Remuda Ranch

Family Dynamics in Eating Disorders: An Introduction

Carolyn Newsome, MA, CPC, & Jim Schettler, MMFT, CMFT,
Department of Family Therapy
Remuda Ranch Programs for Anorexia and Bulimia

The LORD God said, “It is not good for the man to be alone...” For this reason a man will leave his father and mother and be united to his wife, and they will become one flesh... God blessed them and said to them, “Be fruitful and increase in number...” (Genesis 2:18, 24, 1:28).

And now a word to you parents. Don’t keep on scolding and nagging your children, making them angry and resentful. Rather, bring them up with the loving discipline the Lord himself approves, with suggestions and godly advice. (Ephesians 6:4; The Living Bible).

From many Biblical passages, Christians have long understood the critical role of the family in shaping children and forging a healthy society. Mental health professionals began to discuss the importance of family during the 1950s and 1960s, with pioneering work by scholars such as Virginia Satir and Salvador Minuchin. Although every person lives in many social contexts–such as society, culture, religion and friendship circles–the family is often the most influential. Satir (1972) echoed this ancient Scriptural wisdom when she recognized through her work that the family is the “factory” where people are made and that parents are “people-makers”.

In 1978, Minuchin, Rosman, and Baker treated 53 cases of anorexia nervosa with family therapy. They obtained a 90% improvement rate with positive results maintained for years. These findings dramatically demonstrated that family dynamics contribute significantly to eating disorders. Through the present time, the importance of family dynamics in the etiology and maintenance of eating disorders is widely understood. Family therapy continues to be associated with better outcomes than individual treatment alone (Howatt & Coombs, 2003). Although much individual work is clearly necessary in treating eating disorders, family therapy must be a consideration for successful and thorough treatment. When carefully integrated with Scripture, family therapy theories, conceptualizations, assessments, and skills can prove invaluable with eating disorder patients.

This article therefore examines some of the major constructs of family therapy and demonstrates the necessity and potential efficacy of family therapy with eating disorders as opposed to a strictly individual approach.

Perspectives on the Family

The body is a unit, though it is made up of many parts; and though all its parts are many, they form one body... God has arranged the parts in the body, every one of them, just as he wanted them to be... God has combined the members of the body ... so that there should be no division in the body, but that its parts should have equal concern for each other. If one part suffers, every part suffers with it; if one part is honored, every part rejoices with it. (1 Corinthians 12:12, 18, 24-26)

Just as God designs the Body of Christ to function with an integration of different talents, gifts, structures, and roles, He designs families to operate similarly. When the family is not operating as designed, problems ensue. “If one part suffers, every part suffers with it” (1 Corinthians 12:26). Problems play out within the family as a whole and in the lives of its individuals. The family is therefore a crucial element in understanding many difficulties faced by individuals, including eating disorders. Several family therapy theories and constructs express well the Biblical concept of “one body, many parts” and offer detailed frameworks for understanding how the parts interact and influence one another within the whole.

General Systems Theory (GST)

A main theoretical underpinning of family therapy models is GST. By definition, a system is a set of elements which interact with one another and their environment (Bertalanffy, 1956). These interactions tend to occur in a patterned manner through time despite changes in the environment (Benjamin, 1982). If the patterned manner is not healthy or functional, it can contribute to ongoing problems within the individual elements or the system.

Following GST, family systems theories focus on each member of the family, the relationships represented in the family, and the dynamic processes occurring within the family. Looking at individuals’ issues without considering their relationships within the family system misses important etiologic and maintaining factors of dysfunctional behaviors. Thus, although eating disorders are rarely only about family issues, families can greatly contribute to eating disorder dynamics and addressing the family effectively can enhance the possibility of recovery.

Just as systems tend to resist change, families have homeostatic mechanisms that attempt to maintain a balance or certain way of doing things even when unhealthy (Becvar & Becvar, 1982). If therapeutic work is occurring only with an individual, the system may interfere. For example, if a wife is working on her fears of intimacy by trying to draw closer to her husband, he may sabotage the increased intimacy out of his own fear of intimacy. Therapy with the wife alone would probably not work. Working on the family system is important in this situation to address both partners’ fears of intimacy and assist them in developing ways to seek a deeper relationship with one another.

