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Syracuse University Department of Marriage and Family

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Title: Syracuse University Department of Marriage and Family


1
  • USING A MULTIFAMILY THERAPY GROUP TO ENGAGE
    PATIENTS, FAMILIES, AND PROVIDERS IN THE
    TREATMENT OF EATING DISORDERS
  • Syracuse University
  • Department of Marriage and Family Therapy
  • Syracuse, NY
  • October 5, 2007
  • Mary Tantillo PhD RN CS FAED
  • Director, Western NY Comprehensive Care for
    Eating Disorders
  • Unity Health System, Rochester, NY
  • Clinical Associate Professor, University of
    Rochester

2
  • In Loving Memory of
  • Jean Baker Miller, MD
  • 1927-2006
  • I think that the source of hope lies in
    believing that one has or can move toward a
  • sense of connection.


  • Jean Baker Miller Training Institute
    - jbmti.org

3
  • Why is the Concept of Disconnections so Important
    in regards to Eating Disorders and Recovery?

4
Disconnections
  • Disconnection A disturbance in the flow of
    relationship that
  • prevents or interrupts the experience of
    perceived mutuality and
  • is characterized by
  • Low self-worth
  • Disempowerment
  • Low energy, tension, feeling locked up or out
  • Feeling confused re the self, other, and the
  • relationship intolerance of difference
  • Wanting less connection isolation

5
Relational/Cultural Theory
  • A womans disturbances in her relationship with
    food and in her relationships with others occur
    due to the absence of mutually empathic and
    empowering relationships that are required for
    womens psychological growth, commitment to
    change, and recovery.

(Surrey, 1984 Tantillo, Nappa Bitter Adams,
2001)
6
Perceived Mutuality, Disconnections, Eating
Disorders, and Mental Health
  • Relationships characterized by a decreased sense
    of Perceived
  • Mutuality and increased disconncction may create
    risk for
  • development and maintenance of mental health
    problems such as
  • EDs (Genero et al., 1992 Jack Dill, 1992
    Miller Stiver, 1997
  • Powell, Denton, Mattson, 1995 Steiner-Adair,
    1990, 1991
  • Sperberg Stabb, 1998 Surrey, 1984 Tantillo,
    2000, 2004, 2006
  • Walker Rosen, 2004).
  • Low PM with mothers fathers correlates with
    eating disorder
  • symptoms and general psychological variables
    characteristic of those
  • with EDs (Sanftner Tantillo, 2001 Sanftner,
    Tantillo Seidlitz,
  • 2004 Tantillo Sanftner, 2003 Tantillo
    Sanftner, 2006).
  • For mothers and fathers, PM predicts several
    EDI-2 scales above and
  • beyond the variance accounted for by FEICS
    perceived criticism
  • and emotional involvement. (Sanftner, Cameron,
    Sippel et al., 2003).

7
EATING DISORDERS ARE DISEASES OF DISCONNECTION
  • - Disconnect patient from herself and others
  • - Disconnect family from other families
  • - Disconnect family from staff
  • - Disconnect treatment team from one another

8
Disconnection and Carer Relationships with the
Patient
  • I do not trust her anymore, especially with
    regards to what she told
  • us she was eatingThere is a lot of tension and
    conflictShe can be
  • very distant. She is afraid that I meddle with
    her affairs. Our
  • relationship lacks openness. I am afraid to say
    anything wrong.
  • We just avoided the issues that became too
    awkwardbecause we
  • could already see the sickness and the pain that
    she was in, and we
  • didnt want to cause any more.
  • (Highet, Thompson,
    King - focus groups with carers, 2005 Honey
  • Halse
    in-depth interviews with parents of adolescents,
    2005)

9
Disconnection and Partner Relationships
  • When I think of my family, if I had a picture,
    it would be
  • myself and my daughter standing out the front,
    and the
  • others perhaps in the backgroundI isolate my
    partner
  • and other daughter.
  • During her sickest times, she doesnt want to be
  • touchedhugged. She feels so uncomfortable about
  • herselfyou start to doubt your relationshipour
    sex
  • life has completely stoppedThat really did
    affect the
  • relationship because maybe its me, maybe she is
    falling
  • out of love with mewhy cant I do more to make
    it
  • better?
  • (Highet, Thompson, King - focus
    groups with carers, 2005)

