Exploring Family Based Treatment for Eating Disorders in China

Not much is known about eating disorders in China, especially compared to its East Asian counterparts of Hong Kong and Japan. It would appear that researcher-practitioners in China are not publishing much data about eating disorders in the country; in fact, the author of the study I’ll be looking at in this post, Joyce Ma, practices primarily in Hong Kong. In this study, Ma explores China-specific patterns of ED presentation and how they relate to the social context. As she notes, treatment models have been slow to develop from the mother-blaming paradigm proposed by Chen (1990), which recommended that eating disorder patients be isolated from their parents. No other study appears to have been done (at least that she cites) using evidence-based modalities.

In her study, she reports on the results of treatment with 10 families in a Shenzhen clinic, with patients of a relatively wide age range – one of the patients, a 26-year-old, had in fact been married and divorced already. All of the patients were at least of secondary school age (which means at least 13 years old), with one working as a part-time teacher. All patients underwent family-based treatment rather than individual psychotherapy, with Ma’s model based on Minuchin’s structural family therapy.

Ma identified three main themes in her FBT sessions with the parents, all of which reflected delays in psychological development:

  • Conflicts over food/ eating
  • Not wanting to be treated like a child / not wanting to grow up
  • Resistance to parental expectations

From Ma’s observations, the main priority seems to be educating parents about the disorder and helping them to see the underlying psychological context of the battle over food i.e. the second and third themes. While such issues certainly came up during family sessions, the parents tended to resort to rationalizations that stopped them from recognizing their daughter’s perspective:

“I bought a shop for you and you can run a small business. That would solve your career problem. Why did you turn me down?” (p. 807)

“The fate of a divorced woman would be sorrowful. Besides, her ex-husband is a good man.[1]” (p. 808)

Ma’s three themes, as she indicates, are very much interlinked – the family struggle over re-feeding is an extension of the struggle over independence and autonomy from parents. She suggests, then, that shifting the focus to such issues of development and change in the family would allow “the youths [to] give up using their bodies as the battlefield on which to fight with their parents” (p. 809).

The possible irony here is that in this search for individuation, the patient remains locked in a family-based treatment model that replicates the social structures they’ve grown up and experienced their disorder in. Certainly, the complex family dynamics need to be worked through – but I wonder about some of the more deep-rooted identity crises that can’t be reduced to just being unhappy with their parents’ decisions. Patient T explained that:

“I am in great distress. I am forced to live a life that makes only my parents happy. They would like me to be an ordinary girl” (p. 807)

On the one hand, the sessions helped in changing her parents’ expectations in this area – but on the other, T needed her own space to explore her desires without having them defined as opposing those of her parents. This is particularly true for her (at 20 years old) and the four other college-aged or older patients, and I wonder if family therapy might have served better as an adjunct to individual therapy for these clients. Ma herself notes at the beginning of the paper that family-based therapy is recommended for adolescents of 18 years and under.

Ma’s sample is interesting demographically, and perhaps skewed – she received all of her patients after they had already been to several other treatment centers in the region, so families with less information or resources would probably not have come to her attention. All families were well-off, with the fathers having successful careers; the daughters also largely had ‘conspicuously good’ (p.806) academic performances. This created additional pressures on the patients in terms of their career paths and life choices, and the mother tended to be at the locus of these conflicts as the primary caregiver, even if the father was equally involved:

“Patient G, a 20-year-old daughter with BN, confronted her submissive and depressed mother: “You know I was upset that Dad chose the college for me without attempting to ask me first. Why can’t you be strong and brave and help me fight with him?” (p. 808)

As Ma notes, Western-based models of using FBT to “escalate the family stresses and induce a sense of crisis” (p. 809) may not be an entirely appropriate way of helping family members to accept responsibility for change. The sessions revealed entrenched divisions of responsibility within the family: for example, fathers acted as distant breadwinner and mothers were much more deeply involved in raising their daughters. These divisions of responsibility reflect general cultural patterns. Ma emphasizes especially the fact that the parents she worked with grew up in the 1960s and 1970s and achieved their success in life against the backdrop of extreme political instability and economic uncertainty; this insecurity has likely informed their desires and fears on behalf of their daughter. As a result, any rupture in family roles – and coming to terms with letting go of their daughter’s decisions – poses a deep challenge to how they see their identity as a parent.

