By Mary Tantillo, PhD, PMHCNS-BC, FAED, CGP
This year has reminded us of the damaging effects of disconnections on human survival. Disconnections occur when there is a rupture in relationship, often due to a lack of understanding, inability to regulate intense emotion, and a feeling of disempowerment and invalidation. Disconnections occur when we have difficulty sitting with difference (e.g., different thoughts, feelings, needs) and difficulty allowing difference to strengthen versus destroy connections. In 2020 we have witnessed a myriad of relational ruptures that fuel racism, social injustices, and civil unrest. COVID-19 has reminded us that when we fail to understand our impact on others and don’t allow others’ needs to influence our choices and actions, (e.g., choosing not to wear a mask or physically distance) we will all suffer. It has reminded us of how fragile we are and how our survival depends on an interdependence nourished by mutual trust, understanding, and respect.
Eating Disorders (EDs), like COVID-19, are characterized by a host of disconnections including a disconnection from self (one’s genuine thoughts, feelings, needs and bodily states) and disconnection from others. For example, patients internally experience difficulties identifying and regulating emotions, as well as hunger or fullness. They may increasingly isolate to avoid anything anxiety-provoking or conflictual. Additionally, the person experiencing the ED may not recognize that they have the illness and that these disconnections are at work. It is the interplay of these internal disconnections that increase the risk of interpersonal disconnections with family members who experience the high burden of caregiving with its associated fatigue and emotional distress.
The ED’s goal is to keep the patient to itself and create and maintain interpersonal disconnections with loved ones. These disconnections may lead to increased anxiety, defensiveness, and/or anger for the patient, accompanied by increased avoidance and isolation. In these situations, the caregiver may respond in similar ways. The ED then offers itself up as the solution to these interpersonal disconnections, working to numb or regulate the patient’s emotions or return a sense of control. Thus, interpersonal disconnections with loved ones can unwittingly perpetuate the ED.
Individual therapy, single family therapy, and group therapy can all assist in identifying and repairing disconnections and promoting reconnection with self and others. However, multifamily therapy group (MFTG) is a treatment modality that leverages the combined strengths, resources, and coping strategies of a number (e.g., 5-7) of patients and families. It offers opportunities for healing, growth and change that are different from what occurs in other therapies. For example, because family members in MFTG focus on individuals with EDs in other families, as well as their own child or partner, they have opportunities to reflect on their lives from new and different perspectives. The opportunity to learn about self and others in this way promotes a sense of universality (feeling connected with others who share one’s experience) while also reducing defensiveness, shame, and blame. Through this experience MFTG decreases caregiver burden and distress and fosters validation and connection among patients and families.
In essence, MFTG becomes a therapeutic village in which group members experience a strong sense of belonging and purpose. MFTG allows for an interplay of diverse perspectives that influence healing and growth in individual members, families, and the group as a whole. Interdependence is valued, promoted, and used to foster growth and change. Together patients and families can try out new ways of thinking, explore new values and goals, and experiment with new behaviors.
Below is a brief vignette showing how the MFTG therapist and group members helped a young adult patient and her parents identify and move through a disconnection related to mealtimes. The excerpt begins after mom (Ann G.) notes a disconnection that occurs at the table because her husband (Tom G.) means well when trying to help their daughter, but his approach is not working. Lindsey (21-year-old daughter) is having difficulty describing what she feels at those times.
Therapist: Lindsey, if you are having a hard time figuring out the feeling, try to focus on where you feel it in your body. Are you feeling anything physically right now like in your stomach or head or chest or limbs?
Lindsey: I feel tension in my head and a heaviness in my chest.
Therapist: When you have felt these things before, do you remember what you were feeling in your heart? Do any of the feeling words you see on the feelings sheet fit with the physical experiences you are having?
Lindsey: I guess sad and frustrated. And… probably hurt.
Therapist: Excellent work. Can you say more about where those feelings are coming from? How are they related to what goes on at meals?
Lindsey: I know my dad wants to help me, but the way he does this is NOT working.
No matter what I say to him, he does not get that his approach is not helping.
Therapist: So, you are feeling sad, frustrated, and hurt because you do not feel heard by dad?