10
Disconnection and Sibling Relationships
  • With the boys, the type of thing they say,
    little things that
  • mightnt worry us, but youre watching everything
    you
  • sayand now the boys dont say anything at all.
  • They have lost their friendship they lost it
    last year
  • because her sister was no fun anymoreIt was like
  • having a total stranger in the houseThere is
    sometimes
  • a real sadness that she hasnt got a real sister
    shes only
  • got a sometimes sister.
  • (Highet, Thompson, King - focus
    groups with carers, 2005)

11
Disconnection and Social Relationships
  • Because so much of adult interaction
  • involves foodIve said on a number of
  • occasions to our friends that dont know
  • about the eating disorder, if it involves
  • food, we cant do it. Or I go to things by
  • myself sometimes as well.
  • (Highet, Thompson, King - focus
    groups with carers, 2005)

12
Disconnection with Professional Team Members
  • wed sort of put ourselves in the hands of the
  • doctors, then. Obviously we hadnt been able to
  • fix the problem, so we had to hand her over. And
  • so part of that was putting up with whatever
  • treatment we got. We had to. We had to rely on
  • them totally.
  • (Honey Halse in-depth interviews
    with parents of adolescents, 2005)

13
Disconnection with Professional Team Members
  • wed been her mum and dad for 16 years and
  • we were used to working problems through with
  • her, and then suddenly, these barriers came down
    and we
  • felt that things were happening to her and being
  • discussed with her and that we were being blocked
    out of
  • it yet we were the ones she had to come back to
    when
  • they had had their little go with her.
  • (Tierney qualitative
    interviews with parents of adolescents, 2005)

14
Its All About Relationships
  • Parallels between relationships patient has with
    herself, others, and food and relationships among
    staff

15
Mutual Relationships
  • Mutual relationships are characterized by
  • The Five Good Things
  • Self-worth
  • Sense of energy/zest
  • Increased clarity re oneself, the other, and the
    relationship
  • Increased sense of empowerment
  • Increased desire for more connection

16
Perceived Mutuality
  • Bidirectional flow of thoughts, feelings,
    activity
  • Sensing one influences others and allowing
    oneself to be influenced by others
  • Involves emotional vulnerability, attunement,
    responsiveness to subjective experience of the
    other
  • Takes in the wholeness of the other (similarities
    and differences)

17
  • Mutual relationships occur only when
    difference and similarity are honored in
    relationship, when there is space for each person
    in the relationship and attention to the
    integrity of the connection.

18
Mutual Relationships
I
YOU
WE
Mutual relationships honor the integrity of the
connection between people and space for each
person in the connection. Mutual relationships
allow for difference in connection.
19
Disconnections
  • Disconnection A disturbance in the flow of
    relationship that
  • prevents or interrupts the experience of
    perceived mutuality and
  • is characterized by
  • Low self-worth
  • Disempowerment
  • Low energy, tension, feeling locked up or out
  • Feeling confused re the self, other, and the
  • relationship intolerance of difference
  • Wanting less connection isolation

20
Serious and Repeated Disconnections
  • The most damaging disconnections are
  • those that occur without relational
  • repair. They prevent family members
  • from embracing difference (e.g.,
  • different thoughts, feelings, needs) and
  • erode mutual empathy and
  • empowerment required for healing,
  • growth, and recovery.

21
  • Family stress and illness can lead to an
    experience of decreased perceived mutuality and
    put family members at risk for increased
    disconnection, e.g., experience of low
    self-worth, shame, disempowerment, inability to
    tolerate difference, tension, feeling locked up
    or locked out in relationship, self-doubt,
    confusion re oneself, others and the
    relationship, and increased isolation.

22
Relational Reframing of Etiology of Eating
Disorders
  • Eating Disorders are Diseases of
  • Disconnection
  • - Biology Serotonergic Disturbance Starvation
    B/P
  • - Psychology Disconnections Relational
    mismatches
  • - Socio-Cultural Toxic Societal Values
    that objectify
  • womens (and mens) bodies and teach us
    to value
  • ourselves from the outside in
  • - Spirituality Hopelessness
    Meaninglessness Isolation

23
Genes and Environment
  • Family aggregation, twin, and linkage and
  • association studies all suggest a role for
    genetic
  • risk environment
  • - Heritability estimates AN 48-76 BN
    54-85
  • - Family morbidity and comorbidity
  • - What is inheritable may be eating regulatory
    mechanisms,
  • temperament and character styles, and
    biologic
  • predispositions such as ovarian hormone
    activity
  • - chromosome 1 (AN-R) and 10 (BN)
  • - polymorphisms on various candidate genes
    regulating body
  • weight, appetite, eating behavior, and
    serotonin
  • - disconnection in how brain integrates
    information

