I received the following comment to my post entitled "Whatever Happened to Family Therapy" from Laura Collins, parent and author of Eating With Your Anorexic
. Laura has pointed out that my biases (and perhaps those of other therapists as well) may become a barrier to families seeking treatment:
As the parent of a child with an eating disorder, I can tell you that "family therapy" is often presented to the family in the traditional model you allude to: "I remain keenly aware of family dynamics and their contribution to the eating disorder."
The newer (and evidence-based) models of family therapy in EDs, like the Maudsley approach, don't just include parents - they regard family as the greatest resource and authority.
I've made countless calls to clinicians over the years and it is pretty clear early on whether the clinician sees parents as a help or a hindrance. Most lean toward the latter.
That may explain the attitude reflected by parents. We feel blamed, marginalized, and hopeless.
The following day I wrote to Laura, asking if we could engage in further dialogue on the topic of families and treatment. My response to Laura follows:
First, I want to apologize for sounding blaming toward families; that was not my intention. I have certainly worked with dozens of families that are intact and healthy with an anorexic child. I'm well aware of the Maudsley approach and have been supportive of its use with many families. These families are generally willing to do whatever it takes to help their child, and have often taught me about perseverance and patience. I see in hindsight that I should have been more careful with my writing - by not making this clear my posting sounds as if I think all families are homogeneous.
Having said that, I have also worked with families where past and current interactions seem to have direct bearing on their child's eating disorder. I haven't found the Maudsley approach to be adequate in families where, for example, dad is a practicing alcoholic; where mom is a chronic dieter or has an eating disorder herself; where parental conflict is intense, chronic, and parents are openly threatening divorce, etc. It seems to me that in order for Maudsley to be effective parents have to be reasonably problem free and able to work together effectively. Am I wrong?
Laura's answer to me:
First, I need to say that I operate from the assumption that EDs are biologically driven illnesses, triggered by malnutrition, which require complete nutrition and intensive psychological intervention and support and skills training to overcome. That is what the medical and psychological literature have established, and it bears out in our family's experience.
That said, not everyone is born into a family that is well-equipped to offer the kind of support the sufferer needs to get healthy and stay healthy. The population at large has a lot of mental illness, addiction, over-stressed people, and histories of abuse. In the case of EDs, it is likely that other members of the family suffer from mental illness by definition: these are genetic illnesses with familial groupings.
Yet the same thing is pretty much true of families with a child who presents with cancer. The more cohesive and healthy the family unit, the better able the family will be to learn what needs to be done, and to follow through on the complex needs of recovery. But I doubt a doctor or therapist would turn away, or dismiss the chances, of a family whose child had cancer because of a poor support system. We'd still try, perhaps harder. We'd take the family where they are, strengthen it, support it.
Our family, by the time we reached a therapist's office with our ill daughter, looked pretty pathological. We were very stressed, frightened, argumentative, unhinged really. Looking back, I know this is completely normal - if we hadn't been unglued by our daughter's erratic and scary behaviors we would have been strangely detached. We had already read and heard enough about EDs to feel accused, pathologized, guilty, and angry.
But here's something interesting: almost all of the eventually successful Maudsley families I've met (and I've met too many to count now) were earlier told by a clinician that we were not candidates, or we were not told about the idea at all. I don't think this is because we were not good candidates, I think this was the bias or lack of experience of the clinicians. Pre-morbid pathology was assumed.
I think most clinicians are still very uncomfortable with genuine collaboration with parents. Minuchin and Bruch wouldn't approve!
When families like ours are given support, encouragement, and practical information - and the benefit of the doubt - we are able to move mountains. When empowered to take back authority from the illness ravaging our child, we are able to overcome other challenges. Maudsley therapy asks that of us.
Not all families are good candidates for Maudsley support at home, but I dare say most are. And those that are not will still be the ones the child comes home to - and therefore need a good understanding of the psycho- and bio-dynamics of the illness. They deserve to be told they did not cause their child's illness - affirmatively and repeatedly. They need to hear what they CAN do to help, what boundaries they CAN establish.
I don't describe this anywhere as well as Lock and le Grange, of course. But perhaps the testimony of other parents will help: www.maudsleyparents.org .
I welcome further dialogue on this. I think we are at a time of change and growth in the treatment of EDs. I am optimistic for the future!
So, readers (and I assume there are both professionals an families out there who are reading this!) Laura and I have agreed to continue to dialogue on this topic. Please join us! This promises to be a lively and rewarding discussion! Until next time, Gail firstname.lastname@example.org