Australian and New Zealand Journal of Family Therapy 2019, 40, 203–214

doi: 10.1002/anzf.1363

Addressing Emotional Communication in

Family Relationships in the Treatment of
Young People with Anorexia: A Case Study
Heidi Joyce1 and Greg Dring2
1
Brownhill Centre, Cheltenham, UK
2
Independent Practice, Bath, UK

Family-based treatment (FBT) is an evidence-based approach to anorexia nervosa in young people. Because it is
not always successful, attention has been given to how families experience the treatment. A number of therapists
have proposed possible additions to, or improvements in, the model. In successful cases relational containment
may be achieved in the first phase of treatment. The treatment is often successful, but when initial goals, such as
weight recovery, are not achieved, continuing to use the techniques described in the manual may become unhelp-
ful. Sometimes therapists may need to address issues such as emotion coaching that are not specifically addressed
in the FBT model. We describe a case in which the therapist addressed the family’s emotional style in the first
stage of treatment. This focus enabled progress to be achieved despite the adolescent’s continuing difficulty in eat-
ing without parental support, and her escalating symptoms of anxiety and obsessional compulsive disorder
(OCD). Therapy helped the adolescent and family understand that anorexic and OCD symptoms can be under-
stood as a way of distracting from and managing distress. When this connection was made in therapy, the parents
could help their daughter to manage distress in more adaptive ways. Parents may need help with their own diffi-
culties in processing distress. In this case the parents needed the opportunity to resolve feelings of grief about a
miscarriage in order to do so. We propose that therapy should address family difficulties with managing distress
from an early stage.

Keywords: anorexia, family-based treatment, Maudsley model, adolescence, emotion-based, attachment

Key Points

1 Family-based treatment is an evidence-based approach to the treatment of anorexia nervosa in young peo-
ple.
2 The treatment is often successful, but when initial goals, such as weight recovery, are not achieved, continu-
ing to use the techniques described in the manual may become unhelpful.
3 In order to progress, families may need the therapist to help them process communication about distress.
4 In this case the therapist helped parents to process unresolved distress about a miscarriage. This seemed to
unlock further communication between the parents as a couple and then with their anorexic daughter.
5 We propose that managing distress be presented as one of the initial goals of therapy, and discussed at an
early stage.

Family therapy has been demonstrated to be an effective treatment for children and
adolescents with anorexia nervosa, at least when it is undertaken within three years of
onset. This holds true irrespective of the family therapy treatment model employed. A
remission rate at the end of treatment, or at follow-up, of roughly two-thirds of ado-
lescents treated is reported in case series and comparative trials (Eisler et al., 2000; Le
Grange, Eisler, Dare, & Russell, 1992; Minuchin, Rosman, & Baker, 1978; Paulson-

Address for correspondence: Greg Dring, Independent Practice, Bath, Somerset, UK.
gdring2000@yahoo.com