24
(No Transcript)
25
Figure 2.6 Structures of the social brain. The
structures represented here are hidden beneath
the surface of the brain (Cozolino, 2006 in
Siegel, 2007, p. 39).
26
Disconnections Within the Brain
  • 1. Consistent findings
  • a) unilateral hypometabolism, predominantly in
    the
  • temporal region (66-75)
  • b) severe deficits in executive functioning
    (e.g., cognitive
  • rigidity (poor set shifting) and
    in visuo-spatial memory
  • (66)
  • 2. The hypometabolism cognitive deficits
    persist at
  • follow up, independent of weight/BMI, mood,
    EDE
  • 3. There is a significant correlation between the
  • hypoperfusion and the cognitive deficits

  • (Lask, 2006)

27
Key Dysfunctions in AN and Their Primary
Structures
  • i) Distorted body image
    Somato-sensory cortex
  • ii) Increased anxiety
    Amygdala
  • iii) OCD and excessive drive
    Basal ganglia
  • iv) Enhanced sense of reward Nucleus
    accumbens
  • v) Visuo-spatial deficits
    Parietal cortex
  • vi) Executive impairments
    Frontal cortex
  • How might these be connected?
    (Lask, 2006)

28
Somato-sensory Cortex (DBI)
Parietal Lobe (visuospatial deficits)
Frontal (executive deficits)
Insula
Nucleus Accumbens (reward)
Basal Ganglia (obsessional drive)
Hippocampus (contextual memory)
Amygdala (extreme anxiety)
29
The Integrative and Regulatory Roles of the
Insula
  • i) ANS regulation
  • ii) Appetite and eating regulation
  • modulates the reward value of food
  • iii) Self-recognition
  • iv) Monitors body state and body image
  • v) Monitors the gut (hippocampus of the
    gut)
  • vi) Reception, perception integration of
    taste
  • vii) Perception and integration of disgust
  • viii) Perception of pain
  • Integrates thoughts and feelings
  • (Lask, 2006)

30
The Insular Hypothesis
  • The insula fails in its role as a connection and
    regulator between those cortical and sub-cortical
    structures most relevant in AN

  • (Lask, 2006)

31
Starvation and Disconnection
32
Keys, et al The Biology of Human Starvation U
Minnesota Press 1950
33
SYMPTOMS OF LOW ENERGY INTAKE (STARVATION)
  • Irritability
  • Depression
  • Obsessive-Compulsive traits
  • Social withdrawal
  • Conflict
  • Food related habits
  • Body image distortion
  • Loss of appetite
  • Kreipe, 2005
  • Hair
  • Skin
  • Headache
  • Fainting, dizziness
  • Chest pain
  • Constipation
  • Loss of menses
  • Fatigue, weakness
  • Cold intolerance

34
SIGNS AND SYMPTOMS OF VOMITING OR LAXATIVE ABUSE
Physical health
Mental health
  • Weight loss
  • Electrolyte disturbance
  • ? K
  • ? CO2
  • Dental enamel erosion
  • Low blood volume
  • Knuckle calluses
  • Guilt
  • Depression
  • Anxiety
  • Confusion
  • Kreipe, 2005

35
Disconnections The Neurobiology of Shame
  • Sudden decrease in pleasure (stress produces
    corticosteroids that decrease endorphins)
  • Rapid inhibition of excitement (less activity in
    excitatory ventral tegmental limbic
    forebrain-midbrain circuit and more activity in
    inhibitory noradrenergic lateral tegmental limbic
    forebrain-midbrain circuit Robins and Everett,
    1982)
  • Cardiac deceleration by vagal stimulation
  • Parasympathetic conservation-withdrawal in
    helpless,
  • hopeless situations
  • Individuals become inhibited and avoid attention
    promotes inauthenticity
  • Individuals want to be unseen (Schore)
  • (Banks, 2003)

36
The Neurobiology of Disconnections
  • Trauma and early unresponsive relationships
    characterized by
  • chronic and serious disconnections can lead to
  • Increased corticosteroids and neuronal cell death
    in affective centers of the limbic system
    (Kathol, Jaeckle, Lopez Mella, 1989 Perry,
    1997)
  • Developmental overpruning (d/t toxic effect of
    overwhelming stress). Overpruning of the
    corticolimbic system that contains genetically
    encoded underproduction of synapses can lead to
    high risk conditions (Schore, 1997).
  • Permanent alterations in opiate, dopamine,
    norepinephrine, and serotonin receptors (Lewis
    et. al. 1990 Martin et. al. 1991 Rosenblum et
    al. 1994 Van der Kolk, 1983).
  • Physiological reexperiencing of disconnections.

