This is an open access article distributed under the terms of the Creative Commons
Attribution License (The issues surrounding eating disorders and obesity are considered by many scholars to be complex because they involve a number of interrelated factors. They also involve serious damage to physical health, intense psychological and familial suffering and resonate with high financial costs to the Brazilian health system. Eating Disorders (ED) are psychiatric disorders characterized by disturbances in eating behavior. For the current classification manuals of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders, V edition - DSM-V of the American Psychiatric Association (2013) and International Classification of Diseases and Related Health Problems, 10th edition - ICD10 World Health Organization - WHO (Organização Mundial de Saúde, 1993), there are three main diagnostic categories: Anorexia Nervosa (AN), Bulimia Nervosa (BN), Eating Disorders Not Otherwise Specified (EDNOS) and, more recently, Binge Eating Disorder (BED) has been validated in the DSM-V as a diagnosis due to its clinical usefulness (American Psychiatric Association, 2013). Obesity, on the other hand, to the World Health Organization (Organización Mundial de la Salud, 2012), is a metabolic, endocrine and nutritional disease, not part of the mental and behavioral disorders. In the DSM-V (American Psychiatric Association, 2013) criteria for the identification and evaluation of this pathology as psychiatric disorder are not described, even in the category of eating disorders, although some authors include it didactically in the category of ED due to the similarities of the operating aspects of other disorders and characterized by disturbances in eating behavior and may present linked psychological syndrome (Flaherty & Janicak, 1995).
Research conducted by the Ministry of Health (Ministério da Saúde, 2012) shows that obesity increased among Brazilians. Currently, 13% of adults are obese, and the highest rate is among women (13.6%) rather than among men (12.4%). In 2006, when the first edition of the study Risk and Protective Factors for Chronic Diseases Surveillance By Telephone Survey (VIGITEL) was presented, 11.4% of Brazilians were obese. In 2007, this ratio rose to 12.9%. On the prevalence of anorexia nervosa in adolescent and youthful Brazilian population, Fráguas (2009) says it is between 0.5% and 1% and bulimia between 1% and 3%. These numbers are increasing every year, reaching even younger ages. Also according to the author, the statistics show that 90% of people living with these eating disorders are women aged 14 to 18, although this age is decreasing and reaching girls under 10 years. The average age of girls with anorexia fell from 12-14 years to 7-8 years, reaching all socioeconomic levels, which before was restricted to the most privileged classes. The difference between genders has also declined, whilst still being more significant in women.
The study of families with members diagnosed with eating disorders began in the 70s, with studies of Palazzoli et al. (1998) in Italy and Minuchin (Minuchin, Nichols, & Lee, 2009) in the United States. Both investigated the specific and repetitive cycles of symptoms and relationship issues that seemed to characterize the families of anorexic children and adolescents. In their studies were found families with difficulties in handling limits, conflictual relations, and inefficient communication, among other features. It was based on the literature known about the issues and the experience of researchers over many years of working with families in different contexts that we prepared this research project.
In addition, the finding of the absence of a treatment program and follow-up of patients in the public system of the Brazilian Federal District and the high demand for care at the Clinic School of the Catholic University of Brasilia also motivated us to study the disorders focusing on family relationships. The objective was to build a psychosocial methodology for children and adolescents diagnosed with eating disorders and obesity, involving their families, based on the knowledge of the intrapsychic aspects, family and social thereof.
Method
In order to meet the study objectives, we prioritize the methodology of qualitative research, which is characterized as a personalized, dynamic investigation procedure (González Rey, 1999). For this author, it is an effort in search of different forms of knowledge production in psychology, enabling the theoretical creation of reality that is pluridetermined, differentiated, irregular, interactive, historical and representative of human subjectivity.
So far we have 18 participating families. The project, approved by CNPq, is still running, and we have a Master's thesis and three Doctoral theses in progress, which will raise the number of participating families. Participating families were sent to UCB through partnership with the Department of Health of the Brazilian Federal District, public schools and Nutrition and Psychology professionals. For the survey data, it was conducted an interview of the family life cycle with the preparation of a genogram, a Multifamily Group, a group with children, a group of parents of obese children and application of Rorschach test in obese adolescents, adolescents with anorexia nervosa and adolescents with bulimia nervosa.
