Eating Disorders and Family Boundaries

Allan Schwartz, LCSW, Ph.D. was in private practice for more than thirty years. He is a Licensed Clinical Social Worker in the states ...Read More

In August of 2006 Dr. Dombeck wrote an excellent essay about "Boundaries and the Dysfunctional Family ." If you have not yet read this essay I highly recommend it especially as the present web log refers back to the issue of boundaries.

One of the observations I have made during the many years I have been seeing clients with eating disorders is that they often come from families with serious boundary problems. Salvador Minuchin referred to this boundary issue as enmeshment.

As Dr. Dombeck points out, boundaries are barriers and, for human beings these barriers exist as ideas that allow us to distinguish self from non self. Therefore, these boundaries are not actually visible but exist as psychological constructs.

In families, there are important boundaries that are generational in nature. In other words, there are boundaries between children and parents. If a family is functioning in ways that are healthy then the boundaries between parents are children are flexible, Flexibility means that there is the right amount of authority in the hands of parents to allow for the guidance, socialization and education of the children. At the same time flexibility permits parents to allow children the experience of age appropriate autonomy so that they can grow in self confidence as they learn to function outside of the home.

A dysfunctional family is either: one in which the children are granted too much autonomy for their age and are, in reality, neglected, or: one in which parents and children become enmeshed so that boundary lines are violated.

Case studies in the field of eating disorders as well as my own observations show that eating disordered patients tend to come from families that are extremely enmeshed with the result that the sense of autonomy, individuality and independence has not been established by adolescence and young adulthood, especially for females. It is for this reason that the treatment of young women with eating disorders includes family therapy in order to address the problem of enmeshment.

These are fictionalized examples of the types of boundary problems I have observed:

A young woman wants very much to please her parents. Both mother and father are accountants. Therefore, instead of taking the premedical course of study that she wanted during her college years, she studied accounting, went to graduate school and became a certified accountant earning an excellent living at a large business firm. However, she suffered from a mixed type of anorexia-bulimia but insisted there was nothing wrong with her. She hated her career but would not admit to any anger at either of her parents. Her parents purchased her a condominium, selected the furnishings and art work for her and came to visit each weekend, stocking her refrigerator with food of their choosing. They never knew how little of the food she actually ate.

During her childhood a young woman’s parents purchased a large television set for the family and placed it in her room. In order to watch television, the entire family had to go to her room. When she was very young this strange arrangement did not seem to bother her. However, when she became pubescent and started to rebel she was upset by family member walking into her room to watch their programs. These family members included her parents, brother and sister.

To make matters even worse, her sister’s clothes were stored in her closet necessitating the need for the sister to further intrude into her privacy.

There was never any explanation for these strange arrangements. What is significant is the fact that this patient became bulimic during the early part of her adolescence. Her sister and brother each developed their own types of psychological disorders.

The last example is of a young woman who suffered from a case of anorexia that was serious enough for her to be hospitalized. Her extremely self centered parents were unforgiving of her for the hospitalization. They were convinced that she was being ungrateful to them for having raised her. In family meetings the father, who did not want to be there, was outraged by the inconvenience and cost this was putting him through. Her mother felt abandoned by her daughter’s hospitalization. It had always been the job of the daughter to care for her mother. Caring for this mother included listening to her mother’s complaints about her father’s poor sexual prowess. It never occurred to the mother that this was totally inappropriate information for her daughter to hear about. In fact, the mother discussed all the details of her unhappy marriage telling her daughter things that the mother should have been discussing with other adults.

In all three cases these patients had no sense of self. Specifically, this means that none of them had any idea of what career choices they wanted for themselves, what taste in music they preferred or what political issues were important to them.

Each one of the three felt totally responsible for the well being of their parents and would do nothing that they believed could cause hurt or disappointment. They would not express anger at either of their parents and all insisted that their parents did the best they could.

In each case the young women had parents, particularly mothers, who made decisions for them. These mothers never recognized the fact that their daughters were now adults and needed to make their own decisions. Interestingly, each one of these patients denied that there was anything wrong with their mother making these decisions.

All three had great difficulty making decisions regardless of whether they wee dealing with major or minor issues. For example, selecting a movie to go to was a daunting task. Most often they would tell whomever they were with that "anything would be fine."

In each of the cases the patients came to realize that restricting food was the only way they had of exerting some measure of control over their lives. However, this came only after a lot of hard therapeutic work.

Finally, in all three cases no one in the respective families noticed how thin their daughters were and all three families expressed surprise at learning about the eating disorder. It was only in case 3 that the parents expressed resentment at the diagnosis and at their daughter.

There are additional factors behind eating disorders in addition to enmeshed family dynamics. Among these are:

1. The emphasis on physical beauty being defined as being thin in all of the media that influence young adolescents.

2. Traditional role expectation that girls prepare themselves to be mothers who nurture others at the expense of themselves.

3. Despite all of the social changes that have occurred the emphasis continues to be on girls being passive and exerting their influence through sexual beauty and through being aggressive and assertive.

4. It is not simply that, for girls, the emphasis is on physical beauty being defined as being thin but on physical beauty as a vitally important trait if she wants to feel accepted.

In the United States, eating disorders begin to exert themselves among girls from as early as nine and ten years old. For many young women anorexia or bulimia is full blown by the time they are in Middle School. Surveys show that most college women have experimented with purging at least once.