The Role of Family Therapy for Adolescents With Anorexia Nervosa

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.

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

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.