Family Structure

Family structure is another element to understand when working with families. Structure includes several concepts, including power, hierarchies, coalitions, alliances, boundaries, and subsystems. Structural family therapy views changing a family’s unhealthy structures as critical in resolving problems (Minuchin, 1974). Changing the structure means changing specific ways of relating within the family.

A healthy structure entails a family with appropriate internal and external boundaries; a balance of power within the marital dyad; and parents who are in charge and who foster age-appropriate responsibility, privileges, and freedoms in their children. This ideal is frequently skewed. Common in families where there is an eating disorder is a power imbalance. The parental subsystem is either overly passive with too little power, or overly controlling with too much power.

The overly passive style forces children into maturing too quickly, does not equip them with tools to handle adult responsibilities, and leaves them confused about who is in charge. In this situation, an eating disorder may be the child’s method of getting the parents to take charge and act like adults.

The overly controlling style prevents children from developing confidence in their ability to be independent and from learning to benefit from failure. It may lead to anger, resentment, and rebellion against parental control. In this situation, an eating disorder may be used to gain more power or to rebel.

Family therapy helps render power relations appropriate for the child’s age. Teaching parenting skills, assertiveness, boundaries, and how to equip children to become responsible adults is often part of the therapeutic process.

Also common in eating disorder families are unhealthy alliances or coalitions. If the marital subsystem is weak, frequently a child becomes a surrogate spouse and provides emotional support to one or both parents. This can evolve into an unhealthy coalition where one parent/child is pitted against the other parent. Although the child may enjoy the specialness of the surrogate role, eventually resentment builds, along with feelings of pressure to maintain the role and a realization that the role has detached the child from the other parent. Guilt over abandoning the needy parent for whom the child is a surrogate may nevertheless keep the child in this role. An eating disorder may arise in this situation for several reasons. By suppressing secondary sexual characteristics, it is a symbolic way for the patient to remain child-like and avoid the confusion of being a surrogate spouse who is sexually maturing. The eating disorder delays maturation so the child can remain in the surrogate relationship indefinitely and need not deal with the desire to separate from the needy parent. The eating disorder can also be a way for the child to bring the parents together and to focus their energies back on the child rather than on themselves.

Family therapy illuminates these dynamics and provides direction to create healthier structure. In this scenario, marital therapy would strengthen the marital subsystem and parental dyad, and empower the needy parent to find more appropriate emotional support. Therapy would work with the family to create a healthier role for the child and would also help in bridging the emotional gap between the child and the distanced parent.

Multigenerational Patterns

Family therapy looks not only at the current context in which individuals live, but also at past generational contexts. It is common for patterns of relating to be passed down through the generations and to influence behavior without awareness. For eating disorder patients, the disorder may serve to influence a spouse to conform to inherited relational expectations. For example, a wife who experiences her husband as insufficiently nurturing or protective compared with multi-generational expectations may obtain additional nurturance/protection from him through the sick role associated with the eating disorder. In family therapy, it is possible to explore together what the multi-generational patterns have been for each spouse. The couple can be helped to create a shared, realistic, and healthier vision of their relationship. The underlying function of the eating disorder can then be fulfilled instead through mutually satisfying relational choices.

Relational Skills

Common in eating disorder families are communication problems, including lack of emotional communication, an unsafe environment for emotional openness, an invalidating environment, indirect or unclear communication, communication triangles, and lack of communication in general. An eating disorder may be a way of suppressing emotions so as not to express them verbally in this unsafe atmosphere or a way of communicating something indirectly. If a girl with anorexia becomes angry with her father but cannot express this openly, she can punish him by not eating and thus lead him to feel worried and helpless.

There are many resources on effective communication and conflict resolution skills. It is important to teach the family these skills as a whole because they work best if everyone is using the same skills and coming from the same frame of reference/ understanding. Family therapy can assist the family in creating a validating and safe environment for honest communication and can be the context in which new communication skills are practiced until the family trusts itself as a haven for honest expression. As healthier communication develops, the eating disorder is no longer needed as a voice or passive-aggressive expression.

