Q: Explain the role of family involvement in eating disorder recovery?
A: Families touched by eating disorders are in crisis—family members need the support and guidance of the treatment team in this uncertain, stressful time, while at the same time, their loved ones struggling with anorexia, bulimia, binge eating disorder and related conditions need meaningful participation from their families to help them achieve lasting recovery.
Regardless of the patient’s age, engaging loved ones in assessment, education, family therapy and discharge planning is so valuable.
In children and adolescents, family involvement generally refers to participation of parents/guardians, and involves family therapy, multifamily education and group therapy sessions. My training and background is pediatric and adolescent specifically—in this population, families are closely involved as they are tasked with managing re-feeding and supporting recovery skills until their young loved ones are developmentally ready to assume these responsibilities themselves.
Family support is equally important in adult patients, although involvement can be a bit more complicated. “Family” is more loosely defined for adults—family can mean a spouse, significant other, adult child (if appropriate/clinically indicated), parent(s) or even a trusted friend. Because adults have different kinds of meaningful relationships, the basic criteria for participation in the eating disorder treatment process is consent/willingness, and a commitment to be involved in their loved one’s recovery.
Regardless of the age of the patient, a treatment approach that engages, educates and encourages families is so important to empower them to do whatever is needed to support the patient in the areas they are struggling. Honestly, it’s hard work—involving loved ones in a productive recovery effort entails looking at each person’s own issues, beliefs, questions and dynamics, which requires vulnerability and commitment. However, when family work is done in a supportive, compassionate way, it can rally whole families in the march toward recovery.
Q: What are the key aspects of family involvement in eating disorder treatment?
A: Because eating disorders can be so powerful, families tend to end up functioning around their loved one’s eating disorder, and as a result they often struggle to conceive of a life without the eating disorder. When we talk about family involvement in treatment, we’re not just talking about family therapy and mending connections, but also educating families about these complex illnesses and their role in the treatment process, as well as engaging them in both the assessment and discharge planning phases of treatment.
Some families come into treatment knowing very little about eating disorders, while others know a great deal (much of which can be inaccurate or counterproductive information). At a fundamental level, families want to know what has happened to their loved one, what to expect moving forward and how they can help. They also want to know “why” their loved one is struggling with their eating disorder.
As clinicians, we should carefully avoid the notion of blame—after all, this collaborative stance is a foundation of family-based work. It is essential for the treatment team to reiterate that there is no single cause of an eating disorder and to educate families about the complex interplay of factors that contribute to an eating disorder—biological, genetic, personality/temperament, developmental functioning, environmental pressures (family, school, peer and sociocultural pressures). When combined with a developmental transition, life event or experience, these factors can trigger eating disorder symptoms and behaviors.
In addition to providing accurate eating disorder information and teaching skills to help families support eating disorder recovery, clinicians should explain the treatment process and honestly address potential pitfalls they may encounter as recovery progresses. This education helps families remain hopeful and have realistic expectations about the road ahead.
While in treatment, potential pitfalls include:
- Patient is not successfully completing meals and weight has dropped
- Weight gain has halted
- Parents/families are ready to “throw in towel”
- Parental and/or family conflict has significantly increased
- Patients and/or parents are “done with this monitoring stuff” and/or “done with family therapy”
Following discharge, potential pitfalls include:
- Patient’s weight drops and eating disordered behaviors begin to resurface
- Parents struggle with normative adolescent behaviors in their child
- Family dynamic issues are surfacing and parents/families are resistant to addressing them
- Body image issues are causing distress (even when eating disordered behaviors are significantly reduced and ideal body weight is restored)
The most likely pitfalls generally depend on the age of the patient and the family’s unique recovery challenges, but outlining common barriers to recovery can minimize the sense of crisis and hopelessness when obstacles emerge.
Remind loved ones that eating disorder recovery is hard—for the patient and family alike—and that it is normal for participants to feel frustrated, discouraged or exhausted. When facing challenges, the role of the treatment team is to empower the entire family to be proud of their progress and successes, to problem-solve with them and to encourage them as they continue to implement recovery skills.
Assisting with the assessment process
In addition to reviewing information from referring providers, gathering physical data (height, weight, BMI, etc.) and assessing medical stability and dietary needs, families bring valuable insight in the preliminary assessment.
Providers can invite parents and loved ones to share their interpretation of their loved one’s eating disorder behaviors, developmental issues, family history (including psychiatric), the marital relationship and life stressors. Perhaps most importantly, a family interview helps to establish a therapeutic alliance.
Talking to parents and participating loved ones honestly about recovery and setting expectations for the therapeutic relationship—while being realistic and encouraging—helps to foster trust and buy-in.
In conjunction with an interview of the patient (their interpretation of their behaviors and their thoughts about treatment), the family’s unique recovery needs become more clear and this information informs the development of an individualized treatment plan.
Transitioning out of treatment
We know that preparation and planning with known variables goes a long way in supporting lasting recovery. In addition to collaboration with community and referring providers, families can be involved in the transition out of treatment. After all, these supportive networks play an ongoing role in sustaining eating disorder recovery in addition to the patient’s continued outpatient therapy.
Discuss how the patient and family are working towards health and how to support success after leaving treatment. These conversations ensure that patients and families are working toward a common goal and know what to expect in terms of decreasing frequency of sessions, developing a relapse prevention strategy and other treatment referrals should new issues arise that need addressing.
Be involved in your loved one's care
At Eating Recovery Center of Austin we offer Partial Hospitalization and Intensive Outpatient Programs for adults and adolescents. At both levels of care, families are involved in family therapy sessions and multi-family education groups. These groups bring multiple patients and families together in a supportive therapeutic environment for education, sharing of experiences and fostering support and connection.
Additionally, parent groups explore meaningful topics related to recovery, supported family meals provide opportunities to apply skills in a “real world” context and assessment and discharge planning phases of treatment also engage families for insight as appropriate.
Our multidisciplinary treatment team is committed to the idea that eating disorders can truly be treated. We take every opportunity to encourage families to have hope and prepare them for the challenging yet rewarding work of healing and restoring health in their loved ones and in their families.
Allison Chase, PhD, CEDS is Executive Director of Eating Recovery Center, Austin, TX, providing comprehensive, compassionate outpatient care to patients and families touched by eating disorders.