Eating Disorders Multifamily Therapy Group: Capitalizing on the Healing Power of Relationships
Eating Disorders Multifamily Therapy Group is a group treatment that targets patients and their families/significant others in an effort to help them see the impact of an eating disorder and recovery on their relationships and vice versa. It also provides a forum in which a variety of people can use their collective resources to address the challenges, dilemmas, and disconnections associated with recovery (McFarlane, 2002).
In the Eating Disorders Program at Unity Health System in Rochester, NY, this group is run in a weekly, 8-session format for outpatient and partial hospitalization patients and their loved ones. The group is based on Relational/Cultural theory (Miller; Tantillo), Stages of Change theory (Prochaska), and Cognitive-Behavioral theory (Wilson; Garner). Some of the didactic material is based on the work of Siegel. The main goals of the group are listed in Table 1, and the group session topics are listed in Table 2.
The strength of Multifamily Therapy Group is its ability to promote a sense of universality and cohesiveness when patients and families quickly discover they are not alone in their experiences with the illness and the recovery process. Since mutual relationships are seen as critical to recovery, a main goal of the group is to help members develop and experience connections with each other that involve the “Five Good Things” (Miller): 1) self-knowledge and knowledge of the relationship, 2) sense of empowerment, 3) self-worth, 4) sense of energy or zest, and 5) desire to establish more connection with others outside the immediate interaction.
Since mutual connections are based not only on similarities but also on the appreciation of differences, much of the work is focused on increasing members’ abilities to honestly communicate whatever they are thinking or feeling. Through didactic instruction, small group exercises, and large group process discussion, both patients and their loved ones practice being open to differences and developing healthy ways to express them—while remaining in connection. This is especially important in families who are struggling with an eating disorder, where there is often a general avoidance of conflict and a fear of honest expression.
For example, patients who are so distracted or fatigued because of starvation, are not even aware of their need to express feelings, needs, or thoughts to their families. But when they become better nourished, they have a great deal of anxiety about expressing themselves. They fear that if they do, they might suffer more disconnection (e.g., rejection, loss, invalidation, or criticism) or unintentionally hurt others. Family members are also fearful of expressing different perspectives or feelings because they do not want to upset their loved ones and somehow “cause” them to become more symptomatic.
The group emphasizes how the inability to label and express differences can actually maintain the eating disorder and obstruct recovery. As long as a patient remains disconnected from her/his authentic needs and feelings and unable to state these to others, s/he will remain connected to the eating disorder. This will also be the case as long as family members avoid thoughtfully sharing their concerns in regards to watching the sufferer’s struggles.
One example of how Multifamily Therapy Group encourages the openness and expression of differences is illustrated by a recent group session. Group members decided they wanted to discuss how unrealistic expectations can lead to tension and disconnection. Patients and family members began to share some of their various experiences and how their relationships, symptoms, and recovery were impacted.
At one point, a father (Mr. R.) in the group turned to his 17-year old daughter (Lisa) and said, “I feel like you are too hard on yourself with your school work. You expect yourself to always get A’s and maintain a 4.0. That’s unrealistic. You are being unfair to yourself. It’s too much pressure.” Lisa looked down. I then asked her if she experienced things in the same way as her father, since her experience could be similar or different. Lisa said, “I’m not sure what to say. I don’t know.” I then turned to the group and said that I was sure that this father and daughter were not alone in how they felt and wondered if anyone had a similar story.
Another father (Mr. S.) said to Mr. R., “I think I know how you feel right now. I said the same thing to Megan (his daughter) and discovered that she felt pressured by me to always be exceptional in her performance. This was a surprise for me because I never meant to pressure her or make her think she had to be perfect. He chuckled a bit and said, “I finally took a risk and talked about a concern I had about her, only to find out that I was in some way unknowingly contributing to it. Maybe Lisa has to feel like you are ready to hear whatever she has to say next.” Megan smiled and agreed. She said, “My father kept telling me to ease up on myself, and I would think, ‘You have got to be kidding. He is always asking me about my grades, and he is such a perfectionist himself.’ I was worried he would think less of me. I was thinking in extreme ways, like if I wasn’t getting A’s, then I must be a slough. I know I am perfectionstic too, but it didn’t help watching him be hard on himself in his own life and having him always ask about my grades. I finally told him all this, but I was worried he would feel hurt. I know he means well.
