The family therapy of anorexia nervosa

J. psvchror. Rex.. Vol 19. No. 2.‘3. pp. 435-443. Prmted I” Great Bntam

0022.3956185 13.W+ .OO Pcrgamon Press Ltd

1985

THE FAMILY THERAPY OF ANOREXIA NERVOSA CHRISTOPHER DARE Department of Children and Adolescents, the Bethlem Royal and Maudsley Hospitals INTRODUCTION ANOREXIA nervosa is a condition

which affects a population of predominantly young women preoccupied by their weight and their (misperceived) shape. The largest proportion of papers presented at this conference are concerned with the investigation of the incidence and nature of the condition and less so with the therapy. This is quite proper in the light of the many uncertainties about the subject. However, a priority of interest in causes over treatment is shared by the entire system with which we are involved. That is to say the population of anorexic subjects, their informal and family networks, and the group of professional helpers who become involved with them. All members of this system express a great interest in the causes of the condition. Certain elements in the system also express considerable commitment to preventing drastic changes in the anorexic youngsters’ weight. The young person with the symptoms of the condition is liable to avoid treatment, believing that it will impose a terrifying change on her. At the same time, she may suffer a great deal of distress about the condition and its probable consequences. The fact that the parents’ cooperation is often thought of as incomplete by the professional helpers, has been taken to suggest that they are resisting change in their daughter. The social network appears to support change, in the direction of increased weight, girth and appetite, but this is not so always, for example, in the world of ballet and fashion modelling, as GARNER and GARFINKEL (1980) and LOWENKOPFand VINCENT (1982) have suggested. From time to time we have observed ourselves and our colleagues acting in ways that appear to be the contrary of therapeutic. This is not, I hasten to add, because we have an investment in keeping our workload high but as an aspect of what can only be termed a “countertransference enactment”. We have observed ourselves or others apparently feeling so closely identified with the patient’s symptomatic anxieties, that we come, momentarily, to share her misperceptions, and to believe that therapy is making progress when in fact the patient has merely permitted herself to evade weight gain. These various locations of resistance to change are important if the subject of the family therapy of anorexia nervosa is to be put in its right context. It is important to make another, preliminary, position statement. An interest in causes has certain “associations”. Knowledge of causes sounds as if it is likely to lead to rational therapy but this is not necessarily true. Therapy that is effective may turn out, eventually, to owe its efficacy to links with causes, but a clear aetiological understanding does not have any necessary connection with the development of therapy. For example the cultural preoccupation with thinness has been suggested by GARFINKEL and GARNER (1982) to be one of the multi-factorial components in the aetiology of anorexia. Even if shown to be indubitably important, it is not readily susceptible to intervention by mental health 435

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personnel. On the other hand, effective therapies can evolve independently of knowledge of causation; the widespread and apparently useful self-medication with acetyl salicylic acid for headache is a case in point. An effective therapy can also evolve from pre-suppositions about aetiology which turn out to be entirely erroneous. It is thus illogical to keep in close juxtaposition notions of family aetiology for anorexia and the utilization of family therapy for the condition. A reason for the reiteration of this point is the widespread belief that communication of aetiological knowledge to a patient is helpful. Most of us have a belief that “knowledge is a good thing” and however sceptical we are with the practice of interpretation and the theory of insight producing therapeutic change, we all communicate to our patients our understanding of what is going on in them. I have observed this in several clinicians regardless of their acknowledged disbelief in the efficacy of such communications. The practice is defined as: in pursuit of open and honest communication; for the purpose of enhancing cooperation; as therapeutic re-framing or as the therapeutic technique of making constructions. These are rationalisations for having said things to patients which are equivalent to interpretations, that is, drawing the patient’s attention to motivations or beliefs of which he had no conscious awareness. Our belief in the importance of knowledge leads us to act as though telling patients what we think are the causes of their state, will help alleviate their condition. I am sure that this is not due to the influence of psychoanalysis although, like all psychoanalysts, I find myself confusing discussion of causes and unconscious meanings, with therapy. (I also, of course, believe that insight provoking interpretations can, under appropriate conditions, be therapeutically beneficial.) This preamble has been given because I want to disentangle concepts of the family aetiology of anorexia nervosa from a discussion of family therapy for the condition. This is appropriate even though I think it useful to include family features as one of the interacting factors that give rise to, or perpetuate, the clinical picture and even though I believe that family therapy may be highly efficacious in some cases. AETIOLOGICAL