The instruments used were: 1) semi-structured interview map of the family life cycle, built for this purpose, containing 65 questions about family history, since the beginning of the parental couple to the present time; 2) Genogram (Carter & McGoldrick, 1995); 3) Rorschach Test (Anzieu, 1981; Chabert, 1993; Traubenberg, 1970); 4) Roadmap for the MFG meetings (Costa, 1998); 5) Script for meetings with the group of children; 6) Script for meetings with the group of parents.
All research activities were held at the Training Centre for Applied Psychology - also called CEFPA, of UCB, which has adapted rooms for group activities, mirror for observation and appropriate material for the proposed activities. The data collection activities were carried out by teachers, master students, doctorate students and Scientific Initiation students that are part of the research team. In the first contact with the families, it was signed by the parents of children and adolescents, the Term of Informed Consent, previously approved, along with the research project by the Ethics Committee of UCB with its opinion of No. 055/2010. 5 meetings were held with the Multifamily Group, each with specific objectives and activities; 4 meetings of the group of children and 4 meetings with the group of parents. The Rorschach test was applied and analyzed completely, but it was given the most attention to the answers given by teenagers to boards related to paternal and maternal figures, the experience with the matriarchal matrix, the father figure and authority, adaptation to reality, female figure / matriarchal individuation and relation to the world. The interview and the MFG meetings data, group of parents and group of children were transcribed and smoothed out in light of qualitative epistemology according to González Rey (1999). The test data were analyzed according to the Rorschach protocols under the interpretation of, mainly, the French School (Anzieu, 1981; Chabert, 1993; Traubenberg, 1970). The test data were analyzed connected with the answers of the adolescents about parental figures and related to the characteristics of family dynamics.
Results and Discussion
In this work we present, quite succinctly, some data from the Multifamily Group (MFG), the group of children and the interview with the family and use of Rorschach test with adolescents.
Data From Multifamily Group Meetings
In the meetings with the families, the parents refer to their life story and the time in which they lived in the countryside, where they had a restricted diet, determined by the seasons and without access to the variety of food they have today. According to them, this history has an influence on the choices they make today and the desire to give their children the very best, which often means an unhealthy diet. The purchasing power of households, which has increased in recent years in our country, has also enabled increased access to the variety of food consumed by households. As a social system, the family lives in a larger context which is society (Minuchin & Fishman, 1990), and is influenced while, at the same time, influences this context. Therefore it is very important to know the environment where the family lives and their culture and story to understand its dynamics, its problems and how the system deals with them and tries to solve them.
Families also refer to moments of gatherings as very pleasant, where there is plenty of food and fellowship among family members, as illustrated in following statements: "... she wants to party every week, barbecue ..."; "We make lunch, spend the day together, sometimes we have lunch at my sister's house, go to the home of another sister ... we always stays in family, always're all assembled"; "We meet every Sunday, and coming in my mother's house, there are no pans, there are very large pots with food for everybody, and those that arrive end up eating."Dos Santos (2003) points to the tradition that these families have in the pleasure of eating, and eating a lot. In this sense, feeding is no longer only a source of obtaining energy, becoming something central in these families, which means that people eat without control. The food fulfills not only its role as physical nourishment, but around it family members strengthen their emotional ties. Thus, obesity may be a way of maintain the stability of family relationships of families with difficulty dealing with the expression of feelings of its members. Using the methodology of Multifamily Group enabled the research team to identify several factors related to family dynamics considered important both in children and adolescents obesity, keeping as well as in the treatment and monitoring of obese member and their family.
Other important data observed in MFG were: 1) the need of families to promote concrete actions towards remedying the food problem, such as changing habits and changing of family relationships; 2) the importance of understanding that in addition to specific actions it is necessary to face the problem of obesity as part of procedural changes involving all family members; 3) families find it difficult to set limits and rules regarding the standard eating habits of its members; 4) difficulty of some families to talk about 'obesity' and to understand the severity of the disease; 5) the importance of harmony and coherence of the couple toward the family as a whole; 6) some families neglect medical, nutritional and psychological care, on the other hand they have difficulty in accessing health services; 7) importance of parents taking care their own health to be good role models for their children; 8) families usually only care when the child has a health problem as a result of obesity (comorbidities), ie, obesity itself is not seen as a problem; 9) in some families there is the presence of grandparents who influence children's eating habits, contrary to the rules imposed by parents; 10) obesity is not the only problem found in these families, but have also been observed drug use, depression, violence, neglect, and other symptoms.
