PHOTO: Monika Kozub
Text: Anna Nagygyörgy, Viktória Farkas y Alejandra Misiolek
In the past, family environment was considered as the main reason for having an eating disorder. Therefore, children and adolescent patients had the treatment in hospitals instead of at home to benefit from a different ambiance.
Eating disorders in adolescents: the unhealthy family environment
Thanks to alternative theories in the 1960 it has changed, and we see a more sophisticated picture of the role of the family in the development of eating disorders. The revolutionary work of Minuchin and colleagues (1) explains the psychosomatic family model that served as a basis for treatments aiming to change the patterns of family functioning.
Let’s see what the typical interactions in the family of a child with an eating disorder look like, based on the model:
- Enmeshment: it means an intensive relationship with a lack of boundaries.
- Rigidity: is the opposite of adaptability, even if it is needed, there is no change in the interactions.
- Overprotectiveness: it refers to being very concerned for the family member’s welfare.
- Lack of conflict resolution: no possibility to negotiate.
In addition to this typical family organization, the child’s involvement in the conflict of the parents and the child’s physiological vulnerability together are the three main characteristics of psychosomatic families. In many cases, the divorce of the parents leads to the involvement in the parent’s conflict, thus the risk of developing an eating disorder rises. No matter if the child is avoiding or forms a coalition with a parent, the symptoms intensify.
Nowadays there are more and more real-life stories shared with the public with an intention to help others in recovery and with prevention.
In the testimony of Olga Alejandre told in the book The Beauty of Being You: The True Story of How I Overcame an Eating Disorder (2), she tells how she lived through the divorce of her parents. Participating in the court hearings, she felt that she had to choose and defend a parent which is a clear example for the coalition formation. In this book, we can follow the story of her binge eating disorder.
What does the family look like in the case of anorexia?
There are many possible ways a family can influence a child’s relationship with food. Based on the model described above and on clinical experiences, a prototypical family of a child with anorexia could be described as the following: there is a lack of boundaries between both parents/one parent and child – this might mean not giving enough personal space to a child or adolescent, for instance, not guaranteeing alone time in their own room. The relationship is also intensive in the way that the child does not have their own hobbies or parts of their life that are only theirs.
In such a prototypical family, it is also important to mention the so-called separation-individualization phase which does not go in the usual way. During this phase, the child would need autonomy and to figure out who they are apart from the family. At the same time, they still need to be taken care of by their parents which causes difficulties. When this need for separation comes and there are no boundaries and no space for autonomy, one of the ways an adolescent finds control over their life is through food. This is where they get to food restriction and the development of anorexia.
An example of relational patterns in the families of adolescents struggling with eating disorders
Through an example from Glen O. Gabbard’s clinical book, Psychodynamic Psychiatry in Clinical Practice (3) we can see how family patterns can repeat themselves in different situations later in life.
A 19-year-old girl with bulimia has been admitted to a hospital because of bingeing and purging. In her family, she was told what she could and could not eat and furthermore, she did not have enough autonomy in her life. While she was in the hospital she didn’t cooperate with the doctors and nurses when it came to food consumption. Because of the medical staff dictating what and when to eat, she felt forced and victimized, just like she felt with her parents. By taking control of her eating, she wanted to separate herself from others and their expectations. From her point of view, working together and obeying the medical staff had the risk of being only an extension of them and not an individual – just as she felt with her family.
How to help a teenager with eating disorders? Family therapy as treatment of choice
By now it remains clear that family background plays a crucial role in eating disorders, thus the first-line recommendation is family therapy. There are several evidence-based family therapies targeting eating disorders, which are commonly focused on the strengths of the family. With this approach, we can focus on the way family members can help by collaborating in therapy.
Parents are trying their best when it comes to their children, but everyone has their unconscious relational patterns, background, and own family history with blind spots. That is why we sometimes need a third person, a therapist, who can help us see how certain things done to help, can become a problem at the same time. When we are experiencing these things from the inside – as a member of the family – it is difficult to look at it from the outside.
It is important to mention that family therapy is also a trial-and-error process – so the way to do it is by collaborating with a therapist and seeing how working together can implement changes. Another crucial part that family therapy works on is the emotions experienced. Families suffer because of their child’s eating disorder symptoms, and they need emotional support. Furthermore, they have a strong bond with their child, and they spend a lot more time together with the child or adolescent than a therapist does. Therefore, helping the adolescent through the family is much more beneficial and efficient. That is why both individual and family therapy are complementary and inseparable to help an adolescent with their eating disorder.
- Minuchin, S., Rosman, B.L., & amp; Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. Harvard University Press.
- Alejandre, O. (2023). The beauty of being you: The true story of how I survived the ED. B EDITIONS
- Gabbard, G. O. (2000). Psychodynamic psychiatry in clinical practice (3rd ed.). American Psychiatric Publishing, Inc.
- Zinser, J., O’Donnell, N., Hale, L., & Jones, C. J. (2022). Multi-family therapy for eating disorders across the lifespan: A systematic review and meta-analysis. European Eating Disorders Review, 30(6), 723–745. https://doi.org/10.1002/erv.2919