CONSIDERATIONS

In my opening paragraph I outlined a system consisting of the patient, her family and wider social network, and the group of professional helpers whom her symptomatic state has recruited. A comprehensive aetiological scheme would assume potential aetiological factors as deriving from all elements of this system (including iatrogenic factors). And the contribution from the different elements may have complex interactions with each other. Thus, the wider social networks of our patients seem to have importance. The increasing incidence reported for the disorder may be connected with changed expectations of social role performance and especially with stereotypes of ideal feminine achievement and shape. But these factors impinge on our patients through the mediation of the family. The associated hypothalamic/pituitary features of the disorder are not necessarily determined simply by physiological constitution or genetic make-up. Social changes, which are not, solely dietary, have lowered the age of physical pubescence whilst different social changes have raised the age of psycho-social definitions of adulthood, e.g. the prolongation of secondary and tertiary education. The extension of the total time to complete adolescence as a psychosocial and somatic transition may, for all we know increase psychological casualty in this phase of the life cycle. The increased incidence of anorexia nervosa could be

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one consequence. The different factors suggested as being of potential aetiological significance cannot be assumed to operate separately by simple addition of one on top of the other, and an initial inspection suggests complex interactions. A discussion of the suggested familial factors in the aetiology of anorexia nervosa separated from other factors is artificial, but will be attempted for reasons of economy of space. DESCRIPTIONS OF FAMILIES

A description of the familial features in anorexia nervosa can be ascribed to two groups of authors-those, who, over the last one hundred years, have described aspects of the families from either an empirical clinical view or by means of a psychodynamic formulation and those, mostly writing in the last decade, who espouse a “family systems viewpoint”. The late nineteenth century physicians, who named and epitomised the syndrome, were aware of the importance of the intense involvement of the families with the anorexic patient. These observations could not be fitted into any available conceptual framework until, nearly half a century later, investigators of the incidence of neurosis in the family of the patients or clinicians with a psychodynamic formulation in mind, began to extend these half forgotten and incidental observations. Later still, there evolved the conceptual frameworks that gave rise to family therapy, by utilizing aspects of communication and information theory, the development of the inter-personal perspective in psychodynamic theory and, above all, general systems theory. (For an outline of the development of family theory and therapy, see DARE, 1985.) My intention, in this paper, is to give a scheme for accommodating information at different levels into an inclusive and coherent account. It is difficult for many mental health researchers and clinicians to move from the perspective of the physiology and psychology of the individual to the social and inter-personal frameworks of thinking about families. The scheme presented here derives from the clinical practice I have evolved in the Department of Children and Adolescents at the Maudsley Hospital and in the supervision of the family therapy on the Medical Research Council funded treatment trial in anorexia nervosa headed by Professor Russell and Dr Szmukler. I will present the scheme both in its general form and incorporate the many different types of observations that have been made about the families of anorexic patients. There are categories of information at five levels: 1. The socio-cultural and historical perspective. 2. The genealogical and intergenerational perspective. 3. The demographic and life cycle features of the family. 4. The structure of the family as an interpersonal network or transactional system. 5. The psycho-biological characteristics of the individuals in the family. There will now follow a brief explanation of what is meant by these headings and an outline of the features of families of anorexic patients within the first four of the categories. (The fifth category is self evident, familiar and outside my current scope.) The socio-cultural and historical perspective Family structure and functioning are clearly undergoing constant change. (There are a few historical accounts of the family available to the general reader. They are exclusively about WesternEurope.See: SHORTER,~~~~;FLANDRIN,~~~~;STONE,~~~~;ANDERSON,