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 Heidi Joyce and Greg Dring

Karlsson, Engstrom, & Nevonen, 2009; Russell, Szmuckler, Dare, & Eisler, 1987;
Wallin, Kronovall, & Majewski, 2000). Most recent studies (Lock, Couturier, &
Agras, 2006; Loeb et al., 2007; Lock et al., 2010) have been based on the treatment
manual (Lock & Le Grange, 2013; Lock, Le Grange, Agras, & Dare, 2001). This
approach is called family-based treatment (FBT).
Almost all studies that have published data relating to outcome have adopted the
strategy initiated by Minuchin et al. (1978). At the outset parents are asked to take
responsibility to manage improvements in eating. Parents are guided to supervise their
anorexic child’s meals with the aim of restoring a healthy weight. There are good
pragmatic reasons to adopt this approach. In many cases it leads to a rapid improve-
ment in the young person’s physical health. It is then possible to hand back decisions
about eating to the adolescent. Often, this is followed by improvements in mental
state, and a reduction in those tensions in family relationships that arise from the
presence of a life-threatening psychological disorder.
Currently, the dominant treatment for eating disorders is the Maudsley Model,
(Dare & Eisler, 1997) or its manualised equivalent, FBT. The model is based on the
proposition that perceived relationship difficulties in the families of young people
with anorexia are a result of the tensions arising from the existence of the anorexia in
the system. It does not seek to explain the onset of anorexia. It argues that uniting
the family, especially the parents, in challenging the symptoms, leads to a virtuous cir-
cle of change. The parents’ relationship is strengthened by their experience of ensur-
ing their adolescent’s physical recovery. The young person’s mental state is helped by
the improvement in their nutritional state. The therapist can then help the parents
support their adolescent in engaging with age-appropriate developmental challenges
such as peer relationships. Finally, the therapist can address issues in the parental dyad
that may arise when the adolescent moves towards a greater investment in relation-
ships outside the family and eventually leaves home.
Nonetheless Lock and Le Grange (2013) acknowledge that 50% of young people
are not fully recovered from the eating disorder at the end of treatment. Lock et al.
(2006) followed up adolescents treated with FBT for 4 years, on average, finding at
least two-thirds required further psychological treatment, and/or medication. An
unpublished manual by the Maudsley therapists (Eisler, Simic, Blessitt, & Dodge,
2016), emphasises the value of a wide range of family therapy approaches, including
those drawn from attachment theory, especially in cases where it is difficult to make
progress. This manual has yet to be specifically tested in research.
A number of difficulties can be encountered by therapists using the FBT manual.
Despite therapeutic efforts to support the process of taking charge of the young per-
son’s eating, parents may sometimes struggle to make changes. When progress is
made with weight recovery, some adolescents are unable to take back control and
maintain a healthy weight. In that case they may develop a long-term dependency on
parental supervision. Such a situation makes it difficult for them to enter into age-
appropriate independence and peer activities. In some cases when weight recovery is
achieved, the adolescent experiences continuing severe anorexic anxiety, leading to
depression and self-harm. Sometimes the adolescent may experience severe obses-
sional-compulsive disorder (OCD) post-treatment, and this may be as disabling and
challenging to family relationships as the anorexia had been.
Difficulties encountered with the FBT approach may arise because the approach
does not sufficiently address the distress that drives the anorexic symptoms. This may

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sometimes account for treatment failure or for the continuing difficulties reported
in many cases by Lock et al. (2006). Since some adolescents do not benefit, and
some are left with residual symptoms of anxiety and depression requiring further
treatment, in many cases therapists may be confronted with a need to provide further
treatment.
Wallis et al. (2017) report a qualitative study of changes in family relationships
resulting from FBT. They drew their observations from interviews with members of
33 families successfully treated (emphasis added). These were drawn from a larger sam-
ple with varying outcomes. They argue that when FBT is successful the structure and
therapeutic leadership it provides creates ‘relational containment’ for the young person
and family. By implication, in less successful cases ‘relational containment’ may not
be achieved. In that situation progress is not made and the difficulty then may be that
the therapist will simply repeat efforts to have the parents take charge. They argue
that progress can be made if the therapist can reframe adolescent anger and distress as
care-seeking. This helps parents take a less critical stance. Then, ‘Providing time in
sessions to help adolescents’ articulate their experience, and supporting parents to lis-
ten in a validating way may be an important way to help the adolescent engage and
seek support . . .’ (Wallis et al., 2017, p. 9).
Conti et al. (2017) describe a qualitative study of a single case in which weight
recovery was not achieved despite the use of the FBT approach. In that case they
argued that it is counter-productive for therapists to continue attempts to follow the
manual. The parents felt criticised and undermined in the parental role when they
were unable to help their adolescent achieve weight recovery. In addition, Conti et al.
(2017) argue that the approach may offer little to the adolescent, since it ‘. . . sets up
the task as adversarial where the aim is to vanquish the problem from a person’s life;
such an aim leads to increased vulnerability and fatigue and reduced personal agency
. . .’ (Conti et al., 2017, p. 422).
Faced with such difficulties, and given the relatively limited treatment effective-
ness of FBT (Richards, Subar, Touyz, & Rhodes, 2018), a number of therapists have
proposed that in such cases additional approaches should be offered when problems
persist after FBT. Some of these approaches focus on the communication and pro-
cessing of emotional distress. For example, Robinson, Dolhanty, and Greenberg
(2015) argue that emotion-focused family therapy (EFFT) should be used as an add-
on to FBT when progress is difficult. In this, the parents become the ‘emotion
coach’ for their child. The approach also addresses parents’ own ‘emotional blocks’
to managing re-feeding such as may arise when a parent is overwhelmed with feelings
of depression, or shame about perceived failures to be effective, or in parenting more
generally. Peterson, Fischer, Loiselle, and Shaffer (2016) describe a case in which the
father of the adolescent was experienced as making excessive demands for perfor-
mance. Emotion coaching for the adolescent, and for his parents, was used after the
adolescent had achieved weight recovery in FBT. Wagner et al. (2016) argue that
attachment-based family therapy (ABFT) should be used as an add-on treatment. In
this approach the therapist works with the adolescent to identify ‘attachment rup-
tures’ and prepares the adolescent to discuss these with their parents.
In one way or another all these approaches facilitate emotionally laden communi-
cation between the young person and their parents. There is currently insufficient data
to judge the therapeutic effectiveness of these approaches (Richards et al., 2018).

