James Lock, MD, PhD

Eating disorders as classified by DSM-5 include diagnostic categories for anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive feeding intake disorder, and feeding and eating conditions not otherwise specified. These are serious illnesses associated with numerous psychological and medical comorbidities, including increased risk of death.

Patients with eating disorders are notoriously difficult to treat and are also known to have high relapse rates. Resistance in eating disorders is common and can help explain why treatments often fail and why patients drop out. In general, resistance can refer to the conscious and unconscious factors that prevent a patient from engaging fully in the treatment process. Importantly, patient resistance is not uniform across the different eating disorder diagnoses, and how it is addressed also depends on the age of the individual.

Why patients with eating disorders resist treatment

 Patients with eating disorders are typically terrified of weight gain and will go to great lengths to avoid this outcome. To decrease anxiety about weight gain, patients sometimes adopt behaviors that they believe will “protect” them from gaining weight-eg, scrutinizing body parts, daily weighing, following strict rules about when and how much to eat, and overexercising. Patients become highly invested in these safety behaviors, which results in decreased willingness to change them and increases therapeutic resistance.

 Another key factor that affects resistance to change is whether patients view the disorder as ego-dystonic (ie, part of themselves) or ego-syntonic (ie, separate from themselves). Individuals who experience the behaviors associated with the eating disorder as problematic and incongruent with how they see themselves view their eating disorder as ego-dystonic; this view is typically endorsed in bulimia nervosa and binge eating disorder. As a result, these patients often want help because they are frustrated with unsuccessful weight loss attempts and are ashamed of their binge eating/purging behaviors. This desire for help leads to an improved therapeutic alliance and motivation to change.

In contrast, individuals with eating disorders who experience their behaviors as congruent with their personality and have a certain amount of pride in the ability to diet and exercise to extremes view the eating disorder as ego-syntonic. This ego-syntonic view is most often seen in anorexia nervosa. In most cases, when the eating disorder is experienced as ego-syntonic, there will be little or no motivation to change the behaviors, which results in high levels of treatment resistance that increases with time.

Ego-syntonic patients typically avoid therapy and will often attend only because of outside pressure (eg, to please a loved one). In these cases, it is extremely difficult to form a therapeutic alliance or to agree on goals for treatment. For example, these patients will be opposed to weight gain, although it is necessary in underweight patients with anorexia nervosa. This discrepancy in treatment goals between patient and clinician leads many patients to drop out of therapy, a common problem in anorexia nervosa.

In general, individuals with eating disorders resist treatment for many reasons. It can be helpful to both patient and clinician to understand and distinguish potential sources of process resistance and outcome resistance as an early step in the therapeutic process.

 Process resistance refers to resistance related to necessary changes for improvement and is associated with high levels of anxiety and discomfort. Examples of process resistance include gaining weight, eating more regularly, and eating larger amounts and/or foods that have been avoided. Outcome resistance, on the other hand, refers to concerns about the ultimate changes that will result once the behaviors and cognitions maintaining the eating disorder are no longer available to use as a coping strategy (eg, cannot binge as a coping strategy and may have to start attending to other unpleasant responsibilities in life that have been avoided because of the eating disorder).

While ultimately not helpful, these eating disorder behaviors and cognitions function as a temporizing measure in ways that the patient may or may not be aware of. For example, the individual with anorexia nervosa may not feel negative emotions as intensely while in a starvation state and thus, when eating normally, will need to learn to tolerate these emotional experiences. Most patients with an eating disorder struggle with both process and outcome resistance.

How a clinician can address treatment resistance

The options of how to proceed when encountering resistance will depend on the age of the individual and the type of disorder. Generally with 

, if there is not a strong desire to change the behavior (ie, the eating disorder is ego-syntonic) we recommend using a family-based approach.

 In this model, the adolescent’s resistance to change is circumvented because this treatment targets changing parental behaviors related to promoting weight restoration rather than directly confronting the adolescent. However, the therapist must overcome parental resistance and avoidance by facilitating learning and teaching strategies to change the behaviors that maintain their child’s eating disorder.

A pivotal intervention in the first session that is repeatedly modeled throughout the treatment process is externalization. Externalization allows parents to view their child’s firm resistance as part of the illness and not their child’s bad character. This separation allows the parents to focus on the task at hand (ie, re-nourishment) without getting sidetracked by the child’s verbal and nonverbal protests or by their guilt at making their child do something that is so distressing to him or her.

 When working with an adolescent or adult who is somewhat motivated to change her eating disorder behavior, individual therapy can be effective. However, recognition of the need to change behaviors and the ability and willingness to do the hard work to change them can be quite different. For example, patients with bulimia nervosa will often want to stop binge eating but are resistant to giving up the restrictive eating habits that lead to the binge eating episodes.

