Exploring Family Based Treatment for Eating Disorders in China

Not much is known about eating disorders in China, especially compared to its East Asian counterparts of Hong Kong and Japan. It would appear that researcher-practitioners in China are not publishing much data about eating disorders in the country; in fact, the author of the study I’ll be looking at in this post, Joyce Ma, practices primarily in Hong Kong. In this study, Ma explores China-specific patterns of ED presentation and how they relate to the social context. As she notes, treatment models have been slow to develop from the mother-blaming paradigm proposed by Chen (1990), which recommended that eating disorder patients be isolated from their parents. No other study appears to have been done (at least that she cites) using evidence-based modalities.

In her study, she reports on the results of treatment with 10 families in a Shenzhen clinic, with patients of a relatively wide age range – one of the patients, a 26-year-old, had in fact been married and divorced already. All of the patients were at least of secondary school age (which means at least 13 years old), with one working as a part-time teacher. All patients underwent family-based treatment rather than individual psychotherapy, with Ma’s model based on Minuchin’s structural family therapy.

Ma identified three main themes in her FBT sessions with the parents, all of which reflected delays in psychological development:

• Conflicts over food/ eating
• Not wanting to be treated like a child / not wanting to grow up
• Resistance to parental expectations

From Ma’s observations, the main priority seems to be educating parents about the disorder and helping them to see the underlying psychological context of the battle over food i.e. the second and third themes. While such issues certainly came up during family sessions, the parents tended to resort to rationalizations that stopped them from recognizing their daughter’s perspective:

“I bought a shop for you and you can run a small business. That would solve your career problem. Why did you turn me down?” (p. 807)

“The fate of a divorced woman would be sorrowful. Besides, her ex-husband is a good man.[1]” (p. 808)

Ma’s three themes, as she indicates, are very much interlinked – the family struggle over re-feeding is an extension of the struggle over independence and autonomy from parents. She suggests, then, that shifting the focus to such issues of development and change in the family would allow “the youths [to] give up using their bodies as the battlefield on which to fight with their parents” (p. 809).

The possible irony here is that in this search for individuation, the patient remains locked in a family-based treatment model that replicates the social structures they’ve grown up and experienced their disorder in. Certainly, the complex family dynamics need to be worked through – but I wonder about some of the more deep-rooted identity crises that can’t be reduced to just being unhappy with their parents’ decisions. Patient T explained that:

“I am in great distress. I am forced to live a life that makes only my parents happy. They would like me to be an ordinary girl” (p. 807)

On the one hand, the sessions helped in changing her parents’ expectations in this area – but on the other, T needed her own space to explore her desires without having them defined as opposing those of her parents. This is particularly true for her (at 20 years old) and the four other college-aged or older patients, and I wonder if family therapy might have served better as an adjunct to individual therapy for these clients. Ma herself notes at the beginning of the paper that family-based therapy is recommended for adolescents of 18 years and under.

Ma’s sample is interesting demographically, and perhaps skewed – she received all of her patients after they had already been to several other treatment centers in the region, so families with less information or resources would probably not have come to her attention. All families were well-off, with the fathers having successful careers; the daughters also largely had ‘conspicuously good’ (p.806) academic performances. This created additional pressures on the patients in terms of their career paths and life choices, and the mother tended to be at the locus of these conflicts as the primary caregiver, even if the father was equally involved:

“Patient G, a 20-year-old daughter with BN, confronted her submissive and depressed mother: “You know I was upset that Dad chose the college for me without attempting to ask me first. Why can’t you be strong and brave and help me fight with him?” (p. 808)

As Ma notes, Western-based models of using FBT to “escalate the family stresses and induce a sense of crisis” (p. 809) may not be an entirely appropriate way of helping family members to accept responsibility for change. The sessions revealed entrenched divisions of responsibility within the family: for example, fathers acted as distant breadwinner and mothers were much more deeply involved in raising their daughters. These divisions of responsibility reflect general cultural patterns. Ma emphasizes especially the fact that the parents she worked with grew up in the 1960s and 1970s and achieved their success in life against the backdrop of extreme political instability and economic uncertainty; this insecurity has likely informed their desires and fears on behalf of their daughter. As a result, any rupture in family roles – and coming to terms with letting go of their daughter’s decisions – poses a deep challenge to how they see their identity as a parent.

Overall, I think two main points come through in this study: one, that family dynamics will be an area of high tension in Chinese eating disorder treatment and need to be handled carefully; and two, that treating eating disorders – at least among this group of patients – will require addressing entrenched constraints on identity formation. When the first 20 years of the patients’ lives have been guided by parental and social expectations, forming a new identity in recovery is all the more difficult.

[1] This case is especially complex because she was a victim of domestic abuse, which the parents only found out about in treatment; they rationalized the beatings as because their daughter had been bingeing and purging.

Reference

Ma JL (2008). Eating disorders, parent-child conflicts, and family therapy in Shenzhen, China. Qualitative health research, 18 (6), 803-10 PMID: 18503021