REGULAR ARTICLE

Treatment Perception in Adolescent Onset Anorexia

Nervosa: Retrospective Views of Patients and Parents
Inger Halvorsen, MD, PhD1,2*
Sonja Heyerdahl, MD, PhD2
‘‘perception of therapists’’ total score and
ABSTRACT
the items ‘‘therapists’ knowledge of ED’’
Objective: To investigate perception of
and ‘‘usefulness of pediatric inpatient
treatment in former patients with ano-
treatment’’ correlated with ED symptoms
rexia nervosa (AN) and their parents, and
at follow-up. The perception of therapists
to determine whether this was related to
scores of the parents were not associated
outcome and treatment characteristics.
with the ED outcome of their daughters.
Client satisfaction is important for treat-
More family therapy sessions were associ-
ment engagement and adherence.
ated with the former patients’ satisfac-
Method: Forty-six (of 55) girls with ado- tion with the therapists, while higher age
lescent onset AN, 33 mothers and 26 at admission was associated with their
fathers participated in a follow-up study mothers’ satisfaction.
conducted 8.8 (SD 3.3) years after start of
Conclusion: In spite of good ED out-
treatment. The former patients were
come, former patients were only moder-
assessed using diagnostic interviews.
ately satisfied with their treatment,
Only nine participants (19%) had an
whereas parental satisfaction was high.
eating disorder (ED) at follow-up. Per-
V
C 2007 by Wiley Periodicals, Inc.
ception of treatment was assessed by
questionnaires.
Keywords: client satisfaction; parent
Results: Parents reported having an satisfaction; anorexia nervosa; eating
overall positive perception of treatment. disorders; follow-up
However, reports from former patients
were significantly more negative than
from the parents. In former patients, the (Int J Eat Disord 2007; 40:629–639)

from patients with eating disorders (ED) treated by

Introduction
The demand for assessment of consumer satisfac-
tion as a quality parameter in health services has
increased over the last two decades.1–4 The former
belief that the ‘‘doctor knows best’’ has been
replaced by an increased emphasis on patients’
opinions.5 However, the validity of client satisfac-
tion measures is debatable.2,6,7 Most studies of cli-
ent satisfaction have low participation rates.3,8,9
Patients who have dropped out of treatment are
seldom included, and participants are often selfse-
lected from patient associations or self-help
groups. These participants may differ significantly
Accepted 13 May 2007
*Correspondence to: Inger Halvorsen, Regional Eating Disorder
Service (RASP), Ulleval University Hospital, NO 0407 Oslo, Norway.
E-mail: inger.halvorsen@r-bup.no
1 toration of physical health.3,17,18 At the same time,
Department of Child and Adolescent Psychiatry, Buskerud
Hospital, Drammen, Norway
2
The Research Department Centre for Child and Adolescent
Mental Health, Eastern and Southern Norway, Oslo, Norway
Published online 2 July 2007 in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/eat.20428
V
C 2007 Wiley Periodicals, Inc.
health services.9–11 Knowledge is lacking on
whether client satisfaction is related to outcome in
patients with ED.
There is a paucity of studies of client satisfaction
in anorexia nervosa (AN).4 To our knowledge, only
five studies explicitly address client and/or parent
satisfaction in children and adolescents with AN.12–16
These studies investigated satisfaction during
treatment,16 at the end of treatment,12 and retro-
spectively 6 months,13 18 months,14 and 4–22
years15 after admission.
Dissatisfaction with treatment may cause treat-
ment delay, failure to engage, and withdrawal from
treatment.11,17 Patients with AN often report nega-
tive treatment experiences.9,10,15,18–20 Studies of cli-
ent satisfaction in ED indicate that patients tend to
be most satisfied with the therapeutic alliance and
less satisfied with treatment elements aimed at res-
these treatment elements are viewed by the thera-
pists as crucial for improvement.
Extreme fear of eating and weight gain are core
symptoms in AN. Treatment aimed at helping the
patient to overcome the illness will usually raise

