The theory and practice of MFT for eating disorders

1. The theory and practice of MFT for eating disorders Ivan Eisler Kings College, Institute of Psychiatry, London, UK Rotterdam June 2010

2. 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.

3. 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

4. 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. Mara Selvini Palazzoli

5. 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

6. relations and friends generally the worst attendants separating the patient from the family over-anticipation of infant’s needs by mother enmeshment over-protectiveness rigidity, lack of conflict resolution. “psychotic” family games

7. Why families?

8. Why families • The myth of the “psychosomatic family” • The family as a resource • Family reorganisation around illness

9. Stages leading to family reorganization 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 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 Health16, 55–70

10. Family life and eating disorder • The central role of the symptom in family life • Narrowing of time focus on the here-and-now. • Restriction of the available patterns of family interaction processes. • The amplification of aspects of family function • Diminishing ability to meet family life-cycle needs • 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

11. 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

12. 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

13. Multi-family group therapy

14. 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“

15. 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“

16. 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“

17. 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.

18. Intensive MFG programme for adolescent anorexia nervosa • 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

19. 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

20. 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

21. 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

22. Thursday 9.30 – 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. MFG training • pennie.fairbairn@slam.nhs.uk • ivan.eisler@kcl.ac.uk