family patterns associated with anorexia nervosa

Journal of Marital and Family Therapy 1989, Vol. 15, NO. 1,29-42

FAMILY PATTERNS ASSOCIATED WITH ANOREXIA NERVOSA"

Darryl N. Grigg John D. Friesen University of British Columbia

Margarette I. Sheppy University of Alberta

A family systems perspective was used to explore familial transactional patterns related to anorexia nervosa. Father, mother and daughter, interpersonal assessments of parental initiative and daughter responsive behaviors as reported on Benjamin's (1974) Structural Analysis of Social Behavior (SASB), were com- bined to serue as data for a hierarchical cluster analysis. Out of the 22 families with a n anorexic child and the 22 matched control families, 7 family groups with unique family dynamics differentiating one from another emerged out of the clustering procedure. Prototypic family profiles were established and examined using Benjamin's (1984) program Figure (FIG) to explicate central features of the family transactional relationships. With no single family pattern characterizing the families of the anorexic daughters, the study challenges earlier family theories that postulated a single anorexogenic family system, and supports a broader, more complex view of anorexics and their families.

Patterns of relationship within families have long been of central interest to family therapists. In the belief that symptoms are both system maintained and system maintaining, theorists, practitioners and researchers, alike, have concerned themselves with the patterns of relationship seen as dysfunctional or symptomatic. However, the linkage between specific repetitive patterns of family relationship and the development and maintenance of particular symptom behaviors remains, by and large, poorly understood.

Family interactive processes have been construed from a variety of vantage points. Theoretical models have proliferated as a result of the search for a more accurate metaphor to describe the intricate family weaves practitioners are confronted with daily. Many of these models would seem to serve the practitioner well, functioning as frame- works within which to comprehend the multi-layered orchestrated behavior of families, as well as providing therapists with theoretical stances essential for guiding treatment. However, there remains a great need for further research investigating the way in which intrafamilial interactions affect symptom behavior such that theoretical positions may have a more empirically secure moorage.

*This paper was presented at the 11th Western Canadian Conference on Family Practice,

Darryl N. Grigg, MA, is a Doctoral Candidate in Counselling Psychology, University of British

John D. Friesen, PhD, is Professor of Counselling Psychology, University of British Columbia,

Margarette I. Sheppy, EdD, is Associate Professor, Faculty of Nursing, University of Alberta,

Banff, Alberta, Canada, May, 1987.

Columbia, 5870 Toronto Road, Vancouver, BC, Canada, V6T 1L2.

5870 Toronto Road, Vancouver, BC, Canada, V6T 1L2.

17239-92 Avenue, Edmonton, Alberta, Canada, T5T 3K7.

January 1989 JOURNAL OF MARITAL AND FAMILY THERAPY 29

Family Theoretical Perspectives of Anorexia Nervosa A substantial range of opinion exists regarding the association between patterns of

family behavior and the symptom of anorexia nervosa. Nonetheless, some form of relationship between them has long been noted. Laseque (1873) astutely wrote:

The relatives and friends begin to regard the case as desperate. It must not cause surprise to find me always placing in parallel the condition of the hysterical subject and the preoccupations of those who surround her. These two circumstances are intimately connected, and we should acquire an erroneous idea of the disease by confining ourselves to an examination of the patient. (p. 152)

Theoretical disagreements arise as to the manifestation of this “intimate connec- tion” between family members and anorexic children. Broadly speaking, the theoretical postures reviewed below may be broken into three forms of explanation: (a) uni-dimensional, (b) bi-dimensional, and (c) multi-dimensional. While a vast number of rival perspectives pertaining to the development and treatment of anorexia nevosa exist, including psychodynamic, cognitivelbehavioral, physiological, biochemical, and socio- cultural theories, it is beyond the scope of this paper to review these. The theoretical models presented below serve as elaborations of the three broad explanations which focus on the role of family interactions in the development and maintenance of the symptom.