International Journal of Eating Disorders 40:7 629–639 2007—DOI 10.1002/eat 629

HALVORSEN AND HEYERDAHL

ambivalence and fear related to loss of control.21,22 TABLE 1. Demographic, treatment, and follow-up
characteristics of the sample (N 5 48)a
These illness characteristics make it particularly
difficult for patients with AN to request effective Mean 6 SD (Range)
treatment. Thus, issues related to motivation At Treatment Start
and ‘‘readiness for change’’ are essential in AN Ageb (years) 14.9 6 1.8 (9.2–17.8)
treatment.23 Duration of eating problems (months) 11.0 6 6.6 (3–36)
BMI (kg/m2) 15.1 6 1.6 (12.3–17.8)
ED specialists agree that parents should be BMI percentile for age 2.1 6 3.9 (0.001–15.7c)
included in the treatment of young patients with Weight loss corrected for increase of 24.6 6 7.8 (10.0–51.5)
height from start of EDd (%)
AN.24 Treatment engagement and adherence in Socio-economic family background 2.6 6 1.5 (1–5)
children and adolescents depend on the parents’ (1–5, with 1 as the upper class)e
trust in treatment, as well as on the adolescents’ During treatment
Lowest BMI 14.9 6 1.7 (12.0–17.8)
own motivation.25 One of the reasons for the better Days in pediatric ward (for those 59.3 6 37.6 (5–150)
prognosis in adolescent AN, compared with later hospitalised, n 5 28)
onset AN, may be that parents support children to Duration of treatment (months) 20.2 6 14.9 (1–62)
Family therapy sessions (all subjects) Number (%)
persevere with treatment. 20 16 (33)
Surprisingly, we have found only four studies 21–50 20 (42)
assessing parent satisfaction in adolescent AN [50 12 (25)
Additional individual therapyf 17 (35)
treatment,12–14,16 and there are no comparisons of One or both parents received sick 39 (81)
satisfaction between mothers and fathers. In the leave/did not work outside homeg
present study, both parents participated closely in At follow-up
Time from treatment start to 8.8 6 3.3 (3.5–14.5)
the treatment and daily care of the patient, allow- follow-up (years)
ing us to assess and compare parents’ perception Age of the former patients (years) 23.8 6 3.4 (16.2–30.5)
of treatment. BMI, n 5 46 21.1 6 3.1 (15.2–31.6)
EDE global score, n 5 45 1.6 6 1.3 (0.04–4.8)
Overcoming AN may depend on more than treat- a
Including two subjects with parent participation only.
ment factors.26–29 Other important factors may b
Childhood onset: \10 years: n 5 1, 10–11 years: n 5 2.
include support from family, contact with friends, c
BMI percentile [4: 7 subjects with amenorrhea (none prepubertal)
engagement in activities that help the child focus and substantial weight loss (17–35%).
d
Calculated from anticipated weight if the patient had followed her
on something other than the ED, and experiences percentile for weight by height from the start of eating problems.
that improve self-esteem. It is important that those e
Based on both parents’ occupation (1–2: n 5 29, 60%).
who plan and conduct treatment of young patients
f
Number of sessions: 20: n 5 11, [20: n 5 6.
g
Mother received sick leave: n 5 25, mother was not in paid work: n 5
with AN know what clients and parents regard as 13, father received sick leave: n 5 16, father was not in paid work: n 5 1
helpful. (both parents did work outside home without sick leave: n 5 6, missing
data: n 5 3).
The aims of the study were to investigate and
compare how former patients with AN and their
parents retrospectively reported their perception of
them participated in the study personally by completing
therapists (POT) and whether this was associated
questionnaires. All participants were Caucasian except
with outcome and treatment characteristics. We
for one Asian. At start of treatment, 42 (91%) of the par-
also wanted to investigate the views of family mem-
ticipants were living with both of their biological parents.
bers on other helpful factors, and their evaluation
There were no substantial differences between partici-
of inpatient treatment and the family approach.
pants and nonparticipants with regard to demographic,
illness or treatment characteristics (Table 1).
Structured diagnostic interviews were conducted with
Method 45 participants (by telephone with two of the partici-
pants). One participant completed the questionnaires
Participants and Treatment but not the full interview. In addition, two former
Fifty-five girls with a DSM-IV diagnosis of AN30 were patients who did not want to participate personally gave
treated at the Department of Child and Adolescent Psy- permission for their parents to be contacted. The parents
chiatry (CAP), Buskerud Hospital, Norway, between 1986 reported that both of these former patients were func-
and 1998.31 The sample included all female patients with tioning well and without ED at follow-up.
AN under the age of 18 in one Norwegian county (total One mother and one father were deceased. In four
inhabitants 225,261) who received inpatient treatment other cases, patients had no contact with their fathers.
during the time period, as well as almost all patients who We obtained informed consent from patients to contact
received outpatient treatment only.31,32 We succeeded in 36 mothers and 32 fathers, from 37 families. An informa-
contacting all former patients (n 5 55), and 46 (84%) of tion letter and questionnaires were sent by mail to each