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1980.) These changes cannot be summarized here, but if the incidence of anorexia nervosa is increasing, and if family factors contribute to the aetiology, then historical changes in the family may be important. The most obvious of these are the changing expectations for the feminine role, which are affecting the balance and differentiation of husband/wife and father/mother roles. (RAPOPORT and RAPOPORT, 1977; YOUNG and WILLMOTT, 1973.) The sociology of the family is such a vast subject, in its own right, that the clinician can only be asked to ensure some awareness of his or her own ignorance. LESLIE (1967) and ANDERSON(1971) serve as useful texts on the subject. It has been noted above that the available histories of the family are all concerned with Western Europe (and are relevant to areas of the world where family patterns are derived from former colonisers). The social and anthropological scientists redress this balance and remind the clinician of the vast array of functions, kinship systems, constitutions and practices of families in different cultures. We have very little knowledge of the implications of these factors for the incidence, aetiology and course of anorexia nervosa. We are aware that there are reports of strong social class bias among patients presenting for treatment, middle and upper class families tending to be excessively represented, but other socio-cultural variables are much less discussed. GARFINKEL and GARNER (1982, p. 103) note reports of different incidence in different cultures. I consistently ask clinicians from other cultures, about their experience of anorexia nervosa and the reported observations are suggestive. In New Zealand, for example, I was told that anorexia is common in Pakehas (Kiwis of European origin) and unknown among the Maori population. Similarly, a Malaysian colleague reports an absence of anorexia in the Muslim population and observes the disturbance in Chinese families. These factors need to be investigated, formally, to find out actual incidences and then it might prove possible to identify the crucial features. Whatever the nature of the cultural variations, if they exist, they will impinge on individuals, partially through the mediation of the family. The process whereby the wider culture is interpreted and transmitted by the family is itself complicated, and relevant to anorexia nervosa if it is true that these families are more cut off and separate from their surrounding culture, as some observers have suggested. It can also be noted that all families function under the impact of historical and sociological change in that all parents are rearing their children in an historical era different from that in which they had their own major experience of parenting, that is to say when they were children. There is some evidence that youth culture changes at a faster rate than the culture of other generations (the so-called “generation gap”). This may be especially so in our culture, so that parents and adolescents differ markedly in their expected rate of acquisition of economic and sexual freedom. These factors appear of clinical relevance in anorexia nervosa for although many anorexic patients have the customary intense identifications with the culture of their peers, and alienated from the there is certainly a distinct sub-group who are “old-fashioned” interests and activities of their fellow adolescents. It would also seem that this group has a more serious disturbance and a worse prognosis than those who identify with their own age group. In these families, the girls’ lack of progress in acquisition of the youth culture seems to align them more closely to their parents. For themselves, it also serves as a rationalisation of the fears of sexual activities and their disturbance of self-esteem.

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The genealogical and intergenerational perspective The family is placed in its culture by the power and imprint of its lineage. The tradition within which a family exists, the extent to which the power of the past is allowed to affect the present, are themselves dependent on the past. Families are in part self-created and in part the product of the society within which they exist but they are also the product of the forebears of the family. Clearly, in a two-parent family, the cultures represented by the parents can be similar or extremely diverse. They can never be identical. The specific traditions of the two parents will include very many expectations about the rate and nature of adolescent development. In our field, the following have to be considered: the extent and nature of male and female differentiation; the extent to which diversity and dissent are allowed in the family; the way in which identity, separateness, individuality and family group loyalty are expressed; the extent to which parents expect to be involved in their offspring’s lives and how much they, as a couple, subjugate their own lives to those of their children (and “live for the children”); the timing of independence and, perhaps above all, the degree and mode of determining of autonomy in developing children. At this point, I am implying that these things have both socio-cultural origins and idiosyncratic, non-social but psychological origins. A culture may have a tradition of very close control and identification between parents and children, which may affect adolescent differentiation, but specific, personal experiences in the lives of the parents can also exert a powerful moulding effect. The personal, experientially determined expectations about adolescents, and the socioculturally determined expectations, are present, in different ways, in both parents. The two parents by some form of negotiation, evolve a pattern which is specific for their family. It is not, thereby, the same for all children of the family. What is brought into a family, both from the culture and from personal experience, are conscious and unconscious attitudes which find expression in practices and pressures and that thus allow siblings different qualities. Most of the features identified by investigators who specify the genealogies of anorexic patients are purely two-generational, observing, for example the high incidence of neurotic symptoms in first degree relatives (KAY and LEIGH, 1954; CRISP et al., 1974; MORGAN and RUSSELL, 1975; DALLY and GOMEZ, 1979). The Milan associates (SELVINIPALAZZOLI et al., 1978) have put forward detailed views about the transgenerational loyalty systems in the families of young adult patients, some of whom were anorexic. The concepts are psychodynamic hypotheses of the families’ need to keep closeness and trust between the generations. Symptoms are seen as a sort of sacrifice to such an hypothesized need system. WHITE (1983, p. 257) also stresses the inter-generational “demand” for loyalty, as being strong in anorexic families. He also considers the families to have “ . . . certain role expectations of their members. Women in these families are generally expected to be sensitive, devoted and self-sacrificing”. Carl Whitaker (see STERN et al., 198 1) emphasises the familially transmitted disturbance which impairs transition through the separation-individuation phases of personal development. The demographic and life cycle features of the famiIy The family should be defined through its membership: is it a two-parent or a one-parent family? are they biological or adoptive parents? are there members of the extended family present? Authors such as BRUCH (1974) have noted a relative absence of one parent

