Body of Evidence

Dispatches from the forefront of eating disorder science

The Real Relationship Between Families and Eating Disorders

Improving eating disorder symptoms means improving family functioning.

When I first began therapy for my eating disorder over ten years ago, the relationship between my family and my eating disorder was obvious. My family was obviously dysfunctional--otherwise, why would I have an eating disorder. The evidence was everywhere. My mother was stressed and hovering, asking me if and when and what I had last eaten. My dad was distant and unemotional. I was angry and defiant.

Looking back, the signs seemed even clearer. I didn't feel I could express my real emotions. My parents didn't want me to grow up. I didn't have a voice, and so I used my body to express myself. As my illness progressed, so did the family discord. Phone calls deteriorated into slanging matches. Home life became almost unbearably stressful.

Flickr photo by Nicki-G
Enter family therapy. Underweight and barely eating, each week my parents and I duly attended family therapy each week where we worked on what my parents needed to do (or stop doing) in order for me to eat. Anorexia was my only means of control in my life, and my parents' encouragements for me to eat were just making things worse. My eating disorder would get better only when we fixed our family problems.

In the past decade, though, the evidence supporting the role of parents in eating disorders has become clear. Last year, the Academy for Eating Disorders issued a statement that said parents don't cause eating disorders. Other studies have shown that the family dysfunction that exists in people with eating disorders is equal to that seen in other chronic illnesses. It likely results from the stress of the disorder and not as an underlying cause.

But a new study followed a group of 102 adolescent eating disorder patients and their families and indeed found a stressful family climate during acute illness. The researchers, however, reassessed the families at 18 and 36 months. At the final assessment, parents of recovered patients reported higher levels of family closeness and lower levels of family distance than the parents of those who hadn't recovered. The most interesting part of the study was this finding:

Changes in eating disorder symptoms preceded changes in family climate. 

This timeline could quite possibly be the most important finding of the study. If family dysfunction caused an eating disorder, then recovery could only proceed after the family dysfunction was resolved. But that wasn't the case. Improvement in eating disorder symptoms was what caused family functioning to improve. If the researchers hadn't followed the families over time, from diagnosis onwards, they never would have teased out the exact relationship between recovery and better family functioning.

An eating disorder is a phenomenally stressful illness. Every meal brings arguments and worries. Is my child going to eat? Are they going to run to the bathroom to purge after? Will they exercise it off? The person with the eating disorder is anxious and depressed, they feel compelled to engage in behaviors, yet embarrassed of their symptoms.

Recovery begins to ease all of these stresses, which thus improves family functioning.

This isn't to say that difficulties in family functioning can't impede recovery, and that helping the family communicate and function better can make recovery happen more easily. It also doesn't say that family dysfunction doesn't occur in people with eating disorders, because that's not true, either. What this study does say is that eating disorder recovery precedes improvements in family functioning.

The therapists I saw so many years ago really got the cause and effect backwards: to make my family work better, we needed to tackle the eating disorder first.

Carrie Arnold is in recovery from a decade-plus battle with anorexia and is working on her third book, Decoding Anorexia: How Science Offers Hope for Eating Disorders.

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