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Section 15
Family Factors that Influence Anorexia Nervosa

Question 15 | Test | Table of Contents

Emotional role reversal. There were times in all the narratives when experiences of emotional role reversal were discussed. For example, 7 of the women discussed the ways in which they served the role of listener or "therapist" to a parent. Linda (age 18) stated "my mom always needed this emotional support." This role developed in different ways. Three women discussed the belief that listening to a parent's grievances or anxieties about other family members helped to avoid conflict in the family structure. This particular type of interaction, triangulation, is explained in greater detail in the next section (Bowen, 1978; Nichols &: Schwartz, 1995). For some of the women from Asian cultures, it was not considered culturally appropriate for the mother and father to discuss problems together (Lee, 1996). In these families, the young girl who supported her mother emotionally recognized her mother's sense of isolation and wished to show care and provide comfort.

During childhood, the women in this sample felt that the emotional support that they provided created a special relationship between one or both parents and themselves. Nine of these women felt they had a better relationship with their parent(s) than did many of their peers. Meg (age 21) stated, "probably when you think about kids and their parents' relationships, most people don't think it was good so I just have a good feeling when I think about it." As adolescence progressed, some of the women in the study began to recognize how this reversal of roles was problematic. This recognition entailed awareness that listening to and taking care of their parents made it difficult to establish a larger identity for themselves, one that included the establishment of relationships outside the home. Sometimes the emotional support that the women in this study provided their families felt problematic because it was unequal. The sense of inconsistent specialness described by many of the women is described later.

Within relationships, the theme of taking care of parents when they were ill or depressed came up several times and was seen as a way to be a good and dutiful daughter. In relationships, these women with anorexia nervosa were invested in "pleasing" others and fulfilling the "supportive role of a woman." The wish to nurture others in familial and later extrafamilial relationships was equated with "being a good person." These women discussed how the experience of taking care of their parents helped develop their adult values.

The women were aware of their desire to take care of others. A double bind was evinced in that they demonstrated both an awareness of how these tendencies made them uniquely vulnerable to developing anorexia nervosa and, at the same time, led them to value these characteristics in themselves. Ami (age 18) states: "I think my independence is tied a lot to how much, how well, she could deal with being without me, because I think I'm gaining more independence in an emotional way. [Can you say more about how you feel more independent recognizing how she can be without you?] It's, like, before I felt almost like I wasn't allowed to go out and live my own life until she was happy, and if she wasn't happy, I wasn't allowed to be happy. It just made me feel really guilty because I always know how she's feeling, I mean she always tells me and so sometimes I would go home and when I got home, she would say, it's so quiet without you, and it's so hard for me to be happy without you, so I would feel like I had to go home and I couldn't stay and I couldn't have fun and even if once in a while I would stay because I wanted to, I would feel guilty while I was here."
 
Ami's independence was directly tied to messages that she received from her mother that her independence came at the cost of defying her mother's wishes. From a traditional perspective on separation and individuation (Mahler, 1968), Ami seemed to have made a logical error. Generally, independence is believed to relate to how much one can hold the idea of a relationship in one's mind while being away from the parent (Ainsworth, 1989; Lichtenberg & Hadley, 1989). The formulation was reversed in this example because Ami's independence had to do with how much her mother was able to deal with being separated from her. However, from the vantage point of female development and an emphasis on taking care of others, Ami's perspective begins to make sense. In fact, Ami knew both that her mother had placed the education of her daughters above developing her own abilities ("she, like, sacrificed herself, her needs for us, and even if I didn't appreciate it then, I felt it") and that her mother regretted immigrating to the United States. Given the value placed on caring for others, Ami's independence did seem to come at the price of the relationship with her mother. The dilemma that Ami faced was found to be similar to the discussion of moral concerns in the development of depression found in Jack (1993).

When a woman first begins to diet excessively, she often reports an increase in anger and argumentativeness (Bruch, 1973, 1985). Furthermore, the women with bulimia often equated self-induced vomiting with a stance of "throwing up" what could not be swallowed. However, as the disease of anorexia nervosa took hold, the starving young woman lost the energy necessary for a real rebellion (Wolf, 1994). It was a self-perpetuating cycle in which the attempt to rebel against a belief in the requirement of pleasing others was thwarted. The "hunger strike" (Orbach, 1986) against the attempt to take care of everyone turned the girl with anorexia nervosa into an object without the energy to perform the examination of what really needed to be changed.

