Family Therapy for Eating Disorders and Non-suicidal Self-Injury

  • Elizabeth K. HughesEmail author
  • Erica Allan
  • Daniel Le Grange


Non-suicidal self-injury (NSSI) and eating disorders frequently co-occur, especially during adolescence. Several family factors have been associated with risk for NSSI and eating disorders including lack of cohesion and communication, greater conflict and criticism and physical or sexual abuse. Few studies have examined protective factors within the family, and this is an area in need of greater research investment. Overall, research on relationships between family characteristics and NSSI and eating disorders is limited. Currently, family factors are thought to be better understood as risk factors for psychopathology generally, rather than NSSI and eating disorders specifically, and to interact with other biological, psychological and environmental factors. Moreover, family dysfunction may be a consequence of disruption caused by illness behaviours, rather than a cause of the illness itself. Family-based treatment (FBT) for eating disorders does not attribute blame to the family but instead focuses on the family, especially parents, as a resource for recovery. FBT has the strongest evidence base for treatment of eating disorders in adolescents; however, NSSI can make the treatment process challenging for the family and treating team. In this chapter, we describe how NSSI and suicidal behaviour should be addressed in the context of FBT and provide case examples to illustrate three types of situations that may arise (i.e. suicidal patients, patients who engage in low-level NSSI and patients who engage in severe or high-risk NSSI) and how these can be managed while working towards the goals of recovery.


Sexual Abuse Suicidal Ideation Eating Disorder Suicidal Behaviour Binge Eating 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Ahren-Moonga, J., Holmgren, S., von Knorring, L., & Af Klinteberg, B. (2008). Personality traits and self-injurious behaviour in patients with eating disorders. European Eating Disorders Review, 16(4), 268–275.PubMedCrossRefGoogle Scholar
  2. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: American Psychiatric Press.CrossRefGoogle Scholar
  3. Botta, R. A., & Dumlao, R. (2002). How do conflict and communication patterns between fathers and daughters contribute to or offset eating disorders? Health Communication, 14(2), 199–219.PubMedCrossRefGoogle Scholar
  4. Burkhouse, K., Uhrlass, D., Stone, L., Knopik, V., & Gibb, B. (2012). Expressed emotion-criticism and risk of depression onset in children. Journal of Clinical Child and Adolescent Psychology, 41(6), 771–777.PubMedCrossRefGoogle Scholar
  5. Button, E. J., Chadalavada, B., & Palmer, R. L. (2010). Mortality and predictors of death in a cohort of patients presenting to an eating disorders service. International Journal of Eating Disorders, 43(5), 387–392.PubMedGoogle Scholar
  6. Canavera, K. E., Ollendick, T. H., May, J. T., & Pincus, D. B. (2010). Clinical correlates of comorbid obsessive-compulsive disorder and depression in youth. Child Psychiatry and Human Development, 41(6), 583–594.PubMedCrossRefGoogle Scholar
  7. Claes, L., Soenens, B., Vansteenkiste, M., & Vandereycken, W. (2012). The scars of the inner critic: Perfectionism and nonsuicidal self-injury in eating disorders. European Eating Disorders Review, 20(3), 196–202.PubMedCrossRefGoogle Scholar
  8. Claes, L., & Vandereycken, W. (2007). Is there a link between traumatic experiences and self-injurious behaviors in eating-disordered patients? Eating Disorders, 15(4), 305–315. Brunner-Mazel eating disorders Monograph Series.PubMedCrossRefGoogle Scholar
  9. Claes, L., Vandereycken, W., & Vertommen, H. (2003). Eating-disordered patients with and without self-injurious behaviours: A comparison of psychopathological features. European Eating Disorders Review, 11(5), 379–396.CrossRefGoogle Scholar
  10. Claes, L., Vandereycken, W., & Vertommen, H. (2004). Family environment of eating disordered patients with and without self-injurious behaviors. European Psychiatry: The Journal of the Association of European Psychiatrists, 19(8), 494–498.CrossRefGoogle Scholar
  11. Eisler, I., Dare, C., Hodes, M., Russell, G. F. M., Dodge, E., & Le Grange, D. (2000). Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 41(6), 727–736.PubMedCrossRefGoogle Scholar
  12. Eisler, I., Simic, M., Russell, G. F., & Dare, C. (2007). A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: A five-year follow-up. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 48(6), 552–560.PubMedCrossRefGoogle Scholar
