Christian Family Therapy with Eating Disorders
Spring 2004, Vol 3, Issue 2
Guy Braem, MD, MA, CMFT
Department of Family Therapy
Remuda Ranch Programs for Anorexia and Bulimia
But we are meant to speak the truth in love, and to grow up in every way into Christ, the head. (Ephesians 4:15; Phillips Modern English)
This Biblical verse is the basis for Remuda’s family therapy interventions. Teaching, modeling, and practicing the application of this verse within families enables family members to nourish each other “to grow up in every way into Christ”.
Remuda’s week long, intensive family therapy program consists of four major components:
• Education and preparation - Communicating information to families about eating disorders, basic family structures/roles, and family contributions to the development, maintenance, and recovery from eating disorders.
• Family therapy sessions - Called Truth-in-Love sessions, these follow Remuda’s intensive family therapy format. Format incorporates elements of family systems, structural, conjoint, trans-generational, cognitive-behavioral, 12-step, and psychodynamic approaches integrated with Biblical Christianity.
• Formal/informal sharing among families and patients - Sharing among several families to learn from and encourage one other, discover that they are not alone with their experiences, and offer accountability throughout the day and evening so that the five day Family Week is truly intensive and fully therapeutic.
• Family outings - Opportunities for each individual family and patient to be together, unsupervised within the community, to practice recently-learned relationship and communication skills and to enjoy a new freedom in being with one another.
This article focuses on one of these four components: family therapy sessions following Remuda’s Truth-in-Love format. Through this format, Remuda addresses the family issues outlined in the companion article contained in this issue of The Remuda Review.
Family Therapy Sessions: The Remuda Format
Following Ephesians 4, Remuda’s family therapy sessions are called Truth-in-Love sessions. They focus on teaching, modeling, and practicing open and honest communication in a loving way. Such communication promotes an atmosphere of safety and healing, as well as personal and family change.
In his book, Family Love, Alfred Ells (1995) writes:
Studies of family life indicate that being truthful in a loving and appropriate way is a common characteristic of healthy families. But hurtful communication and denial of truth are major traits of unhealthy families. Truth without love is destructive. So is love without truth.
In his book, The Peacemaker: A Biblical Guide to Resolving Personal Conflict, Ken Sande (1997) includes a chapter titled, “Speak the Truth in Love”. His development of this idea was independent of Remuda’s, but similar. He states: “With God’s help, you can learn to speak the truth in love by saying only what will build up others, listening responsibly to what others say, and using principles of wisdom. ‘The tongue of the wise brings healing’ (Proverbs 12:18).”
Eating disorders generally foster secretiveness, withdrawal, and isolation. Patients hide what they are doing and who they are. Speaking the truth in love breaks through the secrets and isolation in a gentle yet powerful way.
Following Ephesians 4, a Truth-in-Love session involves two parts.
Truth-in-Love: Part One. A Truth-in-Love begins with speaking the truth, or confrontation: communicating and presenting one’s history and story in a factual and informative manner. Many families have little idea what has been going on in the patient’s life with the eating disorder and some families do not learn that their loved one even has an eating disorder until just weeks or days before their loved one enters treatment. Likewise, parents have sometimes chosen not to share important personal information or marital issues with their children. Through the Truth-in-Love process, problematic family dynamics and structures–such as those outlined in the companion article in the current issue of The Remuda Review–are discussed and addressed openly in language accessible to everyday people. With open disclosure, there is an honest look at the reality of what the eating disorder and the underlying issues have done to the patient and family. This is only possible when the patient and family experience a sense of love and safety from the professionals involved and each other.
Confrontation is followed by confession. “Therefore confess your sins to each other and pray for each other so that you may be healed” (James 5:16). The families and patients learn a step-by-step process that helps them to talk about wounds and hurts, apologize, and ask for forgiveness. This process is healing and emotionally freeing. It brings relief from years of pain, blame, and shame. Sometimes our family therapists see a physical change in patients from before the Truth-in-Love to afterwards. Patients may stand straighter, look up more, make better eye contact, smile and interact more freely, and evidence greater energy. Guilt and shame may be hard masters, but freedom from them offers a powerful release.
