When an eating disorder strikes an individual, his or her entire family is affected. According to an article by Abigail Natenshon, MA, LCSW, GCFP, 87% of eating disorder patients are children and adolescents under the age of 20. As many in this age group still live at home, the eating disorder develops and plays out within the family dynamic. It often takes on a life of its own and can be the cause of many battles at meal times, family gatherings, holiday events, and can even affect extended family and school environments. Family therapy is an essential part of eating disorder treatment and is necessary to ensure everyone who is a part of the family system is cared for.
The Family System Theory
Developed by Dr. Murray Bowen, family systems theory posits that the family is a unit and the emotional connections fostered by thoughts, feelings, and actions create an interdependent environment. This interconnectedness helps the family to become cohesive and supportive of its members. If there is unrest and tension, emotional connections can become more stressful. If there is a member of the family who tends to take on the emotions of the other members and may take on an accommodating role, leading to overwhelm and isolation. This is the family member who may become more susceptible to addictions, depression, anxiety, eating disorders, and illness.
There are eight concepts to the family systems theory:
- Triangles: A three-person relationship system
- Differentiation of self: Variation in how people are susceptible to pressures to conform to the group
- Nuclear family emotional system: Four basic relationship patterns (marital conflict, dysfunction in one spouse, impairment of children, emotional distance)
- Family projection process: The way parents transmit their emotional issues to children
- Multigenerational transmission: Differences in differentiation across generations
- Emotional cutoff: Managing emotional issues by cutting off family members
- Sibling position: Impact of sibling position on behavior and development
- Societal emotional process: Emotional systems govern behavior on the societal level
Family systems theory can be used to help clinicians understand the dynamics of the family presenting to work through one member’s eating disorder.
Family Involvement in Eating Disorder Treatment
Comprehensive treatment plans at all levels of care will involve family therapy. Center for Discovery residential programs involve the family weekly in a therapeutic way, not only in family therapy but also at meal times by facilitating therapeutic family meals. The purpose of these activities is to observe family dynamics at meal times and in social situations in order to best prepare the family for realignment and a return to balanced interconnectedness.
Some clients benefit from a type of family therapy called Family Based Therapy (FBT, also known as Maudsley). This outpatient approach, which places the refeeding process in the hands of the parents and moves the family through phases of treatment as recovery develops, has proven to be very successful for adolescents with anorexia.
In outpatient settings, family therapy is usually recommended in conjunction with individual therapy, nutrition services, and group work. As the eating disordered member reintegrates back to the system after being away at treatment, therapy is needed to help the family adjust once again. An eating disorder has the potential to isolate family members from one another, create discord in the system, and indeed can be either sustained or eliminated depending on the dynamics of the family system. It is important for clinicians and parents to know that parents do not cause eating disorders. The entire system needs attention and support to thrive again.
Natenshon, A. Family Treatment is Cornerstone of Effective Care for Eating Disordered Children. Treating Eating Disorders, www.abigailnatenshon.com
The Bowen Center for the Study of the Family. www.thebowencenter.org
Recovery from an eating disorder requires an incredibly courageous step into the unknown. It requires relinquishing control and moving through the stages of change to reach acceptance and health. This is easier said than done and takes time. One of the first steps is identifying what purpose the eating disorder serves and therefore what emotional needs it is meeting. Only then can the person begin to find healthy ways to meet those needs and heal.
What is the Function?
Very often, people with eating disorders find themselves in life circumstances that leave them feeling like they’ve lost control. Maybe there’s been trauma or a loss, or maybe bullying at school or a lack of identity. The eating disorder swoops in at these vulnerable times, offering a lifeline in the form of a sense of power and control, a numbing of painful emotions, something to feel accomplished about….a savior that ends up creating devastation and life-threatening complications.
Stages of Change
Moving beyond resistance and denial to contemplation and action feels impossible when the eating disorder is in full swing. Many people arrive at treatment at the urging of family and friends without the slightest idea themselves of why they are there. The stages of change put a timeline to this process, and it is possible to envision when one might arrive at identifying and challenging the purpose the eating disorder serves.
Precontemplation: People in this stage tend to be resistant to change. They are in treatment for others. They feel hopeless.
Contemplation: Recognizes there’s a problem (and perhaps now is aware of the purpose the eating disorder serves) and begins to anticipate an imminent change.
Preparation: People sometimes experience ambivalence in this stage as they prepare for change but still aren’t 100% convinced it’s a good idea.
Action: Time and energy are committed. Behaviors begin to change.
Maintenance: Continued action is required to maintain recovery. It is a fluid process with frequent adjustments.