37
Neurobiology, the Mind, and Relationships
  • Human connections shape the neural connections
    from
  • which the mind emerges. (Siegel, 1999, pg. 2)
  • An individuals abilities to organize emotions
    a product, in part, of earlier attachment
    relationships directly shapes the ability of
    the mind to integrate experience and adapt to
    future stressors. (Siegel, 1999, pg. 4)
  • Either form of disconnection excessive
    integration or
  • excessive differentiation can result in the
    movement of the
  • individual away from complexity, stressing the
    system,
  • entering reactive states of rigidity or chaos,
    and moving away
  • from the balanced capacity for
    self-organization (Siegel and
  • Hartzell, 2003, pg. 218)

38
EATING DISORDERS DISEASES OF DISCONNECTION
  • the most terrifying and destructive feeling
    that a person can experience is psychological
    isolationIt is a feeling that one is locked out
    of the possibility of human connection and of
    being powerless to change the situation...People
    will do almost anything to escape this
    combination of condemned isolation and
    powerlessness.
  • (Miller and Stiver, 1997)

39
  • In the face of significant and especially
    repeated experiences of disconnection, we believe
    that we yearn even more for connection to others.
    However, we also become so afraid of engaging
    with others about our experiences that we keep
    important parts of ourselves out of connection
    that is we develop strategies for disconnection.
  • (Miller, J. B., Stiver, I.P. (1994).
    Movement in therapy Honoring the
  • strategies of disconnection. Work in
    Progress, No. 65, Wellesley, MA
  • The Stone Center.)

40
Disconnecting from Oneself to Maintain Connections
  • In situations with family, its so
    inappropriate to have different opinions,the
    smallest trace of being different makes it easier
    to not be likedI was so cautious of the way I
    sat and the words I used when I was over there
    tonight. I didnt want to make a wrong move, make
    the wrong comment, or even sit, walk wrong. I
    have to close off every part of myself when Im
    with them. I have to lock it away.
  • (Betty, 10/21/03)

41
Lessons Learned through Serious and Chronic
Disconnections
  • Difficult/different feelings/thoughts
  • 1. Cannot exist between us.
  • 2. Are all mine.
  • 3. Mean something is wrong with me.
  • 4. My feelings/thoughts are wrong/bad.
  • 5. So, I am wrong/bad. I am the problem.
  • 6. My feelings/thoughts/actions lead to
    isolation. I am unable to change things.

42
Power and DisconnectionIn any relationship in
which a person has more power over the other, the
danger of harm increases. That person can exert
a greater influence on what happens in the
interaction and will be less likely to seek
mutual engagement. It is more difficult for the
less powerful person to alter the course of an
interaction. (Miller Stiver, 1997, p. 66).
43
Relational Images and Meanings that Lead to
Strategies for Disconnection
  • Relational Image When I try to convey my
  • experience, no one is listening to me.
  • Relational Meaning This is because I am
  • unlovable, unworthy, defective, to blame.
  • Strategies for Disconnection (To avoid the
  • pain r/t the above image and meanings and to
  • maintain available connections) e.g., eating
  • disorder behaviors/thoughts denial of illness.

44
  • My mother called to say she had left my
    daughters birthday cake out on the counter. She
    said she forgot to put it away. She knew this
    could be a trigger for me. I said, Thats OK,
    mom. Its too late anyway. I had already binged
    on the cakeI didnt want her to make that cake
    anyway. My daughter had planned for me to get her
    a special princess cake, but my mother said she
    needed to bake her one. She didnt listen to me.
    She never listens to meI guess my binging took
    care of all that.
  • (Holly, 1/05)

45
Toxic Sociocultural Values
  • Thinness, ultra-independence, control,
    appearance, performance, consumerism,
    individualism bordering on narcissism, etc.
  • Linking control and success with thinness and
    appearance
  • Objectifying womens bodies
  • Socializing women and men to value themselves
    from the outside in
  • Multiple, ambiguous, and contradictory role
    expectations for women
  • Doing vs. Being (together) e.g., decreased family
    meals
  • Emphasis on the I and the me, not the we

46
Spirituality and Disconnection
  • Meaninglessness
  • Isolation Condemned isolation
  • Aloneness

47
EATING DISORDERS DISEASES OF DISCONNECTION
  • Eating disorders are diseases of
    disconnection in which a biogenetically
    vulnerable individual has difficulty staying
    connected to and developing an authentic sense of
    self within relationships with others. This
    struggle is intensified with the effects of
    starvation, binging or purging and a culture that
    emphasizes thinness, appearance, and performance.

