The Role of Family in Developing and Treating Anorexia


Anorexia or anorexia nervosa is an eating disorder with profound negative implications for health. It is generally associated with mood disturbances, abnormal eating behavior, and a distorted body image (Burkert, p. 29). Its core symptoms include an obsessive desire to stay thin, a flawed perception of one’s own body, and a pathological fear of overeating (Burkert, p. 29). Anorexia mostly affects young women during their puberty, with the age of its onset usually ranging from 15 to 19 years (Burkert, p. 29). Up to 2 percent of all women in Western countries have suffered from anorexia during their respective lifetimes (Burkert, p. 29). The precise etiology of the disorder is still unknown, but numerous explanations have been offered for its emergence and progress, with some of those centering on the influence of the patient’s family. This raises a legitimate question of whether the anorexic’s family plays an important role in the development and treatment of anorexia, and, if so, what this role is. Katy Waldman’s essay rejects family-oriented interpretations of anorexia as mostly false, and her vision coincides with the contemporary scientific approach but does not pay enough attention to the family’s role in therapy.

Family Narrative: A Personal Experience

In There Once Was a Girl: Against the False Narratives of Anorexia, Waldman, a recovering anorexic herself, discusses the probable causes behind the development of the disorder based on her own experience and historical and scientific evidence. In the first part of the essay, Waldman tries to establish the moment “when the spores of anorexia first crept” into her. After consideration, Waldman finds these ‘spores’ in her childhood memory of comparing herself to her thinner and, supposedly, prettier sister. Hence, Waldman immediately demonstrates how one can explain anorexia through family relationships. Waldman rejects the idea that her parents exerted any pressure to be thinner or follow the established standards of beauty on her – she emphasizes they are “lovely and kind and interesting people.” Still, when asking herself whether her parents actually “enabled” her and her sister in their sickness, Waldman admits she has no definite answer. Waldman considers the possibility that her parents’ ill-chosen words may have accidentally convinced her that her anorexic sister’s behavior was “not really crazy”, but refuses to blame them. Essentially, Waldman uses her personal life story to illustrate the prevalence of family narratives about anorexia.

From Hysteria to Patriarchy: Anorexia Explained

After that, Waldman touches upon the perceived role of the family in the development of anorexia from a broader perspective and offers a historical overview of different etiological explanations of anorexia. Waldman notes these explanations have often concentrated on psychological aspects of the disease, be that a behavioral anomaly in “‘high-spirited’ patients” or irrational fear of food as an “impregnating agent.” She also notes that, for all this concentration on psychology rather than biology, the family did not attract the attention of medical professionals studying anorexia until the 1960s and the “rise of family systems therapy.” After that, Waldman describes this interpretation in which eating disorders represent “veiled power struggles between compliant kids and pressuring mothers.” She also points to another etiological theory explaining anorexia by patriarchal pressure on women to be thin but distinguishes it from the family-related discourse. While recognizing all these narratives are not without merit, the author refuses to adopt any of them. From her perspective, they all, to a greater or smaller degree, obscure the more profound reasons behind the disorder.

Biological Causes of Anorexia

According to Waldman, these reasons are biological rather than psychological. As Waldman puts it, regardless of any psychological symptoms, most of anorexia’s defining features are most likely the results of “physiological changes to the starving brain”. In her support, Waldman quotes Carrie Arnold’s Decoding Anorexia, stressing that evolution has programmed the human brain to oppose and resist starvation by any means. Waldman also mentions that a typical anorexic’s insula – a brain region responsible, among other things, for creating the mental image of self – work differently from a non-anorexic’s insula. The sources Waldman employs suggest that “lower connectivity and slower processing speeds in the insula” may explain anorexics’ distorted perception of their bodies. Still, Waldman remains cautious enough not to make overreaching statements on the still unclear etiology of the disease and admits that a person without a strong biological predisposition may also develop the disorder. This careful remark near the end of the essay is a correct choice when speaking of an issue still unclear, but it undermines the decisiveness of the author’s argument for the biological explanation of anorexia.

