The Mother-Daughter Relationship in Eating Disorders: The Psychotherapy group of mothers

Abstract

Psychotherapeutic interventions that bring about differentiation, separation, individuation and autonomy in the mother-daughter relationship are recommended as treatment for eating disorders. With this goal in mind, a psychotherapy group for mothers was organized in an outpatient program for adolescents with eating disorders at a public institution, as one of the psychotherapeutic approaches in the multidisciplinary treatment of adolescent patients. Evidence suggests that this approach can be relevant and effective in the treatment of eating disorders. [PUBLICATION ABSTRACT]

Headnote

Psychotherapeutic interventions that bring about differentiation, separation, individuation and autonomy in the mother-daughter relationship are recommended as treatment for eating disorders. With this goal in mind, a psychotherapy group for mothers was organized in an outpatient program for adolescents with eating disorders at a public institution, as one of the psychotherapeutic approaches in the multidisciplinary treatment of adolescent patients. Evidence suggests that this approach can be relevant and effective in the treatment of eating disorders.

Key words: Eating disorders, mother-daughter relationship, group psychotherapy, body image

Abstract

(Relação mãe-filha nos transtornos alimentares: o grupo psicoterapêutico de mães)

Intervenções psicoterapêuticas que promovam a diferenciação, a separação, a individuação e a autonomia na relação mãe-filha são preconizadas e enfatizadas no tratamento dos transtornos alimentares. Com esse objetivo foi instituído o Grupo Psicoterapêutico de Mães no programa de transtornos alimentares de uma instituição pública , como uma das abordagens psicoterapêuticas no tratamento multidisciplinar dos pacientes adolescentes e que vem se mostrando uma intervenção pertinente e eficiente no tratamento desses transtornos.

Palavras-chave: Transtorno alimentar, relação mãe-filha, psicoterapia em grupo, imagem corporal

(Relation mère-fille et troubles alimentaires: le groupe psychothérapeutique de mères)

Les interventions psychothérapeutiques qui favorisent la différenciation, la séparation, l'individuation et l'autonomie dans la relation mère-fille sont recommandées et mises en relief dans le traitement des troubles de l'alimentation. C'est avec ce but que le Groupe Psychothérapeutique de Mères a été inclus dans le programme des troubles de l'alimentation d'une institution publique comme une des approches psychothérapeutiques d'un traitement pluridisciplinaire de patients adolescents. Les résultats suggèrent qu'il s'agit d'une intervention pertinente et efficace pour le traitement des troubles alimentaires.

Mots clés: Troubles de l'alimentation, relation mère-fille, psychothérapie de groupe, image corporelle

(La relación madre-hija en los trastornos alimentarios: el grupo psicoterapéutico de madres)

Las intervenciones psicoterapéuticas que promueven la diferenciación, la separación, la individuación y la autonomía en la relación madre-hija, son recomendadas y enfatizadas en el tratamiento de los trastornos alimentarios. Con este objetivo el Grupo Psicoterapéutico de Madres, se ha establecido en el programa de trastornos alimentarios de adolescentes de una institución pública, como uno de los enfoques psicoterapéuticos en el tratamiento multidisciplinario de los pacientes adolescentes. Las evidencias sugieren que es una intervención relevante y eficaz para ser utilizada en el tratamiento de trastornos de la alimentación.

Palabras clave: Trastornos de la alimentación, relación madre-hija, psicoterapia de grupo, imagen corporal

(Mutter-Tochter Beziehung im Zusammenhang mit Essstörungen: Die psychotherapeutische Gruppe von Mütter)

In der Behandlung von Essstörungen werden psychotherapeutische Interventionen, die die Absonderung, Trennung, Individualisierung und Autonomie in der Mutter-Tochter Beziehung fördern, empfohlen und hervorgehoben. Die Grupo Psicoterapêutico de Mães (Psychotherapeutische Gruppe von Mütter) wurde mit diesem Ziel im Programm für Essstörungen einer öffentlichen Einrichtung gebildet. Sie stellt eine der psychotherapeutischen Ansätze in der multidisziplinären Behandlung von Teenager-Patienten dar und erweist sich als eine angemessene und erfolgreiche Intervention in der Behandlung dieser Störungen.

Schlüsselwörter: Essstörungen, Mutter-Tochter Beziehung, Gruppen-Psychotherapie, Körperauffassung

The space of a lifetime takes place between the caesura of birth and the caesura of death.

