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Family Dynamics in the Treatment of Eating Disorders - Jim

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Title: Family Dynamics in the Treatment of Eating Disorders - Jim


1
Family Dynamics in the Treatment of Eating
Disorders
  • James Gerber Ph.D.

2
Conceptual/Theory
  • Systems Theory Families are systems of
    interconnected and interdependent individuals. To
    understand the person it is necessary to
    understand the family. People cannot be
    understood in isolation
  • Structural Family Therapy (Minuchin) Three
    constructs are essential. These are structure,
    boundaries and subsystems.

3
  • Structure refers to the set of rules (overt or
    covert, idiosyncratic or universal) that guides
    the familys way of interacting.
  • Subsystems are the alliances, dyads that develop
    within the family, i.e. mother/son,
    father/daughter, etc.
  • Boundaries manifest in how proximity and
    hierarchy are managed in the family. In
    disengaged families, emotional distance is
    excessive and lacks support for the individual.
    In enmeshed families boundaries are diffuse and
    are intrusively intertwined.

4
  • In theory, behavior disorders develop when
    inflexible family structures cannot adjust to
    maturational or situational changes. Symptoms in
    the individual emerge in response to dysfunction
    in the system.

5
  • Attachment Theory (Bowlby, J. Ainsworth M.)
    Refers to those parent-infant interactions that
    effect the childs sense of security.

6
  • Central concepts in attachment theory Attachment
    to caregivers is an innate motivation that
    provides for the survival and safety of the
    infant.
  • Secure attachment requires the attunement of the
    caregiver to the infant.
  • Infants internalize patterns of interaction in
    internal working models which form the template
    for relationships through the lifespan i.e.
    caregiver/caretaker, abuser/abused.

7
  • If internalized models are built on the
    experience of reliable and attuned caregivers,
    the child has a secure base from which to explore
    the world.
  • Misattunement and unreliability result in
    anxiety, avoidance and dissociation. This then
    has global impact on the a childs development
    (executive functions, self worth), exploration
    and mastery are restricted.

8
Internal Family Systems
  • Internal Family Systems is based on the theory
    that subpersonalities develop as a way for a
    child to cope with life circumstances. Of
    central focus in the theory and therapy is the
    concept of Self.
  • In IFS, the Self is innate, present from birth.
    The Self contains all of the qualities a person
    requires to find satisfaction in life such as
    compassion, creativity, clarity, etc.

9
  • While parts emerge as a way of coping and is
    adaptive, parts that hold experience that is felt
    to be toxic are disowned. Other parts then emerge
    to manage what is exiled. This creates internal
    polarities between the motivations of the exile
    and the motivations of the manager trying to
    suppress.
  • These exiles hold the burdens (shame, secrets,
    trauma) much like the blacksheep of families do
    in the external family.

10
  • Legacy Burdens Legacy burdens are the residue of
    internalized conflict, be it secrets, trauma or
    shame that pass from one generation to the next.
  • Legacy burdens involve the projection of ones
    internal family (parts) onto ones external
    family, especially children who then are disposed
    to pass this to the next generation.

11
Clinical Practice
  • It would appear that a revision of the overt
    family structure (boundaries, dyads, rules) would
    result in a flexibility that would facilitate the
    growth of the individual.
  • However, what we find is that there is an
    intricate interplay between the internalized
    worlds of the individuals and what manifests in
    the world. Without attention to each the
    ingrained patterns are resistant to change.

12
Case Example 1
  • A twenty year old women is admitted to CW with an
    eating disorder. The family dynamics present as
    an enmeshed relationship between the mother and
    daughter. Then an emotional distance in the
    father-daughter relationship as well as in the
    marital relationship. The woman seems arrested in
    not being able to launch into the world. Though
    bright with past academic success she has
    difficulty in school as well as establishing peer
    relationships. Her relationships with male peers
    are marked by bouts of drinking and brief sexual
    encounters which result in no intimate
    connection.