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 Heidi Joyce and Greg Dring

We present here the case of an adolescent girl who remained dependent on paren-
tal supervision despite weight recovery and presented with disabling OCD after treat-
ment. The case describes the work of a therapist who followed the treatment manual
initially yet at an early stage also provided an active focus on family relationships and
emotional communication. It illustrates how such an approach can unlock progress
when the adolescent continues to struggle with symptoms of anxiety and eating disor-
der despite achieving weight recovery.

Case Study
Issues of confidentiality and consent
The family consented to the use of their material in this case study. Names and bio-
graphical information have been withheld to protect their confidentiality.

Assessment and initial engagement

Rachel was referred to the Eating Disorder Service at age 13. There had been a grad-
ual weight loss in the previous 6 months. At the time of the initial assessment she
was 80% of the median body mass index (BMI) for her age. She was restricting her
eating and engaging in extreme over-exercise, and micro-movements. There were no
other compensatory behaviours or evidence of loss of control of eating. Rachel had a
pre-existing undiagnosed anxiety disorder and OCD characterised by routines and
rituals around daily activities such as bedtimes. Her obsessional rituals had not been
focused on eating issues prior to the onset of her eating disorder.
Rachel had experienced a sequence of losses and transitions prior to the emergence
of the anorexia. These included her older brother leaving home and the family mov-
ing house. Rachel’s mother talked about the very recent loss of her own mother a few
months prior to the assessment. She felt out of touch with her sadness, and the par-
ents said that they usually did not express sadness and distress.
The FBT approach was presented to Rachel’s parents and they accepted the treat-
ment proposal. They saw themselves as practical people and willingly engaged with
the task of supervising meals.

Commenting on family patterns of relationship and emotion expression at an early stage

The next session focused on the parental supervision of meals. Instead of observing an
actual meal, in the manner described by the manual, the therapist invited the family to
enact their behaviour and positioning at a mealtime. She observed that the parents were
skilful in feeding and challenging anorexic behaviours but that they felt overwhelmed
and frustrated by Rachel’s resistance to eating. The therapist observed that Rachel’s par-
ents sat either side of her, to support her in eating, as they did at home. They would
lean in and touch her in an attempt to soothe her when she became agitated but this
seemed to make things worse. The therapist suggested this might communicate their
anxiety rather than being a containing experience for Rachel.
In addition she saw that Rachel cooperated more with her mother than with her
father, creating a split. Rachel was able to say that she thought her parents had differ-
ent approaches and were not consistent. It was noticeable that Rachel’s mother
appeared empowered against anorexia and task-focused when supporting eating. Her
father felt helpless in his efforts to negotiate with Rachel. After the discussion of the

