Family: The Vehicle of Nurturing

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What do I think causes eating disorders? In a word, unmet needs (Ok two words). Humans meet psychological needs through social exchanges, as we are first and foremost social creatures. Our minds become unwell when we are socially isolated because this isolation stops the flow of understanding and nurturing that feeds the mind. However, this flow can be blocked by a number of variables even when we are not isolated. For instance, certain biological predispositions can create affective and cognitive patterns that interrupt the smooth flowing of nurturing in a social system. In order to restore one’s psychological needs, we must a priori understand these potential blockages, imbalances and entropic dynamics that stop an individual from receiving what sustains healthy feelings and behaviors. When treating eating disorders, it is imperative that we help clients recognize variables that interrupt self-sustenance and self-understanding. In other words, what is getting in the way of their ability to be understood and taken care of by those they love?

Case Example: Stephanie

Stephanie was suffering from a longstanding and protracted Anorexia, that started in her early teen years. She had been through several stints of treatment but was unable to achieve a lasting recovery. At our retreat, we do an alignment exercise (involving lop sau #1 from Wing Chung). This shows ways that two individuals share space and make mutual adjustments in order to find balance between self and other. Stephanie was consistently dominant over her father, which indicates that she tends to approach this relationship from a rather inflexible and closed-minded perspective. Dad made adjustments as we instructed, which showed that he is probably willing to do in his relationship with Stephanie as well. This exercise helped Stephanie to see how she was shutting out a major source of nurturing in her life–that of her father. She had not been open enough to rely upon him for the care and help that she desperately needed. After this, Stephanie really challenged her view of her dad and was able to commit to letting him back in to her life, opening up the pathway for him to meet her needs. We also did the alignment exercise with her and her husband, and discovered that the couple tend to lock into a proverbial arm wrestling match, both wanting to dominate the other. We encouraged them to adopt a stance of mutual flexibility, mutual vulnerability, in order to open up the pathway of love and care. We helped Stephanie to move more of her focus and energy onto her marriage and off of other derailments. These adjustments allowed Stephanie to regain a healthy weight and her recovery is sustained.

Case Example: Alex

Alex was a boy of 13 who came to counseling at a very low weight. He was started on an outpatient protocol of nasogastric feeding by his PCP.  During our early sessions, I talked to him about his family, which he described as very healthy and overall really great. However, Alex was be very worried about mom, as mom has health concerns that caused her to be ill and in pain much of the time. Alex reacted to this condition by constricting his own needs, as he didn’t want to add to mom’s stress or contribute to draining her. I encouraged Alex to give more of a voice to his own feelings and reduce the tendency to withdraw from mom because he was preoccupied with adding to her stress. Alex’s dad struggles with untreated anxiety, and Alex responded to dad’ anxiety in a similar fashion–by withholding what he feels and what he needs because he was too preoccupied with dad’s anxiousness. Overall, Alex perceived his family as not really expressive of emotions, so because he didn’t want to be different or make them uncomfortable, he would suppress his own emotional expressions. I encouraged Alex to embrace the ways that he is different from his family and look at his emotionality as something that might inspire others to also share their own feelings. Additionally, I emphasized to him that what he feels is who he is, so to not share his feelings is to effectively disappear. Alex stopped disppearing, he started expressing himself, he gave himself permission to accept emotional and psychological care from those who loved him. He reports that his relationship with his dad and mom are closer than ever. He recovered a healthy weight within 4 months, he embraces wanting to be healthy and is now trying out for soccer and football.

Let me be very clear. Families are NOT to blame for eating disorders. Families ARE the most significant source of emotional and psychological nurturing in all of our lives. When families are blocked from giving the nurturing that sustains us, we become ill. These blocks can be caused by neurological predispositions in the individual with ED, they can be caused by situational stressors and changes in the lives of an already vulnerable individual, they can be caused by a variety of misalignments in relationships. My concern is that, in our drive to remove the blame from families (a very necessary thing), we may be running the risk of not considering enough how family dynamics impact everything the client experiences. It is well accepted that families are a huge strength in recovery, but as a change agent, the help that families can give extends so far beyond weight restoration. In order for weight restoration to be sustained, we must sustain the mind that ultimately helps the individual give “permission” to take care of himself physically, which requires a thorough understanding of all the dynamics of nurturing in a person’s life. Family is the primary vehicle of that nurturing.