Data From Meetings With Children
Four (4) meetings were held with the group of children whose objectives were to know the perception and feelings of the children in relation to their self-image, their family and social relationships; understand the perception of the children on family eating patterns and their knowledge about different foods; assess the willingness of children to make changes in eating habits and the introduction of daily exercise. The children talk about how they are treated by family, school and friends. They complain of nicknames that are used, including by family members, such as the following data show: "The other day a friend said, 'Speak, annoying fatty, speak, get out of here, get out of here'"; "My brother also calls me a 'hairball'". When asked about how they feel in these situations, the children refer to humiliation and seclusion: "I still feel humiliated, but I do nothing"; "Because of that, I dislike leaving home." However, they may have aggressive behavior in response to name calling: "When someone says I'm fat, I kick their ass."
The children also complain of parents who do nothing in the face of nicknames and insults suffered within the family. A child says that when they complain to her mother about the insults of their siblings, the mother "does nothing", showing that resentment from a lack of support and protection from the mother. Such an attitude is worrisome because we understand that the family has an important role in child protection. And studies in children and adolescents show that bullying can lead, in the long run, to the development of antisocial personality disorders and violent behavior (de Moura, 2010). Children also refer to the family's attempts to control the feeding of children, showing they observe the family dynamics and know the different ways used to control the amount and quality of food. One child said: "My mother says, don't eat ... but talking to me does not help too much, or fighting or making a food, like, the first dish to make a food that I like, then in the second make a meal very ugly, that I don't like." Another child says: "... as I'm getting chubby, my mother is cutting many things, is making more salad, is cutting repeats, is making natural". Such information given by the children are according to what parents say, both in the Multifamily Group as the group of parents. They are trying to change the pattern of the household food, but recognize the difficulties involved. Usually this task is the responsibility of mothers, who feel pressured by children and often give in to the requests and preferences of the children, for different reasons. In many cases, when a diet is deployed, it is imposed only to the obese member, which will not work as the others continue to have access to other foods. So to be effective, the change must be assumed by the whole family, for the sake of a proper model and also because in many cases there is only one obese family member, but many of the same trend. Therefore, the change in feeding patterns benefits everyone. In one of the group's activities were discussed issues related to family leisure, physical activities proposed by the parents and what the children think about them.
When asked about what the family usually does together, the children showed difficulty remembering things they do together, mentioning only that "from time to time they travel" and "from time to time they go to the movies." They claim they do little physical activity, they like watching television and "using the computer." Other children talk about what they like to do: "I like playing on the computer"; "I do not like football, no"; "I don't like leaving home"; "I like to sleep late"; "... Love watching TV"; "... Like my sister, she just likes to use the computer and watch Globo's soap opera"; "Exercises? I like to ride a bike, but my father doesn't fix my bike". These statements are in line with the findings of Ballone and Moura (2007), for whom modern life has created highly favorable conditions for the development and maintenance of obesity, including among children, as they cease to go out to play in the streets and squares, due to violence or lack of interest and parents' time, restricting to the home the living space, socializing and leisure, where they spend hours watching television or playing video game.
Concern about the impairment of the obese person's mobility also appears in the speeches of children. In an activity in which they had to put on a blue clown healthy foods and a red clown unhealthy food, a child said: "... this here will get even fatter. In a little while he will not be able to walk right"; other children add their perceptions as follows: "Poor him because he is getting faaaaat. In a bit he won't be able to move one little finger "; "Yeah, if he has to do something quickly, he can't. If there's something to run, he can't do it. The Olympics if he is running, he loses. If he is participating of an obstacle course, he loses. He will not get to even move right." On the other hand, the children make a connection between pleasure and to eat a lot, and between eating little and suffering, as shown by the speech of a child, pointing to the clown that was emptier because he had only healthy foods, "Poor thing that clown, it's hardly eating." It is noticed that eating too much and eating little stir senses of pleasure and suffering in children.
Data From Meetings With Family and the Application of the Rorschach Test
The Rorschach test was applied to three teenagers, one with anorexia nervosa, one with bulimia nervosa and one with obesity. The data presented here are an excerpt of the Mugarte (2012) Master's thesis. We will briefly present some data of each adolescent and their families.