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session Rachel’s parents became more united in their approach. Despite this change
weight loss continued. After 4 weeks Rachel’s weight had fallen to 75% of her med-
ian BMI. At this point different treatment options were considered including inpa-
tient treatment. This mobilised the family. Rachel’s parents became increasingly
empowered and united in managing re-feeding. Their increased cohesion in managing
the eating situation was reflected in a gradual weight restoration.
Rachel’s weight chart showed a consistent weight recovery over the next few
months. However, despite this progress, Rachel responded with greatly increased anxi-
ety, increased ritualistic behaviour, and exercising. Some of her rituals were not speci-
fic to eating disorder, for example, daily routines and counting rituals. Although
Rachel’s physical health was improving, reflecting her weight restoration, the family
described increasing conflict and strain in family relationships. Rachel’s obsessive ritu-
alised behaviours were intrusive and had a pervasive effect on family life. Her parents
felt frustrated and helpless.

Emotion-focused family therapy (EFFT) workshop

At this point it was possible to offer Rachel’s parents the opportunity to attend a
workshop for parents in the EFFT approach. Both parents were keen to accept, and
expected to learn more skills. This fitted with their perception of themselves as practi-
cal people. The 2-day workshop was presented to a group of parents and clinicians.
EFFT is based on the idea that eating disorders develop because the adolescent strug-
gles to cope with distress so that emotions are either avoided, or are experienced as
overwhelming (Robinson et al., 2015). The eating disorder re-directs the adolescent’s
attention away from sources of distress. Parents are encouraged to attend to the physi-
cal signs that indicate unexpressed aspects of emotion, to name the emotion, to vali-
date it, and to meet the emotional need. The outcome of this experience for Rachel’s
parents was that they recognised their own struggle with emotional expression. The
insight developed by her parents was not reflected in symptom reduction for Rachel.
She continued to experience pervasive OCD and anorexic cognitions.

Handing control back to Rachel

Six months after the beginning of treatment Rachel was restored to a healthy weight.
At this stage the therapist, and Rachel’s parents, started to gradually hand back con-
trol of eating to Rachel. She found this very difficult. The therapist attempted graded
exposure to managing one snack at school with her peer group. This led to an escala-
tion of anxiety and distress. Rachel managed eating relatively well when her mother
took charge. At this stage her relationship with her father was strained. Rachel
expressed her frustration with her father and felt misunderstood. He acknowledged
that his impatience with her translated into anger. The family all recognised that the
father’s anger was experienced as criticism, and this seemed to fuel Rachel’s distress.
Rachel’s increased anxiety and obsessions presented a severe problem. Additional
individual treatments were attempted using medication and cognitive behaviour ther-
apy (CBT). Family work continued with a focus on re-integrating Rachel in school
and addressing remaining difficulties with eating. These were: tackling ritualistic beha-
viours with foods, managing her anxieties about eating independently and eating in
social situations with peers. Despite these efforts in the next few months, Rachel lost
some weight and it was necessary to re-engage her parents in supervising her meals at
times. It remained difficult for her to eat without her parents’ support.

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 Heidi Joyce and Greg Dring

Rachel completed individual CBT for OCD with a psychologist but her OCD
symptoms remained pervasive and intrusive.

A turning point
Eighteen months after the beginning of treatment there was a session with the family
that seems to have been an important turning point. Rachel’s parents had been dis-
cussing how to manage the summer holidays. Her father had suggested his wife take
Rachel on holiday without him and his wife was angry about this suggestion. Rachel
became aligned with her mother. Rachel’s voice and demeanour changed, and both
mother and Rachel seemed to reprimand her father. Rachel became angry and
shouted that she worried they were going to split up as she thought they hated each
other. In this way she revealed a fear they had not been aware of.

The therapist names the unexpressed feeling

The therapist commented that Rachel’s mother seemed distressed but that this was
masked by her anger, and that she seemed unable to acknowledge her distress to her
husband. The therapist said she thought that the unexpressed distress gave rise to the
anger and suggested a separate meeting with the parents at the next session.

Developing the discussion of both anger and sadness

In that session the therapist reflected on the theme of anger and sadness. Rachel’s
mother described her struggle with sadness and with letting her husband know when
she needed emotional support. She talked about crying when she miscarried, before
her pregnancy with Rachel. This miscarriage had not been mentioned before in the
course of the work. Rachel’s mother reflected on her memories of intense sadness and
remembered sobbing with physical pain at the time. She became distressed and tear-
ful. At that point her husband leaned towards her in an attempt to comfort her, but
his action seemed to block her feelings.