Upon hearing this, Lisa turned to her father and said “I know I ride myself too hard at times, but I also feel like you are being too easy on me now. I feel kind of patronized by you because now that I’m sick, you are letting so much go in terms of my performance at school and in other areas. It doesn’t feel genuine to me. You have much higher standards for yourself and for me. I feel the same as Megan. I have always felt a lot of pressure to be the best at everything for you.” Mr. R. sat quietly for a moment, and I asked him what he thought about all this. He responded by saying, “Lisa, I am sorry for having pressured you in any way. I do have a number of unrealistic, “all or nothing,” standards that I impose on myself. However, I thought I was trying not to do the same to you. I hated it when grandpa did it to me. I had no idea you felt patronized. I have been trying to correct the error of my own ways, but I guess I am still missing the mark. I am a perfectionist. How can I respond to you in a way that will feel more genuine?” They continued to brainstorm about how they could interact about her schoolwork, so she would feel supported by him but also feel he wasn’t “cutting her unnecessary slack.” Lisa said, “I like that you encourage me to be my best. I am also learning like you, dad, that “the best I can be,” does not mean “perfect.”
Other patients and family members then validated Lisa and her father’s experiences by sharing their responses to what Mr. R. and Lisa had just shared. With the support of the group members and leader, Lisa and Mr. R. could state their differences and grow in their relationship, instead of feeling more disconnected. In the past, when an interaction like this occurred, Lisa would feel frustrated, then guilty, and restrict her food or purge; Mr. R. would feel frustrated and helpless, not knowing how to help his daughter. This was a big change for the better.
Eating Disorders Multifamily Therapy Group helps foster the development of mutual connections in which all individuals within the relationship learn to recognize and appreciate their influence on one another. This relational context greatly enhances the patient’s and family’s abilities to learn more about the eating disorder and recovery process, develop strategies which promote recovery, and nurture growth-fostering relationships with each other—all of which assist the patient to disconnect from the eating disorder.
Garner, D. M., Vitousek, K. M., & Pike, K. M. (1997). Cognitive-behavioral therapy for Anorexia Nervosa. In D. M. Garner and P. E. Garfinkel (Eds.), Handbook of treatment for eating disorders (pp. 94-144). New York: The Guilford Press.
Miller, J. B., & Stiver, I. P. (1997). The healing connection. Boston, MA: Beacon Press.
McFarlane, W. R. (2002). Multifamily groups in the treatment of severe psychiatric disorders. New York: The Guilford Press.
Prochashka, J. D., Norcross, J. C., DiClemente, C. C (1994). Changing for good. New York: William Morrow.
Siegel, M., Brisman, J., & Weinshel, M. (1997). Surviving an eating disorder:
Strategies for family and friends. New York: Harper Perennial [a division of Harper-Collins, Publishers].
Tantillo, M. (2000). Short-term relational group therapy for women with bulimia nervosa. Eating Disorders: The Journal of Treatment and Prevention, 8, 99-121.
Wilson, G. T., Fairburn, C. G., & Agras, W. S. (1997). Cognitive-behavioral therapy for
Bulimia Nervosa. In D. M. Garner and P. E. Garfinkel (Eds.), Handbook of treatment for eating disorders (pp. 67-93). New York: The Guilford Press.
by Mary Tantillo, Ph.D., R.N., C.S.
Reprinted with permission from Eating Disorders Recovery Today
Fall 2003 Volume 2, Number 1
©2003 Gürze Books
About the Author
Dr. Mary Tantillo is the Director of the Eating Disorders Program in the Department of Psychiatry and Behavioral Health at Unity Health System and a clinical assistant professor in the Department of Psychiatry at the University of Rochester School of Medicine and Dentistry. She is a board member and fellow of the Academy for Eating Disorders and a certified group psychotherapist and member of the American Group Psychotherapy Association. Dr. Tantillo has worked with patients with eating disorders for 20 years in inpatient, partial hospitalization, and outpatient settings. Dr. Tantillo has special interests in the areas of women’s mental health and group treatment. Her teaching, research, and publications emphasize the application of Relational/Cultural theory in the understanding and treatment of eating disorders.