Multi-family groups in the treatment of young

adults with eating disorders

Mireille Colahan
a
& Paul H. Robinson
b
Multi-family group therapy is a variant of family therapy in which members
are able to gain insight and learn from each other, provide support and
encouragement, alleviate their sense of isolation and improve communi-
cation and social functioning. This study describes a series of multi-family
groups conducted within the eating disorder service of a large London
NHS Hospital. Ratings made by participants indicated that families viewed
the treatment favourably.
Introduction
Over the past decade, family therapy has acquired an established
place in the treatment of eating disorders. Research has shown that
patients with early onset, short duration, restricting anorexia
nervosa respond well to conjoint family therapy, and that separated
family therapy, in which the parents are seen together, but sepa-
rately from the patient, is also effective (Dare et al., 1990; Eisler et
al., 1997; Russell et al., 1987). Preliminary studies have similarly indi-
cated that family therapy can help younger patients who suffer from
bulimia nervosa (Dodge et al., 1995).
As eating disorders increase, diversify and spread across
culture and class, therapists and researchers have been obliged to
think with creativity and flexibility of appropriate ways to
approach the different types of patients, families and symptoms
that present themselves for treatment. Multiple family therapy, or
multi-family groups, represents a relatively new approach to the
treatment of eating disorders. Such groups have their origins in
the mid 1960s (Laqueur et al., 1964), when they were used mainly
2002 The Association for Family Therapy and Systemic Practice
The Association for Family Therapy 2002. Published by Blackwell Publishers, 108 Cowley
Road, Oxford, OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA.
Journal of Family Therapy (2002) 24: 1730
01634445
a
Senior Family Therapist, Royal Free Hospital Eating Disorders Service,
Department of Psychiatry, Royal Free Hospital, Pond Street, London NW3 2QG,
UK. E-mail: m.colahan@virgin.net
b
Consultant Psychiatrist and Family Therapist, Royal Free Hospital Eating
Disorders Service, Royal Free Hospital, London, UK.
for the treatment of patients diagnosed as suffering from schizo-
phrenia. Over the next twenty years this method was used sporadi-
cally, although never becoming a therapeutic trend, even though
patients and families seemed to enjoy the process, which success-
fully combated the problem of isolation, and avoided some of the
negative experiences often reported in single family therapy
(Squire-Dehouck, 1993). McFarlane (1983) describes how family
members are able to perceive problems as accurately as the thera-
pist, and, in presenting their observations from the position of
being in a similar predicament, help to sidestep other families
resistance.
In the 1980s, the use of multi-family groups expanded, and
ventured into the domain of chronic medical illness (Gonzales et
al., 1989; Steinglass et al., 1982). Evidence has been presented
which demonstrates the efficacy of the multi-family group
approach both in psychiatric and general medical settings
(McFarlane et al., 1995; Steinglass, 1998). However, multi-family
groups were not applied to eating disorders until the late 1980s
(Shekter-Wolfson and Woodside, 1991; Slagerman and Yager, 1989;
Wooley et al., 1987), and recently more widespread and active inter-
est has arisen in the application of multiple family therapy in the
treatment of anorexia nervosa and low-weight bulimia nervosa
(Dare and Eisler, 2000; Scholz and Asen, 2001). This study sets out
to describe the process of setting up a series of multi-family groups
and their outcome.
The group
Selection, recruitment and engagement of families
Within the context of the adult psychiatry department of a large
inner London NHS teaching hospital, the Royal Free Hospital
community oriented eating disorder service offers treatment
programmes to both day and outpatients, as well as to a very small
number of inpatients suffering from a variety of eating disorders.
