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The diagnostic and therapeutic uses of family conflicts in a Chinese context

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Abstract

There are two untested cultural beliefs commonly held among family therapists in Hong Kong: (1) Chinese families are reserved in disclosing their conflicts to an ‘outsider’; and (2) it would be culturally inappropriate to elicit family conflicts in treatment. In this article, an attempt is made to examine these cultural beliefs based on the results of a qualitative study of thirty-five Chinese patients suffering from anorexia nervosa. These patients and their families have participated in a pre-treatment family interview prior to the commencement of family treatment. The results of the study have shown that the afflicted Chinese families are very willing to disclose their difficulties to the researcher. The onset of the disorder has led to different types of family conflicts including: (1) overt family conflicts related to food refusal; (2) covert family conflicts; (3) increased sibling rivalry; (4) increased parent–child conflict; and (5) marital tension and distress. The clinical implications of this study are discussed at the end of the article.

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... There is an old Chinese saying, 'Jia chou bu ke wai yang' (domestic shame should not be published). With an emphasis on preserving their 'face', many Chinese families are not willing to disclose their family conflicts to 'outsiders' (Ma, 2005). Furthermore, the Chinese tend to hide their problems in their house to maintain an outward image of harmony. ...
... For these reasons many Chinese families choose to keep silent about their conflicts, even in front of helping professionals. The one exception is in a small part of larger cities such as Hong Kong, Shenzhen and Shanghai, where the families are more influenced by westernized values and are more open to airing their conflicts (Lee, 2002; Ma, 2005). Eliciting family conflicts and problems directly may be too stressful for Chinese clients to accept and may lead to family members facing a harsh struggle with the family if they open up about a family problem (Dwairy, 2009). ...
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The use of metaphors in family therapy has been extensively written about in western literature, yet very few studies on this subject have been conducted in China. The goal of this study was to summarize the metaphors used by Chinese family therapists. Transcriptions from 36 hours of video-recorded family and couple therapy sessions from eighteen Chinese family patients were qualitatively analysed to identify categories of therapist-produced metaphors that are applicable to the Chinese context. Two major categories emerged: verbal and non-verbal metaphors. Verbal metaphors included four subgroups: story, object comparison, sayings and age. Nonverbal metaphors involved two subgroups: gesture and spatialization. The influence of the Chinese culture on the use of metaphor is discussed. This study adds to the greater understanding of how to integrate metaphors in therapy in the Chinese context.
... that short-term FBT (10 sessions over 6 months) is as effective as long-term FBT (20 sessions over 12 months) to achieve remission, especially among adolescents with less severe eating-related obsessive-compulsive features or adolescents from intact family (Lock, Agras, Bryson, & Kraemer, 2005 Kong has also similarly identified the involvement of extended family and school as facilitators to care and stigma around mental health care as a barrier for eating disorder treatment (Ma, 2005a(Ma, , 2005bSun et al., 2019). More generally, low mental health literacy and the stigma around mental health concerns have been identified as barriers to mental health care in Singapore, and Asia more broadly (Li, 2012;Loo & Furnham, 2012;Picco et al., 2016;Subramaniam et al., 2020;Xu et al., 2018). ...
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Objective This study describes the implementation of family‐based treatment (FBT) in an eating disorder program in Asia as well as clinical outcomes of Asian adolescents with anorexia nervosa (AN) treated with FBT. Method This retrospective consecutive cohort study of 147 Asian adolescents with AN was compared between those in FBT (n = 65) versus treatment as usual (TAU) (n = 82). Variables associated with weight restoration were analyzed between groups. Results Participants' mean age was 14.2 (SD = 1.5) years and 93% were female. Mean presenting %mBMI was 74.0 (SD = 7.8) and average illness duration was 7.7 (SD = 6.1) months. The two groups' baseline characteristics were not significantly different. Weight restoration rates in the FBT group were significantly higher than the TAU group at 6‐, 12‐, and 24‐month time points. A linear mixed model showed the mean %mBMI was significantly higher at 0, 6, 12, and 24 months in the FBT group. The median time to weight restoration for patients on FBT was shorter (FBT: 7.0 months, TAU: 19.0 months; 95% CI [14.5, 23.5] χ² = 15.84, p < .001). Within the FBT group, those that completed ≥9 FBT sessions had significantly higher rates of weight restoration at 12 months. Across all participants, those with a lower starting %mBMI were less likely to achieve weight restoration by 12 months. Conclusion FBT can be effectively implemented in a multidisciplinary eating disorder program managing Asian adolescents with AN with improved rates of weight restoration. Further research is needed to understand the predictors and moderators of remission using FBT in Asian adolescents with AN.
