Self-Starvation: Systemic and Familial Perspectives
There are numerous rationales cited in literature for refusal of food intake amongst women spanning from religious theories to psychoanalytic, feminist and cultural perspectives (Palmer, 2008). However, the treatment for eating disorders has been strengthened by the work of family therapists including Minuchin (1978), Selvini-Palazzoli (1978), Maudsley (Dare et al., 1995; Rhodes, Gosbee, Madden, & Brown, 2005), who focused on understanding the familial and relational contexts surrounding eating disorder symptoms, as well as utilizing curious and respectful avenues to learn about and to work within the individual’s presenting culture and worldview. Unlike intrapsychic perspectives, family systems theorists emphasize circularity of relationships, and assert that specific events do not directly cause the eating disorder to occur; moreover, problems are viewed as created and reinforced by cycles of actions and reactions between people who are interconnected parts of the larger whole (Becvar & Becvar, 1996). Therefore, pathology of eating disorder symptoms, such as self-starvation, does not reside in the mind of the individual, but in the interactions between members of the relational system.
Family impacts on eating disorders: review of theories
Systemic frameworks suggest that the family member suffering with an eating disorder may not be the only family member suffering (Costin, 1999; Levitt, 2001), and that the sufferer may be coping with current issues related to her environment. It is important to note family behavior and symptoms of anorexia nervosa (Schmidt, Humfress, & Treasure, 1997). Several studies have found that anorexics showed more family problems. This information is reflected in recent findings investigating patient’s perspectives of causes of anorexia nervosa, for which ‘dysfunctional family’ environments were a commonly cited factor. For example, increased conflict and disorganization (Schmidt, Humfress, & Treasure, 1997), high paternal over-protectiveness (Calam, Waller, Slade, & Newton, 1990), and increased conflict (Shisslak, McKeon, & Crago, 1990), have all been cited as family pathologies of eating disordered individuals. These eating disordered families have been shown to display lower adaptability and cohesion (Waller, Slade, & Calam, 1990), lower maternal and paternal care (Palmer, Oppenheimer, & Marshall, 1988), as well as less cohesion, expressiveness, emotional support (Shisslak et al., 1990), and orientation towards recreational activities (Schmidt, Humfress, & Treasure, 1997). These family dynamics were thought to be relevant rationales for food refusal amongst anorexic participants in the study.
Family therapists in Western societies have also identified several components of the family context that may contribute to the development of anorexia, including patterns of family interaction (Minuchin et al., 1978), family beliefs (Stierlin & Weber, 1989; White, 1983), family culture (Selvini Palazzoli, 1974) and family sexual abuse or incest (Luepnitz, 1988). Selvini Palazzoli and the Milan team focused particularly on tending to circular processes between the families’ contribution to the disorder, and the behavior of the individual that perpetuates that role (Boscolo, Cecchin, Hoffman, & Penn, 1987; Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1980). The Maudsley model placed emphasis on how individual, family, and sociocultural influences interact to maintain the disorder (Dare & Eisler, 1997). Specifically, Minuchin and colleagues (1978) hypothesized about a specific family context and structural characteristics in families within which eating disorders such as anorexia develop, such as enmeshment, overprotection, conflict-avoidance, rigidity, and involvement of the child in parental conflict. In Psychosomatic Families (1978) Baker, Rossman, and Minuchin observed that anorexic families all possessed similar characteristics, which consisted of interactional patterns that prohibited members, particularly the anorexic, from developing a stable sense of individuality or autonomy. For example, some researchers have suggested that eating disordered individuals may experience parental pressure that is inappropriate for their age, gender, or abilities (Horesh et al., 1996).
