THE FAMILY THERAPY OF ANOREXIA NERVOSA

Abstract

ANOREXIA nervosa is a condition which affects a population of predominantly young women preoccupied by their weight and their (misperceived) shape. The largest proportion of papers presented at this conference are concerned with the investigation of the incidence and nature of the condition and less so with the therapy. This is quite proper in the light of the many uncertainties about the subject. However, a priority of interest in causes over treatment is shared by the entire system with which we are involved. That is to say the population of anorexic subjects, their informal and family networks, and the group of professional helpers who become involved with them. All members of this system express a great interest in the causes of the condition. Certain elements in the system also express considerable commitment to preventing drastic changes in the anorexic youngsters’ weight. The young person with the symptoms of the condition is liable to avoid treatment, believing that it will impose a terrifying change on her. At the same time, she may suffer a great deal of distress about the condition and its probable consequences. The fact that the parents’ cooperation is often thought of as incomplete by the professional helpers, has been taken to suggest that they are resisting change in their daughter. The social network appears to support change, in the direction of increased weight, girth and appetite, but this is not so always, for example, in the world of ballet and fashion modelling, as GARNER and GARFINKEL (1980) and LOWENKOPF and VINCENT (1982) have suggested. From time to time we have observed ourselves and our colleagues acting in ways that appear to be the contrary of therapeutic. This is not, I hasten to add, because we have an investment in keeping our workload high but as an aspect of what can only be termed a “countertransference enactment”. We have observed ourselves or others apparently feeling so closely identified with the patient’s symptomatic anxieties, that we come, momentarily, to share her misperceptions, and to believe that therapy is making progress when in fact the patient has merely permitted herself to evade weight gain. These various locations of resistance to change are important if the subject of the family therapy of anorexia nervosa is to be put in its right context. It is important to make another, preliminary, position statement. An interest in causes has certain “associations”. Knowledge of causes sounds as if it is likely to lead to rational therapy but this is not necessarily true. Therapy that is effective may turn out, eventually, to owe its efficacy to links with causes, but a clear aetiological understanding does not have any necessary connection with the development of therapy. For example the cultural preoccupation with thinness has been suggested by GARFINKEL and GARNER (1982) to be one of the multi-factorial components in the aetiology of anorexia. Even if shown to be indubitably important, it is not readily susceptible to intervention by mental health