For this first multi-family group, we selected four low-weight
patients suffering from anorexia nervosa with bulimic symptoms of
varying degrees in severity, ranging from eighteen months to four
years duration. Three patients were female, one male, their ages
ranged from 17 to 20, and their socioeconomic status and ethnic
origins were mixed. Two patients were in family therapy, one in a
18 Mireille Colahan and Paul H. Robinson
2002 The Association for Family Therapy and Systemic Practice
full-time day hospital programme, and one in a part-time day
programme. Three patients were cohabiting with their families of
origin and one patient was in university accommodation; however,
all the patients attended the multi-family group sessions with their
families of origin, which included parents and siblings, and one
patient also brought members of the extended family. Overall, the
group was made up of twenty-one family members from the four
families.
Organization
Three day-long sessions were planned, with a half-day follow-up.
One week separated the first and second sessions, four weeks
between second and third sessions, with a three-month gap between
the third session and follow-up. Families were asked to bring their
own packed lunches, which they would be able to eat in the unit
dining-room.
The therapist group established to develop the project included
two family therapists (authors), six nurses, one psychologist and a
senior nurse manager, all but one female. The family groups were
facilitated jointly by the two family therapists, one female and one
male, and the four families were each allocated a key worker, whose
role it was to support, explain and encourage participants. In addi-
tion, an art therapist and a movement therapist ran one-and-a-half-
hour workshops in the first two sessions.
Content
The three full days were similarly structured, alternating creative or
experiential sessions with more verbal ones, with regular breaks
throughout. The first day began with introductions, followed by the
drawing up of a detailed family tree. Each family chose a spokesper-
son, who was asked to give details of family members, relationships,
occupation, religion, education, location, etc. The spokesperson
had overall responsibility for offering family details, but others were
encouraged to comment. This proved to be a good joining proce-
dure, while also eliciting information for both staff and families,
who were able to reflect on the similarities and differences between
family structure, history and illness.
Subsequent days started off with feedback on preceding weeks,
how families had managed their homework, and what contact, if
Multi-family groups 19
2002 The Association for Family Therapy and Systemic Practice
any, they may have had with each other. The days ended with the
selection of homework tasks, when each family was asked to discuss
with the help of their key workers what realizable change they
would like to make happen over the next week(s), and each patient
then reported to the whole group what the task was to be. Before
leaving, families were encouraged to exchange telephone numbers,
and to make contact to discuss how things were going, and to keep
each other in touch with new tasks they might have set up. Overall,
patients contacted patients, and mothers spoke together. There was
less interaction among the fathers. This appeared to reflect the
particularly close relationship between the mothers and their chil-
dren, possibly engendered by the anxiety over the illness, which
consequently distanced the fathers. The homework task, which
each family chose with the help of their key worker, focused on an
aspect of family life particularly affected by the eating disorder. One
particular aim was to open up an opportunity for more parental
closeness, allowing the couple to pull together in a task that could
benefit the whole family. The families agreed that pulling together
would be helpful, although in practice it was something they found
difficult to do.
For example, one patient, who had been unable to eat with the
family for years, had decided to allow the mother to cook a meal
and to then sit down and eat with the rest of the family. This had
been successful. However, in a more severe and chronic disorder,
the young patients interpretation of the homework (to prepare her
own snack and eat it without help from her mother) was simply to
help herself to an ice cube from the fridge.
Homework was experienced by the families as very useful. Some
patients were surprisingly successful in carrying out the small real-
izable changes they had set themselves, and members were able to
perceive how changes in one affected the others. We observed that
patients progressively saw more of their fathers, that interaction
between parents improved and that relationships between mothers
and their ill children gradually became less enmeshed. This created
a more reliable and supportive environment, facilitating both
weight gain and an improvement in eating patterns.
