Expressed Emotion and Stress in Families: How the Family Plays a Part in Maintaining Anorexia

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Families are not to blame for the development of eating disorders. However, eating disorders are serious mental health conditions that can strain the relationships within any family. It’s common for families affected by eating disorders to face challenges relating to one another and caring for a young person with an eating disorder.

Sometimes, the difficulties that arise in families as a result of anorexia nervosa also help to maintain the disorder. While parents usually care deeply for their children and want them to recover, their responses to a young person’s illness can be unhelpful or harmful. They may become over-critical, hostile, or over-protective, behaviours that can make symptoms of anorexia worse.

The good news is that these behaviours and dynamics are changeable. Often, families don’t realise which behaviours are harmful or know how to develop relationships that support a young person’s recovery. But with education and skills training, this can change. 

With the proper support, parents can play an essential role in treatment and recovery from anorexia, helping young people regain fulfilling and healthy lives.

What Do We Mean by “Expressed Emotion” in Families?

Expressed emotion is a tool that researchers and mental health professionals use to gauge the emotional health of families who are experiencing illness. It measures a family member’s attitudes and behaviours towards a person with an illness in five dimensions. These are:

  • critical comments
  • hostility
  • emotional overinvolvement
  • positive remarks
  • warmth

Criticism and emotional overinvolvement are usually considered the two primary dimensions of expressed emotion:

  • Criticism describes blame, dislike, or resentment that family members feel towards an ill young person.
  • Emotional overinvolvement describes attitudes of over-protectiveness, clear over-concern, self-sacrificing behaviors, or exaggerated emotional responses.

Research has found that expressed emotion in a family is related to recovery in many different illnesses. For example, people with schizophrenia and depression are more likely to experience relapse when their families make more critical comments, are more hostile, or are over-protective (emotional overinvolvement).

Expressed Emotion and Stress

Some experts suggest that high levels of expressed emotions in families are a type of “toxic family stress” that can be triggered by illness within the family. In research, toxic family stress is a particular kind of stress that is persistent and uncontrollable. Young people experiencing toxic family stress also lack supportive, warm relationships that can protect them against its harmful consequences.

When parents face the stress of an emerging illness, they sometimes respond through criticism, hostility, and over-involvement. This may create a home environment characterised by stress and high emotions that can make mental health symptoms worse. It may also cause negative interactions between parents and children, preventing parents from effectively managing a young person’s behaviours.

Sustained exposure to stressful home environments can be harmful to young people in several ways. It may make young people more sensitive to stressful events, leaving them more vulnerable to mental health symptoms. It might also make mental illness relapses more likely when families’ reactions to early symptoms are unhelpful or harmful. Finally, it may affect young people’s response to treatment for anorexia nervosa and other mental health disorders.

How Does Expressed Emotion in Families Affect a Young Person’s Recovery from Anorexia?

Research shows that expressed emotion in parents is linked to treatment outcomes and treatment drop-out among people with anorexia nervosa. Family traits like maternal criticism may be particularly damaging to a young person’s recovery journey: emerging evidence suggests that even low levels of parental criticism may have an impact on treatment outcomes.

On the other hand, expressions of warmth from parents to young people may make treatment more effective.

Experts have established that a young person’s relationships with others play an important role in the development and maintenance of anorexia. Emotional and social traits like sensitivity to rejection, social anxiety, and comparing oneself with others make it more likely for a young person to develop the disorder. These traits can cause young people to withdraw or become isolated from other people, allowing thoughts about eating, weight, and body shape to dominate their lives. A tendency to compare oneself with others can also drive body dissatisfaction and preoccupation with beauty ideals. 

When a young person develops anorexia, the reactions of other people to their behaviours can make interpersonal difficulties worse. Family members may feel frustrated by a young person’s refusal to eat and respond with criticism or hostility. People with anorexia often suppress their emotions and have limited non-verbal emotional expression, particularly with facial expressions. This can make relationships even more difficult.

Sadly, hostility, criticism, and over-involvement from family members can make young people more isolated and withdrawn. This allows thoughts and behaviours related to food and body shape to continue dominating their daily life rather than placing value on their many strengths and attributes that are so often expressed in relationships with others. 

Understanding the Positive Aspects of Emotional Expression: Warmth and Positive Remarks

While traits like hostility, criticism, and over-involvement within the family can play a role in maintaining anorexia, warm and encouraging behaviours can have the opposite effect. When parents approach young people with warmth and affirm positive speech, behaviours, and attitudes, it can instead strengthen a young person’s recovery journey.

Warmth and positive remarks can help young people develop a positive sense of self, with growing self-worth and self-belief. Families can also reinforce behaviours orientated towards recovery, encouraging sustained, positive change.

Family Therapy and Expressed Emotion

Often, unhelpful expressions of emotion from family members are rooted in a lack of understanding of the illness. For example, family members may not understand the deep psychological distress associated with food and eating and instead see a refusal to eat as a kind of stubbornness. They may not recognise that a young person with anorexia cannot ‘just eat’, causing expressions of criticism or hostility.

Family therapy interventions can support parents and other family members to understand why eating disorder attitudes and behaviours develop and persist. This process encourages empathy with a young person, nurturing relationships of warmth rather than hostility.

Alongside psychoeducation, family therapy typically teaches family members skills they can use to effectively support a young person with anorexia. This might include managing their own emotional reactions, practising motivational interviewing techniques, and avoiding enabling behaviours. Families may also learn skills to improve dynamics throughout the family system, in turn benefiting every family member individually.

The Wave Clinic: Specialist Recovery Programs for Young People and Families

The Wave Clinic offers specialist mental health care for teenagers and young adults living with eating disorders and other mental health concerns. We provide residential and outpatient therapy from our treatment spaces in Kuala Lumpur, offering support to young people and families from all over the world.

Our programs set the global standard for mental health care, combining exceptional clinical care with education, community projects, and an international gap year experience. We support young people to grow, reconnect, and develop the skills they need to build fulfiling futures.

If you’re interested in finding out more about our programs, get in touch today. We’re here to help.

Fiona - The Wave Clinic

Fiona Yassin is the founder and clinical director at The Wave Clinic. She is a U.K. and International registered Psychotherapist and Accredited Clinical Supervisor (U.K. and UNCG).

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