One helpful strategy to deal with this type of resistance is to begin by working with the patient to identify what she wants to change and/or work on. This step may seem basic, but it can be overlooked by therapists and replaced with a presumption that a patient with an eating disorder agrees with the therapist’s perspective and valuation. Achieving initial consensus on the goals of therapy and agreement to work on a particular problem/ behavior introduces a dialogue about how to achieve those goals.

In treatments such as cognitive-behavioral therapy, the first session is spent building a model illustrating how the eating disorder is functioning for the patient. The model includes behavioral, emotional, and cognitive maintaining processes and illustrates the cyclical and dysfunctional nature of the eating disorder. The model is a working document and can be revisited during every session. As a result, it can be used to help the patient learn more about her eating disorder cycle, evaluate the effects of her behaviors, and address resistance as it emerges. As treatment progresses, the model can be refined and elaborated, highlighting emerging targets for treatment.

One way to use this model is to ask the patient if the eating disorder is helping her accomplish the original goal-often this is related to improving self-esteem. In most cases, the co-created formulation will reflect that the behaviors and cognitions related to the eating disorder are not working and the model illustrates instead that the eating disorder is making her feel worse. This use of the model may be the first time that a patient is able to step back and see the difference between what she is doing and what she is trying to achieve.

Another strategy to help overcome resistance is Socratic questioning (ie, successive questions that progressively challenge the logic in a patient’s statements) about why the patient would want to continue to engage in eating disorder behaviors that are dysfunctional. For example, a patient may focus on the fact that vomiting makes her feel better immediately after a binge, although this is obviously a dysfunctional strategy because it undermines her self-esteem.

 provides an example of a typical model that uses a cognitive-behavioral framework. If the patient wants to stop binge eating, the formulation created by the therapist and patient would clearly show the cause behind the desire to binge (eg, rigid rules around food) and what is required (eg, adopting flexible guidelines around meals instead of rules) to change the behavior. Once the patient understands this dilemma-it is up to her to determine how much she wants to stop binge eating. Is it worth changing the restrictive rules she’s created around food?

Rigid rules around food often serve as safety behaviors that theoretically “protect” from weight gain. If patients are unsure about wanting to change their rules around food, the therapist might help the patient explore this by generating a list of the costs and benefits associated with this behavior change. Finally, negative thinking about oneself often perpetuates disordered eating behaviors. A useful strategy to reduce resistance is to provide positive feedback and reinforcement (especially for younger patients) for any effort toward homework and attempts at behavior change. By modeling this consistently (ie, distinguishing between effort and outcome), patients can learn how to think more positively about themselves, which can give them the confidence to push forward.

Adult patients with low or no motivation to change.

, there is sometimes little to no motivation to recover from the disorder, although there is often a recognition of other problems that anorexia nervosa is causing for them (eg, isolation, poor physical health). This lack of motivation is largely due to the ego-syntonic nature of the disorder coupled with chronicity. The combination causes the disorder to become engrained and drastically reduces the likelihood of weight gain, even when the patient appears motivated for treatment.

Given the poor remission rates for patients with chronic anorexia nervosa, novel approaches sometimes focus on minimizing the burden of illness rather than attempting to bring about full weight and cognitive recovery. An example of a therapeutic goal that targets functional improvement that both patient and therapist can agree on would be minimizing harmful exercise practices that lead to injury.

Another example of a functional improvement target is cognitive inefficiencies that contribute to poor quality of life-for example, excessively rigid and detail-oriented thinking. Cognitive remediation therapy (CRT), a novel approach, focuses on improving meta-cognition (thinking about how thinking style affects everyday living), which increases flexibility and the ability to see “the bigger picture” while establishing a strong therapeutic alliance. CRT is intentionally designed to be nonthreatening and, thus, it is not focused on the eating disorder.

The goals of treatment are achieved by playing different games that challenge the particular inefficiencies common in anorexia nervosa. CRT can be used as an adjunctive treatment, and data suggest that when used in this way, it can lead to lower levels of treatment discontinuation.

 By using nonthreatening methods (ie, CRT), agreeing on the same therapeutic goals that do not directly challenge safety behaviors, and by working collaboratively, treatment can be moderated even in the most challenging group.

Treatment resistance in eating disorders is complex and manifests differently depending on diagnosis, patient age, and duration of illness. These factors can inform the clinician about the types of resistance they are likely to encounter and on potential strategies and treatment options that may be useful in overcoming these barriers. However, the role and content of resistance will vary in each case; it is important to understand how each patient views her symptoms and the perceived function they offer in the context of her life. This understanding will help the clinician conceptualize why the patient is resisting and how this resistance is likely to interact with specific symptoms.

Dr Aspen is a Postdoctoral Research Fellow and Dr Darcy is an Instructor in behavioral medicine; Dr Lock is Professor of child psychiatry and pediatrics and Director of the Eating Disorder Program for Children and Adolescents in the department of psychiatry and behavioral sciences at Stanford University School of Medicine, Stanford, Calif. The authors report no conflicts of interest concerning the subject matter of this article.