Creative workshops
Art workshop. The art therapy workshop, in which families were
requested to illustrate together a family event on a large sheet of
20 Mireille Colahan and Paul H. Robinson
2002 The Association for Family Therapy and Systemic Practice
paper, demonstrated clear family characteristics and how different
members interacted with each other. The largest, most exuberant
family chose the smallest corner of the room on which to pin their
paper, whereas the quietest of the families took the largest wall,
starting off with two large sheets of paper. One familys members
moved around following directions while the patient sat on a stool
in front of the sheet, orchestrating. Two fathers had to slot them-
selves in from the side or from below, leaving only a meagre imprint
of their presence on the sheet. The most impressive feature,
however, was that three of the four families drew idealized coloured
representations of family mealtime gatherings, while one family
drew a bleak, black and white image of their anorexic reality. The
rest of the group were extremely shaken by this and acknowledged
that they had been trying to deny the reality of their own situation.
The power of the image was striking. While the families who illus-
trated idealized family scenes were impervious to therapists
attempts to encourage them to think more realistically, it was the
impact of the fourth familys image showing them the horror and
bleakness of their anorexic experience that freed up the group,
allowing them to think more creatively and realistically.
Movement workshop. The movement therapist conducted two exer-
cises after some warming up: one to elicit conflict and the other
cooperation. In the conflict exercise (a tug-of-war), two family
members fought with each other, the loser eventually being
helped out by another member. Competitiveness, alliances and
protective patterns were acted out via this exercise. We noticed a
marked competitiveness between one daughter and her mother,
who pulled so forcefully that her thin, fragile child fell in a heap
and had to be reinforced by her brother. The family did not
acknowledge this competitiveness.
In the cooperation exercise, the family attempted to bounce a
large ball on a sheet held taut between members of the family, then
to pass the ball from one familys sheet to another. We were struck
by the fact that the family whom we had first thought of as the most
disorganized was the most successful at this, conducting it with mili-
tary-like precision. This was the same family who had been the most
openly competitive during the conflict exercise. The family we had
seen as the most harmonious, however, the same family which had
not acknowledged its competitiveness, was unable to keep the ball
off the ground. It seemed that not being able to acknowledge the
Multi-family groups 21
2002 The Association for Family Therapy and Systemic Practice
extent of the conflict was a handicap to carrying out the coopera-
tion task, suggesting a difficulty in negotiating and communicating
effectively.
The movement workshop enabled some family members to look
at conflict and cooperation in the family in a lively and positive
atmosphere, and, whereas some members did not see the relevance
of the workshop, all engaged vigorously in the task.
Family sculpt. In this workshop, the sculptor (a member of the
family) was asked to place the family in the position that best
reflected emotional relationships (Heinl, 1987). The first sculptor
for each family was the patient who had been asked to adopt a
family with whom to share lunch. The second and subsequent sculp-
tors (different members of the family) were asked to sculpt the
family, first, as they saw them then, and second, how they would like
the family to be. Absent members were played by members of staff
or members of other families. We observed that most of the patients
craved more distance between themselves and their families than
their parents wished. We saw how the tightness of the mothers rela-
tionship with the patient contrasted with an apparent lack of close-
ness between the two parents. We saw how two of the fathers were
in the process of getting closer to their families, in parallel with the
mothers being able to relax their protectiveness towards their chil-
dren. In one case, the sculpt portrayed the father clearly separate
from the patient (a male) who was close to his mother and sister,
supporting and being supported by them. The father was distressed
by this, saying that he had not realized his position, and this
prompted him to make plans to go out for the first time with his
son. This father had experienced problems with alcohol abuse, and
taking his anorexic son to the pub resulted in his returning home
earlier in the evening, leading to an improved relationship between
himself and his wife.
The families were able to see and acknowledge that for the
patients to be able to separate they would have to give up their
eating disorder, and for the parents to grow closer the patients
would need to move out.
The family sculpt illustrated powerfully for everybody how the
fathers were usually placed peripherally to the rest of the family with
the mothers both constrained and supported by the anorexic
patient, and how the other family members were also affected. It
was notable that the patients who had eaten with families they had
22 Mireille Colahan and Paul H. Robinson
2002 The Association for Family Therapy and Systemic Practice
been asked to adopt produced sculpts which were felt to be accurate
by the members of that family.