Uni-Dimensional Minuchin, Baker, Rosman, Leibman, Milman & Todd (1975) and Minuchin, Rosman

& Baker (1978) examined the structural characteristics of the “anorexic families.” Five predominant features of family interaction were identified as recurrent themes. Their theory emphasizes familial patterns of enmeshment, overprotectiveness, rigidity, lack of conflict resolution and the involvement of the sick child in unresolved parental conflict. Sargent, Liebman & Silver (1985) noted that these characteristics form a matrix for ongoing family behavior. This structural view of the recurrent family patterns was not meant to present a static picture of family relationship and no statement regarding etiology was intended. However, such qualification must be weighed against seemingly contradictory statements by Minuchin et al. (19781, who clearly stated that “certain transactional patterns seem to be characteristic of all anorexogenic [italics added] families” (p. 29).

Selvini-Palazzoli (1970,1974) also described “anorectic families”; however, she did so from the perspective of communication theory. She placed the accent on a family pattern which was in a constant state of tension and frequently subject to numerous trivial arguments. Furthermore, she identified major problems in communication, processes of blame shifting, or avoidance of responsibility as well as high levels of marital discord to be associated with anorexia. Absent or distant fathers complemented by overinvolved dominant mothers, denied coalitions between anorexic child and parents, and a desire to be secretive and gloss over family problems to outsiders were also found to be observable repetitive patterns characteristic to the symptomatic families she studied.

Bi-Dimensional Strober and Yager (1985) noted variability in the family constellations associated

with anorexia nervosa from a developmental perspective. For them, two dominant family patterns are discernible and recurrent in the families of anorexics they worked with. One pattern is characterized by a “centripetal process” dominated by themes of excessive cohesion. In this pattern, family relationships are colored with a lack of permissiveness,

30 JOURNAL OF MARITAL A N D FAMILY THERAPY January 1989

reduced emotional expressivity as well as frequently impoverished extrafamilial con- tacts.

In contrast, the second family pattern they identified as associated with anorexia nervosa is characterized by a “centrifugal process.” These family relationships lack cohesion and attachment. They tend to be families which are highly conflicted well before the onset of the anorexic symptoms. The researchers note that the centrifugal interactions are characterized by threats of abandonment, clinging dependency, and expressions of disappointment. The predominant theme of lack of control is recurrent in family relationships that are marred by openly expressed marital discord.

Multi-Dimensional Garfinkel and Garner (1982) suggested that the families of anorexics are a heter-

ogeneous group. For them, there is no one type of family relationship or family structure unique to anorexia nervosa. Rather, from their perspective, there may be a number of risk factors or difficulties related to the family that may predispose a child to anorexia nervosa. However, these are set against a backdrop of many other nonfamily related risk factors. Recently, Garfinkel, Garner & Kennedy (1985) have noted some common disturbances in the interaction patterns of families with anorexic children related to communication, affective expression, expectations and role performance, but maintain that vast differences also exist in the families they have studied.

Research Objectives It should be clear from the brief sketches of these four theories that there is a

pronounced difference of understanding regarding the family interaction pattern(s) of children with anorexia. The purpose of this research was to empirically investigate the association between perceived family patterns of relationship and the anorexia nervosa. In particular, we wanted to examine the plausibility of uni-dimensional explanations as they have tended to dominate the family therapy literature (Yager, 1982).

To test this view, two research hypotheses were formulated: Hypothesis I stated that families containing anorexic daughters will manifest transactional patterns reli- ably differentiating them from the control group of families; hypothesis 2 predicted that all families of anorexics would realize a near-isomorphic family transactional pattern, such that they would be empirically grouped together to form a single family type.

A parallel research goal was to generate a methodological procedure for empirically studying family patterns consonant with the notion that families function, not as a single objective unit, but rather, as networks or systems of beliefs (Bogdan, 1984). To this end, in this study “the family” was defined as an intrafamilial set of interpersonal perceptions regarding the fathertdaughter and motherldaughter relationships.

METHOD

The Families The subjects were 22 families with an anorexic daughter and 22 matched control

families with a nonanorexic daughter. Families varied in composition and number of children; however, for the purpose of this study, only the interpersonal views of the mother, father and indexed daughter in each family were considered in the analysis. The anorexic and control families were matched on the variables of socioeconomic status, child adoption, step parentage, parental age and the ages of the identified anorexic and nonanorexic girls. All daughters in both groups were presently living at home at the time of testing.

