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Family Therapy for Anorexia Nervosa in Adolescence: A Review

Article  in  Journal of the Royal Society of Medicine · July 1991

DOI: 10.1177/014107689108400617 · Source: PubMed

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 Journal of the Royal Society of Medicine Volumie 84 June 1991 359

Family therapy for anorexia nervosa in adolescence: a revisew

M Hodes MSc MRCPsych I Ei*ler MAf C Dare MRCP FRCPsych Department of Psychiatry,
Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF

Keywords: family therapy; anorexia nervosa; adolescence

Anorexia nervosa is a serious psychosomatic disorder This, in combination with dissatisfaction concerning
in which the sufferer, usually female, believes she is the traditional treatments has led to the development
fat despite all attempts to persuade her otherwise and of a novel approachh -:family therapy. This development
in consequence tries with all her determination to lose has occurred despite the growing evidence for
weight'. A rigorous diet is adopted, sometimes in constitutional and genetic -factors in the aetiology
conjunction with other strategies for weight control of anorexia nervosa2O. Family members form the
such as the use of laxatives, self-induced vomiting or context in which individual development occurs.
excessive exercising. This regimen, in addition to Because of their interdependence, the psychological
emaciation, leads to amenorrhoea in women or the evolution of each family nember is closely-entwined
equivalent endocrine disturbance in men, ie a loss of with the development of the family as a unit.
libido. Severe metabolic disturbances such as hypo- This is manifested by -the members' behaviour
kalaemia, bradycardia, aniypotension are eventually and communications beingboth influences upon and
inevitable if weight loss is not reversed. The vomiting responses to -each others' behaviour and communica-
may cause parotid enlargement and damage to tions. Families, like all social groups, -strive for
the teeth2. Anorexia nervosa may effect, sometimes stability from which ensues an intrinsic tendency
disastrously, physical development interfering with to avoid change2l. Processes serving stability are
growth, breast development and delaying puberty3. counteracted by the need to adapt to extern changs
Cerebral abnormalities are demonstrable and the and the pressure brought about by the individuals'
capacity of the brain to return to normal, with body- "maturational drives. There is a balance between
weight restoration, is; not yet known4. Associated continuity and change which allows the family to
psychiatric disorder is common; principally depression evolve and continue to provide for the basic
with its risks of attempted usicideM6. Patients with psychological needs of its members. In anorexia
anorexia nervosa may -present to different medical nervosa, which is associated with a delay or reversal,
specialists, but those with prepubertal onset are of the normal maturational -processes22, there
especially likely to present to paediatricians7. appears to be an excess of those aspects of the family
Anorexia nervosa is associated with a high morbidity life that tend towards stability. As the illness
and mortality, which recent studies suggest is 15% progresses the family becomes increasingly organized
or more at 20 year follow-up8'9. There is growing aroundthe self-starving behaviour of the youngster
evidence for the serious nature of anorexia nervosaW° and its style of functioning becomes locked iinto a
and the epidemiological findings suggest that the pattern which the family fmds difficult to change.
disorder is becoming more common'1. All this This understanding of the role of -the family -in
indicates the need for effective treatments. sno nervosa does not imply that there is a family
Treatment has traditionally relied on inpatient aetiolog for the disorder2s; it may account.in part
psychiatric care, the initial aim of which is to.get the for those clinical experiences in -which the family
patient to eat more'2. This may be combined with a seems to oppose thetreatment-offered to the patient.
behavioural programme to ensure weight gain'3.
Such approaches are almost always effective in restor- Styles of family therapy
ing weight to a healthy level, and management after A number of groups concerned with the treatment
discharge from hospital typically includes supportive of anorexia nervosa have-applied this theoretical
psychotherapy, with appropriate nutritional counsel- orientation to their work. Selvini Palazzoli and her
ling and monitoring of weight and physical health. associates consider the 'dysfunctional' family to beone
Nevertheless, di from the hosital wrd is often in which members make. secret coalitions with one
followed by weight ladsometimesrelapse requir- another, which prevent clear definitions of the
ing further admission. A variety of specific treatments relationhip. Foristance in the 'anorectic' family
have been used on an outpatient basis including the patient may have a secret, close and unacknow-
psychoanalytic and behavioural psychotherapy and ledged-relationship with her father. He,in turn has a
pharmacotherapy. A number of studies-of different mutually critical and rigid relationship with his wife,
pharmacological agents have failed to s*ow that they but without these differences being discused. The
are of clinical benefit'4-'5. The various psychotherapies anrectic daughter's involvement in this relationship
that have been advocated have received little prevents her from being able to strive for the
systematic evaluationl"16-'7. Two publised studies of appropriate maturational gDae16. Treatment consists
individual psychotherapies arb inconclusive'8-'9, of sessions in which interventions resembling pscho- 0603 4)2 00/0
therapeutic interpretations are made describing the ® i
Family therapy perspective rules the family members follow.- The a is that by Th Royal
Many clinicians have nQted the intensity of a family's mking the rules explicit, the family will reject them Society of
involvement in the anorectic daughter's illness. and adopt new rules that will not interfere with the Medicine
360 Journal of the Royal Society of Medicine Volume 84 June 1991
adolescent daughter's maturation and separation. The
rationale and treatment of this group is rather
abstruse and despite enthusiastic claims for its
success, no serious attempts have been made to