Family Life Cycle

Developmental issues are often part of eating disorder etiology or maintenance. Hence, understanding both individual and family life cycle development is important. Each developmental stage brings its own challenges, obstacles, and joys. Proceeding successfully to the next stage depends largely on accomplishing the previous stage’s tasks and feelings/beliefs about the next stage (Carter & McGoldrick, 1989).

Individuals with eating disorders often fail to develop age-appropriate psychological independence from their family of origin (e.g., Root, Fallon & Friedrich, 1986). The reasons for this difficulty are many, including individual, social, and familial factors. The process of growing up is complicated in modern societies, necessitating an integration and resolution of numerous social, intellectual, financial, and technological pressures on adolescents. Consequently, today’s parents have a difficult job in steering their children through the tasks necessary to become psychologically independent. Teenagers, likewise, have more difficulty finding a functional balance between autonomy and parental support/closeness. This developmental impasse within the family system is usually characterized by suppressed feelings–particularly anger, grief, and dependency needs. These emotions may be suppressed because they conflict with the family’s understanding of ideal behavior.

Not surprisingly, then, eating disorders develop most often around the time of transition to high school or college. Puberty can be frightening because of past sexual abuse which makes becoming a woman terrifying or because of growing distance in a girl’s relationship with her father due to his inability to relate to a daughter with a mature body. Frequently 18 year-olds fear becoming adults. Some may have been overprotected and not adequately prepared for adulthood. Others may fear failure due to perfectionistic standards. Still others may fear what will happen to their family if they leave home. Will a depressed mom be okay if the patient leaves? If the family was a child-focused family, what will happen to the parents when the last child leaves? Does that child feel responsible for keeping the parents together? An eating disorder may be a way of keeping the child at home or dependent on the family for any of these reasons.

Life cycle dynamics of this kind can often be assessed and addressed most effectively through family therapy because they involve subtle communications between parents and children and messages that therapists may have difficulty uncovering without the opportunity to observe the family interacting.

Family Types Common in Eating Disorder Development

There is not a single type of family in which eating disorders arise. However, in our experience treating thousands of families we have found that families with an eating disorder member are often repressed emotionally and stuck in rigid roles and expectations. They may be unaware of these roles and expectations and the impact they are having on the eating disorder. We briefly describe five types of families commonly discussed in the literature and their relationship to eating disorder development.

The perfect family. The perfect family is similar to the idealized all-American family and embodies many positive qualities. Obviously, there is really no such thing as a perfect family, but there can be a sense that people view the family as perfect. In this circumstance, the child may feel imperfect and unable to live up to the high behavioral expectations of the family.

Perfect families are usually intact. The children feel loved and generally report closeness to the family. Achievement is valued highly. The dysfunction of the family occurs most in its prohibition of negative feelings, minimization of interpersonal problems, and promotion of fairy-tale endings to problems. Upon close inspection, many perfect families’ closeness is a sign of enmeshment or the stifling of individuality out of fear that it may threaten the family’s identity. An imbalance between autonomy and closeness prevents teenagers from moving into adulthood.

In these families, the eating disorder may become the patient’s voice. It may be the patient’s attempt to become physically perfect to fit into this perfect family. Or it may be a conscience-pleasing rebellion: “I love my family and would never embarrass them by becoming a drunk or drug addict. An eating disorder is a nice way to rebel.”

The perfect family often does not see its dysfunction and is unwilling or unable to talk about what is happening within the family. This family is at times so rigidly structured that it takes what Nichols & Schwartz (1995) refer to as “...therapeutic dynamite” to change them. Effective family therapy with such families requires powerful interventions, including activities that promote emotional experiencing.

The overprotective family. The overprotective family provides a safe and secure physical and psychological environment for children. The major dysfunction lies in the parents’ inability to change the rules to encourage independent behavior in a timely, age-appropriate manner and to support children’s need for increased autonomy during adolescence. These families provide so much for their children that children feel indebted and guilty for being angry and wanting to grow up. With too few opportunities to learn by trial and error, it is premature for children from overprotective families to leave at any age since they feel incompetent and ill-equipped to deal with the world.