The age of the daughters in the study ranged from 15 to 23 years (M = 8.3, SD =

2.29). All anorexic subjects satisfied the criteria for anorexia nervosa as outlined in the

January 1989 JOURNAL OF MARITAL A N D FAMILY THERAPY 31

DSM I11 (American Psychiatric Association, 1980) with the exception of five girls whose weight loss ranged from 15% to 23% standard body weight. All of these five subjects had been diagnosed as anorexic by a psychiatrist specializing in the disorder and satisfied other criteria specified in the DSM 111. In addition, six of the anorexic girls who had previously been classic restricting anorexics had recently adopted bulemic-like strategies or a bingeJpurge cycle as a means of maintaining their anorexic body weight. The mean age of the anorexic a t the onset of the illness was 16.2 years (SD = 1.91) and the mean duration of the illness was 23.5 months (SD = 16.05). Two subjects had never menstruated; all others had suffered from amenorrhea for a period of 3 to 60 months (M = 13.4 months, SD = 12.45) prior to presentation for treatment.

All the nonanorexic girls in the study were receiving medical services from Family Practice Units and other community agencies for nonpsychiatric conditions (e.g., broken limbs, tonsillitis, bronchitis). None had a history of psychiatric disorder. The selection of comparison group subjects who were under the care of a medical practitioner was an attempt to control for some of the changes in family patterns which may arise as a reaction to family stress during prolonged illness of a family member (Yager, 1982). The experimenter, a t the time of testing, noted and recorded clinical impressions of familial interaction patterns such as overt family tension, conflict, sulking, protesting and submitting behavior in the indexed child, as well as parent behaviors in both the anorexic and control families.

Statistical analyses were conducted comparing the anorexic and control families on a number of demographic variables, including socioeconomic status, number of stressors and separatiodloss events, family form, heights, weights and ages of subjects including mothers and fathers, birth order and family size. No statistically significant difference between the anorexic and control families was revealed in the demographic analyses.

Instrumentation In order to investigate the complex interpersonal patterns of family behavior, Ben-

jamin's (1974) Structural Analysis of Social Behavior (SASB) was selected as the mea- surement tool. Designed to measure both reciprocal psychosocial behavior and self- concept, SASB is a circumplex model based on the interpersonal theory of Sullivan (19531, representing an expansion of previous circumplex models by Murray (1938), Leary (1957), and Schaefer (1965). Recently shown as a means for operationalizing and measuring family processes that have proven difficult to validate (Benjamin, 1979a; Benjamin, 1984; Humphrey & Benjamin, 19861, SASB is established on the core dimensions of affiliation and autonomy seen as present in all relationship. Qble 1 presents an adapted version of the transactional behaviors measured in Benjamin's SASB cluster model.

Table 1 'Jkansactional Behaviors (TB) Measured on SASB

Focus

TB# Initiating TB# Responding

1. Freeing and Forgetting 2. Affirming and Understanding 3. Loving and Approaching 4. Nurturing and Protecting 5. Watching and Controlling 6. Belittling and Blaming 7. Attacking and Rejecting 8. Ignoring and Neglecting

9. Asserting and Separating 10. Disclosing and Expressing 11. Joyfully Connecting 12. Trusting and Relying 13. Deferring and Submitting 14. Sulking and Scurrying 15. Protesting and Recoiling 16. Walling off and Distancing

32 JOURNAL OF MARITAL AND FAMILY THERAPY January 1989

As the table reveals, eight circumplex-ordered initiating and eight complementary- responding behaviors are considered in the interpersonal rating scheme’ For example, ratings of the polar opposite initiating behaviors of the autonomy dimension, Freeing and Forgetting (TB-1) and Watching and Controlling (TB-51, are complemented by the corresponding polar opposite responding behavior ratings of Asserting and Separating (TB-9) and Deferring and Submitting (TB-13).

