Emotion-Focused Family Therapy for Eating Disorders
By Dr. Adele Lafrance, PhD, C.Psych
Some say necessity is the mother of invention. That was certainly the case with the development of Emotion-Focused Family Therapy (EFFT) — a treatment model designed to help caregivers support their loved one’s physical and psychological recovery from an eating disorder (ED). For a number of years, I worked as a family therapist in a hospital-based ED treatment program in Canada. We followed the best practice guidelines to support families to wellness in many cases. There were some families, however, who did not recover in spite of our best efforts and through no fault of their own. I started to recognize patterns in the cases who were deemed “non-responsive” and found that many seemed to be related to challenges with emotion – whether that of the affected child, their parents, or even their clinician and treatment team.
Affected Individuals. Many adolescents and adults in treatment for an ED share that their symptoms serve a purpose, that of control. Control of what though? Their body? Their environment? Their lives? What I discovered alongside other researchers in the field was that ED symptoms served to control, numb, or even suppress the experience of uncomfortable emotion, whether it was fear, sadness, anger, shame, or all of the above. Therefore, a recovery focused on behavioral symptoms was necessary, but not sufficient. In fact, I observed many young people “recover” from an ED only to then develop other mental health disorders, including problems with substances. The ED symptoms resolved but the emotional processing deficits fueling the illness persisted and were sometimes expressed in other ways. As such, I felt strongly that a recovery focused both on behavioral symptoms and emotion processing was critical, especially for those individuals who didn’t respond to standard treatments.
Parents and Caregivers. More and more, the field is recognizing the healing power of caregivers in the treatment of ED across the lifespan. However, when parents and caregivers take on meal support and symptom interruption, their supportive actions sometimes lead to emotional distress for their loved one. I will never forget the first time that I heard from a parent that when they insisted that their child eat one more bite, plates went flying. In response to their loved one’s sometimes uncharacteristic displays of emotion, many parents report feeling paralyzed with fear – fear that they were somehow making their child worse, or that their child’s obvious distress could lead them to tumble into depression, or worse, lead to suicidal thoughts, urges or actions. This fear can also rob caregivers of their confidence in the treatment approach, and sometimes lead them to withdraw or even to engage in behaviors that enabled the ED symptoms. Sound familiar? If so – you aren’t alone.
Clinicians and Teams. I found that clinicians were not immune to the influence of emotion either. Over the years, I had the privilege of conducting research in this area and listened to the stories of many clinicians who shared with me that they too had been hijacked by emotion in a way they believed interfered with their ability to support families toward recovery. We really are all human! For example, some clinicians shared with me that they sometimes excluded parents from treatment if they felt they were being obstructive or were too critical. Others shared that they avoided difficult topics if they thought their client might become angry or complain about them to their supervisors. I was so grateful that these clinicians took the risk to share their vulnerable experiences so that together we could start to figure out how best to address these emotional challenges.
And so, on the basis of these and other observations, EFFT for ED was born. Along with Dr. Joanne Dolhanty, I drew from caregiver experiences and the wisdom from the many clinicians and researchers who came before us in order to create a model that could serve as a roadmap for both the physical and emotional hurdles along the path to recovery. These wise men and women include Ivan Eisler, Janet Treasure, James Lock, Daniel Le Grange, Leslie Greenberg, Daniel Siegel, and many more.
The EFFT Model
There are three main areas of intervention in EFFT for ED. They include supporting caregivers to become agents of change by increasing their involvement in supporting their loved one with: 1. meal support and symptom interruption, 2. emotion processing, and 3. the healing of family wounds – whether related to relationship injuries, or the burden of child and/or parental self-blame. Parents and caregivers are taught specific strategies in each of these three domains with opportunities to practice. The associated skills are designed for use in person, over the telephone, even by text or e-mail for those caregivers who live far away. Caregivers are then taught to combine these three sets of skills to increase their effectiveness. For example, not only are parents taught meal support techniques – they are also taught emotion coaching strategies so that they can respond effectively to the emotional reactions that often surface ahead of, during, or after meal times. If a parent or caregiver hesitates to become involved in their adult child’s treatment because of a strained relationship, the EFFT clinician helps the caregiver to strengthen, or even repair the relationship with their loved one. Doing so increases the willingness of their loved one to include their caregiver as a collaborative partner in their ED recovery.
Caregivers are encouraged to take on these roles regardless of their child’s age, level of motivation, or involvement in formal treatment, thereby creating hope for those families for whom the affected child refuses service. And, if a caregiver struggles to support their loved one’s recovery in these ways, the EFFT clinician simply encourages the caregiver to move through these impasses using specific tools and therapeutic techniques.
