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Implications and Results of Family Therapy in the Treatment of Anorexia Nervosa
April 27, 2011
It is decades old – a silent killer – and long has the family been blamed for, even shunned from the treatment of this deadly disorder. Anorexia nervosa is certainly no new matter, and its treatment has long been in development. During the late 1800’s, doctors usually considered parents to be an obstacle in the treatment process, their influence being described as “’particularly pernicious’” (Grange, 2008). Treatment usually occurred in isolation, so parental and family factors did not come into play. Even into the 20th century, the family was still viewed in this negative light in regards to treatment processes. The parental exclusion that resulted was “sometimes referred to pejoratively as a ‘parentectomy’” (Grange, 2008).
However, in the 1960’s, authors from the Child Guidance Center in Philadelphia developed a theoretical model regarding family involvement in the onset and of eating disorders – specifically anorexia nervosa. Because family problems and conflicts are often an underlying cause of the development of anorexia, it makes sense that the family as a whole ought to be a part of the treatment process. The model, however, did not necessarily blame the parents; it simply involved them in the process of treatment so that changes could be made more permanent (Grange, 2008).
Much development has occurred in the field of family therapy for anorexia nervosa in recent years, so there is a wealth of research on the subject. This literature review will answer the question, ‘What are the implications of family therapy in the treatment of anorexia, and how effective has it been shown to be?’ I will review two sources involving four different types of family therapy, doing so by defining the problem and family therapy, outlining the implications of these therapy methods, and analyzing both the failures and successes of the treatments. I will conclude by describing the types of therapy found to be most effective for certain types of patients through this literature review.
Definition of the Problem and Therapy:
Most people are aware of the general definition of anorexia nervosa. It has become a hot topic in today’s culture – but no more than that. The condition is usually sensationalized in the pop culture world and often overlooked in daily life. Concern does not usually begin until lives are in danger, and at this point the root of the problem is already so pervasive that therapy and treatment are an extremely difficult process. Family therapy seeks to address this root issue. Before describing what this involves, however, the myths regarding anorexia nervosa must be dispelled, and truthful light must be shed on the symptoms.
The medical definition of anorexia nervosa involves strict criteria regarding weight and bodily cycles. The most recent DSM IV-TR criteria for anorexia nervosa include: “weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected” (DSM-IV-TR, 2000) and the absence of 3 menstrual cycles in a row if the patient is a postmenarcheal female. However, the criteria also include symptoms that involve attitudes, thought processes, and emotions. These, of course, are much more difficult to quantify and are often present before the clear physical symptoms (DSM-IV-TR, 2000).
There does exist, however, a detailed test that seeks to measure these “psychophysiological signs characteristic of primary anorexia nervosa” (Garner, 1979). This test is called the Eating Attitudes Test (EAT), and includes 40 items which measure many of the less concrete symptoms of anorexia. The test has been administered to many groups, but in the specific literature reviewed, a group of anorexic females and a control group were given the test. The results were clear. Only 7% of the control group scored as high as even the lowest anorexic female. The study concluded that a significant correlation exists between group membership and the score on this test (Garner, 1979).
It is obvious that the traits addressed on this test are closely tied with anorexia nervosa. Therefore, these questions must be presented for a full definition of the problem. Overall, they addressed specific fears of foods, preoccupation with food and eating, feelings of guilt after eating, and obsession with body shape. The full set of questions is displayed on the following page (Garner, 1979). On this sample test, the most symptomatic response for anorexia nervosa is marked with an “X.” This type of response leads to a higher score on the test.
In summary, the definition of anorexia nervosa is a compilation of external symptoms prompted by less definable qualities. The EAT attempts to measure these psychological traits and provides a helpful list for defining anorexia at its core.
It is this core that family therapy attempts to tap into for positive results. Very often, family problems or residual scars from childhood are the cause of the psychological issues that rear their head in the form of an eating disorder. The root of the problem must be examined to decide how to address it. More often than not, the issue will be far more complicated than simple cognitive problems of the individual. Relationships – particularly within in the family – put stress on pre-existing problems and even cause new ones. There is no getting around it; the family must be involved in the process of therapy, even if not the primary cause.
Family therapy involves four key principles. The first is that a member of a family can only be fully understood when viewed with regard to the behaviors of the rest of the family. The second principle states that families are “systems in which the whole is greater than the sum of its parts” (Schlundt, 2011). Third, family therapists view psychopathology as not the faults of the individual but a result of the interactions of the family as a whole. Finally, this method of therapy claims that you cannot simply treat the individual, but the entire family. The therapy requires most, if not all, of the family to attend treatment sessions. At these sessions, the family interactions must be observed and the therapist attempts to identify the core problem. Issues involving conflict resolution, respecting boundaries, and parenting styles in general are involved in dealing with the problem healthfully (Schlundt, 2011).
Specific Implications of Methods:
Clearly, the principles of family therapy are general by nature, and can be applied using many varied methods. This portion of the literature review will discuss comparisons of multiple versions of family therapy and discuss the specific implications that these hold for the family and therapy sessions. Many different factors must be taken into account when attempting to provide suitable treatment for patients struggling with anorexia nervosa, including structure and duration.