... As complicações orgânicas decorrem, principalmente, da desnutrição na AN e dos distúrbios hidroeletrolíticos na BN, mas também há diversas complicações no nível psicossocial que merecem atenção, uma vez que os sintomas afetam também o bem-estar psicológico e familiar, gerando tensões insuportáveis . Pacientes que desenvolvem esses transtornos apresentam dificuldades nos relacionamentos interpessoais e nos esforços para se manterem funcionais, seja na esfera do estudo e/ou do trabalho (Leonidas, & Santos, 2014;Ma, 2005;Sicchieri, Santos, Santos, & Ribeiro, 2007). ...
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... Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity (World Health Organization, 1986). The onset of physical and mental illnesses has detrimental effects on psychosocial functioning of the afflicted person (Ma, 1996; Tang et al., 2007) and the family well-being (Johnson, 1998; Ma, 2005; Ptacek, Pierce, & Ptacek, 2007; Wong, 2000). Hitherto, community samples have rarely been used in a Chinese context to examine the linkage of self-reported physical and mental health to perceived general family functioning. ...
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Chapter
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Chapter
Review of the LiteratureFamily-Based Treatment for Adolescents with Anorexia NervosaPutting Together a Treatment TeamSetting Up TreatmentConclusions
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A controlled trial comparing family therapy with individual supportive therapy in anorexia nervosa and bulimia nervosa was undertaken. Eighty patients (57 with anorexia nervosa; 23 with bulimia nervosa) were first admitted to a specialized unit to restore their weight to normal. Before discharge, they were randomly allocated to family therapy or the control treatment (individual supportive therapy). After one year of psychological treatment, they were reassessed, using body weight, menstrual function, and ratings on the Morgan and Russell scales. Family therapy was found to be more effective than individual therapy in patients whose illness was not chronic and had begun before the age of 19 years. A more tentative finding was the greater value of individual supportive therapy in older patients. To our knowledge, this is the first controlled trial of family therapy in anorexia nervosa and clarifies the specific indications for this treatment.
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In this case study of early-onset anorexia nervosa in a male patient from Hong Kong, clinical features are outlined and compared with those of their Western counterparts. Implications of being the only son in a traditional Chinese family and the process of acculturation and cultural conflicts of growing up in a Western-oriented society are put forward as significant psychodynamic factors in the etiology of his illness.
Article
Synopsis A mixed retrospective–prospective study of 70 Chinese anorexic patients in Hong Kong shows that although they were similar to Western anorexics in most other ways, 41 (58·6%) of them did not exhibit any fear of fatness throughout their course of illness. Instead, these non-fat phobic patients used epigastric bloating (31·4%), no appetite/hunger (15·7%) or simply eating less (12·9%) as legitimating rationales for food refusal and emaciation. Compared to fat phobic anorexics, they were significantly slimmer pre-morbidly ( P < 0·0001) and were less likely to exhibit bulimia ( P = 0·001). The possible explanations for the absence of fat phobia and the interpretive dilemma this provokes are discussed from historical, pathoplastic and cultural anthropological perspectives. It is argued that anorexia nervosa may display phenomenological plurality in a Westernizing society, and its identity may be conceptualized without invoking the explanatory construct of fat phobia exclusively. As non-fat phobic anorexia nervosa displays no culturally peculiar features, it is not strictly speaking a Western culture-bound syndrome, but may evolve into its contemporary fat phobic vogue under the permeative impact of Westernization. Its careful evaluation may help clarify the aetiology and historical transformation of eating disorder, foster the development of a cross-culturally valid taxonomy of morbid states of self-starvation, and exemplify some of the crucial issues that need to be tackled in the cross-cultural study of mental disorders.