The teenager with anorexia nervosa presents disturbance within the limits Me-not-Me, inside-outside, internal-external (fantasy-reality). Her mode of existence is the introverted type with regard to addressing the conflicts, with demonstrations of lack of balance. Her greatest difficulty is to modulate affections, especially when she is invaded by destructive impulses and intense emotional discharge, which reveals some concern for presenting suicidal ideation. These data show the need of the subject to seek therapeutic assistance. The indicated strategies would be the reformulation of concepts about herself in an attempt to reduce the distorted views about her and her body. She presents an impaired body image, difficulties relative to the body and acceptance of self, distorted self-perception and / or projections of body image. She shows the absence of body image integrity and construction of a distorted self-image.
The identificatory models correspond to places and precise functions, - the place of the mother, the place of the father who are responsible for the broadcast of family representations. According to Chabert (1993), image building to of self is related to the way the subject establishes its relations with the object. The teenager does not show actions that can characterize a good relationship with the parental figures. This lack of positive identifiers reflected in an isolation perspective and distortions about oneself and for others. Shows no feelings that demonstrate a link connection, affection or admiration for the father figure, on the contrary, provides answers with shadow content, indicating the possibility of something hidden. These responses are due to the detachment of the father figure. The analysis of the aspects that make up the integration of family dynamics data and test data shows that the adolescent perceives the parental figures as missing - the relationship with the father - and with affective detachment - the relationship with the mother. The relationship with her father comes with emptiness and rejection feelings that cause the feeling of abandonment. The actual behavior of the father towards her, suffer from mother's interference, in openly demonstrating her great resentment about him, for he did not wish to assume paternity of the daughter and not having it acknowledged the mother in the role of mother. In a way, the teenager's mother favors feelings of abandonment and father instability about the daughter when telling her of his proposal for the mother to have an abortion.
Through these affective references, the adolescent builds her intrafamily connection unsteadily, does not feel safe and comfortable to establish direct and affordable contacts. In part, these unstable processes are enhanced by the adolescence she is living. Her family is in the stage of the Family Life Cycle, where the children are teenagers, a period marked by increasing complexity and need for family reorganization in terms of rules, boundaries, communication, etc. The border between the adolescent and the mother is rigid, not allowing contact and communication is difficult (Minuchin, 1982). The presence of the symptom in the adolescent in the context of this family probably has the purpose of get attention and care.
The answers of the adolescent with bulimia nervosa show a strong sense of inadequacy and inferiority, in the attempt to compensate for feelings of inadequacy. There are components in her structure that deserve watchful care like the sharp suicidal ideation. Some features, such as increased self-deprecating sense, are indicative of greater difficulty to recover her self-esteem.
The most childish perception of herself indicates lack of quality on human representation, revealing trouble in interacting with another. It suggests a tendency to isolation and problems in providing positive interpersonal interactions. Her emotional limitations generate a need to block the feelings, preventing the trade of affection and freedom in the expression of feelings in the interpersonal field.
The adolescent's peculiar characteristics are indicative for seeking therapeutic assistance, more focused on distortions about herself and another, in an attempt to reduce fanciful ideas and achieve a search of adaptation to reality. The responses show trouble in accepting the self, the thought of seeing yourself "different from others" and the difficulty to integrate yourself and others. Just in maternal slides, there are indications of their quest to establish a bond (via double-answers), but still with some difficulty for differentiation and ability to appointment of their own identity. So there is not really a denial of the relationship, but instead there is the denial of difference, which signals their trouble keeping preserved their own identity.
It features a distress index and anxiety about the body, represented by a sequence of answers with morbid content, anatomy and blood. Because it is a board with maternal characteristics, reveals a desire or attempt to differentiate, but it is invaded by a strong emotional charge, revealing a discomfort represented by red as aggressive expression.
The adolescent responses characterize experiences of fear and an astonishment reaction to the representation of the father figure. Reveals some fear of the masculine image, characterizing a sense of inferiority. It shows ambivalence toward identification with the mother figure, shown by the symbiotic character with her mother and with little differentiation capacity. The adolescent has responses that refer to the lack of differentiation and individuation, but express the need to be together, the desire to find their space and hence their differentiation is manifested in the following answers with. The teenager's childish attitude is enhanced by both references of parental figures. His verbalizations and the representations of the answers lead us to believe that the parental figures fail to create a proper relational context for the development of her identity and independence. The function of the symptom in the family is perhaps to highlight the childishness and weakness of the daughter, as shown in the mother's statement about her physical condition: "we did not know what to do. My daughter will melt, my daughter is going to disappear".
