The theory and practice of MFT for eating disordersIvan 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.

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

enmeshmentover-protectiveness rigidity, lack of conflict resolution.

“psychotic” family gamesover-anticipation of infant’s needs by mother

Why families

?

Why families

• The myth of the “psychosomatic family”

• The family as a resource

• Family reorganisation 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

Stages leading to family reorganization around illness

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

1. The central role of the symptom in family life

2. Narrowing of time focus on the here-and-now.

3. Restriction of the available patterns of family

interaction processes.

4. The amplification of aspects of family function

5. Diminishing ability to meet family life-cycle needs

6. The loss of a sense of agency (helplessness) 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 ANGeneral 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 ANGeneral 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 treatmentBasic 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 treatmentBasic 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 treatmentBasic 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.

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

Intensive MFG programme for adolescent anorexia nervosa

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

Thursday9.30 – 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