There are in it historical and psychic reverberations from at least two preceding generation and they last for at least two succeeding ones.

(Marina Ribeiro, De mãe em filha)

Freud published "A case of healing through hypnosis" in 1893 that is considered one of the first psychoanalytic studies to focus anorexia nervosa in a context that approaches the mother-baby relationship. With psychoanalysis still in its beginning, Freud used hypnosis to treat a mother that manifested anorexic symptoms and could not breastfeed her newborn babies.

In 1895, at the "G manuscript", Freud highlights the melancholic aspect of anorexia, opening a field in which to consider object-relations as significant elements for the understanding of the metapsychological aspects expressed in eating disorders.

The interest of psychoanalysts though only starts to focus in the mother- daughter relationship with Hilde Bruch, who in 1978 affirmed that the mother of an anorexic patient is someone who cannot intuitively grasp the baby's needs, because she reacts to them according to her own desires, giving little room for the child's individual expression.

Mara Selvini - Palazzoli related the difficulties with object-relations and the pathological body experiences. She traveled the path that Hilde Bruch pioneered. Considering the body experiences, a disturbed mother-daughter relationship - that probably happens in anorexia - may stimulate feelings of alienation, imperfection and lack of control of the body, feelings that, if repressed, can be acted out as anorexic behavior. (Selvini - Palazzoli et al, 1999).

Other authors as Bidaud (1998) and Ribeiro (2011) illustrate the formative aspects of the mother-daughter relationship by analyzing the greek myth of Demeter (mother goddess of the Earth) and her daughter Persephone. They consider it an expressive scenario for said relationship.

Persephone had been "snatched" by the desire of Hade, the king of dead, which leaves Demeter heartbroken by the loss of her daughter. The threat of separation is so frightening, that causes her to "cease eating and drinking" as a symbol of the anguish felt by both mother and daughter. This "anorexia" would be a response to the distress caused by the separation of mother and daughter, and could be seen as an attempt to keep the relationship unharmed. In Bidaud's understanding, it is a "narcissistic trap" in which the intolerance to separation prevails, deriving to an undifferentiated and in discriminated mother and daughter pair.

Within this pair, according to Eliacheff (2004), one becomes the "mirror" of the other and the daughter becomes a narcissistic projection of the mother. This kind of link is prone to identity confusion and is prejudicial to reciprocity.

Gonzaga (2010) wrote about this identity related issues, and proposed an understanding that takes into account the motherly narcissistic overinvestment. This would result in the confinement of the patients in the early images projected from the link between mother and baby. Those images, as founders of the body psyche and ego, would reenact the distorted body perception in anorexia nervosa.

Cobelo (2008), in investigating the possible influence exerted by the mothers' imaginary in patients with eating disorders extends our understanding by observing body dissatisfaction and eating disorders symptoms in mothers of adolescents suffering with anorexia nervosa.

Some clinical studies have investigated the problems underlying the relationship between these patients and their family, or their mothers, of which we would like to highlight:

Stice et al. (1999) studied 216 children and their parents during their first five years of age. They verified some aspects as predictive of eating disorders in childhood such as: a) in the mother: body dissatisfaction, internalizing of beauty ideals, diet, bulimic symptoms and overweight; b) in the child: the length of suction during breastfeeding and overweight.

Another study with the same goal, by Schoebridge e Gowers (2000) compared 40 adolescents with anorexia nervosa diagnosis and a control group. The results showed significant attitude differences in the patient's mothers when compared with the control groups. The anorexic girls' mothers had cared for the baby almost exclusively, presenting great distress in leaving their daughters in a child care center or school. The patients were also older than those with no eating disorder when they first spent a weekend away from home. Based on this data the authors concluded that a high degree of maternal concern during childhood could be associated with a higher risk of later developing anorexia nervosa.

According to Lofrano e Labanca (1995) this elevated concern could lead to inadequate responses by the mother. They affirm that the absence of consistent and adequate responses by the mother would harm the development of the baby's body identity. The lack of a conscious perception of body functions, would lead patients with eating disorders, to a feeling of perplexity in face of development demands.