Therapist: Dad, your wife and daughter see your desire to help Lindsey at meals. At the same time, it sounds like you may feel challenged by the ED with how to best support Lindsey. Do you see it that way or is your experience different from what they are saying?
Dad: Yes, they have told me that my approach is not helpful, but I am tired of watching my daughter not get the proper nutrition. I feel like my wife does not take the bull by the horns at times. I end up feeling like I have to do that, so the ED does not win.
Therapist: So, you feel pressured to step in and try to fix things as her dad. Dads do feel a pressure to fix things. That makes sense. Do you know exactly what you are feeling as you describe this to us?
Dad: I feel like I am the bad guy all the time. I have to have the heavy hand. It does not feel good, but I will do whatever it takes to help my daughter get her life back. I am afraid my daughter is getting taken advantage of by this illness that won’t let go. I feel like I am in a battle at the table to help my daughter get free.
Therapist: That sounds like a lot of pressure for you at meals. I am sure you are not the only dad here that has felt this pressure. I am wondering what our other parents think or feel about this?
John (another patient’s dad): Tom, I have felt a similar way with my daughter, and it can be very tempting to step in and try to take total control. It’s so hard to watch this illness bully her at the table. My frustration with the ED gets going and I want to stop the bullying. I have learned over time that this leads to more disconnection though. We have had a number of conversations away from the table about pacing and the words she finds helpful when the ED bully arrives at the table.
Marie (another patient’s mom): Tom, a similar dynamic has transpired with us too. We have found the more my husband pushes, the more I tend to back petal, trying to soften what is happening at the table. We have learned that we have to prepare each other before the meal by reminding each other that the more he pushes hard on our son, the more this will probably trigger my protective responses at the table. Neither of these are ideal, and they are just what the ED wants because then we are at odds with each other and my son is not getting the help he needs to feel empowered to eat his meal. He needs us to be alongside him, calm and centered.
Mom: My husband has been enlisted in the armed forces for over 20 years now. He is not used to backing off in the face of the enemy. I keep telling him this is more complicated though because his daughter is also at the table. We have to find a way to support her while not supporting the illness.
Therapist: So, dad, now we can understand even more, how painful mealtimes must be for you and Lindsey. What do you think about what the other parents and your wife have shared so far? Is it similar or different to what you experience?
Dad: Yes, it is similar. I get angry and afraid and I feel compelled to stop the enemy which I view as my daughter’s ED. This exasperates my wife and daughter, but I am unsure what to do.
Therapist: Lindsey it sounds like the ED creates lots of pressure for you and your dad and you both end up feeling frustrated and overwhelmed. Is there anything that would make things more helpful at the table when the ED is trying to have its way with you?
Lindsey: Dad, I need to take a small break sometimes at the table. I know you think I am avoiding eating, but I just have to calm down when I feel a bad wave of anxiety. I feel totally out of control, and I know you want me to push through it. But sometimes I need to take a breath and slow down for just a minute.
Sam (another young adult patient): You know Mr. G, I was watching a military program the other day and they talked about how sometimes great generals had to retreat in a battle so they could win the war. Maybe remembering that would help when everyone is at the table? (Group members smile.)
Dad: I never thought of it that way, Sam. It makes sense.
Therapist: Excellent thought, Sam. Lindsey is asking for a moment to breathe and re-center and the good solider in her dad is probably better able to allow for that if he knows in the end that this approach will actually lead to a good outcome. Tom, I think that approach would keep you and your daughter connected and working together against the ED. If she feels connected to you during meals despite her intense emotions, she won’t feel inclined to restrict to deal with them.
Lindsey, it is excellent that you suggest to dad that you breathe when you have severe anxiety. You are reminding him that it is important for him to breathe too. I am wondering if you can tell him this at those times? Can you say, dad, I need to breathe for a minute?
Lindsey: Yes, I can try, but sometimes, I am just so overwhelmed, I am not even thinking clearly enough to say that.
Therapist: Dad, here is where you can help. Can you ask her if taking a breath would be helpful? Can you actually take a long deep breath with her at those times and acknowledge her need to pace herself a little slower? Your allowing her to breathe and breathing with her helps her slow down the intense emotions inside and allows her to feel more freed up to do what is required to care for herself.