48
Genetic Neurobiological Vulnerability to
Disconnections and Mutual Connections
  • Genotype can create neurobiological
  • vulnerability to disconnections and can moderate
    the impact of environmental pathogens (e.g.,
    disconnections) on a person. However, another
    variable, e.g., perceived mutuality or social
    support, can moderate that gene by environment
    interaction (Caspi, 2006).

49
Multifamily Therapy Group Review of the
Literature
  • Schizophrenia
  • Lacquer, LaBurt, Morong (1964)
  • Detre, Sayer, Norton (1961)
  • McFarlane (2002), Dyck et al. (2000) manualized
    PMFTG treatment and conducted empirical research

50
Multifamily Therapy Group Review of the
Literature
  • Schizophrenia
  • McFarlane (2002), Dyck et al. (2000) Research
    findings
  • -vastly more effective than individual
  • treatment or meds alone
  • -more effective in decreasing morbidity and
  • relapse rates and improving vocational
    outcomes
  • in comparison to Psychoed Single
    Family Tx

51
Multifamily Therapy Group Review of the
Literature
  • Schizophrenia McFarlane (2002) Dyck et al.
    (2000) PMFTG Research findings
  • -benefits that increase with time up to 4 or
    more yrs
  • -specifically more effective than single family
  • approaches for 1st episode and high
    risk patients,
  • poor responders to meds, and patients
    in families
  • with high expressed emotion
    emotional
  • overinvolvement, hostility, criticism
    (Vaughn, 1989
  • van Furth et al, 1996).

52
Multifamily Therapy Group Review of the
Literature
  • Chronic Medical Illness
  • (Gonzales and Steinglass, 2002)
  • Chemical Dependency
  • (Kaufman and Kaufman, 1979)
  • Child Abuse
  • (Asen, George, Piper, Stevens, 1980)

53
Multifamily Therapy Group Review of the
Literature
  • Eating Disorders
  • Asen, Stein, Stevens, McHugh, Greenwood,
  • Cooklin, 1981
  • Cooklin, Miller, McHugh, 1983
  • Dare Eisler, 2000
  • Scholz Asen, 2001
  • Shekter-Wolfson Woodside, 1991
  • Slagerman Yager, 1989
  • Wooley Lewis, 1987

54
Multifamily Therapy Group Review of the
Literature
  • Eating Disorders PMFTG Research Findings
  • Lack randomized controlled trials
  • Decrease in family distress and high expressed
    emotion in families of ED pts (esp. emotional
    overinvolvement) (Uehara et al, 2001)
  • Symptomatic Improvement (wt gain, decreased B/P
    episodes, stabilized eating, return of menses)
    (Dare Eisler, 2000 Scholz Asen, 2001)

55
Multifamily Therapy Group Review of the
Literature
  • Eating Disorders PMFTG Research Findings
  • Improved familys perception of patient symptoms
    (Uehara et al, 2001)
  • Reduced inpt LOS Reduced number relapses
    Quicker recovery after relapse (Sholz Asen,
    2001)
  • High patient/family satisfaction (Dare Eisler,
    2000 Scholz Asen, 2001).