Caregiver Blocks. In EFFT, caregiver “emotion blocks” are defined as behaviors that interfere with caregiver confidence and supportive efforts that are fueled by emotion – most often fear and self-blame. In fact, process research has revealed that the more fear and self-blame caregivers experience, the lower their belief in themselves and their role in their loved one’s recovery and the more likely they are to engage in behaviors that accommodate or enable ED symptoms. For example, if caregivers are scared that their loved one will become suicidal if pushed too hard with meal support, they are more likely to “back off” out of fear. When such blocks surface, the EFFT clinician supports the caregiver – without judgment – to identify and work through these emotion blocks to help them get back on track with supporting their loved one. This means that, in these instances, rather than deeming parents and caregivers as “unsupportive” or their involvement as “inappropriate,” clinicians can target the emotions fueling these processes and enlist caregivers as powerful and positive agents of change.
Clinician Blocks. Similar to above, when emotional blocks occur in clinicians, they commit to identifying and working through their own problematic reactions that arise through “emotion-focused” self-reflection and supervision. For example, well-intentioned clinicians may discourage a caregiver’s active involvement in their child’s treatment if they 1. present with high expressed emotion, 2. engage in overt criticism of their loved one, or 3. display symptoms of a mental health issue or personality disorder. Although there may be valid limitations or concerns related to the involvement of such caregivers in treatment, we’ve found that more often than not, when clinicians can work through their apprehension using the tools and techniques of EFFT, they can uncover new avenues for working with these caregivers in a positive manner and with the knowledge that a little bit can go a long way.
Food, Feelings, and Family – Oh my!
Eating disorders are associated with high rates of illness and premature death. They seriously impair one’s quality of life and are considered very difficult to treat. Although parents and caregivers are regarded as important agents of healing when the patient is a child or adolescent, this is not necessarily the norm when the individual with the ED is over the age of 18 or when caregivers are thought to be obstructive. Yet, research shows that with targeted support and skills training, parents and caregivers can play a significant and positive role in their loved one’s recovery, even if at first, it doesn’t seem so. And when their emotions take over and they behave in ways considered less than optimal – a very normal experience when faced with a life-threatening illness – parents, caregivers and clinicians deserve compassion and support in order to navigate these roadblocks. Developed first as a treatment for ED, the application of EFFT has now expanded to general mental health with research showing promising results for individuals and their caregivers.
For more information on EFFT, please visit: www.emotionfocusedfamilytherapy.org
About the author:
Adele Lafrance, PhD, C.Psych is a Clinical Psychologist and Associate Professor in the Psychology Department at Laurentian University. She is also the co-developer of Emotion-Focused Family Therapy. Dr. Lafrance has published extensively in the field of clinical psychology and currently supports the research base for EFFT across the lifespan. She has developed and researched a supervision model for clinicians and acts as a consultant and trainer for individual clinicians and organizations worldwide. Dr. Lafrance is perhaps best known for her work promoting family-focused clinical care for children, adolescents and adults struggling with mental health issues, including eating disorders.
Adele, this is a great piece, and so needed in the field. This is the first time, I’m reading a deeper understanding of the complexity of ED in the family system, and including this in the individual’s treatment.
Like Virginia Satir’s first work in Family Based Therapy, prior to that, the individual issues were treated as exclusively their own creation. We are interconnected beings and family dynamics create, stimulate and maintain these internal “coping strategies” and faulting the individual alone I believe robs them of the recovery they struggle to find. “Inoculating” the individual against future behaviours from the family is part of this process, however, it’s not enough. Recovery and relapse seem like they are just a breath apart. I’m so grateful for your insights and deeper understanding of the family’s focus.
More recently with the discovery of Mirror Neurons in 2007, it now serves to validate the importance of responding to others to create a connection. This powerful bond between mother and child influences recovery daily. The withdrawal of support, subsequent anger and frustration are all felt as the individual struggles with the recovery process, often dragging them back through their personal timelines into triggering emotions.
When mothers withhold connection to maintain control, express negative emotions, or simply through patterns of behaviour they have not emotionally matured themselves; they not only maintain the cycles of drama, they ensure they have continued support for their emotional needs.
With my cases, I insist I see the mother to ascertain her awareness and availability in supporting the recovery. I have also found the clients with Eating Disorders have a higher than normal EI dysfunction and seem to have an aborted maturity at approximately the age they start the disordered eating. Their EI development is critical post-recovery, and this is often where the disorder has stopped while the EI continues to dominate the landscape in failed attempts, self-imposed criticisms and lack of self-worth. This wobbly and self-defeating pattern needs patience and maturing strategies. Allowing with internal permission, the ability to experiment with life, and fail, and review the feedback. Adjust and try again. The internal critic must be satisfied and supported as EI matures. And the family(mother) is often in crisis as their ‘scapegoat’ is no longer sustaining the behaviours. This is no way, lays blame at the mother’s feet, however, it draws to attention the vast need for the Emotional Family Based Therapy to which you so eloquently write. It’s so needed if these individual families are to recover.
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