Finding a Voice

Family Therapy for Young People with Anorexia

Greg Dring

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429913761
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Young people develop anorexia because they are unhappy. In the process of becoming anorexic they silence themselves and distance themselves from parental support. Family therapy can help patients by improving their communication with their parents. Therapists can support parents in helping their children to find their voices. This book presents a review of the research evidence that has guided the development of family therapy for young people with anorexia. In addition, it presents the current evidence for a family model. A flexible model is proposed to meet different family scenarios and levels of treatment resistance. Greg Dring argues that the evidence indicates the need for an assertive approach to therapy, drawing on the full range of family therapy skills available, in order to re-instate a healthy relationship between parents and children. This book is intended for family therapists and other clinicians in Child and Mental Health Services who work with young people with anorexia.

CHAPTER ONE
The challenge of finding a voice

This book is written for family therapists who treat young people with anorexia. In the United Kingdom these therapists work predominantly in the National Health Service (NHS) in Child and Adolescent Mental Health Services (CAMHS). The book aims to empower family therapists to provide effective treatment. The intention is to support family therapists both as therapists and as members of multi-disciplinary teams. In addition the book addresses the question of how best to organise effective treatment services for these young people. The evidence is that family therapy is an effective treatment for the young patient with anorexia, at least within three years of onset. Despite that, it seems clear that effective treatment is not always being provided in the United Kingdom, judging from the data provided by Gowers et al (2007). If we do not achieve this with young patients with anorexia the consequences are very serious for them. Steinhausen (2002), in a meta-analysis of anorexia outcomes studies made during the twentieth century, found no evidence for improvement in outcomes for adults with anorexia. The implication is that despite the development of creative new treatments for eating disorders, patients with anorexia still have a poor prognosis. As yet, there is no very effective treatment for adults. It is therefore crucially important to provide effective treatment for young patients in the early phase of anorexia.

Today, Maudsley Model Family Therapy is being implemented in several regional areas of the NHS as a treatment to be delivered by clinicians who are not trained as family therapists. Family therapists in CAMHS will be expected to supervise and support these clinicians and need to be well informed about the issues involved.

The argument

The argument presented in this book questions the prevailing orthodoxy about family therapy for anorexia. Even to write the words “family therapy for anorexia” is to contradict the orthodoxy, since it maintains that this is not “family therapy”, but “family work”. This means that the goal should not be to change the family relationships, but only to overcome the anorexic behaviour, and its effects on the family, and only then normal development will re-assert itself. That is the proposition of the current treatment manual, Lock et al (2001) and Lock and Le Grange (2013). For this reason some people argue that family therapy skills are not required.

The Academy for Eating Disorders position paper by Le Grange et al (2010), on the family and anorexia, sets up unhelpful dichotomy. They reject “any etiologic model of eating disorders in which family influences are seen as the primary cause of anorexia nervosa or bulimia nervosa Le Grange et al (2010, p. 1)”. The old Psychosomatic Family Model of Minuchin et al (1978) is criticised by Le Grange et al (2010) both for its inaccuracy and for making families feel blamed. This position reflects that taken by Dare and Eisler (1997) in the paper that introduced the current Maudsley Model. It is also the position taken by the authors of the treatment manual, Lock et al (2001) and Lock and Le Grange (2013). Despite this the Academy takes the position that the family may make some contribution to the aetiology, probably in conjunction with other influences such as genetic factors.

Curiously enough, students of individual therapy may now have a better grasp of family issues in anorexia than family therapists, who are expected to accept the new orthodoxy. It is time to move on from a preoccupation with the Psychosomatic Family Model and to reconsider the existing research. A model derived from clinical observation and systematic research in the 1970s is unlikely to be either right or wrong in all respects. Family therapy thinking itself has moved on considerably since the 1970s. Knowledge of child development and the interface between family relationships and child and adolescent development has also advanced providing some new perspectives, and a much larger evidence base. There is sufficient evidence that the families of anorexic patients are not a random selection of families. There can be little serious doubt that family experiences contribute to the development of anorexia. Some of these influences were recognised by Minuchin et al (1978), while others were not.