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families whilst other (e.g. YAGER, 1982) have pointed out that this may be an histocially transient feature. Family crises due to losses (death, separation or divorce), and addition of family members by birth, adoption or re-marriage may be more or less stressful. However, the particular contribution of the move into adolescence by offspring and their removal thereby, is the naturally occurring “crisis” that is thought to be most clearly the basis for some family features of anorexia nervosa. Authors as diverse as CRISP (1980) and HALEY (1980) concur with this. The view that the families of anorexics are in some “need” of their children for family purpose and stability, is the central theme of therapeutic interventions to be described in the final section of the paper. The life cycle location of the family is not, however, solely determined by the age and psycho-social maturation of the children because, despite the usual views of the trajectory of an individual’s life, development does not cease at the end of adolescence. All members of the family, from youngest to oldest, are pursuing their own course of life. Although the process of leaving home dramatises the adolescent passage as a crisis, parents who are in the mid-life phase, have also to make psychological changes incumbent on physical processes. The coincidence of especially critical transitional stresses in several members of the family at once, constitutes a strong demand for the development of new attitudes, interests and skills and the giving up of others appropriate to the preceding phase of life. Should this not occur, the family may undergo major stresses from which anorexia nervosa may be seen as providing a respite, albeit a most distressing one. It must be emphasized that this formulation does not have necessary aetiological implications. If these processes are proven to be important, they need be neither maintaining nor originating factors for the complaint (although they may turn out to be one or the other or both). The anorexia nervosa could, in principle, have completely separate origins, but it could then be drawn upon by the family, for the different members own life cycle purposes. The structure of the family as an interpersonal network or transactional system The psychodynamic theorists of the family, beginning in the 1930’s developed implicit and explicit views as to the interpersonal structure of the family. BRUCH (1974, pp. 80-86) as part of a lifetime’s work in this field, summed up the apparent normality of many of these seemingly well functioning families. She suggested that the mothers, often frustrated in their own lives, are conscientious parents and somewhat subservient mothers. She sees the families as success orientated, often preoccupied with fitness and health, and “proper” behaviour. The parents deny difficulties for the most part and above all “there is a great(er) imperviousness to the child’s authentic needs” (BRUCH, 1974,pp. 82). These ideas are very similar to those of BECKER et al. (1981). The family atmosphere is . largely performance oriented and sexually repressive to a frequently anachronistic degree. Often enough the family cuts itself off from the outside world, with the patients frequently showing an excessive degree of loyalty and conformity to the family even after adolescence. The family is quite obviously dominated by one of the parents, who also dictates the ascetic ideal (p. 9). SELVINI-PALAZZOLI (1974) has stressed as well, the severe restrictions on autonomy that the anorexic offspring experiences within the family. She too sees loyalty as a major motivation, as has been mentioned above. She emphasizes the “three-way matrimony” whereby the two spouses incorporate the child with the symptoms within a triangular