13
  • A secure maternal attachment is necessary for
    the infant to explore the world. However, in
    reference to mother-daughter Zerbe writes,To
    grow we must loosen some of the intense powerful
    ties to our mothers thus permitting a new kind of
    connection to form. Mothers must permit this
    evolution to happen. This task is more easily
    said than done. (Zerbe, K. 1993)

14
  • If not taken to pathological extremes, the
    father-daughter relationship can provide the
    daughter with a sense of specialness and
    lovableness. It also remains important for the
    daughters ineluctable urge to separate from the
    mother. When a father is unable to help his
    daughter move out of the maternal orbitthe
    daughter may turn to food as a substitute
    (Zerbe, K. 1993)

15
  • In treatment the patient struggled with her
    conflict in launching into the world as an adult.
    As with other patients she described an inability
    to tolerate her emotions and a diminished sense
    of self, especially in regard to her relation
    with men. It is notable that as the therapy
    unfolded she described the tremendous grief
    related to the emotional distance and perceived
    rejection of her father.

16
  • Overtly, we could invite the two of them to share
    time and learn skills to communicate. But this
    did not alter the shell that restricted the
    fathers empathy and understanding.
  • In IFS work with the father he connected with his
    own experience of alienation in childhood and
    lack of guidance in adolescence. This was held in
    his own exiled parts. What he spoke of in his
    experience was identical to what his daughter
    also described.

17
  • Through the IFS work he was able to acknowledge
    and have compassion for his own injury and
    struggle. This then allowed him to understand and
    relate to his daughter in a way that built
    connection. In addition, the emotional block that
    was removed allowed him to be more open in his
    marriage which fostered the parental dyad.

18
Case Example 2
  • A twenty six year old woman, six months pregnant
    with a history of episodes of restricting,
    binging and purging since the age of twenty.
    Struggles with alcohol, body image and disordered
    eating were evident earlier in her life. Her
    relationship with her parents was complex and
    helps to highlight the interplay of outward
    systemic dynamics, attachment and the internal
    system.

19
  • Her relationship with her mother and father
    display seemingly contradictory motivations. She
    stated that she was close to her mother and there
    was an emotional enmeshment evident in both of
    their inability to see the other emote without
    their own distress and need to fix the other.
    However, she also stated that her mother was
    unemotional and felt disconnected from her.

20
  • On the other hand, she could elaborate on her
    father and their relationship. She felt she was
    identified with him (in personality and body
    type), by others as well as in her own perception
    . This was problematic in that he had suffered
    his own abusive childhood and was prone to
    volatile outbursts. While seldom directed at the
    patient, she viewed his behavior with contempt.
    This then interfered with the availability of her
    father as a source of specialness and support.

21
  • So while emotionally enmeshed with her mother
    their was a misattunement. Both of these dynamics
    interfered with her sense of security and
    emotional development.
  • Her fathers emotional volatility was seen as not
    safe and her contempt for him led her to disown
    her own emotions especially anger.

22
  • In therapy a number of statements did highlight
    her experience. For example she stated that from
    mid childhood she had fantasies of being
    kidnapped or raped. These were not frightening to
    her. She explained that at least in the fantasy I
    was desired. I just want to be cherished.
  • From another avenue she became aware of how her
    relationship with her mother was similar to her
    mothers relationship with her own mother, and
    described being aware of the emotional gulf
    between them i.e. the legacy burden.

23
  • On particular note was her awareness of how she
    and her sister were treated differently by her
    mother. Her sister, the pretty one, was the
    object of admiration by others. She felt a sense
    of pity from her mother but that was of no help
    since, its so bad no one even knew how o help
    me. Compensatory strivings for achievement and
    perfection were used to alleviate the void and
    sense of being defective.

24
  • In individual therapy with the IFS model she
    came, over time to access the disowned child
    parts of self, to revise the self contempt and
    view them with compassion. This resulted in her
    being able to view and begin to relate to herself
    differently, both in behavior and internal self
    talk.

25
  • In family therapy, her mother was receptive to
    this discussion and validated that her
    relationship with her mother was similar in the
    misattunement and that this was a pattern
    stretching back to other generations. Her mother
    also related to the patients sense of self pity
    and described a similar experience. The pretty
    sister was an avenue for her to escape her own
    self contempt.
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