Family Dynamics in the Treatment of Eating Disorders

James Gerber Ph.D.

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.

• Structure refers to the set of rules (overt or covert, idiosyncratic or universal) that guides the family’s 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.

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.

Attachment Theory: (Bowlby, J. Ainsworth M.) Refers to those parent-infant interactions that effect the child’s sense of security.

• 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.

• 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 child’s development (executive functions, self worth), exploration and mastery are restricted.

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.

• 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.

• 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 one’s internal family (parts) onto one’s external family, especially children who then are disposed to pass this to the next generation.

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.

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.

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)

“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 daughter’s ineluctable urge to separate from the mother. When a father is unable to help his daughter move out of the maternal orbit…the daughter may turn to food as a substitute” (Zerbe, K. 1993)

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.

• 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 father’s 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.

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.

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.

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.

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.

• 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 father’s emotional volatility was seen as not safe and her contempt for him led her to disown her own emotions especially anger.

• 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 mother’s relationship with her own mother, and described being aware of the emotional gulf between them i.e. the legacy burden.

• 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, “it’s 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.

• 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.

• 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 patient’s sense of self pity and described a similar experience. The “pretty sister” was an avenue for her to escape her own self contempt.