A special issue of the Journal of Family Therapy has highlighted the role of family therapy in the treatment of eating disorders in adolescents, and the growing body of evidence to support taking a family-inclusive approach.
Eating disorders have a significant impact on the functioning and well-being of a family unit. Family processes may also play a role in the maintenance of disordered patterns of behaviour. Whitney and Eisler (2005, p. 577) capture the way in which a family can be affected:
“The impact of the illness on the family is immediately evident...just as issues around food, eating and weight dominate the sufferer’s thoughts and behaviours, food may also take a predominant role within family life and interactions”.
The national standards published by the NEDC include the importance of the role of the carer and family in the treatment of an eating disorder. Family Based Therapy (FBT) sees parents and care-givers as the primary resource for recovery and the most appropriate support for regaining a healthy weight and ending unhealthy behaviours.
Generally, FBT is implemented as an intensive, outpatient treatment model. FBT is separate to traditional family therapy which addresses interpersonal and relationship issues within a family unit, although this may form part of an FBT approach. While commonly used with adolescents, there are also new developments in the use of family and couple therapy models to treat adults.
While many forms of family and couple therapy are suggested as important in working with eating disorders, there are only a handful of family-inclusive treatment options that have been empirically evaluated.
The NEDC National Framework (2010) and Evidence Review (2010) both acknowledge that family oriented interventions are an integral component of any treatment model for children and adolescents with anorexia nervosa and that evidence in other uses of family based interventions is emerging.
The UK National Institute of Health and Clinical Excellence guidelines reviewed all available research evidence prior to 2004 and concluded that the best outcomes for anorexia nervosa in patients under 18 years of age were obtained from family therapy (NICE, 2004).
The Journal of Family Therapy special edition includes a methodological review of family-based treatment in the last 25 years (Downs & Blow, 2013). Overall they found studies of family-based treatments for eating disorders to be promising. Particularly promising were those using the Maudsley approach and adaptations for adolescents with anorexia nervosa who are still in the early stages of illness.
A meta-analysis conducted by Couturier, Kimber, & Szatmari, 2012 indicated that behaviourally based FBT (or Maudsley Family Therapy) for adolescents with both anorexia nervosa and bulimia nervosa is superior to individual therapy at a 6-12 month follow-up. In addition, they reported that family therapy focusing on intervention with disordered eating behaviours should be recommended as the first line of treatment for adolescents with eating disorders.
A recent Cochrane review meta-analysis also examined family-based interventions for individuals of all ages with anorexia nervosa and concluded that remission rates were higher in family therapy compared with standard treatment. However, there was not enough evidence to determine whether family therapy had better remission rates than other types of psychological interventions.
The findings of the Cochrane review may have been influenced by the inclusion of both adult and adolescent participants and a wide range of family therapy models. Evidence is less clear on the outcomes of FBT for adults with anorexia nervosa, and those of any age with other eating disorders. There is some evidence that adolescents may have a better response to family interventions when compared to adults. Currently, the largest evidence base specifically relates to the Maudsley Approach; traditionally implemented with adolescents.
FBT holds significant promise for adolescents with anorexia nervosa and the growing evidence base for this approach to treatment is also developing a body of supporting research-to-practice initiatives. Further research and evaluation is needed in this area of practice, particularly as it relates to other eating disorders, different age groups and different family-based therapy models. Family based therapy is evidence based and should be considered as a treatment option for anyone with an eating disorder. No single treatment will be effective in all instances but this is a form of treatment that has promising outcomes for many and places the family as an integral component of the treatment team.
For further reading on adolescent family based treatment in clinical practice, please refer to some of the other articles included in the special edition of the Journal of Family Therapy:
Adapting family-based therapy to a day hospital programme for adolescents with eating disorders: preliminary outcomes and trajectories of change.
Multiple family therapy for adolescents with anorexia nervosa: a pilot study of eating disorder symptoms and interpersonal functioning.
Patients' characteristics and the quality of the therapeutic alliance in family-based treatment and individual therapy for adolescents with anorexia nervosa.
Innovations in Maudsley family-based treatment for anorexia nervosa at the Children's Hospital at Westmead: a family admission programme.
For more up-to-date research on best practice in eating disorders, explore our knowledge hub.
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