Coaching emotional support

At this point the therapist partially mirrored the father’s action of leaning towards the
mother, and invited him to interrupt his natural and familiar response and to find
another way to offer support. She discussed emotional holding, for example, making
eye contact and being present without making physical contact. Mother was able to
reflect that her husband ‘being there,’ without leaning in enabled her to access and
connect with her sadness. She cried freely and said she had not previously allowed
herself to feel sadness, or to cry in this way, since the miscarriage. She realised she
had not been able to express her sadness when her own mother died. Instead she had
just ‘got on with things.’ Mother thought that Rachel becoming ill had become her
most immediate concern, distracting her from her own distress.

Linking symptoms and parental behaviour to unexpressed distress

The therapist proposed to the parents that this distraction from distress might also
have been mirrored in Rachel, that her illness distracted her from her own emotions.
The therapist shared with the parents her recollection that they unintentionally shut
Rachel down when they both leaned towards her and touched her. Trying to comfort
her in that way seemed to become a block for her emotions. In this way the family
had a shared pattern of avoiding expressions of distress. She thought that leaning in

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and touching Rachel might also be transmitting their own anxieties to her, intensify-
ing her anxiety.
Rachel’s parents were uncertain if Rachel was aware of the miscarriage. They dis-
cussed talking about it in the next session and how they might find new ways to help
her express her feelings.

Making connections to experiences of loss

In the next session, with Rachel and her parents, the therapist talked about the fam-
ily’s experiences of transition and change. It was clear there had been a succession of
losses in the year before she was diagnosed with anorexia. Rachel and her parents
reflected on these changes initially with fond memories of the home before they
moved. Rachel remembered not wanting to move. She also recollected her pet guinea
pigs died, which she said was her last memory of crying.

Connecting the parental experience to their daughter’s experience of loss

Rachel’s parents sensitively explained about the miscarriage. Rachel responded in words
initially saying she was sad, but then became tearful. She seemed to fight with her tears
but then cried openly. Her parents verbally soothed, made eye contact, and were able to
validate her feelings without their usual style of reaching to stroke Rachel that had
seemed to become the blocking action. Rachel’s tears flowed and she said she felt unable
to stop them. She said it felt unfamiliar that neither parent was touching her and there
were ‘no hands on me.’ She had previously described ‘pushing feelings away.’ Rachel
was helped to regulate her emotional distress and then reflect on it and said she was ‘feel-
ing sad.’ The therapist proposed that Rachel’s eating disorder and OCD symptoms
allowed her to ‘zone out,’ to suppress feelings, to disconnect. At the end of the session
Rachel asked her parents to take her out for a meal to ‘celebrate the sadness.’

Building emotional literacy

After this the therapist proposed the family watch the Disney Pixar film ‘Inside Out,’
suggesting that the family may find the film helpful and interesting. The film uses
animated characters to describe and illustrate emotional language and emotional liter-
acy. The film was reflected on by the family at home and in sessions and became a
vehicle for opening up their communication about emotional expression.

Opening up communication is matched by de-escalation of symptoms

Following this session Rachel’s mother said she noticed Rachel talking more about
things ‘instead of bottling things up.’ Also, mother and daughter had been able to
look at old photos and reminisce. At that stage there had been a substantial de-escala-
tion of her anorexic behaviour. There was a noticeable reduction in micro-movements
in sessions that her parents said was mirrored at home. Residual eating disorder and
OCD behaviours were described as more episodic than constant.

