Smith ScholarWorks Theses, Dissertations, and Projects 2014 Conceptualization of anorexia nervosa : a theoretical synthesis of self-psychology and family systems perspectives Molly E. Gray Smith College Follow this and additional works at: https://scholarworks.edu/theses Part of the Social and Behavioral Sciences Commons Recommended Citation Gray, Molly E., "Conceptualization of anorexia nervosa : a theoretical synthesis of self-psychology and family systems perspectives" (2014). Masters Thesis, Smith College, Northampton, MA.edu/theses/797 This Masters Thesis has been accepted for inclusion in Theses, Dissertations, and Projects by an authorized administrator of Smith ScholarWorks. For more information, please contact scholarworks@smith.
Molly Gray Conceptualization of Anorexia Nervosa: A Theoretical Synthesis of Self-Psychology and Family Systems Perspectives ABSTRACT Anorexia nervosa is a life-threatening psychiatric disorder that has increased in diagnostic prevalence over the last century. Findings suggest that individuals at greatest risk are females between the ages of 15-22, who demonstrate heightened levels of perfectionism and a need for control. This theoretical thesis hopes to provide clinical social workers and other mental health professionals with a deeper understanding of the psychological, familial, and developmental factors contributing to the onset of the disorder in order to increase the effectiveness of future treatment. Self-psychology will be examined to offer a possible developmental and psychological framework for understanding the emotional challenges and distorted thought processes of the anorexic patient.
Bowen's adaptation of family systems theory will be used to support the resilience and strength of the patient’s family unit by uncovering and addressing dysfunctional patterns. The aim of this thesis is to suggest that approaching treatment for anorexia nervosa through the synthesized lens of self-psychology and family systems theories may help address the multifaceted and deeply engrained aspects of this complex disorder. Conceptualization of Anorexia Nervosa: A Theoretical Synthesis of Self-Psychology and Family Systems Perspectives A project based upon an independent investigation, submitted in partial fulfillment of the requirements for the degree of Master of Social Work. Molly Gray Smith College School for Social Work Northampton, MA 01063 2014 ACKNOWLEDGEMENTS I want to give a special thanks to my partner for supporting me and dealing with the stress that inevitably stemmed from this long and demanding process.
Additionally I would like to thank my thesis advisor Bruce Thompson for pushing me to expand and develop the scope of this theoretical exploration. The product would not have been as comprehensive without his guidance and consistency. I appreciate his dedication to the field of social work and his diligence throughout the past year. TABLE OF CONTENTS ACKNOWLEDGEMENTS.
ii TABLE OF CONTENTS. iii CHAPTER I INTRODUCTION…………………………………………………………………….5 - 9 II METHODOLOGY ……………………………………………………………………10 -16 III PHENOMENON …………………………………………………………………….17 - 43 IV FIRST THEORY: SELF-PSYCHOLOG …………………………………………….44 - 55 V SECOND THEORY: FAMILY SYSTEMS ………………………………………….55 - 66 VI CONCLUSION ………………………………………………………………………67 - 84 REFERENCES …………………………………………………………………………….85 - 94 CHAPTER I INTRODUCTION Anorexia nervosa is a life-threatening psychiatric disorder that has increased in diagnostic prevalence over the last century (Hoek, 2006). With a mortality rate that exceeds any other psychiatric illness, anorexia remains one of the more complex disorders to treat (Hurst, Read & Wallis, 2012). Medical understanding of anorexia nervosa has evolved in recent years.
However, psychological treatment techniques and etiological factors still remain largely inconclusive. Both socio-cultural and feminist theories have been applied to the disorder in the hope of establishing preventative interventions. These theories attribute increased prevalence rates to the unrealistic beauty standards created and enforced by popular culture. However, documentation of cases pre-dating televised and printed media have discredited these theories as the sole contributing factors (Brumberg, 1988).
Recent neurological research has helped strengthen medical understanding of the possible biological risk factors but have yet to be accompanied by effective interventions. High relapse rates and low incidence of life-long recovery have suggested that current treatments are failing at addressing the true source of the problem (Goodsitt, 1997). Previous treatment regimens have frequently focused on addressing solitary contributing factors, missing the multifaceted environmental, developmental, and psychological aspects that have contributed to the development of anorexia nervosa (Brumberg, 1988). 5 History and Definition The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) defines anorexia nervosa as "persistent energy intake restriction; intense fear of gaining weight or of becoming fat; and a disturbance in self-perceived weight or shape" (APA, 2013).
The main diagnostic criterion for anorexia nervosa is a body weight below the expected age, sex, and height of the patient (APA, 2013). Anorexia nervosa is separated into two subcategories: restricting type and binge-eating/purging type. The following chapters will focus on both manifestations of anorexia, as research has established that these categories are often fluid, with patients transitioning between sub-types throughout the treatment process (APA, 2013). Connection to Social Work Practice Anorexia is the third most common chronic illness amongst adolescents in the United States (Robinson, Strahan, Wilson & Boachie, 2012).
The disorder affects individuals across all age groups and genders but is most common in females 15-22 years of age (Eisler, Simic, Russel & Dare, 2007). Hoek (2006) reports that over the last century the rates of those diagnosed with anorexia nervosa has increased to an estimated .3% of the population and is still on the rise (as cited in Hurst, Read & Wallis, 2012). A longitudinal study revealed that 5% of those diagnosed with anorexia will go on to die from it, and less than 50% of those who receive treatment will achieve full, life-long recovery (Steinhausen, 2002). This theoretical thesis hopes to provide clinical social workers and other mental health professionals with a deeper understanding of the psychological, familial, and developmental 6 factors contributing to the onset of the disorder in order to increase the effectiveness of future treatment.
