A Multi-Family Approach to Eating Disorders

The “Maudsley model” of family-based treatment has shown that actively involving parents in their child’s eating disorder treatment improves the chances that treatment will be successful. A specialized inpatient unit for treating eating disorders at the Alexian Brothers Psychiatric Hospital, Tienen, Belgium, has included parents in treatment for several decades. Dr. Walter Vandereycken and Lies Depestele recently described their multi-family approach to treatment of teens with eating disorders (Int J Child Adolesc Health 2008; in press).

Benefits of a multifamily group

According to the authors, disruptions from an eating disorder often lead a family to feel powerless, reinforces dysfunction, and restricts interplay among family members, resulting in a “frozen” family. The eating disorder becomes overpowering to the family. At the Alexian Hospital, families are encouraged to reflect on their ways of interacting with each other and with the eating disorder (see box, right).

Design of the sessions

The first session is designed to help families become acquainted and to encourage them to work together in a group context. Family members are invited to introduce themselves, and the therapist creates a positive atmosphere by asking questions such as “What is typical for your family?” and “What do you appreciate your daughter/mom/dad for?” Other questions challenge participants to ponder what they can and should not reveal about their relationships.

Symptoms and weekends. Sessions 2 and 3 focus on symptoms and weekends. At the next two sessions, the meetings begin with a joint meal. Some patients bring their prepared meal from the ward, while others, when far enough along in their own treatment, can share the meal served in the evenings for families. Some sessions feature role-playing; for example, mother plays father, father plays daughter, and daughter plays mother. Using this approach, a family can have a conversation about how everyone experienced the last weekend together. Some family members are surprised at how well the other family members seem to know what they are thinking or feeling, while others are shocked because the role-playing reveals that the family members seem like strangers. The authors report that the families often regard these joint meals as very important and some groups spontaneously organize their own joint meals outside the hospital.

Family structure and teen development. The fourth and fifth sessions focus on family structure and adolescent development. Participants are encouraged to reflect on their own family function and how they view the functioning of the other families. One exercise uses the “goldfish-bowl” conversation method. The daughters all are seated in the middle of the room and encouraged to discuss a certain issue. The parents are seated in a circle around them but are not allowed to interrupt the discussion. Then parents and daughters change places, and the parents can now comment on the previous discussion among their daughters. A similar discussion takes place with the mothers only in the center, then the fathers only in the center of the room. After each discussion, the individual families have the chance to reflect among themselves, and finally they are invited to tell, in the group setting, what they have learned about their family’s characteristics.

In another exercise, families must make a portrait of another family in a nonverbal way. For example, Family A must portray Family B by using family C as a statue. Family B has to observe the statue and express how they experienced this portrait and what they want to change in the future.

Life after discharge from the hospital. The sixth and final session focuses on what family life may be like after the patient is discharged. Possible pitfalls and emergency scenarios are discussed in group, and relapse is explained as a normal part of the recovery process. Emphasis is placed upon what can be done when relapse occurs. Finally, all family members are encouraged to express how they have experienced the multi-group family sessions.

A sense of relief and solidarity

Dr. Vandereycken reports that thus far participating parents have been very enthusiastic about the family sessions, and most mention a growing feeling of solidarity among their families and other families. Most families are also relieved when they recognize their own situation while learning about the other families. The daughters already know this from their own inpatient treatment program, but for many families it is the first time they feel understood. Families can also “mirror” others, and the chance to model behaviors in familiar situations encourages participants to experiment with new interactions. It also allows the therapist to feel more at ease and less at risk of becoming absorbed in certain family conflicts or coalitions.

And a few drawbacks for some families

There are some pitfalls to the multifamily group setting, according to the authors. Some families stay behind the “barrier of safety” that is so well known in group therapy. Some family members, particularly the parents, may fear the confrontations that can occur in a group. There is also a desire to be accepted as normal and without problems—a trait particularly common among families of anorexia nervosa patients. Overall, the authors have found that only a few family members will not participate. The barriers may also be lowered because most families have regular psycho-educational group meetings, which are organized for all parents of girls admitted to the 35-bed eating disorders unit.

Divorced or renewed families may also have problems working within the group setting. For example, some divorced parents do not want to meet with each other in a group setting. In such cases, the authors try to arrange meetings so that either the mother or the father joins the group; parallel individual sessions are then held with the other parent and the hospitalized daughter. And, finally, some parents, such as those who are very critical of their child, will do much better in separate counseling sessions. Later, if the intrafamilial atmosphere is improved, such families may be able to join a multi-family group.