The first test utilized two structurally different methods of family therapy – “conjoint family therapy” and “separated family therapy” (Eisler, 2000). In both methods, the family is not labeled as the cause of the patient’s anorexia, but a joint tool for recovery, and the parents are encouraged to initiate re-feeding without criticism or blame towards the patient. Also, the therapy seeks to disclose all information regarding possible consequences of starvation and the urgent need for the patient to take back his or her life as soon as possible. Finally, both methods provide great support for the family involved throughout the treatment process. The families usually met for treatment once a week in the beginning, but towards the end, the break between sessions widened to 4 weeks (Eisler, 2000).
The differences between the two types of therapy lie in whether the individual met with the therapist alongside his or her parents or apart from them. Conjoint family therapy employs the former method, involving the entire family and careful observation of the interactions. Each member of the family is given the chance to speak his or her mind freely. These sessions involve frank discussion of the dangers of the situation and warm encouragement to begin moving in a more positive direction. Separated family therapy, on the other hand, simply involves split therapy sessions for parent and child. With the parents, the therapist provides information about improvements that can be made for the child’s health and recovery. With the patient, the therapist counsels and listens supportively, discussing his or her individual experience with anorexia and how this relates to family relationships (Eisler, 2000).
The second test compared another set of family therapy methods that differed by duration: long-term and short-term. These employed many of the same principles as the previous two methods of treatment, but sought to test differences due to duration. The shorter treatment involved weekly session for 7 weeks, monthly sessions for an additional 2 months, and concluded with a session 6 months after the last. The longer tests required weekly sessions for 7 weeks, then sessions every other week for another 6 sessions, and finally another 7 monthly sessions. More specifically, both forms of treatment were “highly focused on behaviors and thoughts associated with anorexia nervosa and sees the adolescent as incapacitated mostly in terms of his or her eating disorder” (Lock, 2005). The notion that parents are the sole cause is dispelled, and the therapist does everything in his or her power to sympathize with the parents so they may better find a solution for the problem. Furthermore, even the siblings are involved in the treatment process as a support for the struggling patient. In short, these treatments – though of different lengths – allow parents to develop a re-feeding plan for their child; the therapist merely offers support and guidance (Lock, 2005).
Outcomes of the Various Methods:
The first set of methods involved methods of family therapy that differed structurally: conjoint or separated. This test involved forty adolescent patients suffering from anorexia nervosa that were randomly assigned to either conjoint family therapy or separated family therapy. The participants were tested before and after treatment using many different assessment measures, including questionnaires on self-esteem, mood, obsessive qualities, and eating disturbance. Of course, details of weight, presence of a menstrual cycle, and frequency of purges was also taken into account when measuring for improvements. By the end of the study, only 36 had continued for a significant period of time (Eisler, 2000).
Overall, the group improved significantly due to the treatments. However, a smaller number of patients saw significant improvement from the conjoint family therapy. Of the adolescents who underwent conjoint family therapy, 47% experienced what is described in the study as a good or intermediate outcome. On the other hand, 76% of the patients in separated family therapy experienced good to intermediate results (cite 3). The chart on the following page shows specific variable improvements among the groups:
When each variable is observed, only a few showed a large statistical difference between the two treatment groups. However, the two are clearly favored more depending on the specific variable involved. More specifically, CFT produced a fairly significant result in the areas of "mental state, psychosexual adjustment, mood, and obsessionality, and on three self report measures” (Eisler, 2000). It can certainly be concluded from this study that family therapy, as a whole, is an effective method of treatment for patients with anorexia nervosa. However, the type of family therapy needed seems to largely depend on the individual situation and what variables need the most improvement. (Eisler, 2000).
In the second set of methods, 86 participants were chosen to undergo the two different types of treatment, with only 77 reaching successful completion. There did not to be a significant statistical difference between the two treatment outcomes. This demonstrates, perhaps the fact that “for adolescents with anorexia nervosa, a short-term treatment with family therapy is as effective as long-term therapy for the majority of such patients when their outcomes are assessed at the end of 1 year” (Lock, 2005). This study came to the conclusion that therapists should consider a short-term treatment plan unless their patients struggle specifically with high levels obsessive traits or compulsivity or come from a family with a divorced or single parent. These conclusions are supported by the following graphs:
It seems clear that family therapy produces positive results for patients with anorexia nervosa. However, this formal literature review has found that many of the different methods’ effectiveness are largely dependent on the individual case of the patient. The duration should be selected based on the family structure and psychological state of the patient. The structure, first of all, is up to the judgment of the family, but also should be dependent upon the specific variable symptoms involved. All in all, however, family therapy has proved to be extremely effective, regardless of presuppositions regarding the family’s involvement in the treatment of eating disorders like anorexia nervosa.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Eisler, I. & Dare, C. (2000). Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, 41(6), 727-736.
Garner, D. M. & Garfinkel, P. E. (1979). The eating attitudes test: an index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 273-279.
Grange, D. & Eisler, I. (2008). History of the family’s role in eating disorders. Child and Adoleschent Psychiatric Clinics of North America, 18, 159-173.
Lock, J., Agras, W. S., Bryson, S., & Kraemer, H. C. (2005). A comparison of short- and long-term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry, 44(7) 632-639.
Schlundt, D. (2011). Family therapy for eating disorders. (Powerpoint presentation). Retrieved from: https://oak.vanderbilt.edu/webapps/portal/frameset.jsp? tab_tab_group_id=_4_1&url=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_136884_1%26url%3D
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