Other researchers have suggested that eating disordered individuals may also be more likely to receive low parental contact, and criticism from their families about weight, shape, and eating behaviors (Fairburn, Welch, Doll, Davies, & O’Connor, 1997). Furthermore, belief systems within anorexic families are thought to be rigid with high regard for loyalty to the family and specific role prescriptions for the anorectic family member (Palazzoli, 1978; White 1983). For example, families with an anorexic child may place emphasis on achievement, success, appearance and weight (Bruch, 1973; Hall & Brown, 1983). In regard to the egosyntonic nature of the state of emaciation, Russell (1995) acknowledges a variety of contributing psychosocial factors and asserts, “the patient avoids food and induces weight loss by virtue of a range of psychosocial conflicts whose resolution she perceives to be within her reach through the achievement of thinness and/or the avoidance of fatness” (p. 10). Banks (1992) says that extreme emaciation in one such patient was “a means of attracting attention from her peers and family” (p. 875).
Selvini-Palazzoli and Viaro (1988) and Selvini-Palazzoli, Cirillo, Selvini, and Sorrentino (1989) proposed a six-stage model for anorectic family process that emphasized the enmeshed quality of the eating disordered family as the primary clinical issue. The stages include a covert game in which members of the family disguise their feelings, goals, and intentions where first the parents reach an impasse demanding that the other change. Second, the future anorectic becomes involved in the relationship and may be totally devoted to her mother and confidant. Third, the daughter turns to her father after her mother turns attention away from her and usually onto another sibling. The future anorectic and father share contempt for the mother. Fourth, the daughter differentiates by changing her food intake. The mother’s attempts to control the daughter’s food intake reinforce the problem. Fifth, the daughter becomes disappointed by the father’s choice to not openly side with her against his wife. Finally, the daughter realizes that anorexia gives her power, and other family members become aware of ways they can influence one another vis-à-vis the daughter’s illness.
Family disturbances in roles, communication, regulation of emotion and inappropriate boundaries are also thought to hinder developmental tasks of the anorexic that may include separating from the family and creating an individual identity (Humphry & Ricciardelli, 2004). Two family patterns have been identified in families of anorexia classified as ‘centripetal’ or ‘centrifugal’ processes. Centripetal processes were dominated by themes of excessive cohesion, reduced emotionally expressiveness, and lack of permissiveness. Centrifugal families were characterized by lacking cohesion and attachment with high conflict before the onset of the anorectic symptoms (Schmidt, Humfress, & Treasure, 1997). Several issues can also increase the likelihood of eating disorder development such as coercive parental control (Haworth-Hoeppner, 2000), including a view of their fathers, but not their mothers, as overprotective (Calam, Waller, Slade, & Newton, 1990; Pole, Waller, Stewart, & Parkin-Feigenbaum, 1988); separation-individuation between mothers and daughters (Zerbe, 1995); and a distant father-daughter relationship (Zerbe, 1995). For example, a study by Hodges, Cochrane, and Brewerton (1998) revealed that anorexic subjects in the study perceived their family environment as being less cohesive and supportive than normal population subjects. Furukawa (1994) confirmed the family factor of excessive parental control for Japanese students in cultural exchange programs. Finally, Robinson and Anderson (1985) recognized family loss of a primary parent as a potential factor in a review of clinically documented cases of anorexia in African Americans.
Undoubtedly, it is impossible to grasp a comprehensive picture of the eating disordered individual without considering the relational context of that individual and precipitating factors contributing to the development of symptomatology of food refusal. Minuchin, whose views are widely quoted, stated that certain transactional patterns seem to be characteristic of all anorexic families, including over-protectiveness, conflict avoidance, rigidity and enmeshment (Minuchin, Rosman, & Baker, 1978). Stierlin and Weber (1989) reported the clinical impression that mothers would “on the one hand, anxiously hover over the anorexic daughter, enlist her as a source of concerns…and, on the other hand, treat her as an adult (i.e., parentified) confidante and ally in coalition directed against father” (p. 28). Additionally, eating disordered families were found to demonstrate less openness to discussing disagreements between parents and children than control families. Waller, Calam, and Slade (1989) asserted that ano