630 International Journal of Eating Disorders 40:7 629–639 2007—DOI 10.1002/eat


of the parents. Thirty-three mothers and 26 fathers, from
35 families, returned completed questionnaires. There
were no significant differences between the former
patients with participating and nonparticipating parents
with regard to age, socioeconomic background, parents’
marital status, treatment characteristics, follow-up time,
ED symptoms, and psychiatric disorders at follow-up.
All patients received conjoint family therapy integrated
with a structured regime to restore physical health as
inpatients in a pediatric department or as outpatients.
Parents stayed with patients in hospital or at home to
provide comfort, care, and encouragement. All parents
were extensively involved in treatment except for three
fathers who had no contact with their daughters when
treatment began.
When a patient’s physical condition was serious, or if
outpatient treatment did not result in steady weight gain,
she was hospitalized in the pediatric ward until she was
able to continue gaining weight at home. To ensure con-
tinuity in the treatment, the same therapists at CAP were
in charge during in- and outpatient phases of the treat-
ment and they collaborated closely with the pediatric
ward if a patient was hospitalized.31,32
Common treatment principles for children with seri-
ous illnesses were applied. Food was considered essential
‘‘medicine’’ in the AN treatment, and health personnel
were in charge of prescribing an adequate diet. This was
designed to give a weight gain of about 150 g a day for
inpatients, and about 500 g a week during outpatient
treatment. As with other young patients who are afraid of
taking medicine, the staff used medical authority, infor-
mation, comfort, and emotional support to help patients
persevere with the treatment. Feeding through a naso-
gastric tube was used in seven cases, but never for more
than a few meals. Parental support with meals was highly
valued by staff, but Minuchin’s ‘‘family meal’’ interven-
tion,33 where parents are encouraged to make the patient
eat in a therapy session, was not used in this program.
The family therapy was eclectic and included struc-
tural, systemic, and narrative family therapy approaches.
The treatment focused on family resources and family
members’ efforts to cope with the ED. Psychological
issues relevant to identity, individuation, self-confidence,
and family relations were also dealt with during all
phases of the treatment. About one-third of the patients
received individual therapy in addition to family therapy
(Table 1), usually from one of the family therapists.
No patients withdrew from treatment and none were
transferred to other institutions during the acute phase
of the illness. Subsequently, three patients were referred
to treatment elsewhere, all of whom participated in the
follow-up study. The period of treatment was consider-
able for most patients, with the mean treatment duration
greater than 20 months (Table 1).
International Journal of Eating Disorders 40:7 629–639 2007—DOI 10.1002/eat
TREATMENT PERCEPTION IN ANOREXIA NERVOSA
The follow-up was done a mean of 8.8 (SD 3.3) years
after treatment began, and at follow-up 39 (81%) of the
participants had no ED, one had AN, one had bulimia
nervosa and seven participants had an ED not otherwise
specified.30 Most of the former patients were functioning
well with regard to education, work capacity, and rela-
tionships with their family, partners, and friends.31 How-
ever, a significant minority (40%) had one or more psy-
chiatric diagnoses other than ED at follow-up (anxiety
disorder n 5 12; depression n 5 10; post-traumatic stress
disorder n 5 5; obsessive–compulsive disorder n 5 1;
dissociative disorder n 5 1; schizophrenia n 5 1).31 Psy-
chiatric disorders and general life satisfaction were
strongly associated with the ED outcome.31,34
Interview
The eating disorder examination (EDE)35 was con-
ducted by experienced clinicians who had not partici-
pated in the patient’s treatment. Psychiatric disorders
were assessed using the Mini International Neuropsychi-
atric Interview36 and the Yale-Brown Obsessive Compul-
sive Scale.37 The global assessment of functioning (GAF;
DSM-IV Split version)30 was used to rate global psychoso-
cial functioning. Thirty-six of the interviews were video-
or audio-taped and rated independently by another spe-
cialist. The interrater reliabilities on the GAF and EDE
scales were high (intraclass correlations: .82–.99).31
Questionnaires
Perception of Therapist(s). POT was assessed using a
Norwegian version of a treatment satisfaction question-
naire used in a Swedish national quality register on ED38
The subject’s perception of her/his contact with the
therapist was covered by 11 items (shown in Table 2;
response categories: always, very often, often, some-
times, seldom, and never).
POT Relationship with Family Members. This was
assessed by two questions to the former patients and
four questions to the parents (Table 2) with the same
response categories as the POT questionnaire.
Helpful Factors. We created eight items (Table 4) to
assess potentially helpful factors in recovering from ED
and seven items (Table 4) to assess the parents’ views on
helpful factors for them as parents (response categories:
very important, quite important, not so important, and
unimportant).
Inpatient Treatment in the Pediatric Ward. We created
a set of seven items to assess the parents’ evaluation of
inpatient treatment (Table 5). The evaluation of inpatient
treatment by former patients was assessed by the ques-
tion: ‘‘Overall, how useful was the stay in the pediatric
ward for you?’’ (response categories: very useful, quite
631
632
TABLE 2. Perception of therapists (POT) by patients and their parents
Always/Oftena (%) Mean Scoreb 6 SD Paired t-tests (p-values) Correlations

Patients Mothers Fathers Patients Mothers Fathers Patients/ Patients/ Mothers/ Patients/ Patients/ Mothers/
Items (N 5 46) (N 5 33) (N 5 26) (N 5 46) (N 5 33) (N 5 26) Mothersd Fatherse Fatherse Mothersd Fatherse Fatherse