10 thoughts on “Family: The Vehicle of Nurturing”

  1. I admire your passion, drive, and desire to connect with individuals who are suffering from EDs. In addition, I applaud your courage and transparency in publishing your theories and sharing your thoughts with colleagues.

    I agree with you that we must challenge existing paradigms and constantly question our assumptions in order to advance collectively as a field and provide more effective, compassionate care to those who seek our services.

    That being said, it seems to me that what you present as your new theories on the etiology and treatment of EDs are simply recycled versions of antiquated psychodynamic theories and interventions which have been debunked by modern science.

    Decades and decades of research attempting to elucidate family factors which contribute to the development of EDs have basically come up with nothing. Decades of treatment approaches predicated on deep-seated psychological needs or personal pathology or family interaction styles have led to very poor outcomes and have done significant harm to patients and their families.

    Your concern that “in our drive to remove blame from families, we may not be considering enough how much family dynamics impact everything the client experiences,” is illogical and misguided, in part for the reasons I mentioned above.

    Releasing families from the blame of causing an illness is by no means the same as releasing them from the responsibility of helping their child recover and thrive.

    Think about it: the best available scientific evidence suggests that families do not cause autism or Type I diabetes, and the medical community as well as the general public accept this. However, there is very good scientific evidence showing that family-centered interventions can be extremely effective for managing the challenging behaviors of autism, and for helping to keep diabetes well-controlled during the vulnerable adolescent years. We do not know what causes either of these illnesses, but we do know that well-orchestrated family treatments can help kids with these conditions thrive.

    If someone were to come along and claim that family dynamics or imbalances in relational exchange enery caused or contributed to diabetes or autism, these claims would be dismissed as psychobabble.

    We absolutely need to question and challenge existing paradigms and create innovative treatments, but we don’t need to reinvent the wheel. Especially the square wheel that never really worked in the first place.

    1. Hi Dr. Ravin, thank you for reading the blog and commenting, and for seeing the purpose of challenging extant paradigms. I think the psychodynamic theories need to be generally revised and we need a new way of understanding how people affect one another in all social systems, not limited to family. In my perspective, there is a fulcrum of relational energy between self and others, and in people with certain neurologically-based predispositions, this fulcrum is easily imbalanced, which can lead to unmet psychological needs which leads to pathology. I don’t believe my perspectives are actually a recycling at all because they differ substantially in many ways that are too extensive to describe here. I wrote this blog to reinforce the help that families can provide to someone who is ill from ED. I had heard from some parent groups that me implying that family plays a role at all in ED is absolutely wrong and I wanted to emphasize the positive role that family can play in recovery. Thank you for emphasizing that message. I don’t believe my perspectives are a square wheel at all but I have not yet “proven” that so I suppose it’s fair to say that for now. It’s interesting though how quick people are to discount my theories when I haven’t actually even begun to explain them thoroughly…Please rest assured I do intend to write several books on this methodology, and I will integrate the existing research findings into what I believe is a more cogent picture. I hope at that time to again solicit your feedback. Thanks~

  2. Most parents already know how to bring about recovery in their child or teenager who suffers from anorexia nervosa. More books and more theories from psychotherapists are, frankly, neither needed nor appreciated.

    1. Well, that is an interesting perspective, but it makes me scratch my head because if parents already know how to bring about recovery in their child, then why was the child sick in the first place? I do agree though, what we don’t need is more theories, we need better ones.

      1. Nobody knows what causes a child or teenager to become anorexic, but there is no evidence it is the parents. Furthermore, it is parents who are typically the first to recognize the early signs of anorexia and take positive action. In addition, it is widely recognized that parents are generally more effective than professional psychotherapists in bringing about the kid’s recovery. When professional psychotherapists are in charge of treatment, only about 1/6 — 1/3 of sufferers will recover, according to the best-available research data. On the other hand, when the parents are in charge, the rate of recovery is about double that rate. These figures are freely available for anyone to read. They are published in the scientific literature.
        One reason professional psychotherapists do such a poor job is that a majority suffer from psychiatric illness themselves. In a survey of 298 psychotherapists who treat eating disorders, 70% acknowledged a personal diagnosis of psychiatric illness, including clinical depression, a variety of anxiety disorders, personality disorders, binge eating disorder, and bulimia. Warren, A qualitative analysis of job burnout in eating disorder treatment providers, Eat Disord 2012; 20(3): 175-95 http://www.ncbi.nlm.nih.gov/pubmed/22519896 Most parents, therefore, have learned from experience not to trust the profession of clinical psychotherapy to help their kid recover from anorexia nervosa.

