It’s All in the Family: Use of Family Therapy for the Treatment of Anorexia Nervosa in Adolescents

The use of family therapy as an alternative treatment for anorexia nervosa stems, in part, from the generally high post-treatment relapse rate for the American population [1]. Comprehensive reviews of studies dealing with anorexic individuals note it takes individuals five years on average to overcome the disorder, with 20 percent remaining chronically ill [1]. One possible explanation for the low success rate of most therapies in dealing with the disorder is that anorexia nervosa typically develops during adolescents, and treatment is generally done in in-patient following hospitalization [1]. Thus, participants generally have a hard time maintaining their progress once they are released and placed back within their family system [2]. In this respect, family therapy may be a more appropriate treatment for adolescents suffering from anorexia nervosa, as it allows for change while also accounting for the prolonged dependency the adolescents

experience in a family environment. This emphasis on dependence is crucial to individuals suffering from anorexia nervosa, as some researchers have theorized that the disorder develops from feelings of lack of control over one’s life. Family therapy addresses this issue by providing the family with resources for handling a progressively more independent adolescent while also aiding the adolescent in developing a strong, positive, sense of autonomy.

Family therapy itself is not based on any particular theoretical approach, but rather was developed precisely to treat hospitalized adolescent patients suffering from eating disorders. It consists of three stages that generally occur over the

course of a year. The first stage aims to help parents take control of their adolescent’s re-feeding. During this stage, the therapist attempts to unite the parents, provided the client comes from a two-parent home, having them synthesize a re-feeding plan for their adolescent. The therapist allows the parents to determine their own approach, as they have the best chance of developing a plan that the family can follow. Clients lose some autonomy in this phase, but the therapist reassures them they will gain it back by the end of therapy. This stage emphasizes removing any blame parents might place on themselves or their child concerning inappropriate eating behaviors. The therapist also recruits siblings to support the client and addresses any issues between siblings and the client. This process continues until the client displays a steady weight gain.

This milestone signals the beginning of the second stage of therapy and also shows family members that they have the ability to take charge of the eating disorder [3]. Generally, prior to beginning therapy, the therapist observes the family participating in a typical family meal. The therapist notes the family’s interactions during the meal and uses this information during sessions to address the issues that arise for the parents concerning feeding their adolescent [4].

During the second phase of treatment, the therapist primarily focuses on symptoms of anorexia nervosa but also addresses issues parents still experience in helping their child reach a steady weight gain. Here, the therapist attempts to combat a distorted body image as well as irrational thoughts about eating. This stage is finished when the client reaches a stable, healthy weight with little to no struggle regarding eating at mealtimes [3].

The third stage focuses on addressing the adolescent’s personal issues, including peer groups and personal autonomy. Clients resume control over their eating, and the family works on developing proper boundaries and aiding the client in establishing an appropriate level of personal autonomy. Clients are also taught problem-solving communication techniques to help them develop appropriate coping strategies [3].

The most recent literature on the use of family therapy for anorexia nervosa in adolescents examines its efficacy in comparison to typical “treatment as usual” in a sample of recently released in-patient subjects suffering from anorexia nervosa [5]. In the control group, participants received treatment tailored to their mental and physical states. This included providing support, prescribing medications and discussing eating habits. The family therapy group focused on dealing with past and present family issues, and in particular helping the family recognize how these problems might impact it into the future. Both treatment groups received the same number of sessions over the course of 18 months, and the two co-therapists conducted the family therapy jointly to ensure the approach was consistent.

The study found that participants in the family therapy condition were 3.2 times more likely to have good to intermediate outcomes than the “treatment as usual” group. Similarly, those who received family therapy were three times as likely to achieve healthy weights and experience menstruation. Additionally, in reference to BMI, the gap between the two groups began to widen after around a year of therapy and continued to increase until the therapy’s termination. However, there were no significant findings regarding scores for MINI (mini-Neuropsychiatric Interview), GOAS (Global Outcome Assessment Scale), EDI (Eating Disorder Inventory) or SAS (Weissman’s Social Adjustment Scale). Although the findings suggested that this particular family therapy might reduce the physical symptoms of anorexia nervosa, they also showed that it may not adequately address the disorder’s psychological basis, which the study does not address. Therefore, although the study is quick to observe participants’ positive outcomes physically, it does not address the necessity to also modify psychological symptoms [5].

Another study compared the efficacy of two types of therapy, conjoint family therapy and separate family therapy, and found that conjoint therapy was more effective in treating anorexia nervosa [6]. The conjoint family therapy group received general family therapy, while in the separate group; parents met with the therapist alone and were treated similarly to how they would be in the first stage of general family therapy. Group members learned about ways to relieve their self-blame and about ways to take a firm stance on their adolescent’s eating. The adolescents in this group received supportive counseling aimed at discussing their experiences with anorexia. Unlike the very structured approach of conjoint family therapy, separate family therapy was geared toward addressing the adolescents’ and their parents’ psychological distress. Both treatment groups received treatment with the same therapist and for roughly the same duration[7].

A comparative analysis of these family and global functioning assessments, including the Rosenberg Self Esteem Inventory and Standardized Clinical Family Interview, revealed that there were few significant differences between the two groups [6]. However, findings specified that participants with high familial expressed emotion, measured through the Standard Clinical Interview’s Expressed Emotion rating, were more successful in achieving good to intermediate outcomes in the separate family therapy than in the conjoint family therapy, while they noted no difference in participants with low familial expressed emotion. This supported the study’s hypothesis that maternal criticism, which may play a role in familial expressed emotion, might be counterproductive to an adolescent with anorexia. Conjoint therapy, while effective, may not be appropriate for all families.