Although a wealth of information is generated by the intrapsychic, self-concept part of the Benjamin model, for the purposes of this study, we concerned ourselves only with interpersonal ratings. These were obtained by having each of the family members independently complete a version of Benjamin’s (1974) SASB rating scales called Intrex questionnaires.

Interpersonal ratings are based on subject responses on 72 separate items from the questionnaire which yield the eight initiating and eight responding scores.2 All 72 interpersonal questions are relationally based and are concerned with dyadic functioning. Intrex is designed so that subjects rate themselves and others on a 10-point interval scale ranging from 0 to 100. The instructions to the questionnaire explain that a score of 100 indicates that the item always applies perfectly while a score of 0 indicates that the item does not apply at all. The score of 50 is used as the demarcation point between whether or not a given item is seen as true or false.

The Intrex questionnaires’ versatility allows for a wide variety of relational assessments. The interpersonal foci we were especially interested in was punctuated as parental initiation or action towards daughter, and daughter’s response or reaction to her parents. Thus, fathers and mothers were asked for their views on how they saw themselves behaving towards their daughter and how she, in turn, responds to them. Daugh- ters were correspondingly asked how they felt their mothers and fathers acted towards them and how they perceived their own responses to each of them.

It is beyond the scope of this paper to fully describe the intricacy of Benjamin’s model. While it holds great potential for both research and practice, SASB is a complex instrument. Wiggins (1982) described the model as “the most detailed, clinically rich, ambitious and conceptually demanding of all contemporary models” (p. 18). Interested readers are directed to previous works (Benjamin, 1974, 1979a, 1979b, 1984, 1987; Humphrey & Benjamin, 1986) for a complete explanation of the model and its many applications.

Statistical Procedures Each individual family member’s transactional behavior (TB) scores were listed to

establish family profiles. The 64 ratings comprising each of the 44 family profiles (22 families with an anorexic child and 22 nonsymptomatic families) were constituted by: 16 TB scores representing father’s view of the fatherldaughter relationship; 16 TB scores reflecting mother’s rating of her view of the motherldaughter relationship; and 32 TB scores revealing daughter’s appraisal of the fatheddaughter and motherldaughter relationships. Thus, the family profiles were an embodiment of intrafamilial sets of interpersonal perceptions and served as the data to be entered into the computer analysis.

The 44 family profiles were subjected to the hierarchical cluster analysis program “U.B.C. C Group” developed by Patterson and Whitaker (1978). In view of the particular hypotheses of the study, the cluster analysis was chosen because this procedure specif- ically enables the grouping of units of data based on similarity. The cluster analysis program maximizes both within group homogeneity and between group heterogeneity by progressively pairing family TB scores (father, mother, daughter) sequentially, such that within group variation (error) is minimally increased at each pairing step.

The decision on when to stop the pairing process was based solely on increases in the error term. Since a substantial increase in the error term at any particular step


suggested the pairing of substantially different families, the first major jump in error term was established as the criterion for the step at which the clustering procedure was stopped. In this way, we were able to identify family clusters which were groups of family profiles that shared in the familial relational assessments of one another.

In order to further illuminate the similar familial characteristics upon which the statistical analysis had linked the various family profiles into clusters, prototypical family profiles for each of the family clusters were generated. To do this, the family profiles within each of the family clusters were averaged to produce a mean averaged set of 64 TB scores. Thus, these prototypical family cluster profiles represented a math- ematically based composite of each family cluster. The 64 TB scores of the prototypical family profiles were then entered as data to be further analyzed by an innovative program developed by Benjamin (1984) called “FIG.”

Program FIG produces a version of Benjamin’s circumplex model that allows for a lineal representation of the transactional behaviors. This program graphically displays each set of 8 TB scores and simultaneously compares and correlates the empirically obtained data with a set of 21 theoretically derived best-fit curves. Since the majority of the theoretical curves characterize a range of common transactional styles which have been given descriptive psychological labels, they provide a concise synopsis of the transactional postures being considered. Endowed with these quantities, program FIG was employed as a means of analysis and description of the protypical family cluster patterns presented in the results section.