In an overprotective family, eating disorders may be a means to gain independence from over-control. “You have controlled everything else in my life...you CAN’T make me eat!” The eating disorder may also be experienced by patients as a protective cocoon–a sense of security with rigid rules and requirements to hold onto as they are transitioning from the protective family into the scary world.

The chaotic family. The chaotic family moves from crisis to crisis. “When is someone going to get sick again, drunk again, scream and yell again...when are we going to move again?” Or the family schedule is so busy, rushing from soccer practice to piano lessons to church activities, that there is little routine or stability. This family experiences constant change. At times, someone consciously or unconsciously creates crisis because the family functions only in chaos. Inconsistent rules, explosiveness, and multiple problems among members also characterize this family. This family lacks role models for limit setting, resulting in an inconsistent, changeable balance between autonomy and closeness that severely interferes with the development of trust in self and others.

In this context of unpredictability and insecurity, an eating disorder can become the one predictable factor. Children have been unable to develop trust in themselves or anyone. The eating disorder becomes something they learn to trust. It is always there for the child; no one can take it away. It sets rules on how to use one’s time, what are good and bad behaviors, etc.

The enmeshed family. Enmeshed families are overly close and dependent on one another. There are poor emotional boundaries and little privacy. There is a strong message, spoken or unspoken, that “our family is all you need”. In the enmeshed family, the child cannot develop a separate, autonomous life. In this context, an eating disorder can become the patient’s voice, as s/he perceives no right to have opinions other than the family’s. An eating disorder can establish an identity apart from the smothering enmeshment the patient is feeling. Being “the bulimic one” is at least an identity that distinguishes the patient from the rest of the family. The eating disorder can also fulfill the need for separation and individuation, since its behaviors clearly violate the family’s rules and norms and allow patients to make their own choices.

The disengaged family. In contrast to the enmeshed family, relationships in the disengaged family are overly distant and independent. Self-sufficiency is an important virtue in this family. Home is primarily a place to eat and sleep, and relationships are superficial. Using the common analogy, in the disengaged family there is insufficient strength in the children’s roots so they cannot develop strong wings. They may be launched into flight without sufficient security.

In this context, an eating disorder brings people together because a loved one is ill, and it gives the person with the disorder much needed attention and support. At times, we have heard patients say that they do not want to give up their eating disorder because “My dad won’t talk to me again. He was too busy for me until I got anorexia.” Sometimes patients fear their parents will divorce if they recover, because they have experienced the eating disorder bringing the parents together and working hard to communicate whereas parents were not communicating prior to the eating disorder.

Common themes across family types. Although these five family types are different in significant ways, they also have similarities that can promote eating disorders.

• In each family type, individuation is impeded, whether by the uniformity of the perfect family, the dependency of the overprotective family, or the lack of consistency in the chaotic family.
• Each family type becomes rigidly closed to outsiders when their rules of functioning are threatened. The perfect family shuts strangers out by exceedingly high and rigid expectations and intolerance for differences. The overprotective family has an implicit assumption that no one is good enough for their child. The chaotic family’s internal organization is marked by an inconsistent rules structure that allows the family to create convenient rules to exclude anyone who threatens them.
• In each family type, there is incongruence between non-verbal and verbal communication regarding feelings, especially anger, grief, and dependency. This incongruence between non-verbal and verbal communication impedes children’s trust in their perceptions and feelings; repeated experiences of incongruence lead to a fragile sense of identity and self-esteem.
• Each family type has difficulty resolving conflict, often pulling children into marital conflicts and failing to teach children how to deal with real-world conflicts effectively.
• In each family type, parents may be inappropriately dependent on their children. In perfect families, there may be too much dependence on children to affirm parents’ identities. In overprotective and enmeshed families, there is often a dependence on the child for companionship. In chaotic families, there is physical and emotional dependence on children for responsibilities, including caretaking of parents with multiple social and occupational problems. With all forms of dependency, the child does not have permission to be psychologically autonomous–a necessary internal condition for successfully leaving home.