56
Unity Multifamily Therapy Group (U-MFTG)
Integrated Model
  • Psychoeducational/CBT (Garner, 1997 Fairburn,
    Marcus, Wilson, 1993) Siegel, Brisman,
    Weinshel, 1997 Wilson, Fairburn, Agras, 1997)
  • Motivational/Stages of Change Theory (Garner,
    Vitousek, Pike, 1997 Miller Rollnick, 2002
    Prochaska, Norcross, and DiClemente, 1994)
  • Family Systems PMFTG (Dare Eisler, 1997 Lock,
    LeGrange, Agras, Dare, 2001 McFarlane, 2002)

57
Unity Multifamily Therapy Group (U-MFTG)
Integrated Model
  • U-MFTG - Combined focus on psychoeducation,
    strategies to manage the eating disorder, improve
    communication, and cope but also moves beyond
    emphasis on scientific problem-solving to
    importance of promoting perceived mutuality in
    relationships.
  • Relational-Cultural Theory (Gilligan, 1982
    Miller and Stiver, 1997 Tantillo, 2000, 2004
    Tantillo Sanftner, 2003 Walker Rosen, 2004)

58
U-MFTG Family Systems Assumptions
  • Eds have a multi-factorial Biopsychosocial
    etiology (involving levels of disconnection)
  • Main initial emphasis is on refeeding as
    starvation and B/P episodes can create
    disconnection from oneself and others and
    obstruct optimal use of therapy
  • Disconnections and negative relational patterns
    can exist in the family before or after onset of
    ED.

59
U-MFTG Family Systems Assumptions
  • The family did not create the ED.
  • The ED is presented as something outside the
    family, creating disconnection, burden, and
    obstructing normal development for patient and
    family.
  • Patient not in control of the ED and strategies
    for disconnection (ED symptoms, social isolation)
    are unconsciously driven, driven by starvation,
    etc.)

60
U-MFTG Family Systems Assumptions
  • ED can operate in the family to promote a certain
    mode of organization and interaction
  • The therapist must be active in helping family
    members identify points of tension or
    disconnection and address these to release the
    patient from the grasp of the ED.
  • Emphasis on seriousness of ED and the need to
    work together
  • Most families can help and have some skills
    and/or are receptive to learning new skills
  • Emphasis on mutual empowerment among family and
    staff
  • Role of therapist and process of therapy
    demystified

61
U-MFTG Family Systems Assumptions
  • Experience in relationships is co-constructed
  • Emphasis on validation
  • Importance of meaning, adaptive nature of
    symptoms/strategies for disconnection, and
    relational patterns
  • Critiques toxic societal values/norms that
    oppress and objectify women and men
  • Transferential or symbolic aspects of therapy
    always kept in mind while authenticity and real
    relationships emphasized with family members.

62
Healing within a Relational Therapy Approach to
Multifamily Group
  • Understanding the impact of the eating disorder
    and recovery on relationships and vice versa
  • Experiencing mutual empathy and empowerment
    within the groups diverse therapeutic social
    network (difference within connection).
  • Perceived mutuality recognizing we impact
    others and allowing ourselves to be open to the
    influence of others
  • Understanding the connections between the
    patients relationships with food/illness, self,
    and others

63
Healing within a Relational Therapy Approach to
Multifamily Group
  • Honoring difference within a strong connection
    with one another
  • Practice identifying various disconnections that
    keep the eating disorder in place
  • Transform strategies for disconnection into
    strategies for connection that dont focus mainly
    on food/illness
  • Patients, families, and therapist grow through
    interaction

64
Healing within a Relational Therapy Approach to
Multifamily Group
  • RT promotes development of mutual
  • empathy and empowerment through
  • Focus on patient therapist authenticity
  • Use of real relationship
  • Attention to transferential relationship
  • Use of judicious self-disclosure

65
  • Relational/Cultural Theory emphasizes that
    mutuality involves not only the therapists
    ability to appreciate her/his impact on the
    patient and family, but also an openness to being
    moved by what the patient and family say and do,
    and a willingness to convey to them that s/he has
    been moved.
  • (Miller Stiver, 1997 Tantillo, Nappa
    Bitter Adams, 2001).

66
Therapist Self-Disclosure within a Relational
Therapy Approach
  • Therapist self-disclosure promotes a sense of
    perceived mutuality because it helps the patient
    and family recognize that the therapist has been
    moved in response to their experiences or
    behaviors. This process leads to increased
    self-empathy for each family member and mutual
    empathy among family members. The patient and
    family realize their experiences do matter and
    can be part of relationship (Miller, 1999
    Tantillo, 2004).

