There is a long history of blaming psychiatric illness on dysfunctional families. The most storied example is the "schizophrenogenic" mother. Schizophrenia, a disease classified largely by psychosis or the misperception of things that do not exist, has since been shown to be caused primarily by inheritable, genetic traits in association with developmental brain abnormalities. During the period when psychiatry was grounded in psychoanalysis, the schizophrenogenic mother theory was based on the only means of psychiatric healing at the time. In a field with only psychotherapy at its disposal, putting the blame on an overbearing, emotionally overwrought mother for a primarily biological illness seemed only logical.
Since eating disorder research is still in its nascent period, the temptation to rely on family dynamics--in this case "enmeshed" mothers and daughters--as the primary cause of eating disorders is extremely strong. The extent that biological, hereditary and social factors play a role in the sharp rise in the incidence of eating disorders is unclear, but no one doubts the complexity of these illnesses. Although family dynamics surely play a role for many, the overarching mother-driven theory feels like a frustrated group of clinicians grasping at straws. But that is not meant to dismiss the role of family dynamics either. The effectiveness of the Maudsley treatment, as discussed in the last post, makes it hard to ignore the family as a powerful force that shapes the course of an eating disorder. Acknowledging the toll an eating disorder takes on families--and attempting to help the family heal--is an often neglected part of recovery.
For many patients, the guilt of putting their families through the trials of eating disorder treatment--financially, emotionally and psychologically--for the second, third (or umpteenth) time serves as a huge barrier to progress. For people consumed with caring for others, the realization that getting better causes their family to suffer can be enough for a patient to forgo treatment altogether. It seems easier to function as best as possible and hide the disorder by pretending to be well. The internal suffering feels more bearable than the overwhelming guilt of revealing her persistent, shameful inability to recover.
This pattern usually occurs after someone has been sick for some years and been living independently. The missing piece in this obstacle to recovery is working on healing the long-term effect of an eating disorder on families. There is a wide range of responses from families early in the course of treatment. For some, an eating disorder is a willful act of disobedience from the beginning. A patient in this family often feels as if she caused the eating disorder and in some ways deserves her fate. But other families spend years researching the disease, seeking the best help and participating in the treatment process. After a time with limited improvement, even the most supportive family gets frustrated and eventually can't help but voice their feelings to the patient. It is exceedingly rare to find a family that, in one way or another, doesn't blame the child for her illness after a certain number of years. The simmering, silent anger and sense of loss can cause a seemingly unfixable rift between the patient and her family.
A necessary part of regaining both hope for recovery and healing in the family is to enable someone with an eating disorder to re-engage with her family. As an adult, the patient doesn't need her family to guide treatment anymore. Conveying a sense of purpose and progress can be enough to include families in the process while opening the door for new lines of communication. The entire family almost always remains aware that the eating disorder still dominates the patient's life but is bound to a false secrecy. The burden of maintaining this secret grows into a mountain of frustration and misunderstanding. When a family learns the patient is working hard in treatment on her own, those families which were initially supportive can often address longstanding grievances and try to establish a new joint effort of love and support. The relief of not having to be the driving force behind treatment also allows families to reconnect without the pressure of having to find an immediate cure. In families which blamed the child at the outset, the treatment needs to persevere alone, very separate from the family's influence, and the sense of loss that follows is a key element of recovery.
A patient's rightful place in her family, even after recovering from a protracted illness, is precarious. Families often act like the child with an eating disorder abdicates her ability to be a full member. She can be treated as fragile, irresponsible or even incompetent. On a general level, it is commonplace to view people with eating disorders as incapable in all facets of life. How can someone who can't feed herself be able to function in the world at all? This naive, prejudiced question exposes the fear and complete lack of comprehension of eating disorders in our society today. This will be the topic of the next post.