RESULTS

Hierarchical Cluster Analysis The analysis identified seven distinct family patterns out of the 44 subject families.

Figure 1 presents the essentials of the resulting tree diagram and the family cluster identification numbers.

As Figure 1 reveals, families with an anorexic daughter were represented in all of the family groups to one degree or another. However, three different family groups emerged that were constituted exclusively by families with an anorexic member. Fur- thermore, half the control subject families were grouped together in one cluster. Table 2 presents a concise breakdown of the composition of the 7 family clusters.

As the table reveals, the statistical procedure produced 7 family clusters subgrouped with a startling degree of orderliness. There were 3 family clusters identified that were composed entirely of families with anorexic members (3, 4, 5). Of these family groups, cluster number 5 and 3 are of particular interest. All of the families whose daughters had recently presented bulemic strategies for maintaining their anorexic weight were contained in these two family clusters. Two of the 3 families in cluster 3 contained anorexichulemics and all 4 of the families in cluster 5 did, as well.

An additional 3 family clusters represented infusions of the control group and families with an anorexic daughter (1, 2,6). Taken together, these 3 clusters consisted of almost half the total sample (n = 21). Each cluster, however, contained different sets of relationships and expressed distinctly unique familial dynamics.

Family cluster 7 was composed almost exclusively by control families. Half of the entire control subject families (n = 11) and only one family with an anorexic daughter reported familial interactional patterns similar enough to be grouped together in this cluster.

In summary, the cluster analysis established 3 family patterns of interpersonal relating associated exclusively with families of anorexics. In addition, 3 other family patterns were identified that included blends of families with an anorexic daughter and control families. Finally, one pattern emerged from the statistical analysis which was


Figure 1. Family Clusters Established Through Hierachical Cluster Analysis.

Family Clusters

Cluster Number 1

Family Ident i f icat ion Number*

3 r

19

4 r-l 20

5 6 7

U

- Note. Family Ident i f icat ion numbers 1-22 contain anorexic daughters.

Family Ident i f icat ion numbers 23-44 contain nonanorexic daughters.

Table 2 Composition of Family Clusters

Total Families of Families of

Cluster Sample Anorexics Non-anorexics Number n % n % n %

1 3 6.82 1 33.33 2 66.66 2 9 20.45 5 55.56 4 44.44 3 3 6.82 3 100.00 0 0.00 4 4 9.09 4 100.00 0 0.00 5 4 9.09 4 100.00 0 0.00 6 9 20.45 4 44.44 5 55.56 7 12 27.27 1 8.33 11 91.67

characterized predominantly by families with stable familial relationships drawn from the control subject pool.

Table 3 presents the interpersonal ratings of the 7 prototypical family profiles. This table, in conjunction with table 1, may assist the reader in acquiring a more

complete impression of the dynamics characterizing the 7 family profiles. The following brief sketches of the family patterns of each of the 7 clusters were based on the mean- averaged prototypical family scores presented in table 3 which were further distilled by


w 0, Table 3

Prototypical Family Cluster fiansactional Behavior Scores SASB Transactional Behaviors

0 3

b %

Family Initiating Responding

Cluster Dyad View 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6

FMDA Father 39 78 46 63 36 10 2 5 54 72 48 63 39 14 5 9 Daughter 43 66 42 63 33 6 3 5 44 80 70 76 49 14 3 7

MO/DA Mother 39 78 53 56 36 8 3 4 42 66 52 64 39 14 5 7 Daughter 43 75 48 65 37 10 1 3 46 66 52 68 37 15 11 13


MOlDA Mother 50 92 67 77 26 4 2 0 45 82 63 73 51 16 4 6 Daughter 46 90 63 80 34 5 0 0 48 88 75 80 49 17 3 9







7

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Table 3 (continued) Prototypical Family Cluster Wansactional Behavior Scores

SASB Transactional Behaviors

Family Initiating Responding

Cluster Dyad View 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6





3

1

Note. FA = Father. DA = Daughter. MO = Mother. ti b

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program FIG. Descriptions were primarily anchored in the synopsis of the transactional postures generated by program FIG. Order of presentation below was based on the size of the cluster (percent of sample population).