  13. Federici, A., & Wisniewski, L. (2012). Integrating dialectical behaviour therapy and family-based treatment for multidiagnostic adolescent patients. A collaborative approach to eating (pp. 177–188). New York, NY: Routledge.Google Scholar
  14. Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, 449–468.CrossRefGoogle Scholar
  15. Frye, A. A., & Garber, J. (2005). The relations among maternal depression, maternal criticism, and adolescents’ externalizing and internalizing symptoms. Journal of Abnormal Child Psychology, 33(1), 1–11.PubMedCrossRefGoogle Scholar
  16. Fujimori, A., Wada, Y., Yamashita, T., Choi, H., Nishizawa, S., Yamamoto, H., et al. (2011). Parental bonding in patients with eating disorders and self-injurious behavior. Psychiatry and Clinical Neurosciences, 65(3), 272–279.PubMedCrossRefGoogle Scholar
  17. Gonzalez-Pinto, A., de Azua, S. R., Ibanez, B., Otero-Cuesta, S., Castro-Fornieles, J., Graell-Berna, M., et al. (2011). Can positive family factors be protective against the development of psychosis? Psychiatry Research, 186(1), 28–33.PubMedCrossRefGoogle Scholar
  18. Hay, C., & Meldrum, R. (2010). Bullying victimization and adolescent self-harm: Testing hypotheses from general strain theory. Journal of Youth and Adolescence, 39(5), 446–459.PubMedCrossRefGoogle Scholar
  19. Helgeland, M. I., & Torgersen, S. (1997). Maternal representations of patients with schizophrenia as measured by the Parental Bonding Instrument. Scandinavian Journal of Psychology, 38(1), 39–43.PubMedCrossRefGoogle Scholar
  20. Herzog, D. B., Greenwood, D. N., Dorer, D. J., Flores, A. T., Ekeblad, E. R., Richards, A., et al. (2000). Mortality in eating disorders: A descriptive study. International Journal of Eating Disorders, 28(1), 20–26.PubMedCrossRefGoogle Scholar
  21. Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C., & Agras, W. (2004). Coming to terms with risk factors for eating disorders: Application of risk terminology and suggestions for a general taxonomy. Psychological Bulletin, 130(1), 19–65.PubMedCrossRefGoogle Scholar
  22. Klonsky, E. D., & Moyer, A. (2008). Childhood sexual abuse and non-suicidal self-injury: Meta-analysis. British Journal of Psychiatry, 192(3), 166–170.PubMedCrossRefGoogle Scholar
  23. Konstantellou, A., Campbell, M., & Eisler, I. (2012). The family context: Cause, effect or resource. A collaborative approach to eating disorders (pp. 5–18). New York, NY: Routledge.Google Scholar
  24. Krug, I., Treasure, J., Anderluh, M., Bellodi, L., Cellini, E., Collier, D., et al. (2009). Associations of individual and family eating patterns during childhood and early adolescence: A multicentre European study of associated eating disorder factors. British Journal of Nutrition, 101(6), 909–918.PubMedCrossRefGoogle Scholar
  25. Le Grange, D., Crosby, R. D., Rathouz, P. J., & Leventhal, B. L. (2007). A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Archives of General Psychiatry, 64(9), 1049–1056.PubMedCrossRefGoogle Scholar
  26. Le Grange, D., Eisler, I., Dare, C., & Russell, G. F. (1992). Evaluation of family treatments in adolescent anorexia nervosa: A pilot study. International Journal of Eating Disorders, 12(4), 347–358.CrossRefGoogle Scholar
  27. Le Grange, D., & Lock, J. (2007). Treating bulimia in adolescents: A family-based approach. New York, NY: Guilford.Google Scholar
  28. Le Grange, D., & Lock, J. (2010). Family-based treatment for adolescents with bulimia nervosa. In J. E. Mitchell (Ed.), The treatment of eating disorders: A clinical handbook (pp. 372–387). New York, NY: Guilford.Google Scholar
  29. Lock, J., Agras, S., Bryson, S., & Kraemer, H. (2005). A comparison of short- and long-term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry, 44(7), 632–639.PubMedCrossRefGoogle Scholar
  30. Lock, J., & Le Grange, D. (2013). Treatment manual for anorexia nervosa: A family-based approach (2nd ed.). New York, NY: Guilford.Google Scholar
  31. Lock, J., Le Grange, D., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67(10), 1025–1032.PubMedCrossRefGoogle Scholar
  32. Lopez, S. R., Nelson Hipke, K., Polo, A. J., Jenkins, J. H., Karno, M., Vaughn, C., et al. (2004). Ethnicity, expressed emotion, attributions, and course of schizophrenia: Family warmth matters. Journal of Abnormal Psychology, 113(3), 428–439.PubMedCrossRefGoogle Scholar
  33. Mehler, P. S. (2011). Medical complications of bulimia nervosa and their treatments. International Journal of Eating Disorders, 44(2), 95–104.PubMedGoogle Scholar