Using a setback to consolidate change

A school trip presented a challenge to Rachel to manage her eating unsupervised.
Some of Rachel’s anorexic behaviours intensified again and ritualised behaviours
became more pervasive. In response to this the therapist drew on the EFFT emotion
coaching framework: explore, name, attend, validate, and meet the need. Rachel said
she felt ‘disappointment’ with herself. She felt she was ‘failing.’ The therapist

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 Heidi Joyce and Greg Dring

supported the parents to validate her feelings of disappointment. This allowed Rachel
to be tearful in the session. The therapist reflected on Rachel’s distress as helpful
learning for her and her family. The escalation of behaviours became a therapeutic
clue. Rachel was learning that when she ‘zones out’ from distress and worry this trig-
gers increased illness behaviours as a method of coping and deflecting. The theme of
feelings being mislabelled was explored. The family initially had seemed more com-
fortable with expressing frustration and being cross. The setback was framed as being
useful to the family in consolidating and practising themes from the previous sessions.

Changes in the family’s emotional language

During the family therapy, both Rachel’s parents increased their self-awareness regard-
ing emotional expression. For example, Rachel and her mother had described father
‘muttering’ which they said frustrated them and developed into conflicts. Rachel expe-
rienced the ‘muttering’ as anxiety-provoking as she thought her father was complain-
ing about her. Her mother felt irritated by the muttering, as she felt excluded. Father
said he was aware that he talked to himself, but said he was not always conscious of
what he was ‘muttering.’ He said he recognised that he engaged in talking to himself
at times of stress. He was able to identify a parallel with Rachel’s behaviours. Father
likened his ‘muttering’ to Rachel ‘zoning out.’ In later sessions he had been making a
conscious effort to notice and then interrupt the ‘muttering.’ Mother and Rachel
agreed saying he did it less.
The mother said that she now noticed when her husband or Rachel were strug-
gling with something from the way they acted. In the past, her practical approach led
her to seek solutions rather than to understand the emotional experience. Now she
tried to understand what the behaviour may be communicating. She had been practis-
ing trying to name the emotion, with both her husband and Rachel. Both parents
have said there are times when they would talk more openly about their concerns,
day-to-day, and described efforts to listen and attend, compared to their previous
‘practical’ approach.

Changes in the family structure

Rachel’s parents have come to recognise the unhelpful alliance she has with her
mother during conflicts. They understand that this increases anxiety for Rachel. Her
parents have been actively trying to dilute this process, by acknowledging it when it
happens, explaining to Rachel that they value her views, whilst also reassuring her that
they are tackling things together as parents. Rachel appears to have valued their inter-
ventions as she describes feeling less anxious about her parents’ relationship and her
fears they were going to separate. As they have become more united Rachel seems to
have become more contained.

Ending phase of treatment

At the end of treatment Rachel was maintaining her weight in the healthy range
between 93% and 95% of the median for her age. She was managing some meals
independently at school and eating with her family at home. However, she still had
some difficulty with spontaneous eating and needed routine. This seemed to indicate
Rachel’s continuing insecurity. Her parents addressed this by trying to attune to
Rachel’s emotional and anxiety states as a way of interrupting and diluting residual

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illness behaviour. Rachel herself began to think more about leaving home and going
to university.
In the ending phase of treatment the therapist invited Rachel to review her experi-
ence of the sessions. She described how her parents helped her to eat, and how she
later learned that she had to challenge herself about eating. The therapist understood
that Rachel had become more able to trust her parents feeding her, and then she was
empowered to challenge the ‘anorexic voice.’ Rachel described treatment as helping
‘us as a family manage our emotions,’ ‘we don’t do sadness well,’ ‘we tend to get on
with it.’ Rachel went on to explain that ‘if something bad happens we now do it dif-
ferently,’ that she has learned to identify her feelings more clearly and feels more able
to express them with her parents. Rachel’s parents agreed, saying that as a family they
are learning to accept feelings, especially sadness.
Rachel described the ending of therapy as evoking feelings of happiness and sad-
ness. Rachel and her parents were able to identify that their experience of ending
treatment enabled them to process feelings that were attached to other endings and
changes. The family were keen to ‘celebrate’ the ending of treatment and Rachel
baked a cake that was shared in the ending session. The cake seemed significant in
the context of anorexia no longer dominating Rachel as well as of the family having a
positive experience of ending.