Family Profiles Cluster 7: “The Harmonious Transitional Family.” Comprised of 12 families, 11 of

which belonged to the control group, the transactional pattern of this cluster can be characterized as predominantly friendly and consistent. As a unit, the parents saw themselves initiating much in the same way, assuming mainly affirming understanding, helping and protecting postures with their daughter. Daughters correspondingly responded to their parents by disclosing and expressing, as well as trusting and relying on them.

Issues of control are evident in this family as they negotiate their way through the adolescent transitional stage of family life. Thus, while father saw daughter as submitting to his authority, daughter, in fact, recognized no submissive element in her relationship with her father. Rather, daughter felt that mother interacted with her in a somewhat controlling way, however, she did not find herself compelled to submit to mother’s efforts of control. Interestingly, all of the control families, clinically assessed by the experimenter during the data collection sessions as stable, clustered together in this family group.

Cluster 6: “The Perfect Family.” A quick perusal of the data set for this family cluster presented in Table 3 reveals an astonishing degree of familial similarity regarding the relationships under study. This prototypical family appears intensely friendly and exem- plifies warm, caring patterns of familial relating. Family members did not mention conflict or interpersonal difficulty in their relationships.

The prototypical characterization of families in this cluster is one which finds father relating to his daughter in a very warm, affirming and understanding way. Similarly, mother approaches her daughter in a warm fashion; however, she sees herself as being even more understanding and supportive than her husband is. Daughter’s view of her parents closely parallels their own perceptions. She clearly sees both of her parents as warm and friendly resources for her. In particular, daughter recognizes that her mother’s efforts are very affirming and understanding, as well as nurturing and protecting toward her.

In terms of daughter’s response to her parents, both father and mother perceive their daughter as being warmly receptive to them, although, clearly, the motheddaugh- ter relationship is the closer of the two. Daughter indicates that she is open to her parents and appreciative of them. In particular, she feels that she trusts and relies (TB 12) on her mother in many ways. In fact, daughters in this cluster of families relied on their mothers substantially more than did any of the other girls in the study.

It is clear that the families in this cluster closely shared visions oftheir relationships such that remarkably little disagreement existed between family members’ views of one another. The prototypical family represents one of close agreement and warmth. All family members consistently emphasized caring, understanding, open expression, and trust while denying the existence of tension between parents and child.

Cluster 2: “The Marginal Transitional Family.” In this cluster, 5 of the 9 families had an anorexic daughter. Although each family maintained a thin visage of friendli- ness, issues of control and authority were central to their concern. Father’s image of himself was somewhat removed, friendly and controlling, while his wife did not see herself as having an authoritative role with her daughter. In addition to these over- arching postures of care, both parents expressed a need to watch and manage their daughter’s affairs. They found their daughter to respond to them in a similar fashion, characteristically submitting to their authority in a friendly way, but this was colored by appearances of sulking and appeasing behavior.


Daughter agreed, by and large, with her father’s assessment of himself, but found her mother to be much more controlling than mother did. In fact, daughter claimed that mother regularly resorted to managing her life. Daughter agreed with her parents that she responded to both of them in a submissive, somewhat friendly way, but also noted that she directed a degree of hostility towards mother which mother was seemingly unaware of.

Cluster 4: “The Discordant Distancing Family.” This family cluster was composed entirely of families with an anorexic daughter. It presented sharp contrsts in view between parents and child and a parental unit splintered in approach to their daughter. Father saw himself as essentially distant and removed from his daughter, at times trying to understand her and at others blaming or ignoring her. Mother saw herself as consistently warm, friendly and supportive of her daughter. In addition, parents had very different views of how their daughter responded to them. While daughter seemed somewhat removed and at times argumentative, father maintained that she was mainly friendly and submissive to his authority. Mother found that, despite her efforts, daughter responded in a detached and, a t times, hostile manner to her.