The development of family therapy models for anorexia

It will be argued in the next three chapters that it is useful to distinguish at least three distinct evidence based models of family therapy for young people with anorexia. The first is the Structural Family Therapy model of Minuchin et al (1978), the Philadelphia group of therapists. This was the approach that first demonstrated that family therapy was an effective treatment for anorexia. It is the approach that subsequently became most controversial. Like other early approaches to family therapy for anorexia it saw the patient’s experience in the family as the cause of her anorexia. The second approach is that of Dare and Eisler (1997). They proposed a new model, but retained important ideas from family therapy. However, they specifically stated that family pathology was not a major component of the aetiology of anorexia. The declaration of this position to the family was part of the treatment. The third approach is to be found in the Family-Based Treatment (FBT) manual by Lock et al (2001) and Lock and Le Grange (2013). They presented an approach that owed a great deal to Dare and Eisler, but with a different emphasis in which the contribution from family therapy is virtually absent.

It has been claimed that the series of changes that have transformed the family therapy approach to anorexia are based on evidence. This evidence is reviewed and it is argued that although all the approaches that have been tested are likely to be more effective than traditional treatments, such as in-patient refeeding, or individual therapy, the empirical arguments for the change of approach are hard to sustain. The overall conclusion drawn from these chapters is that all three approaches demonstrate impressive effectiveness in reducing the core symptoms of anorexia: low weight, dietary restraint and amenorrhea. On the other hand it cannot be demonstrated that the successive changes to the treatment approach initiated by Dare and Eisler, and continued by Lock and Le Grange, have improved outcomes, reduced drop-out rates, or improved the quality of outcomes when judged in terms of broader indices of the patients’ mental health. In fact the evidence demonstrates very significant levels of continuing neurotic difficulties in a patient population treated with FBT. It is suggested that the current model sacrifices much that family therapy might offer to these families, and that this may account for the substantial continuing psychopathology demonstrated to exist in patients treated with this model, as demonstrated by Lock et al (2006a). This in turn reflects the assumption that family relationships are not a significant factor in aetiology. Probably family therapists who understand the way that anorexia arises in a family context would have more to offer the patient and her family, and would expect to produce a more complete recovery.

The aetiology of anorexia

There has always been a tension between hereditary and environmental explanations of anorexia. In the past, leading authorities on anorexia, drawing on family aggregation and twin studies, argued that genetic factors probably account for more than half the risk of anorexia. Advances in genetic research have altered the position completely. Recent studies such as those by Pinheiro et al (2010) and Wang et al (2011) demonstrate that there are at most only very slight associations between genetic variations and anorexia or anorexia sub-types. These recent failures to confirm genetic hypotheses shift the balance of the argument back to an emphasis on environmental factors.

To understand the aetiology we need to understand anorexia as a psychological phenomenon. Anorexia occurs most commonly in a young person who has low self-esteem, usually in a girl who has been made vulnerable as a result of the development of an anxious approach to life, accompanied by ideals of perfectionism and obsessionality. It develops in girls and young women who have great deal of difficulty in expressing their own needs, a pattern of behaviour known as “self-silencing”. In this situation anorexia develops at a time of stress. It can be seen as performing a function for the patient, in reducing distress that she is not able to manage in other ways, such as turning to her parents for support. Outside the field of family therapy this is the dominant view of the development of anorexia. There is a long history to this line of thinking. It can be traced back at least as far as the work of Bruch (1974, 1981). Bruch thought that the development of anorexia could be explained by problems in the very early relationship between the infant and her mother. She thought that it was the mother’s inability to respond sensitively to the infant’s needs that set the scene for the development of anorexia in adolescence. It is impossible to know how much weight to give to difficulties in this early relationship, except insofar as they have been validated by studies of the impact of obstetric losses and high concern parenting in the early years on the development of anorexia, Shoebridge and Gowers (2000). However, a great deal of evidence indicates that a variety of family experiences shape the patient’s vulnerability to anorexia.

