By Chris Noorduin, MA, and Walter Vandereycken, MD, PhD
Reprinted from Eating Disorders Review
November/December 2003 Volume 14, Number 6
©2003 Gürze Books
Eating Disorders Unit, Alexian Brothers Psychiatric Hospital, Tienen, BelgiumThose who live with an individual with an eating disorder know that mealtimes can become battlefields. In fact, we find that many parents feel helpless and repeatedly ask for practical and educational ways to cope with these situations. We have organized special family treatment groups to deal with this problem, and this article will outline these sessions in detail.
A Revival of Family Meals as Therapy
The idea of using meals as therapeutic and learning opportunities is not new. At one time, family therapists even used lunch sessions as a setting to induce a family crisis. This approach has been largely abandoned.1
Recently the family meal has had a “therapeutic revival.” In one German multifamily therapy program, for example, a lunch session is a central part of the treatment. Over lunch, families comment upon the interactions they have observed in each other’s family.2 In another program, British clinicians describe a family meal program as a core treatment in their inpatient management of eating disorders.3 Coincidentally, without having heard of these German and British experiments, we developed a similar psycho- educational approach to stressful meals.
An Overview of Our Program
Most patients in our inpatient eating disorders treatment unit are between 16 and 23 years of age, and the average length of stay at our 25-bed unit varies from 2 to 4 months. During treatment we try to involve parents in various ways. They can participate in thematic parent counseling groups twice a month, and/or can have separate family sessions (with varying frequency according to needs and motivation). In both group discussions and family sessions a great deal of time is consumed by “eating-related themes.” The purpose of the meetings is to create a constructive dialogue among parents, daughters, and treatment staff. Eating together is an important part of the sessions.
The Meal Program
Each group consists of four or five families (parents with their daughter, who is an inpatient, and no siblings). We meet three times, with an interval of two weeks between sessions. Since patients stay at home during weekends, we schedule these groups on Monday evenings from 6 pm until 9 pm, so that any weekend difficulties are still fresh in mind. Scheduling a meeting every two weeks also gives the families enough time to practice new skills and agreements between sessions.
A clinical psychologist trained in family therapy, who has met with all parents individually before the group sessions, conducts the group. By the time the sessions begin, he has also met the parents on the ward during the first weeks of their daughter’s admission; however, he is not directly involved in their inpatient treatment.
All family members and the psychologist gather in a dining room, which is also used for the conjoint family meals in the second and third sessions. The psychologist explains the purpose and the practical organization of the meetings. Then he asks each family member to introduce himself or herself without dwelling on the eating disorder. Hence, each member of the group is expected to mention his or her name and age and to briefly tell about their work or school, hobbies, siblings, and so forth. Finally, they are asked to state “what characterizes them as a family.”
Talking about themes not related to the eating disorder is an important part of this session. First, family members feel more comfortable talking with one another when they see the “family behind the eating disorder.” Next, it offers possibilities for recognizing similarities and for making connections between families, which enhances a “group feeling,” and, finally, it shows that very different families can have very similar difficulties.
Around 6:45 pm, we take a short break, while the psychologist writes the following questions on a blackboard in the adjacent “meeting room”:
- For what kind of eating disorder is this treatment intended?
- What difficulties have you experienced as a family before admission?
- What has improved since admission, and how did you achieve this?
- Which difficulties do you still experience as a family over the weekends?
- How can you solve these difficulties?
Each family (seated as separate groups in different corners of the meeting room) is asked to find answers to the questions on the blackboard. To gain more personal contact with family members, the psychologist visits with each family for a while.
Around 7:45 pm, there is another break with tea and coffee. The patients eat, as would be usual on the ward, their “evening snack” (for instance, a piece of cake or a dish of pudding). During this break the psychologist explains that for the second and third meetings it will be the parents’ responsibility to bring along some food that will be substituted for the patients’ usual “evening snack.” In fact, this idea was first suggested by some parents at the beginning of the experiment, and now is a nearly ritualized part of the sessions. Parents cooperate with other parents about the practical arrangements (for instance: who will shop for the food or prepare it?). Neither the daughters nor the psychologist is involved in these arrangements. This stimulates contacts between families outside the therapeutic context, and underscores the social aspect of eating.
