kidnapped or raped. These were not frightening to
  her. She explained that at least in the fantasy I
  was desired. I just want to be cherished.
• From another avenue she became aware of how her
  relationship with her mother was similar to her
  mothers relationship with her own mother, and
  described being aware of the emotional gulf
  between them i.e. the legacy burden.

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• On particular note was her awareness of how she
  and her sister were treated differently by her
  mother. Her sister, the pretty one, was the
  object of admiration by others. She felt a sense
  of pity from her mother but that was of no help
  since, its so bad no one even knew how o help
  me. Compensatory strivings for achievement and
  perfection were used to alleviate the void and
  sense of being defective.

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• In individual therapy with the IFS model she
  came, over time to access the disowned child
  parts of self, to revise the self contempt and
  view them with compassion. This resulted in her
  being able to view and begin to relate to herself
  differently, both in behavior and internal self
  talk.

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• In family therapy, her mother was receptive to
  this discussion and validated that her
  relationship with her mother was similar in the
  misattunement and that this was a pattern
  stretching back to other generations. Her mother
  also related to the patients sense of self pity
  and described a similar experience. The pretty
  sister was an avenue for her to escape her own
  self contempt.