The meal: lunch
Families brought their own food. Members of staff did not eat with
families, but circulated, observing and discussing with the families
what was happening during the meal, and exploring the possibili-
ties of changes.
Each family ate at separate tables on the first day. On another day,
the patients were asked to adopt a family other than their own with
whom to share a table. Parents found this helpful, since they could
talk and ask questions of their adoptive child without getting the
usual emotional response and one patient felt he could address
issues that he normally avoided as they made his mother cry.
Patients also appreciated not having their mothers nagging them.
On another occasion family members were asked to sit at a
mothers table, a fathers table, a patients table or an extended
familys table. The latter included siblings, grandparents, etc.
Families were asked to discuss how things had been since the last
session. It was notable that the patients table was the most silent, as
they strove, quite openly, to hear what might be being said about
them at other tables. Families seemed pleased to see each other
again, and conversation on the fathers table and the mothers table
was animated.
Mealtimes provided an opportunity for people to experience
alternative eating styles, and to conduct conversations with other
families on topics that would cause emotional turmoil in their own
families.
Goldfish bowl discussions
These discussion groups consist of two subgroups, subgroup one
being asked to discuss a topic and sit in the centre of the room,
while subgroup two listens, then subgroup two commenting on what
they have heard while subgroup one listens. This is followed by a
general group discussion. Subgroups, each containing one facilita-
tor, may consist of patients, non-patients, siblings, parents, mothers,
fathers, the younger generation, the older generation, or one
specific family. On day one a subgroup consisting of the younger
generation (patients and siblings) was asked to discuss the topic
Multi-family groups 23
2002 The Association for Family Therapy and Systemic Practice
How is food handled in your family? On day two the fathers were
in the goldfish bowl, discussing their role in the family, followed
by the mothers. Another day, each family took turns being in the
goldfish bowl, discussing changes that had occurred during the
course of the multi-family groups. The mothers in the bowl were
supported and encouraged by the other mothers, fathers by fathers
and patients by patients.
Overall, neither the anorexic nor the parental groups felt that
their position was properly appreciated by the other, and hearing
other members discussing their frustration and suffering, without
being able to engage in the usual acrimonious, blaming arguments,
seemed to have a very strong emotional impact. It appeared that
both mothers and fathers were able to empathize and gain more
insight into their partners dilemmas by hearing other parents
describing similar issues. Families who felt threatened early on grad-
ually became more relaxed as they realized they were not the only
ones, and that they were sympathetically understood by their coun-
terparts in other families. Patients who were quite unable to deal
with their own disorders sensibly and creatively counselled other
patients, who sometimes took the advice. Mothers advised other
mothers, fathers observed with interest the different and similar
ways other fathers dealt with the eating disorder, and involved them-
selves in family life.
Mothers who were struggling with enmeshed relationships with
their children were able to be helped to see, by the children of
other families, how this might be changed, without the accompany-
ing feelings of guilt, resentment and powerlessness sometimes
engendered in family therapy. Parents were enabled to see their
childrens perspective, and children to understand how this
affected their parents within the safety and supportiveness of their
own peer group. Fathers were able to listen to mothers expressing
their feeling that they had been left to handle the situation alone
and their wish that the fathers could be more involved without the
fathers feeling they were being personally attacked. The mothers
listened to the fathers belief that they did provide support to the
mothers in the handling of the eating disorder, and that they were
unable to see how that situation could be changed.
It seemed that listening to the difficulties of other families made it
easier to understand them in their own situation, and gaining insight
from each other was empowering, as opposed to families experience
of being put down by therapists when seen in family therapy.