evaluate it.
A contrasting approach to the family therapy of
anorexia nervosa has been taken by Minuchin and
his colleagues25'26. They describe the family as an
organization that requires, amongst other things, an
appropriate hierarchy, or boundary between the
parents and the children. Like Selvini Palazzoli, this
view regards the absence of a boundary, in terms of
autonomy for the adolescent, as being inextricably
linked to the anorexia nervosa. They claim that the
'psychosomatic family' in which anorexia nervosa
occurs has particular characteristics. These include
enmeshment, which describes over-responsiveness
between family members. Individuals lack privacy
and they intrude on each other's feelings and
communications. This typically takes the form of
overprotectiveness. The need to avoid any discomfort
is associated with the lack of disagreement and
conflict; where conflict does occur it is continuous and
unresolved because of the avoidance of confrontations.
This lack of conflict resolution is related to the failure
of the family to change its rules and adjust to the
maturational demands of its members, and so it shows
rigidity. The treatment requires improving direct
communication between the parents, enhancing their
capacity to accept change and conflict and getting
them jointly to set limits on the adolescent's
behaviour. This may include getting them to control
the self-starvation by forced feeding if necessary27.
By this means a clearer hierarchical structure is
sought for the family, facilitating the acceptance of
individual differences in the family and the ultimate
acquisition of independence by the ill daughter or son.
Efficacy of family therapy
for anorexia nervosa
Minuchin and his co-workers provide some empirical
evidence in support of their treatment techniques26.
They described 53 patients with the disorder, whose
age ranged from 9 to 21 years, with an average length
of illness of less than 9 months. Sixteen therapists
carried out the treatments on a weekly basis over a
number of months. The results showed that 86% made
a full recovery, in 4% the condition was improved and
in 10% their condition was unchanged or there was
a relapse. These apparently impressive results would
have been more convincing if it were not for the
weaknesses in the methodology of the study. These
include the absence of a control group, the use of
relatively crude outcome measures, and a restriction
of the study sample to a population with a generally
favourable prognosis.
Another smaller study describes the use of family
therapy with 25 adolescents (mean age 14.9 years)
suffering from anorexia nervosa28. At the end of the
treatment period most were not fully recovered,
although many showed improvement. The same
criticisms can be raised against this report as that
of Minuchin.
However, Minuchin's work has been the stimulus
for a British study that made a rigorous evaluation
of family therapy29. Family therapy was compared
with individual supportive psychotherapy, the control
treatment, for 57 patients with anorexia nervosa. The
patients were first admitted to a specialized unit to
restore their weight to normal a process requiring
between 10 and 14 weeks. Before discharge from
hospital they were randomly allocated to one of the
two treatments and re-assessed after one year using
established measures30'31. The results showed that
family therapy was significantly more effective than
individual psychotherapy for a subgroup of the
sample, those patients (mean age 16.6 years) whose
illness had begun before the age of 19 years and was
of less than 3 years' duration. Patients in whom the
illness had taken a more chronic course or with a late
age of onset did not respond so favourably to family
therapy.
The style of family therapy used in this study was
active and directive, instructing the parents in the
'facts' about anorexia nervosa and in the need for
weight improvement to precede psychological change.
The parents were strongly encouraged to take over
total control of their daughter's diet in the early
stages of the therapy. The treatment was also
influenced by Selvini Palazzoli's approach in under-
standing that family members feel 'trapped' by their
rules of behaviour and should not, therefore, under any
circumstances feel blamed'6'. Minuchin's approach
was clearly influential in the emphasis upon demand-
ing that the parents support each other and in
ensuring parental authority over eating32.
Current research at The Maudsley Hospital is
investigating the efficacy of outpatient family therapy
for anorexia nervosa without inpatient management.
The current study is also aiming to elucidate further
what are the effective components of successful family
interventions. The results of a pilot project33 are very
encouraging, showing that even without admission
to hospital this treatment is very effective in
producing weight restoration and improvement in
psychosocial functioning for most patients aged
12-17 years.
Family therapy in the management
of anorexia nervosa
When a diagnosis of anorexia nervosa is suspected in
a patient, medical, psychiatric and family assessments
are necessary12. Commonly, younger patients, ie
those aged under 18 or 19 years, will not need hospital
admission, and even management of severe emaciation
or psychiatric disorder such as depression and suicidal
risk, can be tackled effectively by involving the
family in therapy34. The choice of outpatient family
treatment will be guided by the availability of
treatment sessions. For some patients sessions will
need to be held frequently, up to twice weekly for a
week or two and will continue at less frequent
intervals (once every 2-4 weeks) for 6-12 months.
Outpatient family therapy generally proceeds
through three relatively distinct stages32 3. In the
first instance the family is helped to find ways of
resolving the crisis of the life-threatening weight loss.
The parents are forcefully shown how to make a
strong alliance to combat the illness even if this
means that for the time being they become less
responsive to their daughter's wish for independence.
The therapist guides them meticulously through all
the strategies developed by their daughter in her
desperate attempt to avoid weight gain. The therapist
should also show a great deal of understanding and
sympathy for the patient's thoughts and feelings,
especially concerning her terror at the loss of her
control of her weight. The achievement of parental