(POTc questionnaire) Do you think

that the therapist(s):
Understood your problems? 39 81 68 3.20 6 1.15 4.59 6 1.19 4.32 6 1.28 \.001 .080 .196 .42 .07 .32
Received you well? 61 90 92 3.98 6 1.42 4.97 6 1.21 5.19 6 1.11 .001 \.001 .704 .40 .57* .58*
HALVORSEN AND HEYERDAHL

Respected you as a person? 74 88 86 4.28 6 1.59 5.09 6 1.10 5.19 6 1.23 .004 .008 .714 .48* .69* .55*
Let you to talk about what was 56 79 81 3.69 6 1.33 4.64 6 1.50 4.85 6 1.52 \.001 .023 1.000 .21 .39 .67*
important to you?
Listened to you? 67 91 92 3.98 6 1.34 5.00 6 1.15 5.12 6 1.03 \.001 .003 .840 .51* .56* .55*
Let you participate in the 34 74 60 3.07 6 1.30 4.19 6 1.66 3.76 6 1.74 \.001 .437 .049 .45 .15 .75*
treatment plan?
Were able to help you/your 41 73 65 2.98 6 1.18 4.18 6 1.33 3.89 6 1.53 \.001 .029 .086 .37 .38 .70*
daughter?
Agreed with you in the 49 76 78 3.35 6 1.36 4.69 6 1.14 4.30 6 1.55 \.001 .142 .399 .48 .37 .53
treatment goal?
Agreed with you in how the 40 76 52 3.21 6 1.15 4.41 6 1.21 3.48 6 1.25 \.001 .878 .008 .43 2.01 .73*
treatment should be?
Had sufficient knowledge of 62 73 72 3.83 6 1.45 4.63 6 1.38 4.28 6 1.67 .008 .894 .148 .53* .39 .70*
ED and knew what they
were doing?
Valued your own effort in 47 87 80 3.42 6 1.35 4.81 6 1.17 4.52 6 1.36 \.001 .014 .296 .38 .54 .21
overcoming ED?
Total POTc score 39.29 6 12.30 50.96 6 11.96 49.33 6 12.05 \.001 .005 .041 .49* .65* .80*
The therapists’ relationship with
family members:
Had a good relationship with 70 75 84 4.09 6 1.26 4.47 6 1.39 4.72 6 1.28 .418 .81*
your parents/daughter?
Had a good relationship with 82 85 4.71 6 1.33 4.92 6 1.09 .847 .47*
your spouse?
Gave your parents/you enough 53 72 69 3.73 6 1.54 4.28 6 1.37 4.12 6 1.40 .276 .41*
help to support you/your
daughter in overcoming
the ED?
Gave you help to support each 53 68 3.77 6 1.83 3.84 6 1.43 .905 .37
other as parents?
Therapists’ relationship with family 8.17 6 2.52 17.21 6 5.38 17.65 6 4.29 .680 .65*
members: sum score
a
Percentage of answering: always, very often, or often (the other alternatives were: sometimes, seldom, and never).
b
Possible range:1–6.
c
‘‘Perception of therapists’’, 11 items.
d
Pairs: n 5 31.
e
Pairs: n 5 24.
Significance of correlations: *p \ .01.

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 TREATMENT PERCEPTION IN ANOREXIA NERVOSA

TABLE 3. Associations between perception of therapists (POT) and treatment characteristics controlling for follow-up
time and ED symptoms at follow-up
Associations with Family Members’ Total POTa Scores Correlationsb Multiple Regression Analysesc

Independent Variables Pearson’s r Standardized b The Model Explained

Former patient Age at treatment start .19 0.27 Adjusted R2 5 0.19, F 5 2.7, df 5 6.37, p 5 .030
Lowest BMI percentile during treatment .12 0.16
Number of family therapy sessionsd .27* 0.51**
Days hospitalized in the pediatric ward 2.09 20.17
Follow-up timee 2.11 0.02
EDEf global score at follow-upe 2.30* 20.23
Mother Age at treatment start .46** 0.48* Adjusted R2 5 0.27, F 5 2.8, df 5 6.24, p 5 .033
Lowest BMI percentile during treatment .23 0.26
Number of family therapy sessionsd .06 0.37
Days hospitalized in the pediatric ward 2.19 20.15
Follow-up timee 2.27 20.22
EDEf global score at follow-upe .12 0.21
Father Age at treatment start .33* 0.22 Adjusted R2 5 0.26, F 5 2.3, df 5 6.16, p 5 .086
Lowest BMI percentile during treatment .18 0.45
Number of family therapy sessionsd .10 0.46
Days hospitalized in the pediatric ward 2.11 20.22
Follow-up timee 2.31 20.35
EDEf global score at follow-upe 2.04 20.07
a
Sum of 11 items covering perception of therapists.
b
With total POT scores.
c
Dependent variables: total POT scores.
d
Used as a measure of amount of treatment as the main psychiatric treatment was family therapy.
e
Variables included because of potential confounding effects.
f
Eating disorder examination at follow-up.
* p \ .05, **p \ .01.

