Family Treatment is Cornerstone of Effective Care|
for Eating Disordered Children
By Abigail Natenshon, MA, LCSW, GCFP
disorders are family diseases
87 percent of individuals afflicted with eating disorders are children and
young adults under the age of 20. As most of these young people reside at
home, side by side with family members and loved ones, the onset, diagnosis,
treatment and recovery of eating disorders become a shared experience …
played out at kitchen tables, in family bathrooms, restaurants, and health
clubs. The effective involvement of family members in the individual
patient's recovery from an eating disorder can only enhance the speed,
efficacy and sustainability of the healing process.
Though these disorders strike individuals, with eating disorders, the entire
family system becomes affected; in fact, the disorder takes on the role of
another family member. Parents, siblings, extended family, friends and loved
ones all share the experience.
Unprepared as they are, parents and family members invariably become the
primary diagnosticians of an eating disorder. Eating disorders are secretive
and lethal diseases that rarely show themselves in the medical doctor's
office. In addition, their presence is typically silent in laboratory tests
till the latter-most stages of disease.
Eating disorder recovery is essentially a home-based process. Patients
typically spend 50 minutes a week with their therapist or doctor. For the
rest, children live out their recoveries under their parents’ noses “24/7,”
at school, over time, with friends, within the context of daily living; and
that is as it should be. Parents, families, teachers, coaches, all need to
become educated, enlightened, and supported in their efforts to support the
child in recovery.
In research carried out at the Maudsley Hospital of London England, there is
evidence that family treatment is more effective than individual
psychotherapy for anorexics living at home who have been ill for less than 3
The nature and degree of parental involvement will vary widely with the age
and needs of the child, the severity of the disorder and co-occurring
conditions, the skills and emotional capacities of the parents, the quality
of the family therapy and attitudes of the treatment team, as well as the
nature and quality of the ever-changing parent/child connection.
The family-based nature of eating disorders is also relevant to adult
patients, to include both families of origin and nuclear families. No matter
what our age or life stage, we all remain products of the family system in
which we reside(d).
therapy is the most effective way to treat everyone's needs.
Though not disease carriers, parents and siblings become deeply affected by
the presence of an eating disorder within the family system. In families
where various members of the system carry symptoms of eating disorders or
disordered eating, family and recovery issues become more complex. The
potency of the eating disorder typically drives a wedge between family
members, isolating the afflicted child from loved ones at the time of his or
her greatest need; separating the other siblings from parents who tend to be
hyper-focused on the eating disordered child; and at times, creating
conflict and guilt between husbands and wives, particularly for those who
fail to achieve a "united front" in offering their parental response.
Family members need a vehicle through which to understand the complexity of
the disease and recovery processes, a forum to communicate their own
concerns and needs to the patient and with each other, and the opportunity
to learn how best to support the child and the recovery process. They need
personal support and bolstering in the face of what typically tends to be an
extended, convoluted, jarring and frustrating recovery process for the
entire family. Family therapy provides that vehicle.
Therapists treating eating disorders must be vigilant and respectful of the
power of the family system with its potential to eradicate(or possibly
sustain) disease, tapping into the family system as a most powerful resource
as early in treatment as is appropriate and as often as is needed. The
individual child's efforts to make recovery changes are facilitated and
enhanced not only by a family that understands and supports the recovery
process, but by family members who are committed to making
their own parallel personal and
family-based changes to accommodate the needs of the changing child. In
instances where a child's resistance to recovery may be extreme, changes
made within the wider family system, particularly regarding parental
response to the child and disorder, may be sufficient to evoke change within
the afflicted family member. In instances where the patient may be resistant
to, or geographically too removed from family involvement, the skilled
practitioner can conduct family treatment "in absentia."
The potential for the family unit to facilitate change is far greater than
the sum of its parts; children heal more completely, more sustainably, and
more effectively, when families are enabled to become constructively
involved. Clear communication becomes enhanced, and in becoming direct,
eradicates the risk for confidentially breeches and privacy rights
infringements through reporting. Moreover, children who learn to function
and communicate more effectively within the context of their family carry
these valuable interpersonal skills into their other relationships as well,
making life a healthier, happier place to be, both now and in the future.
disorder psychotherapists need to embrace parents and families in treatment
Beware of the warnings of misguided health professionals who believe that
eating disorders are caused by poor parenting, or who consider parental
intervention to be a form of over-controlling interference, diminishing the
child’s autonomy. Such a professional might seek to exclude parents from the
psychotherapy process to protect patient/therapist privacy and
confidentiality rights. This thinking is indicative of a professional
unaware of the uniqueness of these disorders and of the requirements of
their treatment, and of the power of the family system to enhance the
child's recovery. Or, such a clinician might simply be inexperienced with
eating disorders as a treatment specialty, unfamiliar with family systems
theory, or otherwise inexperienced or uncomfortable treating family groups.
When the individual child, teen or young adult patient walks through my
door, I envision the virtual “crowd” of loved ones also requiring attention.
Within the context of family treatment, the eating disorder psychotherapist
needs to encourage the healthy development of the relationship between
parent and child… the therapist is present in the life of the child
temporarily; parents remain parents forevermore. The healthfully bonded
connection between parent and child holds the potential to fill in
developmental milestones missing for the presence of the eating disorder.
The best prognosticator of healthy separation is healthful parent-child
bonding and secure attachment; healthy separation and individuation and the
autonomy that comes of them evoke self-trust, self-esteem, and
self-regulation… all benchmarks of recovery.
It is for the child-patient's therapist to role model for parents loving
limit-setting and problem-solving, inspiring and enabling them to become
their child's and the treatment teams’ greatest advocates. For parents who
have lost faith in their ability to parent, intimidated by a daunting
disorder and the child who has newly become a stranger to them, therapist
education and guidance restores their self-confidence and grounding,
allowing them to fulfill their loving obligation to become "parental" once
again. Parents and child both come to understand that the need for parental
controls of the severely ill child is
temporary, until the recovering individual becomes capable of resuming
the capacity and responsibility for
Parents need encouragement to act, and continue to act, on the knowledge
they acquire within the family therapy process. Parental involvement will
vary throughout the course of recovery. Parents provide
On-going and unconditional support, day in and day out.
Nutritious meals which they prepare, and sit down to eat together with the
Monitoring of food intake; symptom management where appropriate, and case
management where appropriate.
Involvement in family treatment to support the child and recovery process,
and to resolve underlying emotional issues within the family system that may
be driving the dysfunction.
In summary, when it comes to the treatment and healing of eating disorders,
for parents, simply loving one's child is not enough.