control over the patient's diet is facilitated by having
the family eat a picnic meal in an early therapy
session27. The parents are counselled to compel their
daughter to eat in the session at least one mouthful
more than she would choose. As the crisis around
weight loss abates other issues gradually come to the
fore for family discussions. At this stage the therapist
conducts these discussions in such a way that the
primary task of restoring physical health remains
central. When the self-starvation is no longer a
problem and the parents have been able to hand over
the control of eating back to their daughter the final
phase of therapy is entered upon, namely the
discussion of more general family matters. This
concentrates upon the question of age appropriate
individual development and the eventual separation
of the youngster. Implicit in this is the changing role
of the parents as they move into the postparenting
phase of their life. Throughout the treatment the
therapist adopts a caring, non-blaming attitude to
the family, emphasizing that the aim ofthe treatment
is to help the family to mobilize its own resources and
strengths in order to bring about lasting change. Time
and again the therapist must exonerate the family:
it is not the cause of the problem but has a central
part in the cure. In particular, any suggestion that
existing marital difficulties might be the cause of the
illness need to be strongly rejected; marital problems
may themselves be exacerbated by the adolescent's
symptomatic behaviour but viewing them as the root
cause of anorexia nervosa simply engenders disabling
feelings of guilt and self-blame and is in fact not
supported by existing research evidence.
Even in cases where family therapy is likely to be
successful (early onset, short duration of the illness)
the course of therapy is rarely trouble free. Tact and
clinical authority are needed to gain the attendance
of the whole family. This is especially so if another
child has had anorexia and is fearful of being
seen as the cause of the new case. A separated
non-custodial parent who nonetheless has regular
responsibility for feeding the patient must be seen
sometimes separately and together with the domi-
ciliary family. Cooperation can be improved by
separate meetings with a couple who are fearful that
their marital disharmony has caused their daughter's
illness. Sibling attendance is best achieved by paying
courteous and regular attention to their views and
by helping them seek a positive and supportive
relationship with the patient.
In some cases (usually when there is a lack of
progress in outpatient treatment) admission to
hospital may become unavoidable. Involving the
family in treatment will still be essential in several
stages of the inpatient programme3W37. Firstly when
the admission is being planned, it will be helpful in
allaying the patient's, and parents', fears about the
impending separation from the family38. The need
for admission may give rise to guilt or lead to the
family having unrealistically high expectations ofthe
ward staff. These feelings may make it difficult for
the family to work in unison with hospital staff and
weakens their ability to continue to help their
daughter in the process of recovery once she leaves
hospital. During the course of inpatient treatment
many family members will be relieved that the
patient is being cared for by experienced medical
and nursing staff. However in other families the
improvement in the patient is associated with an
Journal of the Royal Society of Medicine Volume 84 June 1991 361
increase in parental psychological difficulties39, and
this can lead to an apparent undermining of the
admission by the parents and cause premature
discharge40. Work with the whole family in the
middle stage of inpatient treatment can prevent this
happening. Some of the parents' difficulties may be
helped by having meetings themselves with members
of the ward staff or the family therapist. The third
stage when family therapy may be useful is at the
time of discharge. The therapy then aims to clarify
roles and responsibilities, increase parental agreement,
and maximize family strengths to produce a context
in which relapse does not occur.
The practice of family therapy requires skill and
specialized training. It places strong emphasis on
working as a multidisciplinary team and to this end
frequently makes use of rooms with one-way screens
and video recording equipment. This enables
colleagues to observe family interactions and the
relationship the therapist has with the family, and
so provide feedback to the therapist. The one-way
screen and use of video also provide opportunities for
training. However, such observation techniques are
uncomfortable for the family. Its use must be
accompanied by an especially careful explanation and
detailed consideration of the feelings of children and
adults alike.
Conclusions
Family therapy is an approach to treatment that has
evolved over a number of years and provides an
understanding of the context in which an illness has
developed. The therapist uses his skills to make clear
that trying to understand this context does not imply
a belief that the family is the source of the problem
but rather that this is a way of helping them to
mobilize their own resources. There is growing
empirical evidence that family therapy provides a
helpful and effective model of outpatient treatment
of anorexia nervosa in children and adolescents.
While some patients with extreme emaciation or
complications of the anorexia nervosa will require
admission to hospital, family therapy will still be
useful as an adjunct to ward management.
Acknowledgments: This paper is based on past and present
research investigating the efficacy of family treatments
for eating disorders supported by the Medical Research
Council.
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