Medical Professionals on the Causes of Anorexia

Complementing Waldman’s essay with a scientific opinion on the subject allows analyzing some details of her argument in greater detail. In the article by Simonovic et al., the collective of authors offers a detailed study of etiological concepts regarding the development of anorexia (pp. 31-43). This analysis allows Simonovic et distinguish five historical stages of explaining the disorder’s etiology: neurotic and hysterical approaches, glandular approach, psychoanalytical approach, family-based and sociocultural explanations, and, finally, neurobiological explanations of recent decades (pp. 33-38). This representation of the neurobiological approach as the last word in studying anorexia supports Waldman’s position.

Family’s Role and Sociocultural Pressure: Not So Different

However, one should also note that the article corrects Waldman on at least one point. Simonovic et al. unite explanations centered on family and patriarchy under a common rubric “Family-based and socio-cultural explanations” (p. 36), Waldman, on the other hand, distinguishes them. This unification emphasizes that families do not act in a social vacuum, but are often agents promoting sociocultural expectations – a notion not stressed in Waldman’s essay. Perhaps this distinction owes much to Waldman’s parents being “lovely and kind” and not exerting their influence to make their daughters comply with sociocultural standards of beauty. This personal experience might have led Waldman to distinguish family-centered and society-centered narratives, while the family in such cases often acts just as an appendage of society at large.

Dangers of Biological Monism

Simonovic et al. also add a point essential for Waldman’s position but absent in her essay. In conclusion, Simonovic et al. caution about an “all-too monistic etiological approach” to anorexia, stressing it may have negative implications for therapy (p. 40). Simonovic et al. offer the period of glandular approach at the beginning of the 20th century, when medical professionals broadly administered hormones to the patients disregarding the disorder’s psychological aspects, as an example of such danger (p. 40). While Waldman does not claim that neurobiological turn explains everything about anorexia either, she does not hint at the negative therapeutic implications of favoring biological explanations too much. Noteworthy enough, she also barely touches on the therapeutic role of the anorexic’s family.

Parents First: The Role of Family in the Treatment

This is a limitation of Waldman’s essay: she discusses the family’s effect – or lack thereof – on the development of anorexia, but not its treatment. Admittedly, she once posits that “exclusion of the parents or caregivers” may impede the therapy, but does not speak about their inclusion. Yet contemporary approaches assign a progressively greater role to anorexic’s family in recovery. As noted by Le Grande et al., in parent-focused treatment, the patient’s parents become “the primary participants in therapy” with whom the clinician mostly works, while the nurse monitors the patient (p. 684). According to Le Grande et al., parent-focused treatment offers a three times greater chance of remission when compared to other kinds of family-based treatment (p. 689). Unfortunately, although Le Grande et al. praise parent-focused treatment as “efficacious,” they do not touch on the greater implications of their findings (p. 684). Concentrating psychological treatment on parents rather than patients themselves means implicitly recognizing that the etiology of the disorder is more biological than psychological. Hence, just as the article by Le Grande et al. allows deepening Waldman’s argument, Waldman’s essay casts additional light on findings discussed in said article.


As one can see, Waldman’s essay concentrates heavily on family-related explanations of anorexia to dismantle them in favor of the neurobiological approach but does not pay close attention to the family’s role in the treatment. Based on her own experience and the historical evolution of etiological theories regarding anorexia, Waldman concludes that psychological explanations based on the family have merit, but are less grounded in evidence than neurobiological explanations. Contemporary medical professionals agree with this approach, but also caution against adopting it in a monistic way. Additionally, Waldman’s drive to reject family-related narratives of anorexia leads her to overlook the role of the family not in the development, but the treatment of the disorder.


  1. Burkert, Natalie Tatjana. Psychological and Neurobiological Aspects of Eating Disorders: A Taste-fMRI Study in Patients Suffering from Anorexia Nervosa. Springer, 2015.
  2. Le Grande, Daniel et al. “Randomized Clinical Trial of Parent-Focused Treatment and Family-Based Treatment for Adolescent Anorexia Nervosa.” Journal of the American Academy of Child and Adolescent Psychiatry, vol. 55, no. 8, 2016, pp. 683-692.
  3. Simonovic, Vasilija et al. “The Historical Discourse on the Etiology of Anorexia Nervosa Results of a Literature Analysis.” Sudhoffs Archiv, vol. 99, no. 1, 2015, pp. 31-43.
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