After the break, each family’s answers are discussed in the group and the overall group is invited to suggest possible solutions to each major problem. At the end of the session each family should at least have one concrete suggestion or “task” they will try out during the next two weeks.
At 8:50 pm, the session ends with a tour around the kitchen and dining room of our ward. Examples of “normal” meals are displayed, and the daughters explain the normal weekly menu of the ward. This helps parents get a better idea of what their daughters are expected to eat at home during the weekend. The psychologist hands out a brochure with practical advice about shopping for food, cooking, and eating at home. The parents also know that each Friday morning they can reach the psychologist by phone if they have urgent questions about the coming weekend.
Two weeks later, the second session starts with a conjoint family meal with the table set by the daughters. During this meal we follow the common rules of our ward: No talking about food, no remarks about each other’s eating behavior, etc. As a group we try to create a relaxed atmosphere (for example, a radio plays softly in the background). Around 6:45 pm we finish our meal. Some family members clear the table and do the dishes; others can have a break.
At 7:00 we begin by evaluating the past two weekends. Each family tells about their meals at home, the moments they enjoyed as a family, and any difficulties they experienced. They also report on the “task” they had agreed upon in the previous session. During this conversation the psychologist makes a link between the meal they have just had and the family meals at home and asks them to think of similarities and differences. This is a safe and effective way for family members to talk about what they find difficult at home.
Next, each family focuses on what they consider to be the most difficult problem over the weekend. Parents and daughters are separated and discuss this issue in separate groups (the daughters go to another room). The psychologist listens to both groups and tries to understand both the parental point of view and the daughters’ perspective.
At 8:00, we take a 15-minute break, during which everybody eats the “evening snack” prepared by the parents (as agreed to in the previous session). After the break the group meets once more to discuss the major difficulties and disagreements between parents and daughters). Once again everyone is invited to propose solutions and suggest new “tasks” they should try out in the following weeks.
The final session starts again with a joint meal, after which all families gather in the meeting room. As in the first session, each family is seated apart and asked to answer the following questions:
- Which difficulties did you experience as a family before the first meeting?
- What has improved and how did you achieve this?
- Which difficulties do you still experience as a family?
- Which task could help in coping with these difficulties?
After a short break, the answers of each family are discussed in the group till 9 pm. Families are also asked to give suggestions and comments about the three sessions. At the end, the psychologist underscores that each family can contact him for further individual appointments.
There is no fee to participate in these group sessions and every month we have enough candidates to start a new series. Parents are mostly grateful for being more involved in the treatment of their daughter. The sessions also give them the opportunity of “tasting” the way of life on our ward.
Most families tell us the meetings have helped them find a constructive way of talking about the eating disorder and its impact on their family life. Before the group sessions were started, some families had endless discussions about the eating disorder, while others avoided talking about it altogether. The family group sessions enabled them to find another way of communicating without getting stuck in conflict.
Working with four or five families together serves more than just economic needs. It offers great support, recognition, and encouragement for families. Some parents and family groups even get together (often for meals together!) after finishing the three sessions. We’ve also noticed that families can learn a lot from each other without the active intervention of a therapist.
These sessions also provide the staff with lots of information about the strengths and weaknesses of individual families. Additionally, it offers us the chance to provide psycho-education and to help correct unrealistic expectations about treatment. Finally, after these group meetings, parents seem more willing to engage in separate family therapy sessions. It seems that we have stimulated their “psychological appetite” to get a better understanding of the eating disorder and its meaning for the whole family.
- Vandereycken W, Kog E, Vanderlinden J. The Family Approach to Eating Disorders: Assessment and Treatment of Anorexia Nervosa and Bulimia. New York: PMA Publishing, 1989.
- Scholz M, Asen E. Multiple family therapy with eating disordered adolescents: concepts and preliminary results. European Eating Disorders Review 2001; 9:33.
- Jaffa T, Honig P, Farmer, S, et al Family meals in the treatment of adolescent anorexia nervosa. European Eating Disorders Review 2002; 10:199.