In this vignette the MFTG therapist first promotes internal reconnection for Lindsey by helping her identify her emotions. She does the same with Mr. G. and then turns to the group to promote universality and connection by normalizing what Mr. G. has shared and soliciting from group members their perspectives on the disconnection experienced by Lindsey and her dad. This intervention reinforces to the group that they have coping strategies, resources, and strengths to lend to Lindsey and her family. The therapist then asks Mr. G. if what he experiences is different or similar to what has been shared in order to invite any differences (thought, feelings, etc.) that can be addressed while remaining in connection with others. The therapist encourages Lindsey to assert her needs with her father, and a fellow patient shares an idea that helps dad reframe his understanding of what breathing with his daughter at mealtimes means. Dad is encouraged to check in with his daughter if the ED slows her ability to assert her needs during the meal. The therapist helps them understand how they influence one another and how they can work together to disconnect the ED vs allow it to disconnect them.
It is almost impossible for the neurological, psychological, and behavioral changes required for recovery to occur when we feel disconnected from ourselves and others. MFTG helps patients and families practice new emotional and relational skills to identify and repair the disconnections created and maintained by the ED. Patients say that relationships with close others are the “driving force” in their recovery, and research shows that social functioning predicts outcome. MFTG provides multiple opportunities for the therapist, patients, and family members to work together and promote internal and interpersonal connections that promote sustained recovery.
Asen, E. (2002). Multiple family therapy: An overview. Journal of Family Therapy, 24, 3-16.
Banks, A. (2015). Wired to connect: The surprising link between brain science and strong,
healthy relationships. New York: NY: Jeremy P. Tarcher/Penguin.
Eisler, I. (2005). The empirical and theoretical base of family therapy and multiple family day
therapy for adolescent anorexia nervosa. Journal of Family Therapy, 27, 104-131.
Langley, J., Todd, G., & Treasure, J. (2019). Caring for a loved one with an eating disorder: The
new Maudsley skills-based training manual. Abingdon, Oxon: Routledge.
Lowe, B., Zipfel, S., Buchholz, C., Dupont, Y., Reas, D. L., & Herzog, W. (2001). Long-term
outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychological
Medicine, 31, 881-890. https://dx.doi.org/10.1017/s003329170100407x
Simic, M., & Eisler, I. (2015). Multi-family therapy. In I. Eisler, A. Wallis, E. Dodge, K. L.
Loeb, D. Le Grange, & J. Lock (Eds.), Family Therapy for Adolescent Eating and Weight
Disorders (pp. 110-138). Routledge.
Strober, M., Freeman, R., & Morrell, W. (1997). The long-term course of severe anorexia
nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors
over 10-15 years in a prospective study. International Journal of Eating Disorders, 22(4),
Tantillo, M., McGraw, J. S., & Le Grange, D. (2021). Multifamily therapy for young adults with
anorexia nervosa: Reconnecting for Recovery. New York, NY: Routledge.
Tantillo, M., McGraw, J. S., Hauenstein, E. J. & Groth, S. W. (2015). Partnering with patients
and families to develop an innovative Multifamily Therapy Group treatment for adults
with Anorexia Nervosa. Advances in Eating Disorders: Theory, Research and Practice,
3(3), 269-287. DOI: 10.1080/21662630.2015.1048478
Tantillo, M., McGraw, J. S., Lavigne, H. M., Brasch, J., & Le Grange, D. (2019). A pilot study
of multifamily therapy group for young adults with anorexia nervosa: Reconnecting for
Recovery. International Journal of Eating Disorders, 52(8), 950-955. https://doi.org/10.
Tantillo, M., Sanftner, J., & Hauenstein, E. (2013). Restoring connection in the face of
disconnection: An integrative approach to understanding and treating Anorexia Nervosa.
Advances in Eating Disorders: Theory, Research and Practice, 1(1), 21–38.
Tozzi, F., Sullivan, P., Fear, J., McKenzie, J., & Bulik, C. (2003). Causes and recovery in
anorexia nervosa: The patient’s perspective. International Journal of Eating Disorders,
33(2), 143-154. https://dx.doi.org/10.1002/eat.10120|
Treasure, J., Smith, G., & Crane, A. (2017). Skills-based learning for caring for a loved one with
an eating disorder (2nd edition). New York, NY: Routled