67
Purposes of Therapist Self-Disclosure within a
Relational Therapy Approach
  • Promote perceived mutuality (mutual empathy and
    mutual empowerment)
  • Demystify the therapists role
  • Create shared value and expertise
  • Promote egalitarianism
  • Demystify process of therapy
  • Normalize and validate symptoms/struggles
  • Promote universality

68
Purposes of Therapist Self-Disclosure within a
Relational Therapy Approach
  • Identify relational dilemmas
  • Identify negative relational images, meanings,
    and patterns
  • Identify strategies for disconnection
  • Move relationship from disconnection to
    new/better connection
  • Identify relational paradox

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Purposes of Therapist Self-Disclosure within a
Relational Therapy Approach
  • Convey flexibility and openness to difference
  • Apologize/Admit errors
  • Convey therapist limitations
  • Create connection by allowing patients and
    families in your head (how you think/feel)

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  • The therapists ability to remain aware of
    her/his own strategies for disconnection is
    important for movement with the patients and
    families along the entire spiral of change, but
    is especially critical in helping them jointly
    contemplate and eventually commit to change.

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  • Each dynamic in group is viewed as a means
    of maintaining connection or as a strategy for
    disconnection (e.g., food restriction, binging,
    purging, denial of illness, minimization,
    avoidance, social isolation). These strategies of
    disconnection are responses to a central
    relational paradox , i.e., an intense longing for
    mutual relationships and a fear of allowing
    oneself to participate in these relationships
    because of severe anxiety, past hurts, and
    violations.
  • (Fedele,
    1994 Tantillo, Nappa Bitter Adams, 2001).

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Aims of U-MFTG
  • Improve quality of family life through decreasing
    stigma, stress, disconnection, and the burden
    incurred by the ED.
  • Improve ED symptoms and a sense of perceived
    mutuality.
  • Promote relapse prevention.

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U-MFTG GOALS
  • Build mutually empathic and empowering
    relationships among patients and families.
  • Increase understanding re impact of
    disconnections on the ED and recovery.
  • Increase understanding re how the ED promotes
    disconnection in relationships and obstructs
    recovery.
  • 4. Increase understanding re ED and stages and
    processes of change, to help families interact
    with patients in ways that promote motivation for
    treatment and recovery.

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U-MFTG GOALS
  • Identify and challenge dysfunctional thoughts
    (e.g., all/nothing thoughts) that obstruct
    recovery.
  • Develop and practice new coping strategies and
    relational skills that promote recovery.
  • Promote a sense of hopefulness and positive,
    healing energy that enables patients and families
    to remain connected and engaged in their work.
  • Decrease isolation and expand families and
    patients social networks.

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U-MFTG Format
  • Outpt. Closed-ended 8 week group
  • cycle with up to 5 families
  • PHP Open-ended 7/8 week group cycle with up to
    9-12 families
  • 1 ½ hours long
  • Program director is group leader along with
    trainee
  • Patient plus significant others
  • Ages 12 and up
  • Adults and adolescents are seen in individual
    treatment when attending outpt U-MFTG

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U-MFTG Schedule Moving from Disconnection to New
and Better Connection
  • Introduction The recovery process and the spiral
    of change
  • Biopsychosocial risk factors for EDs
  • Strategies to promote mutual connection
  • The Family Context Rules and Relationships

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U-MFTG Schedule Moving from Disconnection to New
and Better Connection
  • 5. Identifying points of tension and
    disconnection related to the ED and recovery
  • Nourishing and empowering the We
  • Waging good conflict in connection
  • 8. Wrap-up, good-byes and next steps

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Multifamily Therapy Group Sessions
  • Session 1
  • Group introductions and orientation
  • Promote universality and mutual exchange
  • Spiral, stages, and processes of change
  • Strategies that support patients to stay engaged
  • in treatment
  • Distinguish illness from patient
  • Validate burden of illness for patient and family
  • Emphasize how neither patient nor family caused
    or can alone cure and control the ED.
  • Introduce idea that ED thrives on disconnection
    and isolation and importance of tolerance of
    difference.

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Multifamily Therapy Group Sessions
  • Session 2
  • Biopsychosocial risk factors r/t EDs
  • Introduce relational risk factors
  • Perceived mutuality and negative impact of
  • serious/persistent disconnections
  • Negative relational images, meanings patterns
  • Disconnections can be handed down
  • Importance of relational repair
  • Judicious therapist self-disclosure re
    disconnections
  • Validate and normalize family/patient dilemmas
  • Foster increased authenticity and mutual
    connection

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Multifamily Therapy Group Sessions
  • Session 3
  • Develop strategies for connection that
  • dont involve food and the ED
  • Discuss self, other, and relationship as all
  • needing attention in mutual connections
  • Relationships greater than the sum of its parts
    can provide healing energy for recovery
  • Strategies for connection foster ability to see
    and experience the wholeness of others beyond the
    ED

