2005

Family-Based Therapy for Anorexia Nervosa

Points to Remember

• Anorexia nervosa is a serious eating disorder affecting an estimated 1.2 million Americans, with death rates ranging from 6% to 20%.
• As many as 50% of anorexia nervosa patients never recover completely. Multiple hospitalizations and long-term treatment are common.
• Family-based therapy is a new and promising approach that involves parents in patient treatment, rather than relying solely on physicians and other specialists.

Scope of Problem

Anorexia nervosa is an eating disorder that affects an estimated
1.2 million Americans, most of whom are female. The average age of onset is 17 years. Death rates for anorexia nervosa range from
6% to 20%. Moreover, results from treatment studies suggest that the rehabilitation strategies currently used are not highly effective. By some estimates, only 50% of patients recover completely. This low to modest treatment success rate is a serious concern because it places adolescents and young adults at risk for multiple hospitalizations, medical complications, and death.

Standard Treatment and Their Limitations

A serious limitation of traditional therapeutic models is that they assume adolescent anorexic patients are sufficiently motivated to change. To the contrary, the psychological and developmental reality of the young patients with this disease is that they tend to be in denial regarding the seriousness of their eating disorder. This prevents them from taking the necessary steps for recovery.

Another limitation of traditional approaches is that often a patient is under the care of several professionals — typically a psychologist, a psychiatrist, a family therapist, and a dietitian — who may not be coordinated in their approach to producing a single coherent plan of action. This lack of integrated care can blunt the effect of even the best practitioner in each of these fields. Under this model, parents are often reduced to concerned bystanders.

A New Approach: Family-Based Therapy

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Family-based therapy (FBT) remedies the weaknesses of standard approaches by not relying on the motivation of the patient to recover. FBT views these patients as incapable of making sound choices regarding their health, requiring the assistance of the parents to overcome the illness. A key innovation of FBT is the involvementof the patient's parents at the start of treatment, making them an integral component of the therapy and members of the treatment team. Parents are taught to manage the child's eating disorder symptoms until the adolescent is able to eat well on her or his own. The reason for initial parental involvement is that the treatment strategy is based on the concept that the child is in the grasp of a serious psychological illness. She or he is therefore not well enough to make the necessary changes without nurturing guidance from family. Over time, as the patient heals psychologically, the patient assumes responsibility for eating.

In FBT, therapists mobilize the parents to take charge of the task of "refeeding" their son or daughter. This approach is individualized for each family, and parents learn how they can best go about this task. For example, to encourage weight gain or compliance with meal expectations, a family may devise a set of incentives such as getting to go on a family vacation, using a car, or participating in team sports. Working with therapists, parents are also taught more effective communication styles that focus on restoring family harmony.

In weekly sessions at the clinic, the therapist provides guidance to the family about how best to structure meals and encourage eating and weight gain. At the beginning of treatment, parents may bring a picnic lunch to the counseling session and encourage their daughter to eat while the therapist provides guidance.

By including the parents, one of the advantages of FBT is that it eliminates unnecessary services that do not consistently serve the goal of recovery. For example, in FBT, the patient rarely needs to consult a dietitian because a lack of adequate knowledge or understanding of nutrition is generally not the problem. Under the FBT model, an FBT-trained psychologist performs both family therapy and individual therapy. In addition, group therapy — which is common in traditional settings — is often eliminated because patients with eating disorders tend to be highly competitive; group therapy can undermine recovery by prompting competition for thinness. Group therapy can also become an "educational resource" for patients to exchange new strategies for getting thinner.

Benefits of FBT

Family-based therapy helps achieve key objectives.

• It helps restore the adolescent's body weight and health.
• It guides the formation of new productive behaviors within the family.
• It supports the child with adolescent development.
• It relies on the parents of the patient, which eliminates the need for additional services such as ongoing nutritional education and individual, family, or group therapy. A secondary benefit is considerable savings of health care dollars.
• It allows the patient to spend less of her or his adolescent development in the clinic and more time in school, at work, and in extracurricular activities — all of which support the child's adolescent development.

Disadvantages of FBT

This approach depends on a therapist who has been trained in FBT techniques. The success of FBT also depends on the commitment of family members to be present at therapy sessions and for meals. It may also involve making sacrifices to do what is necessary to help the starving child, including taking time away from work or modifying parental schedules, and setting aside other concerns and activities for a period. Finally, during some parts of the treatment, temporary conflict may occur between parents and the adolescent.

Indications for Use

FBT is most effective for younger adolescents, early in the history of the disorder, before multiple hospitalizations and relapses. The willingness of family members to try this approach also helps yield a favorable outcome.

Barriers of Use

FBT is not recommended if regular attendance of at least 1 parent at counseling sessions is not possible.