Why Family Therapy Truly Matters in the Treatment of Eating Disorders

By the Klarman Center at McLean Hospital

Eating disorders are time-consuming, soul-crushing, and insidious to your suffering loved one…and to you! Watching helplessly as your child/partner/sibling puts themselves at life-threatening risk can result in the ping-ponging between terror, frustration, and fury. By the time someone has gotten into residential care, everyone is worn out. The secrecy and what can feel like a cat and mouse game around eating, food, and other problematic behaviors may have eroded trust. Your loved one may feel taken over by their eating disorder and you may feel like they are lost to you. While the eating part is central to treatment, there is so much more psychological work that is involved in recovery. In addition to individual therapy, family therapy is also crucial.

A dedicated family therapist for weekly meetings who is separate from the individual therapist, or a case manager is critical. The therapy aims at creating a safe space for the discussion of difficult feelings to help the patient and family move towards more open communication and shifting the patterns that have gotten in the way of connections. The family therapist is part of your loved one’s team which includes an individual therapist, psychiatrist, dietician, and other specialized clinicians.

Whether therapy is addressing what has been difficult in the past, the feelings around the eating disorder, or what kind of support would be helpful now, the goal is to ultimately increase openness, foster connection, and help people to move forward together. A hand-out, a set of instructions, and even a family meeting that is focused only on the patient’s needs, will not do this. The family therapy must support a deeper kind of change, healing and finding one another.

In the wonderful words of Maya Angelou:

“We do the best we can with what we know.”

Work that is geared towards growing that knowledge through intensive therapies and having supported behavioral experiences reaps the best outcomes. Patients tend to thrive when they have increased choice in not only feeding themselves, but in moving forward with better self-esteem and towards a life that holds meaning for them.

The involvement of families in this process may differ from family to family. There are, however, certain themes that come up frequently. One of the most common dynamics has to do with the amount of understandable anxiety family members may have been experiencing over time regarding the child’s/friend’s/partner’s bodies. Often there have been years of trying to make sure that your loved one is eating. Sometimes, there are suspicions that something isn’t right- food wrappers that are hidden, long bathroom sessions after meals, weight swings, etc. And, for some families there is a confession, or a trip to the ER, or a concerned call from a friend or provider- and suddenly there are confusing decisions that need to be made about treatment while trying to integrate this new information. There are also those families who have been coached in Family Based Treatment when their kids were younger, and they are less certain of their roles with their young adult children. There may have been tension at the dinner table and difficulty having meals with family friends or extended family; it may have gotten to the point where the family has stopped eating all together or stopped eating the same food at mealtime. Sometimes children who have gone away to college get too sick to finish a semester. Or their struggles became more obvious during the lock-down phase of the pandemic when people were home with each other all the time. For those who have been in and out of treatment, not only may they be experiencing increased hopelessness, but their families may also be profoundly discouraged. One of the fallouts is that families may reach for more and more desperate measures to try to fix things. They may have become the “food police,” monitoring intake, threatening consequences if behaviors are used, locking cabinets, taking doors off of their hinges. Life may have devolved into a “them” vs. “us” battleground. The eating disorder may have become personified and there may be arguments about “who is speaking; the ED or the loved one.”

Residential treatment provides an opportunity to shift these unhappy and often unhelpful patterns. The treatment team takes on the role of monitoring meals, holding the line, making meal plan increases, and watching over medical concerns. The treatment designed so that parents and/or significant others may take a step back from these struggles offers a welcome reprieve and reset. It is crucial that the family/loved ones are supported in “dropping the rope” so that you can support your loved one in the truly difficult undertaking of residential care. Equally crucial is the work with your child/spouse/sibling/friend to help them to experience their ambivalence internally rather than it getting played out with others in what can feel like a battle for control. If the established dynamic had become the anxiety of the family member vs. the eating disorder, there may not be enough space for the person with the eating disorder to understand why they may be holding onto the eating disorder and to understand what internal battles are at play. So, for instance, the child with social anxiety may have come to deal with their loneliness by numbing themselves through weight loss, purging, starvation, or obsessive preoccupation with food/eating/body. It is never as simple or straightforward as recognizing that the eating disorder has the immediate function to mute the painful feelings of self-doubt and social isolation, yet it has really exacerbated poor self-esteem and avoidance. But, in this example, there may be exploration of what may be motoring the eating disorder, what may be alternative ways to respond to painful feelings, and how one might address what leads to those painful feelings that may make a difference. These are the kinds of discussions that may expand understanding and to help people to talk about how they might best be there for each other. There may be feelings about misunderstandings or different parties feeling unseen or unheard. Family therapy provides a space to be curious, to put into words what may be new or difficult, and to repair or deepen fragile connections…and all of this helps drive healing and recovery forward.

The Klarman Center at McLean Hospital expertly offers the approach described above. Our staff is experienced and devoted. We appreciate the complexity of each person engaging in treatment and do not view anyone as “an eating disorder.” Comprehensive psychiatric evaluations are a standard part of our care. Because the Klarman Center is part of a larger, renowned psychiatric hospital, there are resources available that extend far beyond regulating eating.  For example, if indicated, we can order consultations with experts in specialized areas such as substance abuse or OCD, investigate the differential diagnosis and treatment of different depressive disorders, encourage expression through art, explore the role of spirituality in one’s recovery, and have individual sessions aimed at approving body image.  Without minimizing how hard this treatment may be, we believe in recovery, and we will work with you or your loved ones towards a more flexible and more fulfilling life. If you have questions about you or your loved one, please contact us at 617-855-3408 or CRADULKSKI@MGB.ORG