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Section 12
Family-based Treatment

CEU Question 12 | CEU Test | Table of Contents | Eating Disorders CEU Courses
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On the last track, we discussed three manifestations of anger in anorexic clients.  These three manifestations of anger in anorexic clients included:  repression; acting-out; and defense mechanism.

On this track, we will examine three difficulties in employing the family of an anorexic client for treatment. These three family treatment difficulties include:  inability to dissociate; eating strategies; and allowing for client independence.

As you are well aware, much of the literature and research involving anorexia nervosa cites family therapy as one of the most effective treatments for the disorder.  This results from several criteria.  For one, the family provides a constant monitoring system which can regulate the client’s emotional and eating patterns while providing an objective view of his or her behavior. 

Specifically, the Maudsley model provides a basic and the most well-known format for treatment. The Maudsley model was first tested as a means of preventing posthospitalization weight loss in different subgroups of anorexia nervosa clients in a study by Russell, Szmukler, Dare, and Eisler in 1987. The study yielded several striking results. In the subset of younger clients with more recent onset, conjoint family therapy produced an impressive rate of recovery, 90% symptom-free at 5 years.

3 Difficulties in Employing Family for Treatment

Difficulties #1 - Inability to Dissociate
The first difficulty in family treatment therapy occurs when a family lacks the ability to dissociate. As you already know, in the first stages of family therapy and anorexia, the parents and siblings are asked to dissociate the disorder from the client. This prevents emotional escalation and frustration, thus relieving the client of guilt further on.

However, when a parent or sibling cannot dissociate, he or she becomes a risk to the client and to themselves. They may begin to interpret the client’s inability to recover as stubbornness or ungratefulness. Obviously, this poses a risk to the client and his or her support system. 

Dana, age 15, had developed anorexia and weighed 85 pounds. Prior to being recommended for treatment by her high school counselor, Dana’s parents had attempted to break her of her self-starving behavior with little success. Her parents, Harold and Tisa, were of the belief that any problems arising within the family should remain in the family. However, because they could not force their daughter to eat, they became frustrated and began to belittle and bully her into eating. 

According to Dana, Harold would say numerous times, "You’re sick and damaged!  Why are you doing this to us?  You are so selfish!"  As you can see, Harold had interpreted Dana’s refusal to respond to treatment as a personal attack in the form of teenage stubbornness.  Think of your Harold and Tisa.  How do they interpret their son or daughter’s actions?

Difficulties #2 - Eating Strategies     
The second difficulty in family treatment therapy occurs when the family cannot agree or implement eating strategies for the anorexic client. As you know, another primary stage of the Maudsley requires the parents of the anorexic client to monitor and control the client’s eating habits. If a family structure consists of either very strict or very lax parents, creating an effective strategy can become difficult. This is especially true in families where polarization has occurred. 

Technique:  Eating Contract
Molly, age 17, and her parents Christine and Mark, had been trying to develop a strategy to help Molly gain weight.  Up to this point, Christine and Mark had been inconsistent in their discipline of Molly.  Unused to Molly’s newfound assertiveness, Christine and Mark had begun to give in to each of her requests.  Christine stated, "We’re so happy when she eats a little that we don’t force the issue!  We never say, ‘You need to eat more than that.’" 

To help Christine and Mark gain consistent control of Molly, I suggested they write up an "Eating Contract." This contract will stipulate the exact food groups and gram sizes that Molly must consume in a single meal in order to be excused from the table. I asked Mark and Christine to write up the contract and to have Molly sign it willingly.

One stipulation of the contract stated that Molly could not move from the table until she had finished all of her meal on the plate. This contract was not only for Molly’s benefit, but for Christine and Mark’s as well. By giving themselves a set of guidelines to follow, they were less likely to give in to Molly’s requests. 

Think of your Mark and Christine.  Could they benefit from an "Eating Contract?"

Difficulties #3 - Allowing for Client Independence
In addition to the inability to dissociate and difficulties in eating strategies, the third difficulty in family treatment therapy occurs when the parents will not allow the anorexic client any independence once improvement occurs.  I have found that this is most common with adults who have a need to control the actions of their son or daughter. Many times, they experience severe attachment and may fear the sudden independence of a once dependent child.  This can be exceptionally complicated when the client’s parent shows signs of over-protectiveness or attachment prior to treatment. 

Brittany, age 19, had reached a healthy 110 pounds, and wanted permission to live in the dorms of the local community college.  Her mother, Georgia, refused, stating, "She may slip back into it!  I don’t want to lose my baby at the age of 21."  Unknowingly, Georgia may worsen Brittany’s condition by restricting her independence.  Without the reassurance of her mother, Brittany may in fact believe that she is unable to live on her own. 

To ease Georgia’s mind and allow Brittany her independence, I suggested a weekly home visit.  Each weekend, Brittany would return home for Sunday dinner, during which she would share with her parents her feelings and concerns about school and her parents can simultaneously gauge Brittany’s eating habits.  Think of your Georgia.  Is his or her need for control affecting the client’s ability to function outside of the home?

On this track, we discussed three difficulties in employing the family of an anorexic client for treatment.  These three family treatment difficulties included:  inability to dissociate; eating strategies; and allowing for client independence.

On the next track, we will examine three concepts related to redefining identity in anorexic clients.  These three identity defining concepts include:  exposing the false self; allowing the self; and self-neglect.

Testimony of the Eating Disordrs Coalition for
Research, Policy, & Action

- The Eating Disorders Coalition for Research, Policy, & Action. (2002). Testimony of the Eating Disordrs Coalition for Research, Policy, & Action.

Peer-Reviewed Journal Article References:
Criscuolo, M., Marchetto, C., Chianello, I., Cereser, L., Castiglioni, M. C., Salvo, P., Vicari, S., & Zanna, V. (2020). Family functioning, coparenting, and parents’ ability to manage conflict in adolescent anorexia nervosa subtypes. Families, Systems, & Health, 38(2), 151–161. 

Friedrich, W. N. (1992). Review of Unlocking the family door: A systemic approach to the understanding and treatment of anorexia nervosa [Review of the book Unlocking the family door: A systemic approach to the understanding and treatment of anorexia nervosa, by H. Stierlin & G. Weber]. Family Systems Medicine, 10(2), 243–244.

Isserlin, L., & Couturier, J. (2012). Therapeutic alliance and family-based treatment for adolescents with anorexia nervosa. Psychotherapy, 49(1), 46–51.

Online Continuing Education QUESTION 12
What are three difficulties in employing the family of an anorexic client for treatment? To select and enter your answer go to CEU Test.

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