It will outline Kohut’s theory of self-psychology and Bowen's family system's theory in order to assess their possible application to anorexia nervosa. It will go on to provide a hypothetical case example to see, if synthesized, these two theoretical perspectives may provide a more informed framework for clinical practice. Failures of Current Treatment Research has suggested that a need for control is a key factor in the onset of anorexia nervosa, making patients' resistance to treatment common (Williams & Reid, 2012). Early theories developed by Minuchen, Rossman & Baker (1978) assigned blame beyond the individual, attributing adolescent onset to poor parenting styles and disrupted attachments with primary caregivers.
Treatment adapted from Minuchen et al. A large majority of outpatient treatment options involving family systems have focused on the failures of family functioning instead of utilizing family strengths and resiliency factors (Eisler et al., 2007; Lock, Le Grange, Agras & Dare, 2001; Robinson et al. This has inhibited the cooperation of family members throughout the patient’s recovery process (Goldenberg & Goldenberg, 2013). Bowen's family system theory could provide a framework that helps to explain a member's contribution to family problems.
Deeper understanding of relational patterns could allow for system change by emphasizing the effect each member has on the unit as a whole. Consideration of family history could promote members taking responsibility for their actions and current roles within the family. This may stimulate deeper empathy for the individual in treatment, affording them more familial support throughout the treatment process (Walsh, 2012). 7 Inpatient treatment options, for more severe cases of anorexia nervosa, focus on immediate weight restoration in order to avoid debilitating health risks.
Mitchell and Crow (2006) explain that chronic malnutrition can result in the loss of menstruation cycle, peripheral edema, and osteoporosis. Eating Disorder specialist Alan Goodsitt (1997) suggests that inpatient hospitalization has proven to be successful at restoring patient’s weight but neglects to address the distorted thoughts and depleted self-esteem of the anorexic patient. Goodsitt (1997) argues that these treatment options are cost effective and capable of addressing large numbers of patients but often result in a “person who suffers as before, but looks normal - an anorectic clothed in weight” (p. Alternative outpatient mental health therapies such as Cognitive Behavioral and Dialectical Behavioral therapies have been used to treat individuals with pervasive eating disorders.
It is important to note that there are a multitude of treatment formats utilized to address anorexia symptoms. It is the intention of this theoretical exploration to better understand the etiological factors of anorexia nervosa in order to provide a synergized lens that may help practitioners use treatment options that are more effective. Overview of Theoretical Frameworks This research investigation will outline two theoretical frameworks that may help inform more effective treatment options. An outline of family systems theory may lead to therapeutic practice approaches that support the resilience and strength of the patient’s family unit by uncovering and addressing dysfunctional patterns.
An outline of self-psychology theory may provide a conceptual framework for understanding the anorexic patient’s sense of self and suggest practice interventions aimed at the restoration and reinforcement of healthy self-esteem. 8 Bowen's adaptation of family systems theory will be used to demonstrate how "stressful events, environmental conditions, and problems of an individual member affect the whole family as a functional unit" (Walsh, 2012 p. This theory is useful in viewing treatment options for anorexia, as it is most commonly diagnosed in adolescence and has deep effect on other members of the family (Eisler et al. By understanding the patterns of behavior that exist in the anorexic patient’s family system, clinicians can help to promote higher resiliency and functioning in the family unit as a whole.
Self-psychology theory may help to explain the developmental and emotional deficiencies that are associated with anorexia. Viewing treatment through this theoretical lens could shed light on the aspects of the disorder less apparent to family members and therapists alike. Research has shown that anorexia often coincides with a distorted thought process, depleted self-esteem and an inaccurate perception of body weight (APA, 2013). Through the use of Kohut’s theory of self-psychology, developmental factors that contribute to cognitive distortions and individual vulnerabilities may be better understood.
Treatment can be informed by this theory, placing emphasis on the need to specify treatment to the individual’s body image distortion and low self-esteem by reiterating the importance of therapeutic empathic mirroring and supportive counseling (Wassell-Kuriloff & Rappaport, 1987). Anorexia nervosa is a complex disorder that continues to perplex treatment. This thesis intends to provide an alternative way to understand the symptoms of the patient in order to provide a more inclusive treatment approach. The following chapter will introduce the strengths and limitations of each theoretical component as well as provide the ways they may be used in application to anorexia nervosa.
9 CHAPTER II METHODOLOGY This chapter will introduce the theoretical frameworks chosen to better understand anorexia nervosa, offering their relevant applications to future treatment. It will offer a brief description of the underlying concepts of family systems theory and self-psychology, highlighting the strengths and limitations of each. The chapter will conclude with a presentation of personal biases, exploring areas of the thesis which may have been influenced by the individual experiences and clinical perspectives of the writer. Theoretical Frameworks Defined Family Systems Theory Family systems theory focuses on family dynamics and the ways the family system’s functioning affects its individual members (Goldenberg & Goldenberg, 2013).
This theory holds that changes to the individual patient cannot be made without the cooperation and adaptation of the system as a whole. Family systems theory looks at individual anxiety levels as manifestations of family dynamics and the family member’s relationship patterns with other members of the family (Goldenberg & Goldenberg, 2013). Family systems theory will help to better conceptualize how family functioning can contribute to an individual’s symptoms, focusing treatment on addressing the destructive relational patterns that have inhibited members from successfully supporting the individual in treatment. 10 Core concepts underlying family systems theory are emotional fusion and the level of differentiation between family members (Brown, 1999).
Kerr and Bowen (1988) describe differentiation as the ability to develop individual autonomy while simultaneously maintaining emotional connection to the family unit. Families that exhibit unsuccessful differentiation exhibit more emotional fusion and enmeshment.