عملکرد خانواده در بی اشتهایی عصبی: برداشت مادران انگلستان و ایتالیا

This study tested the hypothesis that cultural differences would influence individuals' perceptions of family functioning. Mothers of British and Italian children and adolescents with anorexia nervosa completed the Family Assessment Device (FAD). British mothers perceived their families' communication and role definition as less healthy than did the Italian mothers. In contrast, the Italians perceived their families' behavior control methods as less healthy than did the British mothers. The findings might be explained by differences between British and Italian interpretations of the role of “family,” particularly giving the British emphasis on independence and the Italian emphasis on family life. It is suggested that these culturally divergent attitudes towards family life might have different influences on anorexia nervosa. Finally, implications for family therapy are discussed, taking into account those characteristics that are more relevant for each cultural group.

Research and clinical evidence have suggested that abnormal patterns of family functioning are associated with anorexia nervosa. As far as the research evidence is concerned, several investigations have been performed. For example, Kog and Wandereycken (1988) suggested that families of individuals with an eating disorder show more conflict avoidance and rigidity than controls. In particular, families with a member with anorexia nervosa were found more cohesive than families with a member with bulimia nervosa. Another study (Waller, Calam, & Slade, 1989) reported that there are general dysfunctions in families of individuals with eating disorders when compared with controls. In particular, people with anorexia nervosa report less healthy levels of family affective involvement and behavior control when compared with families of both controls and bulimics. Strober and Yager (1985) suggested that there are two types of “anorexic families,” one characterized by excessive cohesion and one by lack of cohesion. As far as clinical evidence is concerned, a number of different perspectives have been developed. Psychoanalytic approaches have investigated the mother–child relationship and have in common the idea that the child, due to the inadequacy of the caretaker, does not learn to differentiate between physical needs and emotional states and believes that her/his own needs must be denied (e.g., Bruch, 1974). Others (Maine, 1991) have focused on the father–child relationship, suggesting that eating disorders may be linked to “father hunger” and a need for emotional connection with the father. Further clinical theorizations of family functioning and eating disorders have focused on the whole family and the importance of its interactions. Selvini Palazzoli (1974) suggested that there are “anorexic families” where illnesses arise to ward off changes that endanger the unity of the family system. Interactional family patterns include poor parental sharing of responsibility and problem-solving, stifled and disqualifying communication, formation of coalitions against third family members, and lack of autonomy. Mothers are seen as aggressive and overprotective, whereas fathers are seen as emotionally absent. According to Minuchin, Rosman, and Baker (1978), the “anorexic family” is characterized by conflict avoidance and lack of conflict resolution, endless patterns of nullification between parents, the use of solutions to problems that have already proven unworkable, overinvolvement and poor boundary differentiation, overprotection and lack of autonomy, and fear of changes, in particular those brought about by the child's puberty. Recently, it has been argued that family characteristics need to be thought of as one of the factors in a multifactorial system of the development and maintenance of the eating disorders (Lask, 2000). Family therapy is generally accepted as a critical element of treatment for children and adolescents with anorexia nervosa Eisler et al., 1997, Lock & le Grange, 2001, Lock et al., 2001, Onnis et al., 1997 and Russell et al., 1987. However, no systematic investigation has been conducted to determine whether family functioning in anorexia nervosa plays different roles within specific cultures and whether any such differences need to be taken into account in treatment. Studies investigating cultural issues in family therapy Hodes, 1989 and Lau, 1984 point out the need to identify differences in the functioning of families with different ethnic backgrounds, because the family is culturally defined (Textor, 1989). It might be argued that family therapists bring their cultural understanding to the therapy room and may not fully grasp family patterns from different cultural backgrounds (Lau, 1984). Furthermore, therapists