Discussion
At the beginning the therapist noted that there was a disconnection between the seri-
ousness of the problem and the parents’ emotional expression. Holding this in mind
she observed and commented on what seemed an unhelpful aspect of the family’s
efforts to manage distress as it was demonstrated in the family meal enactment.
Rachel’s parents attempted to soothe her in the eating situation by touching her but
this seemed to reduce Rachel’s ability to express what she felt. Rachel was then able
to give feedback on her perception of how her parents approached the re-feeding task.
In these ways some issues in the family relationships could already be addressed at a
very early stage.
However, although these interactions may have built a stronger therapeutic alliance
with all the family members, and may have contributed to progress with weight
recovery, Rachel remained in the grip of anorexia and anxiety. It is interesting that
the crucial issue of unresolved grief, and the associated emotional distance in the par-
ental marriage, emerged at the point when the parents considered holidaying sepa-
rately. The therapist was sensitive to the mother’s underlying distress and not only to
her anger. This allowed the unresolved feelings about the miscarriage, and the hus-
band’s style of providing emotional support, to emerge in the next session. It was pos-
sible both to attend to the impact on the parents and to draw parallels with Rachel’s
difficulty with emotional expression.
Having made this breakthrough it was possible to re-connect the parents and
Rachel around the issue of emotional expression by first discussing the theme of loss
and then introducing the discussion of the miscarriage. This session seemed to pro-
duce a sense of relief in Rachel and she became more able to communicate with her
parents about emotionally charged events. This was followed by de-escalation of
Rachel’s symptoms.

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 Heidi Joyce and Greg Dring

The rest of the therapy built on this progress. It allowed ‘working through’ the
way symptomatic pre-occupations distanced Rachel from distress. It also allowed fam-
ily re-structuring in which mother and daughter could talk to Rachel’s father about
his way of expressing emotion. This in turn allowed the parental couple to address
Rachel’s over-concern and over-involvement in aspects of their relationship;
boundary-making in a way that was respectful of her concerns and allowed her to feel
contained.

Conclusions
Drawing on structural family therapy, Minuchin et al. (1978) argue that the anorexic
adolescent would recover when family re-structuring released them from their role in
detouring conflict in the parental marital relationship. Uniting the parents in the task
of managing re-feeding was seen as the first step in this re-structuring. Today we may
think of the eating disorder as distracting from the adolescent’s distress and can
approach this from the point of view of attachment theory. For example, we can see
that uniting the parents in managing the re-feeding can provide ‘relational contain-
ment,’ and when that is achieved the parents are available to help the young person
regulate their distress, as Wallis et al. (2017) describe. Initially that distress arises in
relation to eating, weight, and shape issues. If the parents are not emotionally avail-
able then they cannot be attuned to their young person’s distress. The adolescent’s
emotions will remain dysregulated, and symptomatic behaviours are likely to continue
or to escalate.
Family communication that leads to emotional distancing, such as criticism, is a
block to parental attunement. Such communications make the parents, as attachment
figures, less available. Similarly, if the parents have experienced unresolved trauma or
loss they may find it difficult to be attuned to their adolescent’s distress. For these
reasons approaches that foster emotional communication within the family seem likely
to improve the outcome of these treatments. In the case we have described, progress
was made when the parents were first helped to communicate to one another about
their own distress arising from an unresolved traumatic loss. This in turn helped open
up the emotional communication between the parents and their adolescent.
It would be natural to ask, why would we wait for difficulties to develop before
addressing such issues? Dring (2015) proposes that the initial therapy contract should
emphasise that the parents will supervise the anorexic young person’s eating, and at the
same time, help them to regulate their distress, and that the therapist will guide them
with both tasks. That proposal was not made explicit in this case and yet emotional
communication was a focus of the work from an early stage. It is possible that such an
approach would be more effective than the current FBT approach in many cases. It
would address from the outset the difficulty so frequently experienced when the adoles-
cent feels there is no help for their distress, and the parents feel overwhelmed by the
adolescent’s distress and resulting resistance to their efforts.
To what extent can the therapist address family relationships at the same time as
addressing the need to achieve weight recovery? The early family therapy approaches
such as that of Minuchin et al. (1978) did that successfully. Research is needed to
examine this question.

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