An overview of research on family interaction and parenting, and their relationship to anorexia, provides abundant evidence of the link between family relationships and anorexia. The old Psychosomatic Family Model is not confirmed by research. On the other hand it is far from true that the evidence indicates that family relationships are not a major factor in aetiology. However, there may be limited value in attempting to link anorexia to family variables such as “conflict avoidance” since it is most likely that it is the specific way in which each child experiences their relationship with their parents, siblings, and other family members, that affects the outcome in terms of mental health. Despite this, three factors stand out. The first concerns the emotional life of the family. Typically the patient does not feel well supported in her family. A lack of effective parental care and closeness can be seen to undermine the development of self-esteem. Insecure attachment is the crucial issue here. In addition, parental vulnerabilities lead the child to put her own needs and feelings second and attend to those of her parents. The second factor is parental psychological control. Despite their consciously benevolent intentions, the parents’ own needs are prioritised over those of the child. The expression of the parents’ needs and attitudes, in the form of parental psychological control, contribute to the development of perfectionism, leading to the development of internalising disorders, including anorexia. Third, parental attitudes to eating, weight, appearance and, more generally, to acceptable self-presentation, prompt attention to the control of eating. In the difficult years following puberty, girls who are vulnerable because of these factors encounter circumstances in which they need to turn to parents for support. Instead of doing so, some turn away and find a temporary solution to the difficulties they face by achieving success in their control of eating and weight. This transition, this turning away from parental support, embracing self-silencing, is the point of entry to anorexia itself.

A family model of anorexia

A number of conclusions can be drawn from the research. Many factors contribute to the development of low self-esteem, internalising disorders, eating disorders and anorexia. Insecure attachment, and resulting deficits in the ability to regulate emotion, affects the patient and often her parents too. This probably accounts for the patient’s difficulties with self-esteem, in managing emotion, and in asserting her own needs. Parental psychological control is a factor in the development of inter-nalising disorders, including eating disorders such as anorexia. It may be the factor that contributes most strongly to the development of the pathological self-control and the perfectionistic and obsessive attitudes that underlie anorexia. Parental attitudes to eating and weight, and related attitudes to appearance and achievement, are also important. It is probably often this kind of family influence that causes the underlying psychopathology to be expressed as an eating disorder rather than as, say, an anxiety disorder or depression. Each of these factors could be seen as overlapping with and having implications for at least one of the others. Each can be seen as reflecting the parents’ own vulnerabilities, psychological problems and insecurities. Other family factors, such as the impact of the behaviour of siblings, have received little attention from researchers. Nevertheless family therapists will often see them as having an important impact.

Influences outside the family have to be acknowledged. Many patients suffer very acutely from their experience of cultural influences, peer group influences and extraneous events, such as sexual assaults. Nevertheless, resilience in the face of adverse factors reflects young people’s experience with their carers throughout childhood and adolescence. The effect of current disturbance arising from such factors is mediated through relationships with parents. Therefore, these influences do not act on the individual young person independently of family factors. Some influences outside the family may be helpful. For example, some schools and peer groups may help girls manage feelings about competition, or problems about bullying, better than others.

A crucial issue is that we should not be looking for a general model that describes all cases as the same, like the Psychosomatic Family Model. Instead we need a model rich enough to identify different influences which give rise to vulnerability to anorexia, and the family influences which prevent the patient finding a more functional way of dealing with distress at the point in time when anorexia begins.

Alternative approaches

In recent years, a number of authors have published accounts and case studies of family therapy for anorexia. These accounts present anorexia in a family relationship context. In these approaches, family relationship issues are the focus of the work at an early stage. They present a set of perspectives on treatment that are quite different from the current Maudsley Model and FBT approaches. These approaches cannot yet be described as evidence based.

Micucci (2009) gives an account that is closest to the structural/ systemic family therapy tradition. He sees improving family relationships and communication as essential to removing the anorexic symptom. He presented the case of “Tina”, a teenage girl who developed anorexia in the context of triangulation in the parental relationship. In this case study a relational reframe is presented at an early stage. The message to the family includes the observation that “She is wasting away not only from lack of food but also because of the absence of nurturing and sustaining relationships in her life … I will work with you all, as a family, to give you the chance to begin building more sustaining relationships, so that Tina may begin to grow again”, Micucci (2009, p. 123). In this case the parents were separated and the father had grown distant from the family while each parent believed the other was responsible for the problem. Micucci presents a way of uniting the parents in managing refeeding with Tina despite these difficult circumstances. He draws on older family therapy ideas, but also on ideas about attachment, in his account of the development of the anorexia. His approach is different from the Maudsley Model and Family-Based Treatment approaches in addressing relationship issues between the patient and each parent at an early stage.