Research has also indicated family therapy’s effectiveness in treating sub-threshold cases of anorexia nervosa [7]. This study defined sub-threshold anorexia as either weight loss below 100 percent of one’s ideal body weight, but above the 85 percent cutoff for anorexia or secondary amenorrhea. Weight loss below the 85 percent cutoff comes with the addition of oligomenorrhea, infrequent menstruation.

The study utilized an interesting control group structure that consisted of individuals holding baseline demographic variables and baseline termination percent IBW. The experimental group included participants with sub-threshold cases and participants with comorbid anxiety and depression who were currently receiving medical treatment for these disorders. This design not only allowed for generalization to the general undiagnosed population, but also made it possible to determine whether slight differences between the clinical manifestations of anorexia impact a therapy’s efficacy. The study used a strict termination schedule to maintain fidelity between groups. Depending on which came first, participants were terminated after 20 sessions, one year of treatment or successful progression through the three phases [7].

The study found that clients who met the full DSM-IV criteria for anorexia nervosa showed comparably positive outcomes in reducing their anorexia symptoms, both physical and psychological, except that more severe cases showed no significant change on the EDE Eating Concern Subscale. Researchers also examined participants according to treatment length, and found that stopping treatment early predicted lower body weights, while extended treatment over 20 sessions showed no difference from normal yearlong length treatment [8].

Given the relative novelty of family therapy in the treatment of anorexia nervosa, studies have yet to examine individual critical aspects of the therapy [9]. However, findings that short- and long-term therapy yield similar clinical results speak to its efficacy [10,11]. Because these studies found similar results with short-term therapy that excludes phase three as with long-term therapy that includes it, it would appear that the first two phases of therapy hold a more significant therapeutic advantage over the final stage. Furthermore, this change only affects treatment efficacy in more severe cases and in cases where parents are separated [4], and these results held during follow-up assessments [10].

Generally, research on the use of family therapy in the treatment of adolescent anorexia nervosa has been positive [10,11,12]. However, the treatment’s generalizability to different cultural, socioeconomic and gender groups remains to be seen. Additionally, while anorexia does generally develop during adolescence, further research examining the effectiveness of family therapy for older individuals living with the disorder could prove beneficial. Lastly, as with most treatment methods, further research is necessary to determine which critical aspects of the treatment produce the most beneficial results.

References

1. Dare, C., 1985. The Family Therapy of Anorexia Nervosa, Journal of Psychiatric Research, 19: 435–453.4
2. Lock, J., & Fitzpatrick, K. K. (2007). Evidenced-based Treatments for Children and Adolescents with Eating Disorders: Family Therapy and Family-facilitated Cognitive-Behavioral Therapy. Journal of Contemporary Psychotherapy, 37(3), 145-155.
3.  Lock, J., Agras, W., Bryson, S., & Kraemer, H. (2005). A comparison of short- and long- term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry, 44(7), 632-639.
4. Lock, J., & Fitzpatrick, K. K. (2007). Evidenced-based Treatments for Children and Adolescents with Eating Disorders: Family Therapy and Family-facilitated Cognitive-Behavioral Therapy. Journal of Contemporary Psychotherapy, 37(3), 145-155.
5. Godart, N., Berthoz, S., Curt, F., Perdereau, F., Rein, Z., Wallier, J., Horreard, A., & Kagnaski, I. (2012). A randomized controlled trail of adjunctive family therapy and treatment as usual following inpatient treatment for anorexia nervosa adolescents. PLoS One, 7(1): e28249.
6. Eisler, I., Dare, C., Hodes, M., Russell, G., Dodge, E. and Le Grange, D. (2000), Family Therapy for Adolescent Anorexia Nervosa: The Results of a Controlled Comparison of Two Family Interventions. Journal of Child Psychology and Psychiatry, 41: 727–736. doi: 10.1111/1469-7610.00660
7. Loeb, K., Walsh, B., Lock, J., Grange, D., Jones, J., Marcus, S., Weaver, J., & Dobrow, I. (2007). Open trail of family-based treatment for full and partial anorexia nervosa in adolescence: Evidence of successful dissemination. American Academy of Child and Adolescent Psychiatry, 46(7), 792-800.
8. Loeb, K., Walsh, B., Lock, J., Grange, D., Jones, J., Marcus, S., Weaver, J., & Dobrow, I. (2007). Open trail of family-based treatment for full and partial anorexia nervosa in adolescence: Evidence of successful dissemination. American Academy of Child and Adolescent Psychiatry, 46(7), 792-800.
9. Dare, C., 1985. The Family Therapy of Anorexia Nervosa, Journal of Psychiatric Research, 19: 435–453.4
10. Lock, J., Agras, W., Bryson, S., & Kraemer, H. (2005). A comparison of short- and long- term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry, 44(7), 632-639.
11. Lock, J., Couturier, J., & Agras, S. (2006). Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy. Amrican Academy of Child and Adolescent Psychiatry, 45(6), 666-672.
12. Eisler, I., Simic, M., Russell, G., & Dare, C. (2007). A randomised controlled treatment trail of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up. Journal of Child Psychology and Psychiatry, 48(6), 552-560.

Image Credit: Retrieved February 4, 2013, from: http://guides.libraries.uc.edu/content.php?pid=285456&sid=2367919.

Maria Cimporescu is a Senior at The George Washington University majoring in Psychology with a minor in Biology. She is looking to pursue a Ph.D. in Clinical Psychology. Follow The Triple Helix Online on Twitter and join us on Facebook.

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