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A key feature of the stereotype that exists of those groups and individuals most likely to develop an eating disorder relates to socioeconomic status. The prevailing wisdom about this relationship is that there is an increased prevalence of eating disorders in high socioeconomic groups. The aim of this paper is to assess the validity of this view and to examine the ways in which this stereotype was created. Articles written between the early 1970s and the early 1990s, which include assessment of socioeconomic status, are reviewed and the evidence for and against the stereotype is examined. It was found that existing research fails to support this stereotype for eating disorders as a whole, that the relationship between anorexia nervosa and high socioeconomic status remains to be proved, and that there is increasing evidence to suggest that the opposite relationship may apply to bulimia nervosa. The powerful influence of clinical impression, sources of bias in referral procedures, methodological problems in existing research, and the failure to adequately separate anorexia nervosa from bulimia nervosa when referring to common predisposing factors, are discussed in relation to why the stereotype exists.
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Using a locally devised self-report questionnaire that encompassed both professional and lay explanatory models, this study explored the perceptions of anorexia nervosa (AN) in a large sample of 842 Chinese undergraduates who had little biomedical exposure to this rare condition in Hong Kong. Anorexia nervosa, or yan shi zheng, was conceived as a chronic psychiatric condition of severe weight loss (34%) that arose from mixed psychosocial etiologies. Unlike the more exact professional categorizations but consonant with the lexical meanings of yan shi and Chinese anorectic patients' illness reality, appetitive complaints, sadness and fat phobia were believed to be the main expressions of AN. The illness was seen to affect young women of affluent societies, and to call for help from mental health professionals as well as family members. Although it was not stigmatizing, it would nearly never be admired. Factor analysis revealed a discernible resemblance between lay and professional epistemologies, particularly in the configuration of anorexic symptomatology into "specific" (fat phobic) and "general" types. This implies that in psychiatric disease categories with an uncertain etiology and a substantial cultural component, lay people may package and construct knowledge in a fashion similar to that of professionals. The findings of this study question biomedicine's positivistic claim to psychopathology, and suggest that lay and professional ethnopsychiatric theories and lived anorectic experience are interdependent facets of a socially constructed world.
Article
To evaluate the psychometric properties of the Chinese Eating Disorders Inventory (EDI-1) in a nonclinical population in Hong Kong. 1,172 (females 606, males 566) Chinese undergraduates completed the Chinese EDI-1; 105 of them also completed the 12-item General Health Questionnaire (GHQ-12). In female subjects, the Chinese EDI-1 and its subscales met conventional standards of internal consistency, item-total, item-subscale, and subscale correlations, and exhibited an excellent degree of factorial integrity. The subscales discriminated among male, female, high Drive for Thinness, high Body Dissatisfaction, constitutionally slim, and Canadian female subjects. Female GHQ-12 cases and noncases were only distinguished by the Interpersonal Distrust, Interoceptive Awareness, and Ineffectiveness subscales. 3.3% of female subjects could be characterized as being pathologically weight preoccupied. This study provides preliminary evidence that the Chinese EDI-1 is an economical, reliable, and potentially useful self-report instrument for investigating the psychological and behavioral dimensions of eating disorders in Hong Kong. But further work is needed to evaluate its transcultural validity in clinical and less modernized Chinese populations.
Article
Successful treatment of anorexia nervosa remains elusive for many cases. Involving the family in the treatment of adolescents with anorexia nervosa has proved to be of benefit for young clients with a short duration of illness. In fact, the benefits of family therapy have been shown to be enduring at five-year follow-up. Engaging in treatment and commitment to therapy are important factors affecting treatment outcome. For instance, parental criticism of the anorexic offspring can lead to early dropout of treatment or poor outcome in treatment. The case presented in this article demonstrates how the family's help can be solicited in restoring the adolescent's health in much the same way had the client been admitted to a specialist inpatient facility. Although the treatment in this case was relatively uncomplicated and brief, the family had to overcome their initial exasperation with the client's self-starvation in order to be helpful in the process of the adolescent's weight restoration. When this initial stumbling block was resolved, in part by the therapist's modeling of an uncritical stance toward the client's dilemma, the family was successful in nurturing their daughter back to health. Once the client's weight was restored, and the adolescent reintegrated with her peer group, she could negotiate her continued individuation from her parents, but without the eating disorder to cloud their relationship.
