Anorexia nervosa (AN) is a serious psychiatric condition with a prevalence estimated at 0.48% to 0.7% among adolescent females aged 15 to 19 years.1 Comorbid psychological conditions are also common in patients with AN. Some 60% of patients with eating disorders have a lifetime anxiety or affective disorder. The mortality rates associated with this severely disabling condition are higher than for any other psychiatric disorder,2 with about half of the deaths occurring from suicide and the remainder as a result of the physical complications of AN. In addition, AN is an expensive illness to treat, with costs comparable to those for schizophrenia.3
Family therapy, one of the few treatments for AN that has been systematically examined, may show the most promise, especially for adolescent patients.4 The inclusion of parents in their children's treatment for eating disorder is not universally accepted, particularly when parents are encouraged to make strong behavioral interventions. However, recent studies suggest that families should be included in treatment and that they are often a powerful resource for helping their children recover.
"Worst attendants" or partners in recovery?
The role of families in the management of AN has been controversial from the earliest medical descriptions of the disorder. Gull5 called families the "worst attendants" and Charcot referred to parents as a pernicious influence on their offspring with AN.6 The clinical recommendation arising from these observations was to remove the parents from involvement in their child's care in a maneuver sometimes called parentectomy. Other experts have justified excluding or minimally involving families when treatment targets the individual developmental needs of adolescents, including autonomy, assertiveness, and self-control.7
In contrast, Minuchin and colleagues8 found that family involvement in treatment appeared to benefit young patients with AN, albeit with a focus primarily on ameliorating family pathology related to rigidity, enmeshment, conflict avoidance, and overprotectiveness. It was left to Dare and Eisler and their colleagues at the Maudsley Hospital in London to develop a family treatment protocol that used families as a therapeutic resource to enhance recovery for adolescent AN.9
The birth of FBT
Family-based treatment (FBT), sometimes called the Maudsley method or Maudsley approach, is a treatment that was inspired by Minuchin's findings that families could be an asset in treating youngsters with AN. Dare and Eisler also recognized that inpatient weight restoration in the hands of competent staff often set the stage for recovery. They believed that parents, with appropriate guidance and encouragement, could provide the support at home, thus avoiding hospitalization.
As a result, Dare and Eisler developed an outpatient therapeutic approach to help parents disrupt extreme dieting and exercise in their children. Their program aimed to assist parents in normalizing their children's eating and weight in a way similar to what is done in an expert inpatient eating disorder unit. A manual detailing this approach has been published and used in both clinical and research settings.10,11 A parent guide has also been written to support parents in learning about this form of family treatment.12
Early in FBT, parents are helped to understand the medical and psychiatric seriousness of AN, including the high mortality rates because of cardiac failure and suicide. Although this information raises parental anxiety, the therapist uses this information to show parents that they are a crucial resource in preventing devastating outcomes.
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4. Le Grange D, Lock J. The dearth of psychological treatment studies for anorexia nervosa. Int J Eat Disord. 2005;37:79-91.
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6. Silverman J. Charcot's comments on the therapeutic role of isolation in the treatment of anorexia nervosa. Int J Eat Disord. 1997;21:295-298.
7. Crisp AH. Anorexia Nervosa: Let Me Be. London: Academic Press; 1980.
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10. Lock J, Le Grange D. Can family-based treatment of anorexia nervosa be manualized? J Psychother Pract Res. 2001;10:253-261.
11. Lock J, Le Grange D, Agras WS, Dare C. Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford Press; 2001.
12. Lock J, Le Grange D. Help Your Child Beat an Eating Disorder. New York: Guilford Press; 2005.
13. Le Grange D, Eisler I, Dare C, Russell G. Evaluation of family treatments in adolescent anorexia nervosa: a pilot study. Int J Eat Disord. 1992;12:347-357.
14. Robin AL, Siegal PT, Moye AW, et al. A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. J Am Acad Child Adolesc Psychiatry. 1999;38:1482-1489.
15. Eisler I, Dare C, Hodes M, et al. Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions. J Child Psychol Psychiatry. 2000;41:727-736.
16. Lock J, Agras WS, Bryson S, Kraemer HC. A comparison of short-and long-term family therapy for adolescent anorexia nervosa. J Am Acad Child Adolesc Psychiatry. 2005;44:632-639.
17. Halmi KA, Agras WS, Crow SJ, et al. Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Arch Gen Psychiatry. 2005;62:776-781.
18. Dare C, Eisler I, Russell G, et al. Psychological therapies for adults with anorexia nervosa: randomized controlled trial of out-patient treatments. Br J Psychiatry. 2001;178:216-221.
19. Pike KM, Walsh BT, Vitousek K, et al. Cognitive-behavioral therapy in the posthospitalization treatment of anorexia nervosa. Am J Psychiatry. 2003;160: 2046-2049.
20. Eisler I, Dare C, Russell GF, et al. Family and individual therapy in anorexia nervosa: a five-year follow-up. Arch Gen Psychiatry. 1997;54:1025-1030.
21. Lock J, Couturier J, Agras WS. Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy. Am J Child Adolesc Psychiatry. 2006;45:666-672.
22. American Psychiatric Association Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders. Am J Psychiatry. 2006;163:1-54.
23. Krautter T, Lock J. Is manualized family-based treatment for adolescent anorexia nervosa acceptable to patients? Patient satisfaction at end of treatment. J Fam Ther. 2004;26:65-81.
24. Le Grange D, Gelman T. The patient's perspective of treatment in eating disorders: a preliminary study. S Afr J Psychol. 1998;28:182-186.
25. Pereria T, Lock J, Oggins J. The role of therapeutic alliance in family therapy for adolescent anorexia nervosa. Int J Eat Disord. In press.
26. Lock J, Couturier J, Bryson S, Agras WS. Predictors of dropout and remission in family therapy for adolescent anorexia nervosa in a randomized clinical trial. Int J Eat Disord. In press.
27. National Institute for Clinical Excellence. Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. London: British Psychological Society; 2004.
28. Management of Eating Disorders. Rockville, Md: Agency for Healthcare Research and Quality; 2006. AHRQ publication 06-E010.
29. Dare C, Eisler I. A multi-family group day treatment programme for adolescent eating disorders. Eur Eat Disord Rev. 2000;8:4-18.
- Le Grange D, Lock J. The dearth of psychological treatment studies for anorexia nervosa. Int J Eat Disord. 2005;37:79-91.
- Lock J, Agras WS, Bryson S, Kraemer HC. A comparison of short- and long-term family therapy for adolescent anorexia nervosa. J Am Acad Child Adolesc Psychiatry. 2005;44:632-639.
Dr Lock is associate professor of child psychiatry and pediatrics in the department of psychiatry and behavioral sciences at Stanford University School of Medicine, where he has taught since 1993. He is board-certified in adult as well as child and adolescent psychiatry. He directs the eating disorder program in child psychiatry and is active in treatment research for children and adolescents with eating disorders.
Dr Lock indicates that he has received research funding from the National Institutes of Health and royalty payments from Guilford Press for sales of the books Treatment Manual for Anorexia Nervosa and Help Your Teenager Beat an Eating Disorder.