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Multifamily Therapy Group Sessions
  • Session 4
  • Identify implicit and explicit rules r/t the ED
    and relationships
  • Discuss how rules develop, e.g., previous
    generations, personalities, and culture.
  • Discuss how rules need to change over time to
    promote growth of individuals and relationships
  • Discuss challenges that occur when rules and the
    nature of connections dont change
  • Practice being open to different perceptions of
    the rules
  • Rate rules according to criteria such as ability
    to embrace/avoid difference focus on appearance
    or performance

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UNITY MULTIFAMILY THERAPY GROUP
  • SESSION IV
  • CRITERIA TO RATE FAMILY RULES
  • Is the rule consistently or inconsistently
    applied?
  • Is the rule predictable or unpredictable?
  • Is the rule rigid or flexible?
  • Does it apply to some members and not others?
  • Does the rule promote or inhibit conflict
    negotiation?
  • Does the rule help people embrace or avoid
    difference?
  • Does the rule focus mainly on physical appearance
    or performance?

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Multifamily Therapy Group Sessions
  • Session 5
  • Identify points of tension and disconnection r/t
  • ED and recovery/relationships and problem
    solve
  • EDs are diseases of disconnection can evolve
  • from them and perpetuate them to obstruct
    recovery
  • Impact of serious/persistent disconnections on
  • recovery note all/nothing thinking
  • Strategies for working through disconnection
  • Put connection at the heart of the relationship
  • Stay connected to ourselves (genuine thoughts,
  • feelings, needs) and in relationships
    with others, higher power, nature, etc.

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Multifamily Therapy Group Sessions
  • Session 6-8
  • Strategies for moving out of disconnection to
    new/better connection
  • Empowering the we to move out of disconnection
  • Identify points of tension/disconnection and
  • problem solve
  • Termination, evaluations, accomplishments, next
    steps, follow-up

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Its All About Relationships Team Building
Considerations
  • Learn the language and values of the patient and
    family
  • Build a new culture of shared meanings and common
    language with the patient, family, and staff

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Demographics of U-MFTG families seen 2001-2004
in Eating Disorders Partial Hospitalization (PHP)
and Outpatient (Outpt) Programs
  • Program n Grp Family
    Diagnosis Age Ethnicity
    Gender
  • Cycles Members
  • __________________________________________________
    ______________________
  • PHP 141 16 mothers (54)
    AN (48) lt18 (36) W (134 )
    F (139)
  • fathers (43) BN
    (61) 18gt (105) AA (1) M (2)
  • siblings (30) EDNOS (32)
    H (4)
  • grndpts (5)
    ASA (1)
  • partners (20)
  • friends (30)
  • __________________________________________________
    ______________________
  • Outpt 9 3 mothers (5)
    AN (3) lt18 (1) W (9)
    F (9)

  • fathers (4) BN (2) 18gt (8)
    AA (0) M (0)
  • siblings (8) EDNOS (4)
    H (0)

  • partners (5)
    ASA (0) grndpts (1)

  • friends (1)
  • __________________________________________________
    ______________________
  • Note grp group grndprts grandparents AN
    anorexia nervosa BN bulimia nervosa
  • EDNOS eating disorder not otherwise specified
    W white AA African American
  • H Hispanic ASA Asian American F female M
    male

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Implications for Research and Practice
  • Need more randomized controlled trials of
  • PMFTG to identify
  • Most effective group format/frequency
  • Clarify impact of PMFTG on family functioning, pt
    symptom improvement, family perception of pt
    symptoms, duration and frequency of relapse, and
    tx drop out rates.
  • Compare to single family and other approaches
    esp. for 1st episode, high risk patients, poor
    responders to meds, and patients in families with
    high expressed emotion

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Implications for Research and Practice
  • PMFTG approaches should
  • target predisposing, precipitating, and
  • perpetuating risk factors for EDs (e.g.,
  • negative self-evaluation, high parental
  • achievement expectations, low parental
  • contact, and low paternal care)
  • These are potential sources of disconnection

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Implications for Research and Practice
  • PMFTG approaches should
  • Promote favorable prognostic factors, e.g.,
    friendships, increased self-esteem, more moderate
    level of expressed emotion in families, esp.
    parental criticism.
  • Promote family/patient strengths and resilience
  • These involve a familys ability to embrace and
  • work through difference.
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