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A Family Systems Perspective on Recovery 61 logical and emotional systems of the person with an eating disorder are intertwined. Efforts toward emotional recovery must be preceded or accompanied by recovery of the physiological system. A further complication is that eating disorders become addictions, psychologically and physiologically. However, unlike addiction to alcohol or other drugs, one cannot stop using the substance. One has to eat. This is one of the reasons that eating disorders are difficult to treat. THE FAMILYSYSTEM It is believed that individuals organize into family units to carry out certain necessary tasks, like raising children, nurturing and supporting one another, sharing in household duties, and providing security for one another. To carry out these tasks, a family and its members need order (or predictability) and balance. As with any other system, a family will resist change and in the face of change will gravitate toward reestablishing order and balance. “Order” refers to the family’s predictable patterns of behaving and reacting, as well as the traditional roles played by members of that particular family. This all-important order in the family is achieved by “family rules.” Family rules are of two kinds, spoken and covert. Spoken rules might include those concerning interrupting one another when talking, and those concerning bedtime, homework, when to watch television, or whose job it is to take out the garbage. Because these rules are spoken, they can be discussed, even questioned, in some families. The covert rules are understood and agreed on by everyone, but they are not openly acknowledged or discussed and may even be denied. For instance, in some families it is not okay to be angry but it is all right to be depressed. In other families men are not supposed to be afraid, but acting angry is acceptable. In some families arguing is not allowed. In other families arguing is the way family members connect with one another (Richardson 1984). Spoken and unspoken rules tend to be passed down from generation to generation (Kerr and Bowen 1988). The purpose of rules, spoken or covert, is to control the way people relate to one another and to outsiders. The rules keep order, give
62 A Family Systems Perspective on Recovery a family predictability, and keep everything in balance as long as everyone plays by the same ones (Richardson 1984). In most families the spoken rules are adjusted and changed as the needs of the family and family members evolve during the normal course of the life cycle. The unspoken rules also change, but with more difficulty, since the family is often not consciously aware that they are operating under these particular rules. All families operate with both kinds of rules. A rule only becomes a problem when it inhibits family members from dealing directly with stress or anxiety. When such a prohibition has been in effect for a number of generations, stress builds up and becomes part of the family heritage, which is passed down from generation to generation much like family heirlooms. Stress buildup is not a direct result of the pain and losses the family encounters over the generations. Rather, it results from the effect of the stressful events on the relationships within the family. And this effect is dependent on the family rules for handling stressful events. Sources of Stress in the Family Family therapists work with the family to understand what is stressful and how the family deals with it. I ask families to imagine a stress bucket that sits in the middle of the living room floor. All the stress experienced or inherited by each family member is poured into the bucket. A symptom in the family, such as an eating disorder, is an indication that the bucket has overflowed. The family has developed stress buildup. For the purpose of organizing our thinking we can look at stress as coming from three main sources. Predictable family life-cycle stress. The first source results from predictable family life-cycle stages (Carter and McGoldrick 1989). These stressors are normal and expected, and result from the family’s evolution over time. Therapy with families has shown that certain stages of the family life cycle are particularly stressful: birth of the first child, children in adolescence, and children maturing and going off on their own. This is true partially because of the tremendous changes involved in the ways family members relate to one another as a result of these transitions.
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editor BARBARA P. KINOY EATING DISO
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Eating Disorders New Directions in
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To our patients’ children and gra
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viii Contents 3. Psychiatric Consul
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x Foreword Although serious deficie
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preface In 1994, in the first editi
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Preface xv psychological hazards to
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Preface xvii partial, complete, or
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acknowledgments We wish to acknowle
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contributors Debra Bader, CSW, BCD:
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Eating Disorders
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Introduction diane w. mickley I am
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Introduction 3 needs of patients wh
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Introduction 5 therapy or on medica
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1 Medical Aspects of Anorexia and B
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Medical Aspects of Anorexia and Bul
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Page 42 and 43: 2 Recovery Through Nutritional Coun
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Page 46 and 47: Lesson 1: Daily Caloric Need and Me
Page 54 and 55: ical activity to a normal level. If
Page 56 and 57: patient who binges, it may be helpf
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Page 60 and 61: Figure 2.3 Typical Hunger and Food
Page 62 and 63: herself. She frequently feels hopel
Page 74 and 75: 3 Psychiatric Consultation with Eat
Page 76 and 77: Psychiatric Consultation 51 standab
Page 78 and 79: Psychiatric Consultation 53 difficu
Page 80 and 81: Psychiatric Consultation 55 Obsessi
Page 82 and 83: 4 A Family Systems Perspective on R
Page 84 and 85: A Family Systems Perspective on Rec
Page 90 and 91: she calls her mother and tells her
Page 102 and 103: 5 Relationship to Food as to the Wo
Page 104 and 105: iors—somehow to integrate the fra
Page 106 and 107: treatment, Theresa wanted to see an
Page 108 and 109: Relationship to Food as to the Worl
Page 114 and 115: 6 The Therapeutic Use of Humor in t
Page 116 and 117: The Therapeutic Use of Humor 91 Amy
Page 118 and 119: The Therapeutic Use of Humor 93 was
Page 120 and 121: The Therapeutic Use of Humor 95 ass
Page 122 and 123: The Therapeutic Use of Humor 97 Ron
Page 124 and 125: Jodie’s Story 99 capacity to make
Page 126 and 127: Jodie’s Story 101 house and a ter
Page 128 and 129: Jodie’s Story 103 She did not do
Page 130 and 131: adness. The dream also revealed tha
Page 132 and 133: 8 Eating Disorders and Managed Care
Page 134 and 135: Eating Disorders and Managed Care 1
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Eating Disorders and Managed Care 1
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Cognitive-Behavioral Therapy and Ot
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10 The Nurse’s Role in a Pilot Pr
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The Nurse’s Role in a Pilot Progr
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The Nurse’s Role in a Pilot Progr
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11 Individual Psychotherapy: A Long
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Individual Psychotherapy 135 Such p
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Individual Psychotherapy 137 empath
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weight and shape, as well as change
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Individual Psychotherapy 141 vomiti
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Individual Psychotherapy 143 During
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Individual Psychotherapy 145 and re
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Individual Psychotherapy 147 Mitche
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Young Adult Women 149 to surface an
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Young Adult Women 151 with their at
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Young Adult Women 153 ing; in fact,
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Young Adult Women 155 doomed, and a
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part of a treatment team where the
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13 Recovery margaret goldkopf-woodt
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Recovery 161 I can appreciate both
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Recovery 163 meant. I certainly cou
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Recovery 165 ate other uncomfortabl
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Recovery 167 connection between my
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Recovery 169 safe place, and our ow
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Recovery 171 My pregnancies and mot
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Recovery 173 They seem to be living
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Recovery 175 Self-disclosure remain
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nel. All that I feared, the hurts I
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Afterword 179 surprisingly rapidly
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Afterword 181 With eating disorders
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Treatment helped me to face life, i
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AA/BA. See American Anorexia/Bulimi
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37; prevention of, 29-31; rigid die
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problems and, 19; events triggering
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Keel, P. K., 180 Keller, H., 133 Ke
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Psychoeducational group therapy, 12
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112-20; IPT, 121-22; psychoeducatio
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