useful, somewhat useful, not useful, and worked against
its purpose).
General Life Satisfaction. This was assessed using a
question from a large Norwegian epidemiological health
study39: ‘‘When you think about the way your life is going
at present, would you say that you are by and large satis-
fied with life or are you mostly dissatisfied?’’ (Seven
response categories ranging from extremely dissatisfied
to extremely satisfied).
Statistical Analysis
Differences between the scores of family members
were investigated with paired-sample t tests, and associa-
tions between variables were calculated using Pearson
correlations and multiple linear regression analyses.
Nonparametric statistical analyses were also performed,
with very similar results (not reported). When using mul-
tiple comparisons or correlations, the alpha level was set
at 0.01. All reported p values are two-tailed.
The study was approved by the Regional Committee
for Medical Research Ethics and the Norwegian Data
Inspectorate.
Results
Former patients with participating and nonpartici-
pating parents did not differ significantly on any of
the perception of treatment measures. Follow-up
time was not significantly correlated with any of
the perception of treatment scores of the patients
or parents.
POT by Patients and Their Parents
The former patients’ POT varied substantially on
the different POT items (Table 2). Both parents
rated their own contact with therapists positively,
and they had significantly higher POT scores than
former patients (paired comparisons). The correla-
tions between parents were high for most of the
items. On one item, ‘‘the therapists agreed with you
in how the treatment should be’’, the mothers
had significantly higher scores than the fathers
(Table 2).
The majority of former patients and parents
responded that the relationship between therapists
and other family members had been good. How-
ever, many participants replied that parents had
not received enough help to support their daugh-
ters and each other (Table 2).
Associations between POT and Outcome
Whether or not a former patient had an ED at
follow-up was not significantly related to her own
or her parents’ ratings of therapists on any individ-
ual POT items or total POT scores. The patient’s
EDE global score at follow-up was not significantly

International Journal of Eating Disorders 40:7 629–639 2007—DOI 10.1002/eat 633

634
TABLE 4. Views of family members on helpful factors
Viewed as Importanta (%) Mean Scoreb 6 SD Paired t-tests (p-values) Correlations
HALVORSEN AND HEYERDAHL

Patients Mothers Fathers Patients Mothers Fathers Patients/ Patients/ Mothers/ Patients/ Patients/ Mothers/
Items (N 5 46) (N 5 33) (N 5 26) (N 5 46) (N 5 33) (N 5 26) Mothersc Fathersd Fathersd Mothersc Fathersd Fathersd

What has been of help for you/your

daughter in relation to the ED?
My/her own wish to recover 82 94 88 3.49 6 0.84 3.59 6 0.71 3.48 6 0.71 .182 .633 .165 .26 2.29 2.02
My/her willpower and 85 97 100 3.30 6 0.73 3.76 6 0.50 3.67 6 0.48 .001 .004 .185 .05 2.03 .51*
determination
Support from my parents/me 76 91 78 3.02 6 0.93 3.31 6 0.64 2.85 6 0.66 .269 .078 .009 .00 2.30 .45
Support from my spouse 83 96 3.17 6 0.79 3.42 6 0.58 .135 .44
Support from sibling(s) 51 75 72 2.44 6 1.03 3.11 6 0.88 2.92 6 0.70 .023 .381 .418 .10 2.003 .50
Support from friends 72 88 73 3.02 6 0.97 3.31 6 0.69 2.92 6 0.69 .143 .307 .059 .05 .34 .14
Support from boyfriend 47 64 55 2.37 6 1.33 2.88 6 1.13 2.77 6 1.19 .110 .145 .028 .26 .28 .66
Treatment at CAP 53 81 81 2.70 6 1.08 3.19 6 1.03 3.12 6 0.91 .021 .647 .213 .67* .57* .72*
What has been of help for you as a
mother/father?
Support from my spouse 84 92 3.39 6 0.99 3.60 6 0.65 .426 .86*
Relationship with my children 90 96 3.60 6 0.67 3.50 6 0.59 .680 2.32
Support from family/family 70 48 2.93 6 1.05 2.56 6 0.96 .229 .39
in law
Support from friends 78 58 3.22 6 0.87 2.54 6 0.99 .001 .41
Colleagues/place of work 68 29 2.84 6 1.00 2.08 6 0.83 .001 .23
Treatment at CAP 84 77 3.41 6 0.91 3.08 6 0.93 .022 .56
Information about the ED 84 83 3.29 6 0.74 3.00 6 0.83 .095 2.14
a
Answering very important or quite important (the other alternatives were: not so important and unimportant).
b
Possible range: 1–4.
c
Pairs: n 5 31.
d
Pairs: n 5 24.
Significance of correlations: *p \ .01.

