The theory and practice of MFT for eating disorders Ivan Eisler Kings College, Institute of Psychiatry, London, UK Rotterdam June 2010

Sir William Gull (1873) “The treatment required is obviously that which is fitted for persons of unsound mind. The patients should be fed at regular intervals, and surrounded by persons who would have moral control over them; relations and friends generally being the worst attendants” Charles Lasegue (1873) Described anorexia hysterique as intimately connected to the dynamics and conflicts in the patient’s family and recommended separating her from the family.

Thought that a central causal mechanism of anorexia nervosa was a mother infant relationships in which the mother’s strong need to look after the child leads her to anticipate the child’s needs (e.g. hunger) and to attempt to meet these needs before the infant can experience them herself. Because of this the child never fully develops an interoceptive awareness of her needs, giving her a sense of over-dependence and of pervasive ineffectiveness With the onset of adolescence this leads to a lack of sense of identity and a need for control for which anorexia become the “solution” Hilde Bruch

Mara Selvini Palazzoli An early proponent of the importance of understanding the interplay between the individual and the family system. Was “convinced that mental ‘symptoms’ arise in rigid homeostatic systems and that they are the more intense the more secret is the cold war waged by the subsystem (parent-child coalitions).” Described families as engaging in “psychotic games” and symptoms such as self starvation arising out of such games. Mara Selvini Palazzoli

THE PSYCHOSOMATIC FAMILY First, the child is physiologically vulnerable, …. Second, the child’s family has four transactional characteristics: enmeshment, overprotectiveness, rigidity lack of conflict resolution. Third, the sick child plays an important role in the family’s pattern of conflict avoidance; and this role is an important source of reinforcement for his symptoms. Salvador Minuchin 1975

relations and friends generally the worst attendants separating the patient from the family over-anticipation of infant’s needs by mother enmeshment over-protectiveness rigidity, lack of conflict resolution. “psychotic” family games

Why families?

Why families The myth of the “psychosomatic family” The family as a resource Family reorganisation around illness

Stages leading to family reorganization around illness Accommodation to illness needs Restructuring the family routines Delayed decision-making Imbalance in resource distribution Invasion/disruption of family rituals Distortion of family identity Illness as a central organizing principal Steinglass, P et al (1987) The Alcoholic Family. New York: Basic Books. Steinglass, P (1998) Multiple family discussion groups for patients with chronic medical illness. Families, Systems and Health 16, 55–70

Family life and eating disorder The central role of the symptom in family life Narrowing of time focus on the here-and-now. Restriction of the available patterns of family interaction processes. The amplification of aspects of family function Diminishing ability to meet family life-cycle needs The loss of a sense of agency (helplessness) 1. The high levels of preoccupation with thoughts of food and weight that someone with anorexia manifests is paralleled by the way that issues around food and eating take central stage in the family. As time goes on all relationships in the family seem to become defined by it. It becomes the “currency” of relationship exchanges, the way in which the qualities of relationships are gauged. 2. The anxiety engendered by the life-threatening nature of the problem and the intensity of interactions around meals which often take up the major part of the day result in the family gradually being unable to focus on anything other then the present. What happens at the next meal, indeed the next mouthful takes on immense importance. The intense preoccupation with the present makes every failure at a mealtime overwhelming. The way this gets played out will vary from family top family depending on their usual style of interaction. Families that tend to avoid conflicts will see any argument as potentially disastrous and to be avoided at all costs. In other families conflicts may become more common but are likely to be accompanied by intense feelings of guilt and blame (there is some evidence that this pattern may be more common in families having to contend with bulimic behaviours – ref – but is certainly also found in some families that are dealing with anorexia). 3. Lack of flexibility in the way that families function is highlighted in many theoretical accounts of family functioning (Olson, Beavers, Minuchin, McMasters etc). What is usually emphasized is the importance of flexibility in enabling the family to deal with family life-cycle changes. For the clinician (or indeed the observational researcher) flexibility or rigidity is manifested in the moment-to-moment interaction. While the two kinds of flexibility are connected they are not one and the same. One should not automatically assume that an observation of a rigidity in interaction signifies a family that finds negotiating life-cycle changes difficult. Whether a lack of flexibility is a pre-existing factor which has a contributory role in the development of eating disorders or simply a response to the problem may be difficult to determine (and may be different for different families). Either way it is often one of the most noticeable things when one first meets a family in the consulting room. The family often is as if “frozen”, fearful of doing anything outside of the usual routine. Many families often comment on this themselves. They know that what they are doing isn’t working but are afraid that doping something different could make things worse. Where the problem is of a relatively recent origin change can sometimes happen fairly rapidly 5. Certain aspects of the family organisation (in particular ones that the family itself might have perceived as being unsatisfactory) become more pronounced. Eisler, I. (2005) The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa. Journal of Family Therapy, 27, 104 – 131. Whitney J. & Eisler I. (2005) Theoretical and empirical models around caring for someone with an eating disorder: The reorganization of family life and inter-personal maintenance factors. Journal of Mental Health,14, 575 – 585

Family Therapy for Adolescent AN General principles Treatment with the family vs treatment of the family Identifying strengths and mobilization of family as a resource Central focus on helping family to find solutions The role of information giving Expertise in eating disorder vs expertise in family

Family Therapy for Adolescent AN General principles Challenging disabling family beliefs, perceptions and meanings (e.g. beliefs about guilt and blame) Blocking the central role of the symptom in the family organization Reinforcing of the family adaptation processes that enable developmentally appropriate family life-cycle changes