Triangulation. Another behavior involved in Family Structures that Encouraged Substituting Others' Needs for One's Own involved the anorexic women positioning themselves between the parents when they felt that this activity would decrease problematic interaction. Triangulation, a term borrowed from family systems, is particularly appropriate in describing the experiences of many of the women in this study (Bowen, 1978; Nichols & Schwartz, 1995). Nichols and Schwartz (1995) defined triangulation as "detouring conflict between two people by involving a third person, stabilizing the relationship between the original pair" (p. 595). In such family systems, certain feelings are not spoken. Conflict is detoured and feelings of enmeshment protect against feelings of individuality (Minuchin et al., 1978). Where there was open conflict between the parents in this sample due to substance abuse, separation, or divorce, triangulation often involved parental requests that the child listen to one parent's grievances against the other, or act as a go-between for the parents. Jodie (age 21) often felt caught between her parent's animosity toward one another. "It would be hard for me to go between the both of them, having the both of them talk about each other. And they would say stuff about each other and it was hard because she wanted me to side with her and he wanted me to side with him."

A sense of inconsistent specialness. Alongside the inappropriate use of the child by the parent through triangulation, we found a sense of inconsistent specialness. Four of the women, still close to the silencing experience of anorexia nervosa, could talk only about the positive relationship they felt with the parent. For these women, the sense of dissatisfaction they felt was unnamed or was implied in vague ways. As an example, Meg (age 21) stated, "I think, like, the kids ... were, like, the most important thing to her, so she just automatically cared a little about us." Although Meg described herself as "the most important thing" to her mother, she was left in the care of her abusive father. The feeling of dissatisfaction was implied in the use of the words "little" and "thing." The women in this study who were unable to talk about dissatisfaction in parental relationships, in particular, had a difficult time differentiating themselves from their family of origin.  Five of the women in this study did describe the relationship with a parent as special but also as unsatisfactory. One woman, Sarah (age 18), who was able to describe her ambivalence, stated: "It forced me to grow up really fast and sort of left me with a sense of responsibility that I think a lot of other kids, a lot of my friends, didn't feel. Umm, you know, I think that I always liked that my mom and I were close enough to talk about anything, except for I found a lot that my mom isn't good at listening to me as much as she feels that she needs to talk to me about what's going on with her. But I think that I'm one of the few people that my mom can totally vent everything to that she feels, which in some ways I think is really a good thing. I mean so many people bare a bard time with their parents, you know, communicating."

As she struggled to understand her relationship with her mother, Sarah fluctuated between feeling that it was a positive relationship because she and her mother were close and a negative relationship because the emotional support was unequal. Special in some ways but not in others, her experience of the closeness with her mother was inconsistent.

Some of the women discussed injuries to their early feelings of specialness. Stella's (age 19) description captures the experience:  "I was always, like, really imaginative and kind of out of it when I was a kid, you know, kind of somewhere else. I used to wander off and I used to sit by myself and play with anything, you know, and daydream a tot, a lot of the time. And I remember when I was like 10 or something and you think, "Wow, I must be really something special; everybody has something special." I remember telling my mom that once, like, "Mom, I think I'm going to be something someday, I think I need to be, I'm going to be famous because I'm really special." And I remember her, she said to me, "Everybody feels like that. You'll know you're not special when you're older." "

When a child grows up in a family with brief periods of exciting specialness and long periods of a parent's emotional unavailability, the child may strive to recapture the sense of specialness (Coen, 1992). The feeling that one's care is dependent on acting a certain way makes individuation an experience fraught with dangers, such as the possibility of losing the needed parent. Energy that developmentally should be directed toward one's own pursuits is bound up in a wish to reexperience closeness. An individual in this situation is prone to be hypersensitive to subtle nuances of communication and to seek to control interactions with others (Coen, 1992; Jack, 1993; Selvini-Palzzoli, 1978). Despite the fact that such early experiences are likely to intensify feelings of rage, entitlement, and deprivation (Jack, 1993), it was difficult for many of the women in this sample to talk openly about their anger. All the women found it necessary to qualify or recant any angry feelings toward their parents. Karen (age 20) stated, "It's like I want to give you a well-rounded picture and it's all positive. However, he used to spank us. But we'd deserve it." Although negative emotions could not be discussed, they could be acted out. Betty (age 24) discussed her indirect way of communicating her angry feelings toward her father. Angry at not being seen as a developing individual but only as one of the daughters, Betty showed him what she could not say. "I remember from the time I was 12 my dad said to me ... 'you are the best daughter, you get along with both of your sisters,' but after that I didn't get along with either one of them." Symptoms such as bulimia, fighting, and shoplifting, experienced by five of the women, may have also demonstrated some of their rage.

A belief that some emotions are dangerous. When one experiences repeated feelings of loss of connection, it is difficult to feel safe in the give-and-take of periods of disagreement, sexuality, and love of intimate relationships (Jack, 1993). In addition, many of these women grew up in families in which anger was not expressed openly and, consequently, they had no models for successful resolution of conflict (Minuchin et al., 1978). Listening to the narratives of these women, we heard how hard they were trying to control their sense of betrayal. In trying to find adjectives to describe her relationship with her father, one woman struggled to avoid sounding angry. "I don't want to use the word cruel as describing the relationship but puts you down, you know, when someone puts you down a lot" (Jodie, age 21).

