Triadic Interactions in Families of Adolescents with Anorexia Nervosa and Families of Adolescents with Internalizing Disorders

Abstract

The latest studies and practice guidelines for the treatment of adolescent patients with anorexia nervosa agree in pointing out the key role played by parents in determining the young patients’ therapeutic possibilities and outcomes. Still family functioning has usually been studied using only self-reported instruments. The aim of the present study is therefore to investigate the triadic interactions within the families of adolescents with anorexia nervosa using a semi-standardized observational tool based on a recorded play session, the Lausanne Trilogue Play (LTP). Parents and adolescent daughters, consecutively referred to adolescent neuropsychiatric services, participated in the study and underwent the observational procedure (LTP). The 20 families of adolescent girls with anorexia nervosa (restricting type) were compared with 20 families of patients with internalizing disorders (anxiety and depression). The results showed different interactive patterns in the families of adolescents with anorexia nervosa: they had greater difficulties in respecting roles during the play, maintaining the joint attention and in sharing positive affect, especially in the three-together phase (third phase). The majority of these families (12) exhibited collusive alliances. The parental subsystem appeared frequently unable to maintain a structuring role, i.e., providing help, support and guidance to the daughters, while the girls in turn often found it hard to show independent ideas and develop personal projects. Parents experienced difficulty in carving out a couple-specific relational space, from which the ill daughter was at least temporarily excluded also when they were asked to continue to interact with each other, letting the daughter be simply present in a third-part position (fourth phase). The study of the triadic interactions in the families of adolescents with anorexia nervosa may help to shift the attention from the exclusive mother–daughter relation to the involvement of the father, and of the parental couple as a whole. The family functioning is in fact well established as a maintaining factor of anorexia nervosa or vice versa as a facilitating factor in the therapeutic process.

Are family relations connected to the quality of the outcome in adolescent anorexia nervosa? An observational study with the Lausanne Trilogue Play

“…However, a dyadic peaceful interaction between one parent and the daughter might sometimes be interpreted as a sign of the apparent serenity of a symbiotic relationship, where the aggressiveness may be denied or cut off and cannot be used by the daughter to organize her adolescent individuation process (Balottin, Mannarini, Rossi, Rossi, & Balottin, 2017;Jeammet, 2010;Russell, Kopec-Schrader, Rey, & Beumont, 1992). This hypothesis is in line with the finding of a decreased quality of the interaction in the triadic phase, when families of daughters with anorexia were required to display a greater triangular coordination (Balottin, Mannarini, Mensi, et al, 2017). In line with these findings, this study showed that, differently from what happens in the dyadic phases, the adolescent's specific difficulties in the triadic interactions, as well as the impossibility to carve out a parental couple-specific relational space on the parents' part, appeared connected to the severity of the clinical presentation of adolescent anorexia.…”

“…We can also suppose that these adolescents suffer from a less serious psychopathological condition, because from the beginning of the treatment, they showed better triadic interactive and relational abilities, which may be linked to a more positive perception of autonomy and separation, although sometimes conflictual, from the parents (Brusset, ; Jeammet, ; Russell et al, ). According to recent studies on family functioning and adolescent anorexia (Balottin, Mannarini, Mensi, et al, ; Wallis, Miskovic‐Wheatley, et al, ), a decline in the mother–daughter and father–daughter relationship quality may just reflect a physiological adolescent autonomy process. Accordingly, the main guidelines for the management of eating disorders (APA, ; Espie & Eisler, ; Hay et al, ; Herpertz‐Dahlmann et al, ; Lock et al, ; NICE, ), support family therapy as the first line treatment, especially in the case of less sever and younger patients with a recent onset of anorexia.…”

“…Moreover, certain conclusions on the causal-or rather secondary (consequent)-role of family dysfunctions in relation to eating disorders are not currently tenable because of the cross-sectional design that characterizes most research studies in this field (Jack, 2001;Treasure et al, 2008). The Academy of Eating Disorders (Le Grange, Lock, Loeb, & Nicholls, 2010) In line with these premises, a recent study (Balottin, Mannarini, Mensi, Chiappedi, & Gatta, 2017), conducted with a standardized observational tool based on a recorded play session, the Lausanne Trilogue Play (LTP; Fivaz-Depeursinge & Corboz-Warnery, 1999), by now widely applied in international literature but still underused in the case of adolescent psychopathology, showed the specific relational patterns present in the families of patients with anorexia nervosa, comparing them with families of adolescent daughter suffering from emotional disorders (anxiety and depression). The LTP consists of 15 min of family play: during the procedure the parents are asked to interact with their daughters in four different phases, allowing the direct observation of family dynamics and therefore paving the way to the possibility of therapeutic work based on them.…”

Disorder‐specific attachment characteristics and experiences of childhood abuse and neglect in adolescents with anorexia nervosa and a major depressive episode

“…In the field of AN, findings from researchers using self‐report measurements of attachment report that patients with AN describe their fathers as highly critical, less caring, and more controlling (Orzolek‐Kronner, ). Furthermore, results indicate a paternal tendency to be emotionally absent, cold, and defensive in response to their daughter's illness (Ballotin, Mannarini, Mensi, Chiappedi, & Gatta, ). As a result, patients with AN might feel more alienated from their fathers (Gander et al, ; Horesh, Sommerfeld, Wolf, Zubery, & Zalsman, ; Orzolek‐Kronner, ), which consequently affects the quality of family interactions and the treatment outcome (Ballotin et al, ).…”

“…Furthermore, results indicate a paternal tendency to be emotionally absent, cold, and defensive in response to their daughter's illness (Ballotin, Mannarini, Mensi, Chiappedi, & Gatta, 2017). As a result, patients with AN might feel more alienated from their fathers (Gander et al, 2015;Horesh, Sommerfeld, Wolf, Zubery, & Zalsman, 2015;Orzolek-Kronner, 2002), which consequently affects the quality of family interactions and the treatment outcome (Ballotin et al, 2017). A closer investigation of traumatic experiences and unresolved attachment status in fathers might help to gain a better understanding of underlying mechanisms that cause these defensive responses in fathers.…”