Multi-family group therapy

MFG treatment Basic principles  Creating solidarity “We are all in the same boat together“ Overcoming stigmatisation & social isolation “We are not the only ones with these problems“  Stimulating new perspectives and reflectivity “I can see clearly those things in them but not, when it comes to us  Learning from each other “I like the way others manage this“

MFG treatment Basic principles  Being mirrored in others “We do this just like you“ Positive use of group pressure: “We can’t cop out“ Mutual support and feedback “Terrific how you do this – and how do you think we are doing?!“ Discovering and building on competencies “I can do more than I thought, I am not all helpless“

MFG treatment Basic principles Intensifying interactions and experiences “It’s like a hot house, things happen here“ Practicing new behaviours in a safe space “We can experiment here, even if things go wrong at times“ Encouraging open communication “I am willing to listen, even if what you tell me is painful”  Raising hopes “Light at the end of the tunnel – even for us“

Staff requirements 2 therapists with different professional background + up to 4 trainees Combination of different group structures throughout the programme: all families together, or separated groups of parents, patients and siblings.

Intensive MFG programme for adolescent anorexia nervosa Initial assessment of the patient and the family Introductory evening Four day intensive programme (10.00 - 16.00) 5 – 7 one day follow-up meetings over 9 months Individual family therapy sessions between meetings depending on need Follow-up of individual and family as needed

Introductory evening Welcome Staff introductions Description of aims and structure of 4 day programme Presenting details of snacks and lunch times Psycho-educational talk on the effects of a starvation In smaller groups e.g. parents group and YP group, people introduce themselves to each other and meet “graduate” family members from previous groups. Q&A

Tuesday 9.30 – 10.00 MFG staff meeting 10.00-11.00 Multi family introduction [interactional – e.g get families to introduce one of the families who they met at the Introductory evening, exploring expectations from the MFG. 11.00 – 11.30 Morning Snack +weighing of the AN young people 11.30 – 12.45 Parents: lunch that day planning Young people (YP): ‘Portraying anorexia’ (draw, model or write something that symbolizes anorexia for you/your family) 12.45 - 2.00 Multi Family Lunch/observing YP’s eating patterns, how parents mange YP’s eating, intervening to promote change in patterns 2.00 – 3.00 Extensive feed back on first lunch experience of all families to each other (separate groups observing) 3.00 – 3.30 Afternoon Snack 3.30 – 4.30 Reflections on the ‘portrayals of anorexia’ and pros and cons of staying anorexic

Wednesday 9.30 – 10.00 MFG staff meeting 10.00 - 11.00 Brief feedback from previous day ( one thing that went well) Paper plates exercise “Preparing a Sunday lunch” 11.00 – 11.30 Morning Snack 11.30 – 12.45 Role reversal role play exercise around meal times 12.45 - 2.00 Multi Family Lunch with “reconstituted families” 2.00 – 3.00 Mothers group: feedback of experience of “fostering” another YP with AN Fathers group: feedback of experience of “fostering” another YP with AN YP group: making T - shirt what is helping them being part of the group and what is NOT helping them 3.00 – 3.30 Afternoon Snack 3.30 - 4.00 Visualizing time, place, circumstance when each group participant felt happy, describing it and sharing it with the group

Thursday 9.30 – 10.00 MFG staff meeting 10.00 -11.00 Separate groups to explore siblings/young people/parents concerns and worries 11.00 – 11.30 Morning Snack 11.30 – 12.45 Role-play/sculpt specific issues that have arisen in each family 12.45 - 2.00 Multi-family Lunch 2.00 – 3.00 Collecting treasures game: blindfolded young person is guided by parent/ discussion of the previous exercise 3.00 - 3.30 Afternoon Snack 3.30 - 4.00 Visualizing relaxing place, describe it, share with the group

Friday 9.30 – 10.00 MFG staff meeting 10.00 - 11.00 Individual Families: Time line – how might things look in the year ahead. 11.00 – 11.30 Morning Snack + weighing of YP 11.30 – 12.45 Joint discussion of time charts 12.45 - 2.00 Multi-Family Lunch 2.00 - 3.00 Reconstituted family groups: Developing survival toolkits for mothers, fathers and young people 3.00 – 3.30 Afternoon Snack 3.30 – 4.30 Multi-family Group: Feedback from families and discussion of future plans

Clinical aspects Therapeutic techniques FT techniques: circular questioning, externalisation of the problem, reflecting team, genogram Non verbal therapy techniques: drawing, modelling, collage Action techniques: psychodrama, role play, family sculpting

Clinical aspects Therapeutic techniques Psychoeducation: physiological effects of starvation, ‘normality' of ED families, individual/family life-cycle issues Group techniques: Interaction between families sharing experiences, reinforcing the sense of the uniqueness of each family

Clinical aspects Aims and therapeutic tempo Intensity of therapeutic contact => expectation of rapid (but achievable) aims Injecting hope Fostering an expectation that deeper, longer term change is in the hands of the family

Clinical aspects Therapeutic relationship More variable than is usual in individual or family therapy Informality (but owning expertise) Humour Supervision Informal, as part of the discussion of the multidisciplinary team

Benefits of intensive MFG Bringing together families with shared experiences Focusing on the impact the problem has had on family life Rediscovering family strengths and resilience to enable parents take s central role in tackling their daughter’s eating problems Creating new and multiple perspectives and helping families to take an observational stance Offering expertise in the context of a highly collaborative therapeutic relationship To address problematic family interactions and communications, that have developed around the eating problems

MFG training pennie.fairbairn@slam.nhs.uk ivan.eisler@kcl.ac.uk