We came away from meeting these young women with the impression that they believed that certain emotions and experiences were dangerous. In talking about an interaction with her father, Josslyn (age 19) stated, "It did bother me but I was really afraid to say that." In situations of family violence and emotional abuse, these girls attended to their parents' emotions to avoid conflict and punishment. In nonabusive families, a belief in a parent's frailty led to the situation of silence. With everyone attempting to attend indirectly to each other's needs, there was often a sense of enmeshment and confusion about which members of the family were experiencing what emotions (Selvini-Palazzoli, 1978). Stella (age 19) talked about her fear of any signs of sadness in herself because other women in the family were depressed. Sometimes there was a sense that emotions could be understood without being expressed. "She basically knew what I was upset about just before I'd even have to say it, so she was really good that way" (Meg, age 21). In family situations where problems cannot be communicated directly, there is little chance of directly communicating a sense of need or desire (Minuchin et al., 1978; Selvini-Palazzoli, 1978).

In summary, triangulation, emotional role reversal, a sense of inconsistent specialness, and a belief that some emotions are dangerous were different but interrelated conditions in the formation of Family Structures that Encouraged Substituting Others' Needs for One's Own. These experiences all shared the common factor of being made use of by a parent for the parent's own needs. Where normal needs for nurturance led to a situation of misuse by others, one could either give in to this system or protect oneself from need entirely (Coen, 1992). For the women in this study, the symptoms of anorexia nervosa did both. Refusing to take in, a woman with anorexia nervosa disavowed that she needed anything, that she was even indeed human. Becoming ill, a woman with anorexia nervosa had the experience of acting on dependency wishes. Theresa (age 21), who experienced physical abuse as a child, as well as a period of parental separation, stated that she valued "strong and independent women," whom she defined as having "self-sufficiency' and being "less emotional." At the same time, the theme of being cared for came up throughout the interview. "I remember wanting to be babied the way that other kids seem to be. They got privileges from being sick."
- Wechselblatt, Tracy; Gurnick, Gregory; Simon, Ruth; Autonomy and relatedness in the development of anorexia nervosa: A clinical case series; Bulletin of the Menninger Clinic, Winter2000, Vol. 64 Issue 1, p91.

Screening High School Students for Eating Disorders:
Results of a National Initiative


- Austin SB, Ziyadeh NJ, Forman S, Prokop LA, Keliher A, Jacobs D. Screening high school students for eating disorders: results of a national initiative. Prev Chronic Dis 2008;5(4).

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 225 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about four family factors that influence Anorexia Nervosa.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Associations between Parental Socioeconomic-, Family-,
and Sibling Status and Risk of Eating Disorders
in Offspring in a Danish National Female Cohort

Koch, S. V., Larsen, J. T., Plessen, K. J., Thornton, L. M., Bulik, C. M., & Petersen, L. V. (2022). Associations between parental socioeconomic-, family-, and sibling status and risk of eating disorders in offspring in a Danish national female cohort. The International journal of eating disorders, 55(8), 1130–1142.

Update
Associations between Parental
Socioeconomic-, Family-, and Sibling
Status and Risk of Eating Disorders
in Offspring in a Danish National Female Cohort

Koch, S. V., Larsen, J. T., Plessen, K. J., Thornton, L. M., Bulik, C. M., & Petersen, L. V. (2022). Associations between parental socioeconomic-, family-, and sibling status and risk of eating disorders in offspring in a Danish national female cohort. The International journal of eating disorders, 55(8), 1130–1142.

Peer-Reviewed Journal Article References:
Christian, C., Perko, V. L., Vanzhula, I. A., Tregarthen, J. P., Forbush, K. T., & Levinson, C. A. (2020). Eating disorder core symptoms and symptom pathways across developmental stages: A network analysis. Journal of Abnormal Psychology, 129(2), 177–190.

Obeid, N., Carlucci, S., Brugnera, A., Compare, A., Proulx, G., Bissada, H., & Tasca, G. A. (2018). Reciprocal influence of distress and group therapeutic factors in day treatment for eating disorders: A progress and process monitoring study. Psychotherapy, 55(2), 170–178.

Pila, E., Murray, S. B., Le Grange, D., Sawyer, S. M., & Hughes, E. K. (2019). Reciprocal relations between dietary restraint and negative affect in adolescents receiving treatment for anorexia nervosa. Journal of Abnormal Psychology, 128(2), 129–139.

QUESTION 15
What are four family factors that influence the development of Anorexia Nervosa? To select and enter your answer go to Test.

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