Zubery et al (2005) present a very different model. In this approach, separate treatment for patient and parents takes place at the first stage. The expectation is that parents will prepare food, present it and be present at meal times, but that it is the patient’s responsibility to eat. A parents’ group and multi-family groups are very significant components. Direct communication between parents and patient is expected to improve only at a late stage of treatment. The emotional entanglement between parents and adolescent child are seen as very important in this approach. They describe a case in which this approach successfully engaged a family despite the parents’ initial reluctance to join in the work.

Dallos (2004, 2006) describes an Attachment-Narrative approach to family therapy for anorexia. He developed this idea partly because of his subjective experience as a therapist and partly because of his knowledge of research and theory about attachment, and how it relates to people’s styles of relating to one another and the sense they make of relationships. Dallos (2004) commented that “For years I have wondered whether there was something wrong with myself … since I had great difficulty in helping families where anorexia was the presenting problem, in engaging in conversations about their difficulties, their feelings, the impact of their problems on the relationship and vice versa”, Dallos (2004, pp. 41–42). But, he says, he discovered that this was a common problem for therapists working with these families. He came to see the issue within a frame of reference about attachment and its impact on the ability to express and think about relationships. He thought that attachment insecurities reflected the family relationships of the patient, and those that her parents had experienced in the course of their own development. Dallos (2006) and Dallos and Vetere (2009) describe cases of family therapy for anorexia. The management of the patient’s eating is not the focus of the therapy. The approach integrates approaches from the narrative tradition in family therapy with attachment theory approaches. Again the emphasis is very much on relationships, concentrating on closeness and on comforting in the patient’s relationship with her parents, and on similar issues in the parent’s family of origin. The approach is one that is very relevant to the understanding and management of the parents’ own vulnerabilities and the way that the patient herself is caught up in responding to these vulnerabilities. The approach is not presented as sufficient in itself for the management of an acute anorexic crisis. As it is presented it would seem to be appropriate to a case in which weight had at least been stabilised or one in which the management of weight and eating was in the hands of another clinician. However, ideas taken from this and other attachment-based approaches to family therapy for anorexia could be integrated into an approach that engages the family in the acute stage.

Beyond Maudsley Model Family Therapy

This book proposes to change the therapy model by integrating aspects of attachment approaches with more traditional structural/systemic approaches. This is not a treatment manual as such, and should be read alongside Minuchin et al (1978) “Psychosomatic Families” and the FBT treatment manual by, Lock et al (2001) and Lock and Le Grange (2013). The FBT manual contains much that is useful, but omits much that has the potential to maximise outcomes. A number of technical issues are tackled with a view to helping family therapists make the most of their skills in helping these patients and their families. The proposals draw on ideas taken from older family therapy traditions as well as from attachment therapists such as Dallos (2006), Dallos and Vetere (2009), Diamond and Stern (2003), and Hughes (2007).

Managing guilt and blame

In the present state of our knowledge it is hard to justify the statement to the family that families do not “cause” anorexia. It now seems very likely that anorexia is in fact largely the result of the child’s experience of upbringing. Family relationships are likely...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• CHAPTER ONE The challenge of finding a voice
• CHAPTER TWO The roots of family therapy for young people with anorexia
• CHAPTER THREE The development of Maudsley Model Family Therapy
• CHAPTER FOUR Family-Based Treatment
• CHAPTER FIVE Anorexia is not an inherited disorder
• CHAPTER SIX How should we understand anorexia?
• CHAPTER SEVEN Family interaction research
• CHAPTER EIGHT The emotional life of the family
• CHAPTER NINE Parental authority
• CHAPTER TEN Family attitudes to eating and weight
• CHAPTER ELEVEN Beyond the Maudsley Model
• CHAPTER TWELVE Treatment in context
• REFERENCES
• INDEX