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relationship. PINCUSand DARE (1978, pp. 70-76) quote a case in which the same configuration is expressed as an Oedipal triangle. This view also fits well with Crisp’s observations (CRISPet al., 1974) of the defunct quality of the marriage of the parents of some anorexics. Such a marriage is given a semblance of purpose and intactness by the concentration on the thinness of the child. The most important conceptualization of the anorexic family is indubitably that of MINUCHINet al. (1978). They characterize the families as rigid in their structure, enmeshed in their communication and incapable of resolving conflict. The rigidity needs no further description. The enmeshment refers to the quality of over-protectiveness combined with the belief possessed by each family member (especially each parent) that he knows the feelings and thoughts of every other member including the ill daughter. This is all well summarised in STERNet al. (1981, p. 397): The most glaring characteristic of these families is their enmeshed, undifferentiated quality. Family members are poorly individuated with the primary group concern being the maintenance of overt harmony and closeness. Loyalty, self-sacrifice, and anticipation of others’ needs are highly valued, whereas assertion, disagreement and conflict are viewed as threats to cohesion, if not acts of betrayal. Inevitably conflicts exist but they are denied. . generational boundaries tend to be poorly defined such that a parent may act more like a rivalrous sibling . The anorexic child in particular is often recruited into a stable or shifting alliance.

All that need be added to these summaries is a reminder that the concept of the anorexic families having problems of conflict resolution does not mean that they are always conflict free. To deny and ignore conflicts is likely to lead to a picture of conflict avoidance, but unending argument can occur in anorexic families. They are taken to demonstrate that the characteristic problem is of problem resolution no simply avoidance. The psycho-biologic characteristics of the individuals in the famiIy This head is here given, simply for the sake of completion, as part of the profile of the family which a family therapist would need to bear in mind, but need not be discussed in this paper. THE MOBILIZATION

OF FAMILY THERAPY

The specifics of the practice of family therapy lean on the description of the family which is likely to include some, all or additional features to those outlined above. The nonspecifics of the therapy are more determined by the age of the family members and the cumulative motivation of the family, than the particular problem. For this reason, future developments in the family therapy of anorexia nervosa are dependent on accurate investigation firstly of those features of family life that are potentially addressable by family therapy, and secondly those that have a crucial role to play in the maintenance of the disorder. Family therapists are concerned with problems of how to get families into treatment; what is the minimum necessary number of family members of a particular family needed for therapy to work? How can families be engaged in the therapy and their continued attendance ensured? How can the therapist gain knowledge of family processes whilst showing detailed interest in the problems that the family members themselves hold most important? How can change in family patterns be produced and kept as part of the repertoire of the

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family? What is the minimum length of time a family should be kept in therapy and how should therapy best be terminated? Do other therapies effect the course of family therapy, but if they are indicated how best can they be integrated? How can therapists be trained and on-going work supervised? All these are issues for the practising therapist, and could fill a whole conference, but I have not wanted to make them the centre of my presentation. These issues will be focused upon by those of us who conduct therapies with these families. On the whole, we can find techniques that provide us with the clinical hope of offering help to a broad range of families containing an anorexic patient. Clearly, as MINUCHIN et al. (1978) and as GARFINKEL and GARNER (1982) accept, family therapy seems to be an effective intervention for some young anorexics, with disturbances of short duration and whose families are available for treatment. The place of such therapy in older patients, seems much less clear, although the pioneering work of Selvini-Palazzoli has shown that a significant number of these cases can be kept in treatment and good results may be possible. In our own Medical Research Council Trial, we hope to be able to answer some questions about which sorts of cases show what sorts of responses to family therapy. Preliminary analysis of the results seems to be suggesting that young patients are indeed more helped by family therapy than they are by individual therapy (both groups of patients having been admitted for hospital treatment to reach appropriate body weight). But I am sure that the subject needs an additional approach not to be found as yet in the literature. It would look at the questions raised in the preceding account. They will require further information about the families of anorexics. There is an even greater need to discover what a family therapist should best try to change if family therapy is to be helpful. At the moment the therapy is like a blunderbuss aimed at the most obvious and moving part. The target may be peppered, but the shot is likely to be small and the part hit may have the toughest hide. The family therapist can only address available interventions towards what can be perceived. There is no way that this can be a refined treatment, even though video-taped demonstrations may appear both elegant and dramatic, and there may be developing evidence of useful effect. What is needed is that the family interactions, of the sort that can be tackled by family therapist are assessed to see if they are relevant to the future course of the disturbance. Then the therapeutic efforts need to be researched to find out whether or not the changes they are intended to produce actually do occur, and to an extent required to modify the evolution of the anorexic patient’s life. Then a useful paper on the family therapy of anorexia nervosa can be written. At the moment, all that can be written, are papers on family therapy.