Overall, I think two main points come through in this study: one, that family dynamics will be an area of high tension in Chinese eating disorder treatment and need to be handled carefully; and two, that treating eating disorders – at least among this group of patients – will require addressing entrenched constraints on identity formation. When the first 20 years of the patients’ lives have been guided by parental and social expectations, forming a new identity in recovery is all the more difficult.

[1] This case is especially complex because she was a victim of domestic abuse, which the parents only found out about in treatment; they rationalized the beatings as because their daughter had been bingeing and purging.


Ma JL (2008). Eating disorders, parent-child conflicts, and family therapy in Shenzhen, China. Qualitative health research, 18 (6), 803-10 PMID: 18503021

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Jacqueline is a sociology undergraduate student from Singapore with an interest in mental health and illness, bodily work, and their intersections with the political. She is currently in recovery.


  1. Jacqueline thank you for your article. I live in Chongqing, China now but used the principles of Family Based Treatment for years in my practice in the states. I would love to connect on We Chat. MelanieJacobCQ

  2. What this post is describing is family systems therapy, not Family Based Treatment. There is a huge difference.

    • You’re right, my bad – I should have used just FT throughout. I’m not sure how she would classify her style to be honest, because it sounds like her practice is Maudsley FBT based (re the format), but borrows Minuchin’s principles as a way of elucidating tensions in her context.

  3. Parents and families don’t cause anorexia nervosa. Therefore, treatments aimed at changing family function, including their patterns of communication and emotional relationships, are not effective. Minuchin attempted to change these aspects of families. His treatments failed. If you read the data from his studies, you’ll see that rates of recovery were extremely low. Also, I recommend reading the review of family therapy for anorexia nervosa published by the Cochrane Collaboration. It confirms that there is little evidence to support family therapy.
    By contrast with family therapy, Family Based Treatment (FBT), aims at increasing the sufferer’s weight and then restoring normal patterns of eating behavior. Parents, not professional psychotherapists, are in charge of accomplishing these tasks. FBT has shown the best results in scientific experiments, significantly better than traditional family therapy.

    • Hi Chris,
      Please stop trolling. No further comments from you will be approved on this website (a first for this blog!). Jacqueline likely approved of them because she is unaware of your trolling history. I prefer to engage with people who are open to evidence, as opposed to those who repeat the same thing over and over and over again. I am familiar with FBT data.

    • This is from the Cochrane review article.

      “One form of intervention commonly utilised to treat patients with AN is family therapy. Although there are a number of different forms of family therapy, the current review of 13 trials indicated that the therapy most often tested in trials is family based therapy.

      The trials included in the review had limitations in the reporting of trial conduct and meaningful outcomes. Overall there was some evidence to suggest family therapy may be effective compared to treatment as usual. However, there is not enough evidence to determine whether family therapy is effective compared to other psychological interventions for rates of remission. There were no differences in relapse rates, symptom scores, weight measures, or the number of drop outs between those treated with family therapy versus any other comparison group.

      Mortality was not measured or reported sufficiently to determine whether it is reduced for those treated with family therapy compared to other interventions. There were very little data about general or family functioning.”


      “13 trials were included, the majority investigating family based therapy, or variants. Reporting of trial conduct was generally inadequate. The full extent of the risk of bias is unclear.

      There was some evidence (from two studies, 81 participants) to suggest that family therapy may be more effective than treatment as usual on rates of remission, in the short term (RR 3.83 95% CI 1.60 to 9.13). Based on one study (30 participants) there was no significant advantage for family therapy over educational interventions (RR 9.00 95% CI 0.53, 153.79) or over other psychological interventions (RR 1.13 95% CI 0.72 to 1.76) based on four studies (N=149). All other reported comparisons for relapse rates, cognitive distortion, weight measures and dropouts yielded non-significant results.”


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