Eating disorders can be treated with a mixture of combined psychotherapeutic interventions. Incorporating a systemic approach also makes sense because the clients we see (perhaps because of their age and circumstances) are often very much still connected to their family system. Such systems can be pivotal in both supporting recovery or in maintaining the eating disorder.
A systemic approach views the eating disorder (or “difficulty”) as a consequence of difficulty and / or dysfunction within the system.
It makes sense that balanced, well-functioning systems create and maintain balanced, well-functioning members. A human system consists of 2 or more individuals; the family being a typical example. The system could also be an educational, work or social system (i.e. school, college / university, workplace or friendship group).
Arguably, the family system is the most important.
In eating disorder work we identify the dynamics and relationships between family members, family cohesion and attachments within the interdependent family environment, the stress and pressure (from outside and from within the family), the support and strengths of the family, birth order and sibling rivalry, as well as the family relationship with food and meals.
Some of the questions asked might be:
was food used as a punishment or reward in your family when growing up?
what was role modelled about eating by family members?
was / is any family member significantly under or overweight, and, if so, what did that mean to you?
who was responsible for cooking?
what were meal times like for you?
was there any choice about what or when you ate and were your choices respected?
Parent roles can be internalised and it is worth considering what these roles were and asking for the similarities and differences between the client and their parents. What personality traits does the client share with their family and how do they feel about that? How were boundaries set and maintained and how does that link with how the client sets and maintains their own personal boundaries now? How do family members speak to each other (compassionately? Curtly? Dismissively? Respectfully?) and how does that link with how the client speaks to themselves now?
If the family (or other system) role modelled self-care, kindness, self-value and compassion it makes sense that the client will find this easier to do that for themselves than if it was not, and if there is no “template” for this, it could be a role for the therapist and client to create one together as part of their ongoing work.
Murray Bowen’s family systems work considers triangulation (three people create a mini system, usually two parents at the top corners and a child at the base (3rd corner) forming a triangle). The client and their eating disorder could unwittingly recreate this triangle, with you, as the therapist at the base. Or you and the client can work to create a triangle with the eating disorder at the base, which is healthier in terms of creating change.
Bowen also considers how differentiated the individual is within their family. In one client I worked with, she strongly identified with her brother and mother and had not formed her own separate identity. She had followed her brother to the same university, shared his hobbies and interests and shared clothes and viewpoints with her mother. When she gained weight, and could no longer borrow her mothers’ clothes, and her brother left the university she was still attending, she had what can be described as an identity crisis and this, along with separation anxiety, appeared to be a pivotal factor in triggering bulimia.
Another family dynamic is the projection process. For example, if mum is an unstable alcoholic with her own issues, rather than look at herself, she may choose to focus all her attention on her daughters eating disorder; therefore, her own issues get overlooked.
Sometimes the eating disorder unconsciously serves a useful purpose in families who have split and the eating disorder sufferer has an unconscious secondary gain in maintaining their “problem” behaviour, because it creates attention and focus from both parents who, perhaps will reunite as a result.
These are some of the family issues but they can be played out in other systems too.
Residential services usually incorporate some family based therapy, and / or carers support sessions when the eating disordered person is not yet ready to engage. and The Succeed Foundation have produced a helpful educational DVD of acted vignettes about how best to handle Eating Disorders within the family.
It is important to recognise that families are not the prime cause of eating disorders but can be a significant part of the jigsaw puzzle. Helping the client and working together with their family can help the whole family system to thrive and allow its members to flourish.
Melanie Phelps is a counselling psychologist, associate fellow of the BPS and practitioner for the National Centre for Eating Disorders, clinical supervisor, tutor / lecturer / conference speaker and has held a sessional role as the Eating Disorders specialist at Surrey University.
She has appeared on radio and Sky TV in programmes about Eating Disorders. She runs a private practice on the Surrey Hants and Berks borders and also undertakes psychological assessments for legal cases.
For more information on Melanie's work or to get in touch, email here
Caille, P et al (1977) A Systems Theory approach to a case of anorexia nervosa. Dec 16 (4) 455-65. Family Process.
Kerr, M E (2000) One Family’s story: A primer on Bowen Theory. The Bowen Centre for Study of the Family.
Lock, D, Le Grange (2015) Treatment manual for anorexia nervosa: A family based approach. Google books
The Bowen Centre (www.thebowencentre.org)
The Succeed Foundation (www.succeed-foundation.org)