REFERENCES ANDERSON,M. (1971)(Ed.) Sociology of the Family. Harmondsworth, Penguin Books. ANDERSON,M. (1980) Approaches to the History of the Modern Family: 1500-1914. Macmillan, London. BECKER, H., KOERNER,P. and STOEFFLER.A. (1981) Psychodynamic and therapeutic aspects of anorexia nervosa. Psychother. Psychosom. 36, 8-16. BRUCH, H. (1974) Eating Disorders: Obesity, Anorexia Nervosa and the Person Within. Routledge & Kegan Paul, London. CRISP. A. H. (1980) Anorexia Nervosa: Let Me Be. Academic Press, London. CRISP, A. H., HARDING, B. and MCGUINESS.B. (1974) Anorexia nervosa. Psychoneurotic characteristics of parents; relationship to prognosis. J. psychosom. Res. 18, 167- 173. DALLY, P. and GOMEZ, J. (1979) Anorexia Nervosa. William Heinemann, London.

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DARE, C. (1985) Family therapy. In: RUTTER,M. and HERSOV,L. (Eds.) Child and Adolescenf Psychiatry: Modern Approaches. 2nd Edn, pp. 809-825. Blackwell Scientific Publications, Oxford. FLANDRIN, J-L. (1976) Families in Former Times (Trans. SOUTHERN,R.). Cambridge University Press, Cambridge. GARFINKEL,P. E. and GARNER,D. M. (1982) Anorexia Netvosa: A Multi-dimensional Perspective. Brunner/ Mazel, New York. GARNER,D. M. and GARFINKEL,P. E. (1980) Socio-cultural factors in the development of anorexia nervosa. Psychol. Med. 10, 674-656. HALEY, J. (1980) Leaving Home. McGraw-Hill, New York. KAY, D. W. K. and LEIGH. D. (1954) The natural history, treatment and prognosis of anorexia nervosa based on a study of 38 patients. J. menu. Sci. 100, 411-431. LESLIE, G. R. (1967) The Family in Social Context. Oxford University Press, London. LOWENKOPF,E. L. and VINCENT, L. M. (1982) The student ballet dancer and anorexia. Hillside J. clin. Psychiar. 4, 53-64. MORGAN,H. G. and RUSSELL,G. F. M. (1975) Value of family background and clinical features as predictors of long term outcome in anorexia nervosa. Four year follow up study of 41 patients. Psychol. Med. 5.355-371. MINUCHIN, S., ROSMAN,B. L. and BAKER, L. (1978) Psychosomatic Families. Harvard University Press, Cambridge, M. PINCUS, L. and DARE, C. (1978) Secrets in the Family. Faber & Faber, London. RAPOPORT,R. and RAPOPORT,R. N. (1977) Fathers, Mothers and Others. Routledge & Kegan Paul, London. SELVINI-PALAZZOLI,M. (1974) Self-Starvation: from the Intrapsychic to the Transpersonal Approach. Chaucer, London. SELVINI-PALAZZOLI, M., BOSCOLO,L., CECCHIN, G. and PRATA, G. (1978) Paradox and Counterparadox. Jason Aronson, New York. SHORTER,E. (1975) The Making of the Modern Family. Fontana Books, London. STONE, L. (1977) The Family, Sex and Marriage in England 1500-1800. Abridged Version. Penguin Books, Harmondsworth. 1979. STERN, S., WHITAKER,C. A., HAGEMANN,N. J., ANDERSON,R. B. and BARGMAN,G. J. (1981) Anorexia nervosa: the hospital’s role in family treatment. Fam. Proc. 20, 395-408. WHITE, M. (1983) Anorexia nervosa: a transgenerational perspective. Fam. Proc. 22, 255-273. YACER, J. (1982) Family issues in the pathogenesis of anorexia nervosa. Psychosom. Med. 44, 43-60. YOUNG, M. and WILLMOTT,P. (1973) The Symmetrical Family. Routledge & Kegan Paul, London.