International Journal of Eating Disorders 40:7 629–639 2007—DOI 10.1002/eat

 TREATMENT PERCEPTION IN ANOREXIA NERVOSA

TABLE 5. The parents’ evaluation of inpatient treatment in the Pediatric Department (PD)
Mean Scorea 6 SD
Paired t-testsb Pearson’s
Mothers (N 5 21) Fathers (N 5 17) (p-values) Correlationsb r

Care, competence, and collaboration

1. At the initial admission, we were well received 2.48 6 0.87 2.65 6 0.61 1.000 .70*
2. Our daughter was treated with care and respect 2.38 6 0.80 2.41 6 0.71 .164 .89*
3. I trusted that our daughter received good treatment 2.43 6 0.68 2.35 6 0.79 .497 .57
4. The collaboration between us as parents and the PD was good 2.38 6 0.80 2.37 6 0.72 .678 .84*
Mean score 6 SD on items 1–4 2.42 6 0.73 2.46 6 0.61 .219 .86*
Support and information
5. I did not receive enough support as a parentc 1.95 6 0.83 1.94 6 0.97 .580 .89*
6. I did not receive enough information about the illnessc 1.90 6 0.85 1.82 6 0.88 .432 .74*
7. I did not receive enough information about the treatmentc 2.00 6 0.80 1.88 6 0.86 .432 .71*
Mean score 6 SD on items 5–7 1.95 6 0.72 1.88 6 0.87 .580 .86*
a
Response categories: not true, somewhat true, and completely true; range of scores: 1–3; the higher scores the more positive evaluation.
b
Pairs: n 5 16.
c
Inverse scoring.
Significance of correlations: *p \ .01.

correlated to her parents’ ratings of their POT on
any individual POT items or total POT scores (cor-
relation for total POT scores: mother r 5 .12, father
r 5 2.04). However, the EDE global score correlated
with the patient’s own total POT score (r 5 2.30,
p 5 .047, and with her rating on the item stating
that the therapists ‘‘had sufficient knowledge of ED
and knew what they were doing’’ (r 5 2.45, p 5
.001), indicating that a better ED outcome was
associated with a more positive POT. Correlations
between ‘‘number of psychiatric diagnoses
(excluding ED)’’, GAF ratings, and total POT scores
were low for reports of all family members (r \ .01
for ‘‘number of psychiatric diagnoses’’, r 5 .16–.27
for GAF ratings, NS). The former patient’s ‘‘general
life satisfaction’’ score was positively correlated
with her total POT score (r 5 .37, p 5 .012), but not
with her parents’ total POT scores.
Associations between POT and Treatment
Characteristics
More family therapy sessions were significantly
correlated with the former patient’s total POT score,
and higher age at treatment start with her parents’
total POT scores (Table 3). In addition to correla-
tions, multiple regression analyses were used to
estimate the independent effects of treatment char-
acteristics on total POT scores of patient and
parents (Table 3). Potential predictors and possible
confounding variables were entered in one-step.
We found that ‘‘number of family therapy sessions’’
was a significant predictor of the former patient’s
total POT score, and higher ‘‘age at treatment start’’
of her mother’s total POT score. For the father,
none of the potential predictors were significant
(Table 3).
Views of Family Members on Helpful Factors
Both patients and parents had the highest scores
on the items concerning the former patient’s will-
power and determination and/or her own wish to
recover (Table 4). On the item concerning ‘‘will-
power and determination’’, the parents’ scores were
highly correlated and significantly higher than the
patient’s. Other helpful factors in overcoming
the ED, and for the parents, are also presented in
Table 4.
Evaluation of Other Treatment Aspects
Inpatient Treatment in the Pediatric Ward. All parents,
except one mother and one father, responded
‘‘completely true’’ on the item ‘‘the hospital stay
was necessary to gain weight’’. The parents had
similar scores on all the ‘‘evaluation of inpatient
treatment’’ items (Table 5). Overall, the parents
reported care, competence, and collaboration dur-
ing the hospital stay as good, while they had lower
scores on items concerning support and informa-
tion to them as parents. The mean scores on the
‘‘care, competence, and collaboration’’ items were
significantly higher compared with the mean
scores on the ‘‘support and information’’ items
(t(df) 5 2.5(19), p 5 .020 for mothers; t(df) 5 2.9(16),
p 5 .01 for fathers).
Former patients’ perceptions of the hospital stay
were measured by the question ‘‘Overall, how use-
ful was the hospital stay in the pediatric ward for
you?’’ Most of the former patients viewed the hos-
pital stay as useful overall; 11 (41%) responded very
useful, 14 (52%) quite/somewhat useful, while 2
(7%) responded not useful/worked against its pur-
pose. A higher rating on ‘‘the usefulness of hospital
stay’’ item was correlated with a lower EDE global
score at follow-up (r 5 2.48, p 5 .015).