Many times a patient’s divorced parents have not spoken to each other for perhaps a decade and cannot stand to be in the same room with each other. They come to Family Week and act civilly to one other because of the love they have for the patient. At times, through the process of Family Week, these parents ask forgiveness from one another, heal old wounds, and release years of bitterness.
We end Truth-in-Love sessions with validation: families validate and build each other up, showing that relationships consist not merely of faults but also of strengths and mutual appreciation.
This Truth-in-Love process, consisting of confrontation, confession, and validation, helps reduce the power of the secrets, shame, and fear that have paralyzed the patient and family, sometimes for years.
Truth-in-Love: Part Two. The second aspect of a Truth-in-Love session reflects the latter part of Ephesians 4:15, “to grow up in every way...” As noted in the companion article in this issue of The Remuda Review, patients with eating disorders experience difficulties in the developmental process. Those with eating disorders tend to function emotionally behind their chronological age. They are often afraid to progress because it would mean facing something fearful: more responsibility, the possibility of failure, feelings of guilt and worthlessness, a mature female body, sexuality, trauma, grief, and loss.
Eating disorder patients are overwhelmed by these feelings and do not have the means to cope with them. Ironically, they are also frightened of asking for help because they are afraid they will be hurt if they open up. Their fear is founded: people do hurt us, and the patients have been hurt in past relationships. But the means to healing relationally is also through people, the very avenue through which we have been hurt. This can seem like a double-bind or no-win situation, which can be paralyzing. Eating disorders provide a way to cope with this double-bind by numbing its anxiety and confusion and narrowing patients’ focus to something over which they feel they have control–food and weight. But using the eating disorder to cope leads to further paralysis because the original dilemma is never resolved. It is repressed and avoided and continues to control the patient.
In One Way Relationships, Ells (1990) says that, “Family is the single most powerful influence in shaping our relationships.” To heal the deep relational problems of eating disorder patients, Remuda therefore focuses on the family. The Truth-in-Love format offers patients the safety needed to uncover the relational truths they have been avoiding and, by unfreezing their emotional paralysis and that of their family, to grapple with and grow through their feared, repressed experiences. The developmental process is re-started and the patient can continue toward separation-individuation and adulthood.
To grow up, one needs a direction to grow toward. Remuda’s therapies respect individuals and their choices. Many therapy models operate on the principle that the therapist’s job is to provide a stimulus to provoke change, but then to trust the client to discern through prayer, meditation, counsel, and life experiences to know which change(s) to make and in which direction. This approach engages personal will and responsibility and relies on the guidance of the Holy Spirit speaking within the person’s conscience. Such an approach is consistent with a Scriptural understanding of human beings.
How do growth and maturity occur within families?
First, truthful and loving speech leads to a maturing of relationships. It brings honesty, respect, and self-respect into relationships and inherently believes in the capacity of the persons involved and their relationships to handle the truth and its implications.
Second, family connection and belonging form the foundation for growth, providing the freedom, safety, and stimulus to grow (Cloud & Townsend, 1992). Ephesians 4 lays out the keys to developing this sense of family belonging and connection in a child. It says: “the body ... builds itself up in love.” Love is the most basic need that human beings have (1 Corinthians 13:4-7, 13). In a loving environment, people grow. Scripture makes plain that a loving environment includes: people who believe in us, are kind and compassionate, encourage, provide safety, are honest with us, and don’t give up on us. These characteristics are the very definition of love itself (1 Corinthians 13).