24 Mireille Colahan and Paul H. Robinson
2002 The Association for Family Therapy and Systemic Practice
Changes
Two families had made improvements over the four months. In
the first family, the father had reduced his drinking at the pub, so
that the mother no longer dreaded his return and he and the
patient had become closer. The patients weight was normal and
his lifestyle appropriate to his age, as he was now able to take up
sport, see friends and work. Although he was now able to eat a
much more flexible diet he continued to manifest rigid and
unusual eating times, and monopolized the kitchen in a tyranni-
cal way, but overall his family was tearfully happy at his improve-
ment, and the father, more integrated into the family, was more
relaxed.
In the second family, the patients weight was normal, as was her
eating and social life. She had resumed her former work, but had
realized that it was too strenuous for her, and was therefore in the
process of changing jobs. Her mother, who had been aware of this
well before her daughter, had managed to allow her to come to this
conclusion on her own. Relationships between mother and daugh-
ter, between siblings and between father and daughter, had all
become warmer and more relaxed, as had those between mother
and father and the extended family. It was also significant that an
extended family member, who had had an especially close relation-
ship with the patient because of her own eating disorder, had now
faded into the background.
The other two families had not progressed so well. In one, it was
clear both to other families and to the older sister that the patient,
now almost 18 and only able to eat with her mother, needed to be
given responsibility for her own health, even if this meant her losing
weight. It was equally clear, however, just how difficult it would be
for the parents to risk this happening. We were interested that this
older sister, who had been excluded from the sessions until the
fourth, finally took part, as both we and the families felt that things
could have been different had she been present throughout. This
seemed to illustrate the ambivalence and fear of how life would be
if the patient improved, and all the changes in the family this would
entail.
Although in the last family the patient had put on weight her
bulimic symptoms had increased, and she was very depressed and in
a state of extreme self-loathing. The other families were very clear
that she should take some time off university to concentrate on
Multi-family groups 25
2002 The Association for Family Therapy and Systemic Practice
recovery, and that the eating disorder served as a crutch, protecting
her from taking responsibility for academic failure, but she did not
agree, and it was clearly difficult for this high achieving, academic
family to envisage such a sacrifice.
When, during the fourth follow-up session, the families
discussed the effect of each group on the other, it seemed, in the
families where symptomatic changes had occurred, that there were
also noticeable changes in family members and family relation-
ships.
Feedback
Feedback from families
Feedback questionnaires were completed by each family member at
the end of each day, with ratings of the helpfulness of each session
on a five-point scale (very helpful, helpful, neither helpful nor
unhelpful, unhelpful or very unhelpful), and were completed by all
who attended the workshops. The results are summarized in Figure 1.
26 Mireille Colahan and Paul H. Robinson
2002 The Association for Family Therapy and Systemic Practice
Figure 1. Feedback questionnaire results. Percentage of responses rating sessions
as helpful or very helpful.
Key
Intro: Introduction/feedback; Art: Art therapy; Movt: Movement therapy;
Goldfish: Goldfish bowl; Sculpt: Family sculpt session; Final task: Homework plan-
ning and feedback.
Mean: mean percentage across sessions.
F
I
N
A
L
T
A
S
K
Overall, 65 per cent of responses were positive (helpful or very help-
ful), 30 per cent equivocal (neither helpful nor unhelpful) and 5
per cent negative (unhelpful or very unhelpful). The most popular
sessions were homework task planning and feedback discussions,
the art workshop, family sculpts and goldfish bowl discussions.
Families found it particularly helpful to meet other families with
similar problems. They found it easier to accept observations and
suggestions from each other than from therapists, and felt the
atmosphere of the groups supportive and encouraging. They
formed warm and trusting relationships with each other, and the
two families which did not improve wanted to return subsequently
as part of a new group.
Feedback from staff
Staff were exhausted by the first days sessions, although they grad-
ually adapted and became more familiar with the impact and style
of work as the days progressed. A debriefing period at the end of
each day was important. Key workers said that as therapy progressed
the families became more active and required their help less, apart
from during task planning discussions, and these workers reported
some frustration at feeling increasingly redundant.