A person in the throes of an eating disorder truly believes that the illness brings value to their life. It likely has shown merit at some point, in the form of the purpose it serves in the person’s life. For example, someone who has experienced life in an alcoholic home may now feel in control for once….amid all that chaos, the eating disorder created a way for the person to feel competent, in control, and superior. In this case, the eating disorder creates control where there was chaos and a false sense of self-esteem where there was self-hate and uncertainty. It becomes difficult to build a case against the eating disorder when it has brought some semblance of order to the person’s life. Recovery begins when the person recognizes the purpose served and can accept that what once felt like control has now become out of control and not sustainable. An article by Emily Troscianko (2010) poignantly states: “Somewhere along this road….You may come to see that exerting control is simply no longer what’s required of you.” Letting go catalyzes action, and action leads to recovery.
Troscianko, E. (2010). Why Control Won’t Bring You Happiness. Psychology Today, www.psychologytoday.com
Eating disorders represent a crisis of some kind, be it trauma, low self-esteem, poor body image, bullying….clients present with many different root causes of their disorder. The one underlying theme is distraction and coping. The eating disorder serves as a best friend, a confidant, a powerful secret, and appears at the time the client needs it most. In a storm of chaos and fear and inconsistency, the eating disorder swoops in and rescues the client temporarily from the distress.
Michelle Lelwica (2010) shares that while the client is focused on creating a “good” body or engaging in eating disorder behaviors like restricting or purging, the inner life is being ignored. No matter how thin the client gets, no matter how filling the binge, there is an eternal sense of emptiness and hunger that is never satisfied. All of the crises that pile up in life, all of the hurts and trauma, drive a wedge through the true self. Big questions like “What is important in my life” and “How do I understand my life’s purpose” cannot be answered when the soul is entrenched in an eating disorder. There is simply no energy left for living. Recovery becomes a spiritual journey as clients attempt to access their pain and face it with the help of a higher power.
Randy Hardman and Michael Berrett (2015) explain that many people with an eating disorder have had some degree of personal spirituality in their lives. Some have participated in religious observations and others may have felt connected to yoga or nature or a meditation practice. Despite this, during the course of the eating disorder these connections were lost. Feelings of unworthiness creep in as the eating disorder, which at one point served a purpose, becomes harder and harder to sustain. Indeed, eating disorders cause sufferers to chase false pursuits that ultimately replace spiritual connection. Hardman and Berrett list these false pursuits:
- False sense of control
- False form of communication about pain and suffering
- False sense of being the exception or exceptional
- False crusade for evidence against self
- False pursuit of perfection
- False form of comfort and safety
- False identity
- False compensation for the past
- False attempt to avoid personal responsibility
- False pursuit of approval
Eating disorders may represent some or all of these falsehoods for clients. Richards et al (1997) state that eating disorder clients often have difficulty letting go and having faith, despite their spiritual background, leading to a worship of these falsehoods in pursuit of a sense of control and well-being. Along the way the eating disorder gains control of every aspect of their lives, rendering clients powerless when all they were seeking all along was a powerful sense of being good enough.
Not all clinicians work with spirituality in treatment with their clients, but it is a significant aspect of recovery that can’t be avoided. Clients who wish to regain their spiritual connections, or foster connections for the very first time, can do so in the safety of the therapeutic alliance. Eating disorders are very hard to give up because it is difficult to remember what life was like beforehand and next to impossible to consider what life might be like in recovery. There is so much unknown and that is often one of the biggest barriers to recovery. Spiritual exploration during treatment can help clients resolve any negative impacts their spiritual pursuits had in the past and move forward with new resolve to take care of their physical, emotional, and spiritual selves.
Lelwica, M. (2010). The Spiritual Dimensions of Recovering from an Eating Disorder. Psychology Today, www.psychologytoday.com
Hardman, R. and Berrett, M. (2015). Eating Disorder Recovery: A Spiritual Perspective. BYU Idaho Counseling Center, www.byui.edu
Richards, P., Hardman, R., Frost, H., Berrett, M., Clark-Sly, J., and Anderson, D.
Spiritual issues and interventions in the treatment of patients with eating disorders. Eating Disorders: Journal of Treatment and Prevention, 5(4), pp. 261-279
I have been fortunate enough to experience eating disorder recovery from two perspectives: personal and professional. It has been a joy to emerge from the dark depths of anorexia to discover a life full of purpose laid out before me. Similarly, it is inspiring to witness clients gain insight and move toward health and well-being. In both capacities I have learned the importance of self-compassion as a foundation for lasting recovery.