from different family therapy approaches need to be aware of the cultural characteristics of their client groups, in order for their treatment to explore issues that are relevant in their clients' culture. Moreover, although most family therapy approaches are used indiscriminately in most countries, it has been suggested Hodes, 1989 and McGoldrick & Rohrbaugh, 1987 that some might be particularly suitable to certain cultures because they tackle issues that are more relevant in those cultures. In fact, McGoldrick and Rohrbaugh (1987) point out that the culture of origin of the treatment influences the treatment itself. Therefore, this study aims at comparing family functioning in two different cultural backgrounds: British and Italian. Several investigations have reported differences in the family functioning of British and Italian individuals. For example, British people tend to leave their family home before Italians. The British tend to do so to gain independence, whereas Italians do so to form a family Barbagli, 1997, Censis, 1998, Goody, 2000 and Gullestad & Segalen, 1997. As far as family roles are concerned, these are more clearly defined in Italian families. Italian mothers are the heart of the family, looking after family members and household chores, while fathers are the head of the family, providing economically Carroll, 2001, Censis, 1997, Censis, 1999, Giovannini, 1981, McGoldrick & Giordano, 1996 and Rotunno & McGoldrick, 1982. In contrast, British families place more emphasis on family members' independence and individuality Carroll, 2001, Censis, 1997, Censis, 1999, Giovannini, 1981, McGoldrick & Giordano, 1996 and Rotunno & McGoldrick, 1982. In addition, the family is seen as central in Italians' lives, whereas individuality is of paramount importance to British people Barbagli, 1997, Esposito, 1989, Finch, 1997, Goody, 2000, Gullestad & Segalen, 1997, McGill & Pearce, 1982, McGoldrick & Giordano, 1996 and Rotunno & McGoldrick, 1982. Finally, displays of emotional closeness and expression of emotions are more common in Italian than in British families McGill & Pearce, 1982 and Rotunno & McGoldrick, 1982. Investigations of the eating disorders suggest that culture influences their development and maintenance Garner et al., 1983 and Nasser, 1997. Western culture has been associated with such disorders, and increases of eating pathology in other cultures seem to be associated with the degree of Westernization present in a particular country DiNicola, 1990, Garner et al., 1983 and Nasser, 1997. As far as intra-European investigations are concerned, it was found that Italy is similar to other European places (Rathner & Messner, 1993), and that the biggest differences are reported to be in prevalence rates, with lower rates in eastern Europe than western Europe. A likely common element associated with eating pathology across cultures seems to be “… the presence of family pathology, particularly intergenerational conflicts and confusion over racial identity (Nasser, 1997, p. 47). This echoes the above-mentioned suggestion that changes within the family (e.g., puberty) are associated with problems in families of individuals with an eating disorder (Minuchin et al., 1978). Of relevance to the present investigation, similar prevalence rates for anorexia nervosa are reported in Great Britain and Italy. Investigations of British community samples show a prevalence of 1.1% (King, 1989); whereas those of Italian samples are between 0.8% (Cuzzolaro, 1991) and 1.3% (Rathner & Messner, 1993). Prevalence rates being similar, the present study focuses on the investigation of whether cultural differences influence perspectives of family functioning, comparing British and Italian mothers who have a child or adolescent with anorexia nervosa. Several instruments have been used to investigate family functioning in the eating disorders (e.g., Parental Bonding Instrument—Russell, Kopec-Schrader, Rey, and Beumont, 1992; Family Environment Scale—Strober, 1981). The Family Assessment Device (FAD; Epstein, Baldwin, & Bishop, 1983) has been suggested to be a particularly good measure of pathology in families of individuals with these disorders (Waller, Slade, & Calam, 1990). The FAD is of particular value to this study because it has both English and Italian versions (Roncone et al., 1998). To avoid the danger of contamination of FAD scores by concurrent eating pathology, the perspectives taken will be that of the children's mothers. Waller et al. (1990) have shown their perspectives to have as much discriminant validity as those of their daughters, while fathers' FAD ratings seem to lack any predictive value relative to the pathology of their daughters. It was hypothesized that British and Italian mothers would be distinguished by their responses on the FAD.