It was decided that too many staff were involved, and that in
future sessions the groups would be run by two to four facilitators,
who would also take on the role of key worker when necessary.
Overall, staff were very enthusiastic, seeing the groups as powerful
and worthwhile.
Discussion
There is evidence that conjoint family therapy sometimes results in
families feeling guilty and blamed (Squire-Dehouck, 1993), regard-
less of how far therapists go in their efforts to convey the message
that parents are not to blame for their childs illness. However, clin-
icians and authors have historically overtly blamed and criticized
families. Gull (1874) regarded the families of people with anorexia
nervosa as generally the worst attendants, and felt that the patients
needed to be removed from the family environment, while others
developed the execrable terms schizophrenogenic mother
(Fromm-Reichmann, 1948) and refrigerator parents (Eisenberg
and Kanner, 1956) in relation to schizophrenia and autism. More
Multi-family groups 27
2002 The Association for Family Therapy and Systemic Practice
recently, research demonstrating the negative effect of critical
expressed emotion in a number of conditions (Leff and Vaughn,
1984), including eating disorders (Van Furth et al., 1996), has
conveyed the view that families may have a role in the onset or exac-
erbation of mental illness, as have recent findings suggesting a
possible link between parental over-protectiveness and the later
development of anorexia nervosa (Shoebridge and Gowers, 2000).
Therefore, even though the blaming literature is counterbalanced
by other views supporting a multi-determined aetiology (Eisler,
1995; Garfinkel and Garner, 1982) in which families are seen not as
the cause, but as caught up in a repetitive pattern of interaction in
which any change is difficult (Colahan and Senior, 1995), the family
has been subject to intense study. They have had to accommodate
information that suggests that family function may have an impor-
tant role in the maintenance and perhaps the development of some
psychiatric disorders. It may be that the safety in numbers inher-
ent in the multi-family group approach allows them to explore these
issues without feeling judged. It was our impression that families
were more open to accepting advice from other stricken families
than from professionals.
The workshops take up a total of twenty-seven hours over four
days, and represent a considerable investment of therapeutic
resources. There is little doubt that the clinical staff can be reduced
to one per family. Four clinical staff per series equates to a total of
108 hours, or twenty-seven hours per family. This amount of staff
time could provide six to seven single family therapy sessions, at two
hours per session, with two staff involved in each session. The work-
shops do not therefore use more therapist time than would be dedi-
cated to families using the single family approach.
An alternative approach would be to offer shorter multi-family
sessions over a longer period. We have recently offered fortnightly
evening ninety-minute multi-family groups to families of patients
with anorexia nervosa attending a day hospital. The groups have
been poorly attended, and lacked the impact of the day-long work-
shops. The day-long sessions require an elaborate selection and
setting up process, and families are required to make a serious
commitment. A short session at the end of the day could be inter-
preted as less important, and indeed this seems to be how families
perceive it.
We believe this approach may represent an important advance in
the treatment of anorexia nervosa in adult patients. Other, similar
28 Mireille Colahan and Paul H. Robinson
2002 The Association for Family Therapy and Systemic Practice
work (Dare and Eisler, 2000; Scholz and Asen, 2001), being under-
taken at present in the area of eating disorders, is focused on
adolescents.
Multi-family groups appear to be acceptable, and are reported as
useful to families and provide staff with experiences that are hard to
obtain in other ways. It is our view that this approach should now be
subjected to controlled study in order to test acceptability and effi-
cacy in both adolescents and adults with severe eating disorders.
Acknowledgements
Thanks to Katie Clayton, Yeva Feldman, Rachel Finn, Morven Gray,
Jeannie Moir, Diddy Mymin, Julia Stone, Adele Wakeham and
Heather Warner for their participation in the groups, to the entire
eating disorders team for their enthusiastic support, to the four
families who volunteered to join us, and to Liz Bardsley and Judy
Hildebrand for reading and commenting on the manuscript.
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