        1. It sounds like you are certainly well read and well informed. I found your perspective on psychiatrists and mental illness interesting, although I have also read that approximately 50% of the general population suffer from a mental illness at one point or another in their lives, and I am sure psychiatrists are no exception. There is no hard evidence that parents cause eating disorders–I certainly don’t believe parents cause eating disorders. The relationship between social dynamics and eating pathology is a complex and deeply rooted one that cannot be so narrowly understood as to assign any kind of “blame”. I also can see that parents could be more effective than psychotherapy in treating an ED, because I think ultimately the cure for an ED is restoring nurturing to the self. There are few people better poised to provide this nurturing to a child than her or his parents. I think traditional psychotherapies are not hitting the target with ED sufferers, and this is why we see that psychotherapy is ineffective. My hope is to put forth a method of psychotherapy that will be more effective for helping clients achieve meaningful recovery. Thanks for reading and responding!

          1. In the survey I cited, 50% of the psychotherapists reported that they had personally received a diagnosis of clinical depression and/or anxiety disorder at some point in their lives. It is not true, however, that half the population has suffered from these conditions.

            In the study I cited, 50% of the professional psychotherapists reported that they had personally suffered from clinical depression and/or anxiety disorder at some time in their lives. This is much higher than in the general population. This is why most parents will want to evaluate the mental health of any treatment provider before placing their child or teenager in their care. The provider’s mental health affects competency.

          2. Thanks Chris, I have read similar findings that people who are mental health counselors have themselves suffered from psychological illnesses more often than in the general population. I think this is because our empathy towards others goes up when we have walked in their shoes. Further, I believe that psychotherapists are more likely to be aware of the signs of depression and anxiety in themselves because this is a salient point through our daily lives and our education lays the foundation for seeking help perhaps more often than in the general population. The increase in diagnosis could be due to better recognition and more willingness to seek help among counselors. I see two perspectives with regard to mental illness in psychotherapists–in some cases these diagnoses could be a liability, but in some cases they may lead to better understanding and more care toward clients. It all depends on the individual therapist. There are always bad apples out there and it is important to be careful in choosing a care provider. I also see that the ethical oversight can be lacking. We do have state ethics boards that monitor our CE and licensure. If a client makes a complaint, that ethics board will swing into action, but only IF the client makes the complaint and a lot don’t. However, overall I think psychotherapy is important for recovery for many reasons, and a good therapist can really make a difference in someone’s life. The operant word being GOOD!!! thanks for the talk!

  3. Sorry that my comment was repetitive. I had a technical problem with your comment window. The point stands,however: parents better be really careful about turning over their kids to eating disorder psychotherapists. There is a lot of quackery out there, along with very little oversight and accountability.

    1. Brett,
      Since, as you agree, each sufferer is unique, there is no reason to believe that the therapists’ personal experience of having suffered from a psychiatric disorder necessarily gives them any special or unique insight with respect to other people. In fact, the therapists’ personal experience is more likely to cause them to make inaccurate assumptions about others, and develop a narrow perspective.
      Also, I do not agree that psychotherapy is important for recovery from anorexia nervosa. What is important is restoration of weight and reestablishment of normalized patterns of eating behavior. This is typically best accomplished by parents in the case of children and teenagers. For adults, the treatment known as Mandometer has been used with a large number of sufferers, successfully in about 3/4 of cases. (Published results are available in peer reviewed journals.) Mandometer does not involve psychotherapy. It posits that eating disorders are biologically-based conditions, not psychological, and that in the case of anorexia nervosa the distressing psychological symptoms are a direct consequences of a starved brain, best treated with food, not psychotherapy.

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