Family Dynamics in the
Treatment of Eating Disorders
James Gerber Ph.D.
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.
• Structure refers to the set
of rules (overt or covert,
idiosyncratic or universal)
that guides the family’s
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.
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.
Attachment Theory: (Bowlby, J. Ainsworth M.)
Refers to those parent-infant interactions that effect
the child’s sense of security.
• 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.
• 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 child’s
development (executive
functions, self worth),
exploration and
mastery are restricted.
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.
• 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.
• 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 one’s
internal family (parts)
onto one’s external
family, especially
children who then are
disposed to pass this to
the next generation.
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.
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 fatherdaughter 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.
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)
“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
daughter’s ineluctable urge to separate from
the mother. When a father is unable to help
his daughter move out of the maternal
orbit…the daughter may turn to food as a
substitute” (Zerbe, K. 1993)
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.
• 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 father’s
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.
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.
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.
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.
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.
• 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 father’s emotional volatility was seen as
not safe and her contempt for him led her to
disown her own emotions especially anger.
•
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 mother’s relationship with her own mother,
and described being aware of the emotional gulf
between them i.e. the legacy burden.
• 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, “it’s 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.
• 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.
• 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 patient’s sense
of self pity and described a similar experience.
The “pretty sister” was an avenue for her to
escape her own self contempt.