International Journal of Eating Disorders 40:7 629–639 2007—DOI 10.1002/eat 635

HALVORSEN AND HEYERDAHL
The Family Approach. All parents of hospitalized
patients responded that staying with their daughter
at the pediatric ward had been useful. The parents’
participation in the sessions at CAP was rated posi-
tively by 36 (62%) of the former patients, 31 (96%)
of the mothers and 25 (97%) of the fathers. Twenty-
one (64%) mothers and 11 (42%) fathers had
received sick leave from their work to care for the
patient during the acute phase of the illness. This
was evaluated as useful by all of the mothers
and nine (82%) of the fathers. The ‘‘therapists’ rela-
tionship with other family members’’ sum score
(Table 2) was significantly correlated with age at
treatment start for the mother (r 5 .41, p 5 .019),
but not for the former patient or father (r 5 .26,
p 5 .077, for patient; r 5 .13, p 5 .527, for father).
Conclusion
In this follow-up study, we investigated perception
of treatment in former patients with AN and their
parents conducted a mean of 8.8 (SD 3.3) years after
treatment began. All patients had received system-
atic treatment according to the same basic princi-
ples. Our main findings were that mother and fa-
ther had a similar and overall positive perception of
the treatment, whereas the treatment perception of
the former patient was significantly less positive.
We found no strong relationship between percep-
tion of treatment and ED symptoms at follow-up.
Positive POT was associated with more family ther-
apy sessions in former patients and with higher age
at treatment start in mothers. All family members
rated former patients’ own willpower/wish to
recover as the most important of the potentially
helpful factors.
Few previous studies have investigated how
young patients with AN and their parents perceive
treatment and helpful factors. Since we wanted to
investigate potential relationships between family
members’ perception of treatment and the ED out-
come, reliable information on ED symptoms at
follow-up was important. Therefore, one strength
of this study is the use of a thorough diagnostic
interview, including EDE. The sample can be con-
sidered representative because no patient withdrew
from treatment and there was a high participation
rate of former patients.
A limitation of the study is the relatively small
number of participants, rendering statistical power
low. Information on family members’ views about
treatment was collected at follow-up, while data on
their perceptions of treatment during the acute
636 International Journal of Eating Disorders 40:7 629–639 2007—DOI 10.1002/eat
phase of the illness were not available. Length of
time to follow-up was not significantly correlated
with the results of the treatment perception meas-
ures, but many factors may have influenced how
family members perceived treatment many years
later. As we wanted to investigate relationships
between patient and parent satisfaction, treatment
characteristics and outcome, the questionnaires
could not be filled out anonymously. Thus, there is
a possibility that social desirability may have influ-
enced the family members’ responses.
Rates of patient withdrawal from ED treatment
tend to be extraordinarily high,40–43 suggesting that
many patients are dissatisfied. Factors early in the
treatment that create dissatisfaction may cause cli-
ents and parents to shop around for alternative
treatments.2 In contrast to this, no patients with-
drew from treatment in the present study, and
most patients completed a long-term treatment.
High levels of parental participation and parental
satisfaction may have contributed to the high treat-
ment adherence in this group.
Studies of client satisfaction with health services
tend to find that most clients report a high level of
satisfaction.7 This is consistent with the parents’
reports in our study. However, adolescents with AN
often recall their treatment in negative terms,15,20,24
which is in accordance with our finding that the
former patients had significantly lower POT scores
than their parents. The majority of former patients
rated items related to the therapeutic alliance
(being received well, respected, and listened to by
the therapists) positively (Table 2). They had lower
scores on items concerned with feelings that thera-
pists had ‘‘understood their problems’’ and ‘‘were
able to help them’’. There were similar findings for
their own participation/agreement in the treat-
ment. On these items, average scores were around
three, corresponding to ‘‘sometimes true’’ (Table 2).
As therapists were responsible for the medical
treatment, we find it reasonable that former
patients would feel that they did not have very
much influence on their own treatment. The study
did not include questions about whether patients
retrospectively thought they themselves should
have been allowed to influence the treatment
more, or whether they evaluated positively that
medical aspects of the treatment had been ‘‘non-
negotiable’’.21,23 Further research exploring the
views of patients with AN on such issues is needed.
We did not find that parental satisfaction was
associated with the patient’s ED outcome, and this
supports Kopec-Schrader et al.’s findings.13 Corre-
lations between former patients’ perception of