The responses of the adolescent with obesity indicate lack of emotional control, geared towards the order of interpersonal relationships and compulsion. He manifests himself vulnerable to emotions and his affection reveals itself with detachment of intimate relationships and emotional exchanges. His mode of existence is introverted, which prevents him from performing a confrontation of conflicts maturely and causes a tendency to imagine more than acting. He provides answers that suggest ambivalent feelings reflected in conflicts over his image and identity, revealing that there is no harmony between the self and the self-image. It demonstrates an attempt to achieve a high standard of beauty as a means to fit in external requirements.
At the same time, he express the anguish and also the desire to be free and able to own up to be what he is without the rigidity of internal or external control. These aspects suggest that the subject cannot be recognized as a unified whole and is attached to external values (need to fit into the pattern). He presents himself tied to caricature and images created. There is no representation that establishes a clear sense of self and his body. He presents a certain need to unfold and meet the requirements of the other and keep up appearances or what is expected of him. Reveals a perception of self in a negative light and demonstrates being dissatisfied with his body structure. Reveals a substantial shock to his self-image, reflected by an emotional charge that reveals uneasiness over an image of the body that is represented disintegrated and without form.
The teenager appears to cherish the father figure positively. Establishes a good reaction to authority figures and respects hierarchies. Does not show negative signs about the father figure. The absence of the father (now deceased) is expressed with feelings of failure and impotence. Does not present in a first moment a positive introjection of the female figure. It seems that he is open to dialogue, but their relationship is distant and not enough communication to establish an appropriate relationship, as if they were from different worlds. The answers show an idea of dependence and fear of abandonment. It reveals both a desire to be cared for, but with a need to be free, an ambivalence of feelings that suggest a need for attention and control. In the adolescent family context analysis it turns out that their mode of interaction is pervaded by emotional ambivalence, consisting of experiencing mixed feelings over the same object. He presents this ambivalence when depicts two moments of his relationship with his father. In another moment, he describes the relationship with his father as having a repressive character because his father wanted the children under his control. He points to the "affective mismatch of his family" that is marked by conflicting interests, for he says that the concern of family members is to achieve a better financial condition and, as a result, the affection goes to the background. It seems that in this family the care and affection of reference is linked to the satisfaction of basic needs.
Final Remarks
The research presented is in progress and the partial results show that the methodology offers good prospects for both knowledge on family dynamics as for the treatment of families with obese children and adolescents with ED.
Working with Multifamily Group we were shown various characteristics of the dynamic of families with obese children and adolescents, among which stand out: family difficulty to establish limits and rules related to food; the influence of grandparents in their grandchildren food, going against rules set by parents; family neglect to follow the treatment of obesity; presence of other family problems, such as depression, drug use and violence. At the same time it was observed that as the meetings were going on, families brought data on changes made in family relationships, in the family feeding and the introduction of physical activities.
Through the group of children we observed their knowledge about healthy eating, the dietary family pattern and we verified the attempt to incorporate healthy habits in their diet, both from parents and acceptance by the children. The children expressed grief in face of aggressions suffered because of obesity in the family and school environment, complaining about the lack of support from parents. They demonstrated knowing the familiar control mechanisms in relation to food, an often used resource only with the obese member and not with the family as a whole.
The Rorschach test data were very important because they encourage an understanding of intrapsychic aspects of adolescents, while relating to family dynamics, an unpublished work that demanded a lot of effort and dedication from the authors. Adolescence appears to be the most conducive period to the emergence of ED and obesity, as is the time of the search for differentiation, autonomy and independence of the individual regarding the family. In the three teenagers we identified immaturity and dependence on the family and difficulties in social relationships, which can be related to the difficulty of separation, individualization and differentiation of primary relational objects, i.e. the parental figures. On the other hand, the desire of differentiation is also present, which shows the search for identity.
The role of the family, with its pattern of relationships is important as it is the context in which this quest will happen and the main reference in terms of models, freedom and limits for the construction of the adolescent identity. In the studied families the father figure is represented as erased or ambivalent form, with maternal meddling in building the image of a father figure for the children. This characteristic of family dynamics can influence the identifications, which in turn reflect on the self-image and self-concept. On the other hand, it is present in all three cases, good adaptation to reality, which shows that despite having conflicts regarding parental figures, difficulties in the differentiation and dependence process, there is vitality in the adolescence and the possibility of developing or recover the identification of other references or positive role models in building their personality.