Learning to Love Yourself
A common theme I’ve found threaded through many eating disorder cases is a lack of self-esteem and self-compassion. Some individuals have exhibited a great ability to be compassionate and empathetic towards others, but are unable to give themselves the same respect. More than a few times I’ve heard “They deserve compassion and respect, I don’t.” When pressed as to why this is, most can’t give a concrete answer. It seems to be a deep self-loathing for reasons mostly unknown.
The problem is that when we lack self-esteem and self-compassion, we look externally to receive them. We may think that if we excel in school or work, if we are popular, if we are thin and attractive, we will feel like enough. Over time we discover that even if we achieve all of these things, there is still something missing. That emptiness feels like “I’m still not good enough,” and so we cling to the eating disorder for reassurance that at least we are good at something.
Of course, there are many complex reasons why eating disorders develop and it can take a long time to really unravel the root causes. But the bottom line is that for lasting recovery, we must be willing to sit with and learn to accept ourselves as the amazing, perfectly imperfect humans that we are.
Ten Steps to Self-Compassion
Recovery is an investment in yourself. It is a decision to put yourself as a priority and learn to accept the person you are. There are many ways to accomplish this, but here are ten steps that can lead to self-compassion:
• Practice compassion! That’s right, resolve right now to speak to yourself gently. Give yourself some grace.
• Invest in recovery. This means engaging your treatment team as recommended, doing your homework, and being accountable for your journey to wellness.
• Take your medications as prescribed and follow your meal plan. Learn what it feels like to have your body’s needs met, and learn to cherish that feeling of wellness.
• Practice mindfulness. Learn to enjoy each moment as it comes.
• Recognize and honor your feelings. Make space for them and allow yourself to experience and express them.
• Cultivate your interests and hobbies. Make time for the things you love to do and that bring you joy.
• Practice positive self-talk. Work with your therapist to develop skills to challenge your negative thoughts and replace them with positive.
• Develop a new relationship with your body, one built on acceptance and respect.
• Know your triggers and have a plan to mitigate them.
• Work to accept yourself, your genetics, your mistakes, your achievements, and all of the wonderful, unique things that make you the only you on this planet.
Need further guidance to practice self-compassion and start your journey to recovery? www.prosperityedwell.com
Carolyn Labrie, PhD(c)
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Carolyn Labrie, PhD(c)
New Year’s Resolutions: Small Steps Toward Recovery
A new year brings a clean slate, a chance to forget about the struggles of the past year and make fresh choices for the future. It is common for people to make New Year’s resolutions, goals set to create positive change. In our society, New Year’s resolutions often focus on weight loss and exercise. Go to any gym in January and you will have difficulty accessing equipment because of the crowds. All this focus on appearance and diet can be triggering for people in recovery from an eating disorder. While weight loss goals may have been a focus in the past, in recovery it is no longer a viable option. How can we make healthy, recovery-focused New Year’s resolutions in a culture of excessive dieting and exercise?
Meet Yourself Where You Are
A new year is a great time to take an inventory of where we are and the things we want to change. It is important in this inventory to realize that where we are right now is exactly where we need to be. There is no need to come down on ourselves for falling short of goals or encountering setbacks. Take this opportunity to practice self-compassion and have patience with yourself. In this compassionate space you will be able to see the areas that need more attention and set goals for realistic progress.
One Day at a Time
According to an article on Eating Disorder Hope (2013), among the top 2013 New Year’s resolutions were “becoming more physically fit” and “losing weight.” For anyone with an eating disorder, these resolutions are dangerous. Engaging in behaviors that trigger the eating disorder voice can lead to a relapse. For anyone, these generalized resolutions sound great at the time but quickly feel overwhelming because there is no instruction manual attached to teach us HOW to get there.
The great thing about resolutions is that we are in charge of creating the instruction manual! Recovery is an active process and we place the guideposts with the help of a treatment team. If you are in recovery, your New Year’s resolution might be to practice self-care. You can work with your treatment team to set smaller goals to achieve this. Perhaps this will mean engaging in one self-care activity, however small, per day. Over time these positive actions add up to larger gains in the form of increased mood and self-compassion. Recovery is truly a daily endeavor and if we focus on the moment and use our skills, progress will be made.
This New Year, resolve to put your recovery first. Although you may feel uncomfortable and triggered by the appearance-focused resolutions around you, be firm in your conviction to be well. The choices you make about your recovery will influence the direction your journey takes. Remember that even the smallest positive steps will eventually bear fruit in the form of lasting health and happiness.
Wishing you a New Year full of discovery, joy, and wellness!
Eating Disorder Hope (2013). A New Year’s Resolution Worth Keeping. www.eatingdisorderhope.com