What if they gave a family session and nobody came? A therapist might be the most learned and caring person in the world, but if the family won't exert honest effort, if members can't support each other in their struggle, then things will be very difficult indeed.

Parents and siblings, and sometimes the extended family as well, need to learn about the illness and understand what the patient is experiencing so that they can better support her treatment. While it may help to learn from the family how the patient arrived at the faulty assumptions that underlie her illness, the focus also should be on her current beliefs and how they affect her immediate behavior.

There are lots of reasons families members refuse to get involved. Of course, they must wrestle with their own feelings of shame or guilt or pain. They may feel they can handle things just fine "in-house," not realizing that "in-house" is where the problem sprang up. Sometimes siblings resist because they gain from the illness by earning special favors or freedoms because they don't cause their parents any grief.

The therapist's attitude toward the family has a lot to do with its willingness to take part in treatment. Some caregivers think of parents as meddlers or adversaries and cut them out of the treatment loop. Others see them as "disturbed" and shuttle them off to a course of couples's therapy.

No go. Families have to be actively involved as co-therapists.

Role of the therapist

Therapists sometimes seem to become "temporary parents" of the families they treat. As in a corporate takeover, they step in and shake up the old organization, pointing out problems and suggesting new solutions.

They encourage families to temporarily set aside differences and unite to solve problems. They shore up the parents' authority to make rules to control their child's behavior, but insist that they treat the child with respect and give her as much autonomy as her age and maturity warrant.

Often therapists work with parents to hammer out a plan specifying how much weight their daughter must gain or how they will react to bingeing and purging. The therapist then supports the family in working through the difficulties that arise when the plan is put into practice.

I find it effective to be directly involved in all aspects of the patient's therapy - individual, group, and family. If this is impossible, I work closely with the other caregivers to make sure we're all rowing in the same direction.

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