Article
To examine disordered eating and its psychological correlates among female high school students in three Chinese communities that lay on a gradient of socioeconomic development in China. 796 Chinese students from Hong Kong, Shenzhen, and rural Hunan completed a demographic and weight data sheet, the Eating Attitudes Test (EAT-26), a Body Dissatisfaction Scale (BDS), the Beck Depression Inventory (BDI), and the Rosenberg Self-Esteem Scale (RSES). Compared to students in Hunan and to a lesser extent students in Shenzhen, students from Hong Kong were slimmer, but desired a lower body mass index (BMI), reported more body dissatisfaction, exhibited a more typical EAT-26 factor structure, scored higher on the "fat concern and dieting" factor, and constituted more EAT-26 high scorers. Multiple regression analyses indicated that BDS was the most significant predictor of fat concern at each site, but this effect was strongest in Hong Kong. Hunan students had significantly higher BDI scores but lower fat concern than Shenzhen and Hong Kong students. The consistent gradient of fat concern across the three communities gives credence to the view that societal modernization fosters disordered eating in women, possibly via the gendered social constraints that accompany it. It is also expressive of the marked socioeconomic heterogeneity within China nowadays. The predictable rising rate of eating disorders that follows global change will pose a growing public health challenge to Asian countries.
Article
The clinical and psychosocial characteristics of 16 Chinese adolescents from Hong Kong with anorexia nervosa are reported. In contrast to previous local reports of adult patients, over 80 per cent of these younger patients reported a fear of fatness. It appears that, against the background of increasing Westernization, the illness is taking on a Western pattern, in line with the suggestion that significant concern about weight in anorexia nervosa is a pathoplastic effect of Westernization. There was also a marked increase in the referral rate of patients in the younger age group, reflecting both an increase in the incidence and general awareness of the illness.
Article
(1) To examine social class status of female patients with anorexia nervosa presenting over a 33-year period; (2) to identify any differences in clinical features between the social classes. Retrospective survey using comprehensive clinical database of patients referred to a national specialist center for the assessment and treatment of anorexia nervosa. Social class was defined using UK Registrar General's classification of father's occupation. Statistical methods included initial univariate analyses and subsequent ordinal logistic regression. (1) Social class distribution was consistently weighted toward social classes 1/2. (2) Possible clinical indicators examined included low body weight, binge eating, and consequent weight-regulatory behaviors such as vomiting and laxative and diuretic misuse. These clinical features and their distribution proved to be similar across the social groups. Clinically rated quality of family relationships and types of family constellations were also consistent across the social classes. (3) Dieting prodromata and onset of the disorder occurred at younger ages in social classes 1/2. (4) A modest shift in social class distribution over time was apparent, with slightly more patients presenting post-1985 likely to come from lower social classes. Claims that the social class distribution is a product of referral patterns and acceptances are disputed. We suggest that the social class bias reflects a sociocultural influence; a product of the disorder significantly often arising as an avoidant response to the conflict between social class-related family values/attitudes and adolescent turbulence within that family.
Article
We explored anorexic patients' subjective accounts of the causes of their anorexia and of the factors that fostered recovery. Subjective accounts could assist in understanding this complicated and often intractable disorder. All female new referrals to an eating disorders service underwent extensive interviews including open-ended questions about their beliefs concerning the causes of their anorexia nervosa and factors that led to recovery. Responses were categorized by two independent raters. The most commonly mentioned perceived causes were dysfunctional families, weight loss and dieting, and stressful experiences and perceived pressure. The three most commonly cited factors contributing to recovery were supportive nonfamilial relationships, therapy, and maturation. Individuals with anorexia nervosa perceive both external (family environment) and personal factors (dieting and stress) as contributory to their disorders. The results underscore the importance of interpersonal factors in recovery from anorexia nervosa and suggest that attention to this area in treatment may be beneficial.
Anorexia nervosa in Chinese adolescent
  • K. Y. C. Lai
  • K. Y. C. Lai
The Family Interpreted Basic Books. Family conflicts in a Chinese context Anorexia nervosa and social class
  • D A Luepnitz
  • L Mcclelland
  • A Crisp
Luepnitz, D. A. (1988) The Family Interpreted. New York: Basic Books. Family conflicts in a Chinese context McClelland, L. and Crisp, A. (2001) Anorexia nervosa and social class. Interna-tional Journal of Eating Disorder, 29: 150–156.
Family therapy for the Chinese: problems and strategies
  • J Hsu
Hsu, J. (1995) Family therapy for the Chinese: problems and strategies. In T. Y. Lin, W. S. Tseng and E. K. Yeh (eds) Chinese Societies and Mental Health (pp. 295-307). Hong Kong: Oxford University Press.