Pike and Rodin (1991) published a study in which the goal was to observe how maternal attitudes and behavior could be related with the daughters' eating disorders. The question that guided the study was: "Would the mothers of patients with eating disorders show significant differences in family functioning when compared to those mothers whose children didn't present an eating disorder?". The authors also try to evaluate if mothers that are too concerned about attitudes and behaviors regarding physical appearance, weight and diet, would also be more critical of their daughters, exerting more pressure over them to fit within slimness ideals that could increase their risk of developing eating disorders. The results pointed that the families of patients with eating disorders were less cohesive than those of the control group but the difference was not statistically significant. There was a significant difference though in data referring to the hypothesis of the existence of a relation between maternal dietary difficulties and the incidence of eating disorders in the daughters.

Whelan and Cooper (2000) have analyzed the possible relation between feeding issues in childhood and eating disorders in the patients' mothers. A sample of pre-school children of 4 years of age was divided in three groups: 1) children with feeding issues; 2) children with other issues (behavior, shyness and fear issues); 3) children with no issues. The authors pointed that mothers of children with feeding issues presented a highly elevated rate of eating disorders prior or within the period of the studies.

When the studies lean towards the observation of the attitudes related to maternal care, most of them point to a relation of either neglect or overprotection in the event of the development of an eating disorder. While some authors observed a high rate of bulimia nervosa in women that described maternal care as insufficient, some others describe the overprotective role of the mother in patients with anorexia nervosa (Garcia de Amusquibar e De Simone, 2003).

Regarding weight, body shape and body image it is important to consider that the mother is the first role model for her daughter. A study by Cooley et al. (2008) researched the role of dietary attitudes and body related behaviors of mothers that could serve as models for the behaviors and attitudes of their daughters. In this study 91 female American university students and their mothers, answered questionnaires about body image and feeding attitudes and patterns. The daughters' average age was 21 and the mothers' 48 years old. The results showed dietary symptoms and body dissatisfaction in mothers that were related to those of the daughters, which is pointed as a possible effect of the maternal role model.

These studies concur with what psychoanalysts have proposed in their researches as fundamental to understand the role of the relationship established between mothers and daughters, specially when the latters have an eating disorder such as: maternal body representation (considering trans-generational heritage), early maternal care, aesthetic ideals envisaged by these mothers, the narcissistic arrangements promoted and the emotional bonding between them.

Usually the psychoanalytical authors highlight the identification processes between mother and daughter, and the hard task of the beneficent identity construction, as well as, in the confinement that might derive from this process. Ribeiro (2011) summarizes: "If we are born in a undifferentiated field, differentiation is a tough psychical process. In this sense recognizing the difference of the self and the other, of the genders and of generations, is the zenith of a long road" (op. cit., p. 193).

Important concepts of the processes that promote identification are defined by Dolto (1984), who determines that the body scheme defines the individual as an instance of his species wherever the place, whatever the time or condition in which the subject lives. The body scheme is an interpreter of the body image, allowing to structure the subjectivity it builds itself by learning and experience and it is, in part, unconscious, in part conscious. If the body scheme is the same for every individual, body image is peculiar to each one for it is related to the subject and his history. It is understood therefore that the building of the body image, suffers the influence of subjectivity related aspects that permeate the mother- daughter relationship.

Psychotherapeutic interventions that promote differentiation, separation, individuation and autonomy in the relationship established between mother and daughter are recommended and emphasized by professionals who work in the eating disorders field. (Bidaud, 1998; Brusset, 1999; Weinberg, 2006; Jeammet, 2010; Fernandes, 2010; Miranda, 2010; Ribeiro, 2011).

In that same direction, an important number of studies have shown good results in involving relatives in the treatment of adolescents with eating disorders (Lock et al., 2001; Cobelo, 2004). Few though have focused in the specific mother-daughter relationship, especially in the thoughts, feelings, and behaviors of mothers in relation to their daughters' illnesses.

When thinking about the identification model that the mother offers to her daughter, we must consider the complexity of the mother-daughter relationship and take into account the maternal role in the transmission of cultural values, including those related to weight, body shape and body appearance (Hill and Franklin, 1998).

Helping mothers and daughters through the individuation/separation process by showing the difficulties and how to deal with them can be an important differential in the treatment of those patients (Van Furth et al., 1996).

In proposing interventions in the treatment of adolescents with eating disorders, in a multidisciplinary team of a public institution that complied with this vision and that would take care specially of the patients' mothers, the formation of a working group was considered. A bibliographic review was done and no reference to this model of intervention was found in the literature.