Interestingly, daughter reported that both parents treated her the same, that is, with hostile attacking behavior. Feeling unsafe, unhappy, and at times angry, she claimed to seize her own authority from both of them. The parentkhild relational assessments varied widely, thus, substantiating vast difficulties in communication between family members.

Cluster 5: “The Hostile Conflicted Family.” All 4 families grouped in this cluster had a daughter with anorexia nervosa who had recently exhibited bulemic-like behavior in maintaining her anorexic weight. The prototypical family in this cluster showed a pattern of complementary relationship between the parents in relation to their daughter. For his part, father maintained that he was hostile and attacking toward daughter, while mother reported that she took a warm, friendly and caring posture with the girl. In accordance with these views, parents saw daughter respond in a complementary fashion. Thus, father saw daughter responding towards him in a hostile, distancing fashion, and mother viewed daughter as primarily submitting to her authority in a friendly way, albeit, a t times in a sulking and somewhat withdrawn manner.

From her perspective, daughter concurred with father in his assessment that hostility was his dominant transactive mode of behavior. However, she did not see herself responding in a distancing way. Rather, daughter clearly saw herself as exhibiting a hostile rage in response to him. In contrast with mother’s friendly view of herself, daughter found mother to be mainly a controlling force, managing her affairs. Interest- ingly, daughter responded to the perceived matriarchal intrusions with ambivalence. Sometimes, daughter felt she trusted and relied on her mother, and at others, she was inclined to angrily protest and withdraw from her.

Cluster 3: “The Mistaken Family.” The patterns of relationship characterizing the 3 families with an anorexic daughter, grouped together in this cluster, present a confused weave of distance and warmth. The father in this family cluster saw himself as essentially uninvolved and removed from dealings with his daughter and viewed his daughter as responding ambivalently towards him. That is, at times she seemed sensitive to his few demands and submitted in a sulking manner to them, while at others, she was likely to ignore his requests and avoid him. Mother, too, was somewhat removed from daughter. She tried to initiate interactions in a somewhat reluctant but caring, friendly manner. This posture was qualified by considerable displays of watching and managing behavior which at times deteriorated into attacking, rejecting or even ignoring and neglecting behaviors aimed at daughter. Mother shared her husband’s view of daughter’s responding behavior. Essentially mother was confused by an ambivalent display of approaching and submitting behavior and hostile distancing and walling-off.


Daughter viewed her relationship with her parents in a starkly different fashion than they did. Far from removed, daughter felt that father was very involved with her in a friendly, somewhat controlling fashion. Furthermore, she maintained that she submitted to his authority in a warm, open and trusting way. Daughter’s main contention was with mother, whom she found to be overbearing and predominantly controlling. Despite the outbreaks of conflict, daughter believed that she submitted to her mother’s demands in a friendly way even though she was not always happy to do so.

Cluster 1: “The Ambivalently Differentiated Family.” Of the 3 families in this cluster, 1 contained an anorexic daughter and 2 did not. Father viewed himself as assuming a somewhat removed, but warm and caring stance in relation to his daughter. He did not perceive his daughter’s response to him very favorably, characterizing it as predominantly asserting, separating with frequent protests and withdrawal. His relationship with his daughter was impoverished in comparison to his wife’s relationship with her. Mother claimed she provided friendly support in dealing with her daughter. She found that, although her daughter at times sulked, protested, and retreated into herself, she predominantly responded in a warm, friendly and engaging manner.

In the main, daughter concurred with mother on her impressions of their relationship. The only important divergence of view between the two was that daughter felt she exhibited more autonomy-oriented behavior than mother was aware of. In contrast, daughter was confused by father’s removed initiating behavior and found him to be paradoxically both affirming of her efforts of autonomy, and yet, often controlling in his dealings with her when he was at all involved with her. In response to him, she felt that she predominantly tried to assert herself and separate from him, but also persisted in trying to at least show a degree of warmth towards him.

DISCUSSION

As the results indicate, 7 distinct family clusters emerged from the statistical analysis. Three of these clusters contained only families of anorexics, 3 others constituted blends of families with anorexic daughters and control families, while 1 was comprised predominantly by control families. These findings support the hypothesis that interaction patterns may systematically differentiate control families from families with anorexic daughters.

