Divorce: Families with only one parent may be more vulnerable to problems such as eating disorders if there is inadequate parental control. There may also be more stress due to financial pressure or other such factors. Sometimes the symptom-bearer becomes a kind of substitute parent: taking care of siblings, holding down a job, or acting as a liaison between the separated parents. Sometimes a single parent depends more on his or her family of origin -calling on the grandparents to baby-sit, for example. Such intergenerational households might find themselves embroiled in many different types of conflicts, as different cultural traditions or ways of disciplining children clash.

It’s not uncommon for a divorced young mother, especially one who previously had an eating disorder herself, to revert to her old ways; she might find it easier to become an “ill child” than face up to her new life as a divorced woman. In such cases therapists need to offer extra support. A single mother may need individual therapy to cope with grief or anger over separation from her husband.

Married couples: An anorexic woman who marries may be looking for a husband who will accept her self-starving unconditionally. Similarly, a man who marries an anorexic may imagine himself as the knight in shining armor who will rescue the fair maiden from peril. This type of marriage can be pretty shaky. A woman who develops anorexia after marriage may be wrestling with serious conflicts about maturity. Pregnancy – or the fear of the changes it imposes on the body – may complicate things. Other issues include the emotions stirred as children become independent, or when the marriage starts to fall apart due to incompatibility or an extramarital affair.

Marital therapy improves the couple’s skills at communicating with one another. They may need to explore their attitudes about sex, or learn how to cope with disappointment when marriage fails to live up to their fantasies. Marital therapy may be needed after other forms of treatment have begun to work. A husband may be surprised, for example, when his compliant wife suddenly becomes more assertive or when she discovers deep currents of untapped anger. Counseling can help these people maintain the loving balance that drew them into marriage in the first place.

The multigenerational family: Never overlook the power and influence of the extended family. Many times, a patient’s grandparents, aunts, or uncles exert a tremendous influence on family functioning. Such families are often highly bound by tradition. Loyalty to family is the highest value. Members are expected to sacrifice themselves to “preserve the family honor.” One risk of a large, close-knit family is that members may feel no need to find emotionally satisfying relationships outside the home. Children may be pressured not to marry so that they can stay home and take care of the older generation. As the Belgian psychologist Johan Vanderlinden notes, these families may be starved for the stimulation that comes from contact with the outside world. “The whole family,” he writes, “is emotionally hungry and the anorectic child translates [this] hunger into starvation.”

Family therapy must address the deep and knotty issues related to the extended family. This may mean involving the grandparents in at least some sessions. It’s important for patients in such families to develop autonomy and discover how to balance family loyalties with the need to explore life outside the home. As Vanderlinden puts it, the patient must discover her roots as she develops her wings.


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