The distinct and common dysfunctions combined in these family types are significant enough to derail the families’ ability to launch their children into psychological independence. The therapist is therefore challenged to help these families allow their children to grow up.

Concluding Thoughts

It is not easy to work with most eating disorder families. Family members often distrust the therapist, fearing they will be blamed for their loved one’s disorder. They feel shame, which they mask with myriad well-developed and sophisticated defenses; they are fearful of being judged. These feelings are intensified because they are scared their loved one might die. Furthermore, the conflict between verbal and nonverbal communication within these families, the closed nature of the family system when it is threatened, and some of the families’ ability to appear to function better than they actually do–each of these confound traditional, verbal therapeutic communications.

These families need to experience grace if they are to open up, be free to expose their shame, talk about their feelings, and receive healing. Jesus was able to confront the woman at the well with her dysfunctional relationship patterns because He did it with grace (John 4:6-30). He showed her acceptance and respect, which she was surprised to receive. She was then able to deal with her shame and to tell others both about her history of dysfunction and her healing experience. Jesus spoke the truth in love, which is what hurting families need (Ephesians 4:15, 25).

Consistent with this Scriptural understanding, Satir (1972) held that demonstrating caring and acceptance is the key to helping people overcome their fear, reveal their experiences, and open up to each other. In our experience, families with eating disorders desperately need this caring and acceptance. A willingness to understand and accept–rather than an anxious eagerness to change the family–enables therapists to help people discover and acknowledge deeply held, but poorly understood, fears, desires, and family dynamics. When therapists break the family system’s rule by talking openly about shame and the issues that cause it, they break the invisible bondage that entraps the family members, helping the family to take steps toward self-respect and integrity.

As Gerald May (1991) expressed: “Grace is the most powerful force in the universe. It can transcend repression, addiction, and every other internal or external power that seeks to oppress the freedom of the human heart. Grace is where our hope lies.” Family therapists are privileged to bring God’s grace into family sessions, transcending repression and opening the hearts of family members to experience freedom.

In short, without looking at family issues in eating disorder patients, important etiologic and sustaining elements can be missed. Although much individual work needs to occur with eating disorders, family therapy better addresses some of the key elements. There are obviously no perfect families, but families that function more in keeping with God’s design for the family can liberate blessings that God intends for families to give and profoundly support the recovery of individuals with eating disorders. “If one part suffers, every part suffers with it; if one part is honored, every part rejoices with it” (1 Corinthians 12:26).

References

Becvar, R. J., & Becvar, D. S. (1982). Systems theory and family therapy: A primer. Lanham, MD: University Press of America.

Benjamin, M. (1982). General systems theory, family systems theories, and family therapy: Towards an integrated model of family process. In A. Bross (Ed.), Family therapy: Principles of strategic practice (pp. 34-88). New York: Guilford.

Bertalanffy, L. (1956). General systems theory. Behavioral Systems, 4, 1-10.

Carter, B., & McGoldrick, M. (1989). Overview of the changing family life cycle: A framework for family therapy. In B. Carter & M. McGoldrick (Eds.), The changing family life cycle (pp. 3-28). Boston: Allyn and Bacon.

Howatt, W. A, & Coombs, R. H. (2003). Psychosocial recovery tools for addictive disorders. Counselor: The Magazine for Addiction Professionals, 4, 58-61.

May, G.G. (1991). Addiction & grace. New York: Harper Collins.

Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.

Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. Cambridge, MA: Harvard University Press.

Nichols, M.P., & Schwartz, R.C. (1995). Family therapy: Concepts and methods (3rd Ed., p. 300). Boston: Allyn and Bacon.

Root, M.P.P., Fallon, P., & Friedrich, W.N. (1986). Bulimia: A systems approach to treatment. New York: Norton Books.

Satir, V. (1972). Peoplemaking. Palo Alto, CA: Science and Behavior Books.

Christian Family Therapy with Eating Disorders

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.