What role does the family play in the development, maintenance and treatment of eating disorders?
This essay aims to clarify the role that the family plays in the development and maintenance of eating disorders among adolescents.It argues for a conceptual shift in treating the family as a dynamic system which can be restructured for successfully treatment of adolescent eating disorders.Supportive family participation should be an integral part of the treatment effort to facilitate the recovery of the identified patients.
The role of the family in adolescent eating disorders
For many years, the family has been held responsible for eating disorders such as bulimia and anorexia that are rampant among youngsters (10~20 years of age; Kreipe, 2006).
Consequently, parents and other family members close to the identified patient are portrayed as negative influencers, and are generally excluded from the therapeutic process of the ‘frightening illness’ (Michel and Willard, 2003a). However, a new line of research stemming from Minuchin and colleagues (1978) has reframed the role of the family in a way that creates a profound impact on the development of effective family therapy. In the light of this conceptual shift, the present essay attempts to provide a renewed perspective into the role that the family system plays in the multifaceted aspects of eating disorders.
The development of disordered eating symptoms appears to be characteristic of dysfunctional parenting and abnormal familial situations. For instance, inappropriate parental pressures and overprotection (Horesh et al., 1996; Shoebridge and Gowers, 2000), critical comments and high expectations on shape and weight (Graber et al., 1994), and elevated negative expressed emotions in the family (Le Grange et al., 1992) all increase an adolescent’s chances of developing an eating disorder. Meanwhile, as the family system evolves and reaches its homeostasis where rigid rules of behaviour are observed, the youngsters may find themselves being hindered from establishing an identity or learning adaptive skills to cope with life stressors (Michel and Willard, 2003a). Consequently, eating disorders are maintained as a safe avenue to expressing their individuation from the family of origin (Michel and Willard, 2003b). In addition, medical research from family, twin, and molecular genetic studies seems to vouch for certain genetic underpinnings in disordered eating (Le Grange et al., 2010), giving rise to the speculation that eating disorders emerge from the complex interaction between a multiplicity of genetic and non-genetic family and sociocultural factors (Bulik, 2005; Striegel-Moore and Bulik, 2007).
While the family system provides a holding environment for an adolescent’s development and maintenance of an eating disorder (Michel and Willard, 2003a), the system can in turn be restructured to cultivate an environment that facilitates eating disorder treatment and recovery. Recent research and clinical experience has established that family therapy, i.e. having family members as part of the treatment team, is an effective modality for treating eating disorders among adolescents, and can even enhance the efficacy of cognitive-behaviour intervention for adolescents with bulimia if the family involvement is active and supportive (Lock and Le Grange, 2005). However, if the family is highly critical and hostile, family involvement should be avoided (Le Grange et al., 1992).
To conclude, by viewing the family as a dynamic system, eating disorders become part of the system and its development and maintenance would be subject to the influence of the interaction between genetic or non-genetic family factors. Meanwhile, the family system can be restructured to enhance the treatment of adolescents’ eating disorders by family participation or exclusion based on the nature of the family system (i.e. critical or supportive).
Bulik, C.M. (2005) Exploring the gene-environment nexus in eating disorders. J Psychiatry Neurosci. 30 (5), pp. 335-339.
Graber, J.A., Brooks-Gunn, J., Paikoff, R.L., & Warren, M.P. (1994) Prediction of eating problems: An 8-year study of adolescent girls. Dev Psychol 30, pp. 823-834.
Horesh, N., Apter, A., Ishai, J., Danziger, Y., Miculincer, M., Stein, D., et al. (1996) Abnormal psychosocial situations and eating disorders in adolescence. J Am Acad Child Adolesc Psychiatry 35, pp. 921-927.
Le Grange, D., Eisler, I., Dare, C., & Hodes, M. (1992) Family criticism and self-starvation: a study of expressed emotion. J Fam Ther 14, pp. 177-192.
Le Grange, D., Lock, J., Loeb, K., & Nicholl, D. (2010) Academy for eating disorders position paper: The role of the family in eating disorders. International Journal of Eating Disorders 43, pp. 1-5.
Lock, J. & Le Grange, D. (2005) Family-based treatment of eating disorders. Int J Eat Disord 37, pp. S64–S67.
Kreipe, R.E. (November 2006) Eating disorders and adolescents. Retrieved 11 Jun 2011 from http://www.actforyouth.net/resources/rf/rf_eatingdisorders_1106.pdf
Michel, D.M. & Willard, S.G. (2003a) Family treatment of eating disorders. Clinical Focus 10 (6), pp. 59-61.
Michel, D.M. & Willard, S.G. (2003b) When dieting becomes dangerous: a guide to understanding and treating anorexia and bulimia. New Haven, CT: Yale University Press.
Shoebridge, P. & Gowers S.G. (2000) Parental high concern and adolescent-onset anorexia nervosa: A case-control study to investigate direction of causality. Br J Psychiatry 176, pp. 132-137.
Striegel-Moore, R.H. & Bulik, C.M. (2007) Risk factors for eating disorders. Am Psychol 62, pp. 181-198.