Families usually come to Remuda’s Family Week out of love. The pain, fear, crises, and helplessness that families and patients have been through have stripped away denial and superficial concerns and have refocused the family on crucial issues. Coming face to face with a loved one’s possible death from an eating disorder creates a turning point in people’s lives. The things that really matter come into sharp focus and people become more willing than they have been at previous times to make difficult decisions and take needed actions. Families’ love for the eating disorder patient is awakened by this crucial moment in time; this love is encouraged, brought forward, laid bare, and intensified by the Family Week environment and experiential exercises. “Above all, love each other deeply, because love covers over a multitude of sins” (1 Peter 4:8). This deep love breaks through years of dysfunctional habits of behavior and motivates families to change. Decisions, commitments, and actions are taken that break old patterns of enmeshment, criticism, overprotection, etc., and open family systems to offer experiences of connection and belonging so that they support the patient’s development.
Third, Ephesians 4:29 continues: “Do not let any unwholesome talk come out of your mouth, but only what is helpful for building others up according to their needs...” The intent of this verse is modeled and practiced during Family Week. In loving each other, we take actions and speak words that promote the best interests of other people, to help them grow and become who God created them to be. During Family Week, families and patients work hard at the separation-individuation process. The acceptance and understanding they experience from the therapists and other families build them up and help them to see the value in this scary work. For many families, their fear can be summarized in these words: “If I can’t control what happens to my child, something bad will happen or my child may die.” When families learn how hard patients have been working toward recovery and they experience open, mature, healing communication with the patient, it helps them to believe in the patient’s ability to grow. They become hopeful and find the power to let go.
Fourth, Ephesians 4:16 states: “Each part does its work...” This expresses the idea of appropriate roles and boundaries within a family system. Family members have a specific job to do--to support, listen to, and understand the patient, and to provide models of healthy living and relationships. It is not the work of the family to play the role of caretaker, therapist, food police, problem-solver, or fix-it person for the patient’s life and problems. This understanding reemphasizes the process of separation-individuation. Often families have to learn in truth to say “no” as well as “yes”.
Finally, another way of looking at the developmental process is as integration or reintegration. As discussed in the companion article in this issue of The Remuda Review, each person is formed to be a contributing and meaningful part of a healthy, loving whole or system. No baby is born with the belief that s/he is worthless or has no purpose; no one is born with shame and guilt. As we grow, we learn these things and they isolate us from family and relationships. We forget who we are and what we feel because we no longer like ourselves or our emotions.
The Truth-in-Love process helps people to reintegrate from this isolation, both internally and externally. Families and participants validate one another, teaching each other loving and truthful self-understandings. In addition, since God created us, through his Word we learn critical truths about ourselves and our lives. Such truths are woven into the Truth-in-Love process. Through these identity-building affirmations, the Truth-in-Love process gives patients tools to deal with fear and heal shame. It helps patients to challenge beliefs that may not be true (e.g., “I am worthless”) and to learn what is true about themselves in a way that builds them up and sets them free to journey into recovery, maturity, and adulthood.
Family Perceptions of Family Week
Over 5600 patients and 15000 family members have gone through Remuda’s Family Week program. With few exceptions, they validate the benefit of the Truth-in-Love process. In their own words:
“Our family learned how to communicate.”
“We never talked before. In the Truth-in-Love we discussed taking responsibility and asking forgiveness. It changed all our relationships and I feel I have a real relationship instead of a superficial one.”
“We started to incorporate the Truth-in-Love methods into our lifestyle.”
“My family did not believe in therapy. It made a believer out of them and they went home and got in therapy themselves. It changed my family. It’s OK to cry, to feel. It brought my whole family closer.”
“Coming to Family Week was the first time they took time for me.”
“I felt safe.”
“I benefited from each and every experience.”
“I was skeptical of how this would work, but was highly impressed.”
“Family Week was an amazing opportunity to provide clarity, understanding, hope, unity, and love.”
“Family Week was amazing in assisting us to communicate with each other.”
References
Cloud, H. & Townsend, J. (1992). Boundaries. Grand Rapids, MI: Zondervan.
Ells, A.H. (1995). Family love. Nashville: Thomas Nelson.
Ells, A.H. (1990). One-way relationships. Nashville: Thomas Nelson.
Sande, K. (1997). The peacemaker. Grand Rapids, MI: Baker Books.