The near-isomorphic transactional pattern of families containing an anorexic daughter predicted in the second hypothesis, did not emerge out of the clustering procedure. Contrary to the expectation that a single particular interaction pattern characteristic of an “anorexogenic” family would be found, six patterns of family relationship were identified in this study which were clearly related to the anorexic condition.

The family relationships in the “Perfect Family” seemed to parallel what might be expected of both Minuchin et al. (1975,1978) anorexogenic family, and the centripetal family proess identified by Strober and Yager (1985). Despite clinical evidence to the contrary, these family members seemingly chanted in concert that there are no interpersonal problems here. Relationships in this family cluster appeared unusually close, warm and positive as would be predicted by the excessive cohesion characteristic of enmeshed family dynamics. The familial absence of differences in perception, teamed with a solid denial of any intrafamilial conflict, seems somewhat unlikely, considering the adolescent age of the girls in these families.

The prototypical patterns of both the “Marginal Transitional” and the “Ambiva- lently Differentiated families showed strained family relationships with conflict revolv- ing around the issues of authority and autonomy. Though none of the family models regarding anorexia identified from the literature correspond well to either of these two


family patterns, an association with the anorexic symptom and other less profound family disturbances seems indicated.

The “Discordant Distancing Family” group appeared to us most similar to the families described by Selvini-Palazzoli et al. (1970, 1974). Fathers seemed peripheral or distant while mothers complemented them with a highly involved and controlling stature. In this cluster, daughters chose to paint parents with the same brush, thus, avoiding pointing out any difference between them. In so doing, these girls expressed hostility and needs for autonomy that were somehow lost in the communicative process with their parents.

By far, the most aggressive of the family clusters was “The Hostile Conflicted Family.” In this family, mother’s attempts to smooth over difficulties ended up poorly received by a daughter locked in struggle with her father. With all of the girls in this family pattern demonstrating bulemic-like behaviors, it seems characteristic of the kind of family dynamics we would expect from the “centrifugal process” suggested by Stober and Yager (1985).

“The Mistaken Family” pattern hinged on widely divergent parent and daughter views regarding their relationships. With communication processes functioning poorly, the anorexics and their parents in this cluster held substantially different impressions about one another on both the major interpersonal dimensions of affiliation and autonomy. This family cluster did not fit particularly well into any of the defined family patterns discussed earlier.

Three separate family patterns were identified in this study as solely related to anorexic transactions and characteristics of the families of such girls. Each of these family patterns manifests unique transactional appraisals, differentiating one from another. Yet, we remain hesitant to assert that even these family dynamics are strictly idiosyncratic of the anorexic symptom. Many questions still remain in regard to how these interactional patterns might interface with other dysfunctional family processes or symptomatic behaviors. Perhaps the same transactional processes would be found associated with the expression of other problems such as delinquency or alcoholism. Thus, it remains feasible that particular family patterns, rather than being related to specific symptoms, are connected to family dysfunction in a more general way.

The results from the study best support the views of Garfinkel and Garner (1982) that there is no one family pattern unique to anorexia nervosa. It seems most probable that a variety of family patterns of relationship play important supportive roles to environments that predispose children to anorexia nervosa as well as maintain the symptom. At any rate, in this study no single dominant family pattern associated to anorexia was empirically demonstrated. Consequently, uni-dimensional explanations and terms such as “anorexogenic” and “anorexic family” might well be employed with a modicum of caution.

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NOTES

‘Benjamin (1987) formally refers to initiating behaviors as the transitive focus on what is to be done to, for or about another person, and responding behaviors as the intransitive focus on what is going to be done to, for or about the self.

2A number of versions of Benjamin’s model are available which vary in complexity. In this study, the cluster model which generates eight scores for each interpersonal plane was used. However, in the more complicated full version of her model, 36 initiating and responding ratings are established by the 72 interpersonal oriented questions. A complete explanation of the cluster model may be found in Benjamin (1987).


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