It was thus one of the goals that guided the creation, in 2001, of the so called "Psychotherapeutic mothers' group" that takes place at the PROTAD, the outpatient program for the treatment, teaching and research services of Eating Disorders for children and adolescents, of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo.

All patients' mothers are invited to join in when her daughter or son begins treatment at the clinic and stay in the group until the patient is discharged. The meetings are weekly, last for an hour and are coordinated by a psychologist specialized in family therapy.

Throughout all this years of experience working with these groups, besides difficulties of separation-individuation, lots of topics repeat themselves as, for instance, the need to know about the disease's etiology, "nobody in my family ever had a similar illness", "I can't understand how she got sick... she was a little 'chubby' then started dieting, and then before I could realize she had anorexia". At times they show how difficult it is to cope with an unknown illness that provokes so many feelings such as guilt to name one. Lots of mothers say "I don't know what I did wrong" or "I guess it is because I force-fed her when she was little".

Fears are also present, like the ones expressed in the sentences "what is it going to happen?" and "what if she doesn't heal?" Feelings of anger and injustice also appear in sentences such as: "she shouldn't be doing this" or "it isn't fair what she's doing to us" that are reported specially when the moms have already overcome initial guilt. Also frequent are feelings of impotence "nothing works! ... It's been so hard to deal with her!!" "I always thought that she cut herself because she was gaining weight, now she lost 1,7 kg and also cut herself, now I'm not so sure... I don't know what to do".

In most of the working groups, the questions related to the identification process, in which the mothers show how difficult it is to separate their own feelings from those of their daughters make up an important share of the meetings: "How am I going to eat while my daughter is starving?" or "How can I be happy if my daughter is feeling miserable?"

The questions related to the body images of the patients and their mothers, as well as the concerns towards eating, food etc. appear in almost every meeting and it is very demanding to detach them from the concrete aspects of the problems and make them reach a more symbolic comprehension that can help them elaborate dissatisfactions with their own body.

The experience of working with psychotherapeutic mothers' group points to the importance of this intervention in the treatment of eating disorders. We have observed how working with those questions so inherent to the conflicts that refer to the difficulties of differentiation and separation between mother and daughter, result not only in the possibility of progress in the treatment of young anorexic and bulimic patients, but, above all, enables mothers to identify and elaborate a good portion of these underlying conflicts.

We conclude then, once again referring to Marina Ribeiro (2009), who teaches us:

Every mother-daughter pair is replicated in the following generation; What was at stage in the prior generation, if an elaboration of the conflicts and hardships hasn't taken place, tend to repeat itself in a baffling near manner (... ) put it in another way, more figurative, what we put in the dark cellar of our life and that we no longer want to see, shows up in our children with a blinding shine. (p. 5)

Or as one of the mothers bid farewell: "I'm bad with separations, with saying goodbye. This is the moment to thank for the accomplishments. I thought of bringing a poem, some music lyrics. I thought of that Almir Sater's song, the one that says 'rain must fall upon us for us to blossom'. We are closing a chapter and new things will come, new problems. I thank everybody here, even those who couldn't speak, it doesn't matter, because we see ourselves in each other, we are different but our sorrows are the same".

Citation/Citação: COBELO, A.W.; GONZAGA, A.P. Mother-daughter Relationship in Eating Disorders: The Psychotherapeutic Mother's Group. Revista Latinoamericana de Psicopatologia Fundamental, São Paulo, v. 15, n. 3, p. 657-667, sept.2012 (Suppl.).

Editor/Editor do artigo: Prof. Dr. Manoel Tosta Berlinck

Received/Recebido: 30.5.2012 / 5.30.2012 Accepted/Aceito: 25.7.2012 / 7.25.2012

Copyright: © 2009 University Association for Research in Fundamental Psychopathology / Associação Universitária de Pesquisa em Psicopatologia Fundamental. This is an open-access article, which permits unrestricted use, distribution, and reproduction in any medium, provided

the original author and source are credited. / Este é um artigo de livre acesso, que permite uso irrestrito, distribuição e reprodução em qualquer meio, desde que o autor e a fonte sejam citados.

Funding/Financiamento: The authors have no support or funding to report. / Os autores declaram não ter sido financiados ou apoiados.

Conflict of interest/Conflito de interesses: The authors declare that has no conflict of interest. / Os autores declaram que não há conflito de interesses.

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