treatment scores and their EDE global scores at fol-
low-up were low, except for moderate correlations
with the total POT score and with two items con-
cerning therapists’ ED knowledge and the useful-
ness of inpatient treatment. Most of the former
patients in this study had a good ED outcome, but
perhaps recovery is not necessarily associated with
treatment satisfaction. Our finding that a good ED
outcome was associated with perceived ED compe-
tency in the therapists is consistent with a previous
study of consumer satisfaction in adult patients
with ED.3
A significant minority (40%) of the former
patients had a psychiatric diagnosis other than ED
at follow-up, but psychiatric diagnoses and GAF
scores were not associated with any of the family
members’ total POT scores. However, general life
satisfaction at follow-up was associated with the
patient’s POT. The combination of general dissatis-
faction and perfectionism may be characteristic of
patients with AN.34,44 This may be reflected in a
tendency to be critical and dissatisfied with both
oneself and therapists.
We had expected that a positive POT would be
associated with receiving more therapy, as families
that were positive about treatment may have
wanted more sessions than less satisfied families,
and families that had attended many sessions may
have developed stronger relationships with their
therapists. ‘‘Number of family therapy sessions’’
were significantly associated with a positive POT in
former patients, but in the parents this association
failed to reach significance.
Patients with AN often perceive the illness as a
part of their identity45 and link the AN to a struggle
for control,22 which may lead to extraordinarily
strong feelings of ambivalence toward treatment.21
The parents’ and former patient’s emphasis on her
own ‘‘willpower’’ and ‘‘wish to recover’’ as the most
important helpful factors may indicate that motiva-
tion and ‘‘readiness for change’’ are important
issues in recovering from ED.23
Both parents viewed support from the mother as
somewhat more important in overcoming ED than
support from the father (Table 4). Among the help-
ful factors for parents, mothers rated support from
friends and colleagues as significantly more impor-
tant than fathers did, indicating that mothers may
be more likely to make use of support from a
broader social network.
Despite the fact that the hospitalized patients
had been in poorer physical condition, their ED
outcome was as good as that of patients who had
received outpatient treatment only.31,34 The major-
International Journal of Eating Disorders 40:7 629–639 2007—DOI 10.1002/eat
TREATMENT PERCEPTION IN ANOREXIA NERVOSA
ity of patients replied that the hospital stay had
been useful. The parents reported a high level of
satisfaction with regard to the staff’s care, compe-
tence, and collaboration during the hospital stay,
but they had significantly lower scores concerning
the support and information parents had received.
A possible explanation for this may be that care,
competence, and collaboration items were phrased
positively, whereas support and information items
were phrased negatively. However, Kopec-Schrader
et al.’s study13 also found that parental dissatisfac-
tion with inpatient ED treatment was largely
related to problems in communication and per-
ceived lack of support for parents. Despite a strong
emphasis on supporting parents in this treatment
program, many of the parents had low scores on
perceived support to them as parents. Parents’ level
of anxiety and strain when their child has severe
AN, and their need for support, may easily be
underestimated.46
Our results indicate that both parents found it
valuable to be involved in their child’s treatment,
by staying with her during hospitalization and par-
ticipating in family therapy sessions. The high level
of parental satisfaction with family therapy in ado-
lescent AN is consistent with the studies of Krautter
and Lock12 and Paulson-Karlsson et al.14 In Norway,
parents are entitled to sick leave with full salary
to care for severely ill children under the age of
18. This helped to make their participation eco-
nomically and practically possible. One might per-
haps have expected parents of younger patients to
find the treatment approach used in this study par-
ticularly useful. However, patients’ age at start of
treatment was positively associated with parents’
POT (Table 3), indicating a higher level of satisfac-
tion in parents of older, compared with younger,
adolescents.
Ambivalence toward change is characteristic of
patients with AN, which often leads to struggles
concerning treatment.21–23 Knowledge about how
young patients with AN and their parents perceive
treatment, and what they view as helpful, is impor-
tant when planning and conducting treatment.
However, there is a paucity of studies concerning
patients’ own experiences and perspectives on their
treatment and recovery.47 It is important that future
research includes investigation of how patients and
parents view different aspects of the treatment, and
how their expectations at the start of treatment are
related to treatment satisfaction and outcome. Fur-
thermore, it will be particularly important to ex-
plore patients’ own thoughts concerning typical
dilemmas in AN, such as issues related to control,
motivation, and physical and psychological needs.
637
HALVORSEN AND HEYERDAHL
This could be investigated using more detailed and
ED-specific questions than those employed in the
present study, at different times during and after
treatment. Qualitative interviews to explore how
participants think about their symptoms, treat-
ment, and ‘‘turning points’’ in the recovery process,
are also warranted.
The authors thank psychiatric nurse Anne Andersen
and senior researcher Jörg Richter PhD for their valuable
contributions.
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