  34. Mehler, P. S., Crews, C., & Weiner, K. (2004). Bulimia: Medical complications. Journal of Women’s Health, 13(6), 668–675.PubMedCrossRefGoogle Scholar
  35. Meites, T. M., Ingram, R. E., & Siegle, G. J. (2012). Unique and shared aspects of affective symptomatology: The role of parental bonding in depression and anxiety symptom profiles. Cognitive Therapy and Research, 36(3), 173–181.CrossRefGoogle Scholar
  36. Minuchin, S., Baker, L., Rosman, B. L., Liebman, R., Milman, L., & Todd, T. C. (1975). A conceptual model of psychosomatic illness in children. Archives of General Psychiatry, 32, 1031–1038.PubMedCrossRefGoogle Scholar
  37. Moos, R. H., & Moos, B. S. (1986). The family environment scale. Palo Alto, CA: Consulting Psychologists.Google Scholar
  38. Muehlenkamp, J. J., Claes, L., Smits, D., Peat, C. M., & Vandereycken, W. (2011). Non-suicidal self-injury in eating disordered patients: A test of a conceptual model. Psychiatry Research, 188(1), 102–108.PubMedCrossRefGoogle Scholar
  39. Murray, C. D., Macdonald, S., & Fox, J. (2008). Body satisfaction, eating disorders and suicide ideation in an Internet sample of self-harmers reporting and not reporting childhood sexual abuse. Psychology, Health and Medicine, 13(1), 29–42.PubMedCrossRefGoogle Scholar
  40. Parker, G., Tupling, M., & Brown, C. (1979). A parental bonding instrument. British Journal of Medical Psychology, 52, 1–10.CrossRefGoogle Scholar
  41. Paul, T., Schroeter, K., Dahme, B., & Nutzinger, D. O. (2002). Self-injurious behavior in women with eating disorders. The American Journal of Psychiatry, 159(3), 408–411.PubMedCrossRefGoogle Scholar
  42. Peebles, R., Wilson, J. L., & Lock, J. D. (2011). Self-injury in adolescents with eating disorders: Correlates and provider bias. Journal of Adolescent Health, 48(3), 310–313.PubMedCrossRefGoogle Scholar
  43. Robin, A. L., & Le Grange, D. (2010). Treating adolescents with anorexia nervosa using behavioral family systems therapy. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 345–358). New York, NY: Guilford.Google Scholar
  44. Robin, A. L., Siegel, P. T., Koepke, T., Moye, A. W., & Tice, S. (1994). Family therapy versus individual therapy for adolescent females with anorexia nervosa. Journal of Developmental and Behavioral Pediatrics, 15(2), 111–116.PubMedCrossRefGoogle Scholar
  45. Robinson, P., & Serfaty, M. (2008). Getting better byte by byte: A pilot randomised controlled trial of email therapy for bulimia nervosa and binge eating disorder. European Eating Disorders Review, 16(2), 84–93.PubMedCrossRefGoogle Scholar
  46. Ross, S., Heath, N. L., & Toste, J. R. (2009). Non-suicidal self-injury and eating pathology in high school students. American Journal of Orthopsychiatry, 79(1), 83–92.PubMedCrossRefGoogle Scholar
  47. Russell, G. F., Szmukler, G. I., Dare, C., & Eisler, I. (1987). An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44(12), 1047–1056.PubMedCrossRefGoogle Scholar
  48. Stein, D., Lilenfeld, L. R. R., Wildman, P. C., & Marcus, M. D. (2004). Attempted suicide and self-injury in patients diagnosed with eating disorders. Comprehensive Psychiatry, 45(6), 447–451.PubMedCrossRefGoogle Scholar
  49. Svirko, E., & Hawton, K. (2007). Self-injurious behavior and eating disorders: The extent and nature of the association. Suicide and Life Threatening Behavior, 37(4), 409–421.PubMedCrossRefGoogle Scholar
  50. Treasure, J., Claudino, A. M., & Zucker, N. (2010). Eating disorders. Lancet, 375(9714), 583–593.PubMedCrossRefGoogle Scholar
  51. Viner, R. M., Coffey, C., Mathers, C., Bloem, P., Costello, A., Santelli, J., et al. (2011). 50-year mortality trends in children and young people: A study of 50 low-income, middle-income, and high-income countries. The Lancet, 377(9772), 1162–1174.CrossRefGoogle Scholar
  52. Wildman, P., Lilenfeld, L. R. R., & Marcus, M. D. (2004). Axis I comorbidity onset and parasuicide in women with eating disorders. International Journal of Eating Disorders, 35(2), 190–197.PubMedCrossRefGoogle Scholar
  53. Wright, F., Bewick, B. M., Barkham, M., House, A. O., & Hill, A. J. (2009). Co-occurrence of self-reported disordered eating and self-harm in UK university students. British Journal of Clinical Psychology, 48(4), 397–410.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Elizabeth K. Hughes
    • 1
    • 2
    • 3
    Email author
  • Erica Allan
    • 2
    • 3
  • Daniel Le Grange
    • 4
  1. 1.University of MelbourneMelbourneAustralia
  2. 2.Murdoch Childrens Research InstituteMelbourneAustralia
  3. 3.Royal Children’s HospitalMelbourneAustralia
  4. 4.University of ChicagoChicagoUSA

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