Tools, Not Schools, of Therapy: Integrating Twelve Treatment Models

. May 2013. http:// jackhiroseresources.com/post-one. Accessed August 6, 2014.

Treatment Manual for Anorexia Nervosa: A Family-Based Approach

. 2nd ed. New York: Guilford Press; 2013.

 Lock J, Agras WS, Fitzpatrick kk, et al. Is outpatient cognitive remediation therapy feasible to use in randomized clinical trials for anorexia nervosa? 

Articles

Why do patients with eating disorders resist treatment? How can the clinician address resistance? 

Patient Resistance in Eating Disorders

Eating problems are common in children and adolescents, and eating disorders typically have their onset during these developmental periods.

 Anorexia nervosa is a serious and potentially life-threatening disorder associated with severe food restriction, overexercise, malnutrition, and distorted thinking about body shape and weight. The typical age of onset is early adolescence (ages 12 to 15 years). Bulimia nervosa is characterized by periods of restriction followed by binge eating and purging behaviors (eg, vomiting, laxative use, overexercise) and often begins during middle adolescence (ages 15 to 17 years). A variety of social, developmental, genetic, and familial factors have been implicated in the etiology of these disorders, but their cause is unknown.

In younger children, a range of eating disorders has been identified that includes atypical syndromes, such as selective eating and food avoidance emotional disorder (FAED).

 These atypical disorders are diagnosed as eating disorders not otherwise specified (EDNOS) in the current 

. These disorders typically occur in school-aged children. Children with selective eating are highly sensitive to taste, texture, and amounts of food and have an extraordinarily narrow range of acceptable foods they will eat.

 These syndromes often lead to social, behavioral, and nutritional problems.

Food neophobia may be primary (eg, never learned to eat a range of food), or it may occur in response to an adverse event (eg, choking, vomiting, diarrhea). Selective eating is associated with general anxiety and with autism spectrum disorders. Children with FAED are underweight, do not report shape and weight concerns, and often have somatic complaints (eg, stomachaches). In contrast to patients with anorexia nervosa, those with FAED usually recognize that they are too thin and want to gain weight.

Identification and diagnosis of eating disorders in children and adolescents is a major problem (

). As with many psychiatric disorders, diagnostic classifications of eating disorders in 

 are not developmentally sensitive. Current criteria are appropriate for adults with long-standing disorders. For example, in anorexia nervosa, the requirement of weight loss to a suggested level of 85% of expected weight for height is challenging when applied to a growing child, even when using best estimates for age.

 In addition, the criteria for reporting fear of weight gain requires that young adolescents make verbal statements attesting to this fear; however, many do not connect their behaviors with the emotion of fear. At the same time, their scrupulously avoidant and restrictive eating habits and their reactions to attempts to make them eat are more articulate than the words they speak.

In children with bulimia nervosa, the availability and opportunity to binge eat and purge is constrained by family, school, and other environmental processes that may artificially limit these activities. For these reasons, the behavioral thresholds set for these disorders are difficult to apply to this age-group.

 Consequently, the majority (approximately 60%) of children and adolescents are given a diagnosis of EDNOS.

 This heterogeneous categorization leads to confusion about the diagnosis and problems in specifying treatment, and it sometimes prohibits insurance coverage.

Research studies on treatment of eating disorders have generally lagged behind those of disorders of similar severity and incidence. In the adult literature, there are 9 published randomized controlled studies of psychosocial treatments for anorexia nervosa with fewer than 900 participants.

 Attrition rates averaged 50% in these studies, and no psychosocial treatment was found to be effective. Psychopharmacological studies of anorexia nervosa are also few and consist of small pilot comparisons with no evidence that medications are useful for the disorder.

There are 6 randomized clinical trials for anorexia nervosa in children and adolescents, with fewer than 400 participants studied.

 However, family therapy was examined in 5 of these trials, and data suggest that family therapy is useful for this age-group. On average, between 60% and 80% of adolescents who are treated with family therapy no longer meet diagnostic criteria for anorexia nervosa, while between 40% and 60% reach normal weight for their age and have no evidence of eating-related psychopathology.

No randomized clinical trials of medications for adolescents with anorexia nervosa have been published. A number of small studies of antidepressants and newer atypical antipsychotics suggest that these medications may be useful for secondary anxiety and distress, as well as for promoting short-term weight gain. Long-term benefits are unknown, however.

For adults with bulimia nervosa, cognitive-behavioral therapy (CBT) has been shown to be more effective than placebo, medications, and several other forms of psychotherapy.

 Rates of recovery (ie, no binge eating or purging for 28 days) are about 35% with CBT, although there are much greater declines in rates (approximately 50% to 80%) of binge eating and purging even among those who do not recover. However, there are only 2 published randomized clinical trials in adolescents with bulimia nervosa.

The first of those 2 studies compared a self-help version of CBT with family therapy in 80 adolescents with bulimia nervosa or partial bulimia nervosa.

 There were no differences in outcome between the 2 groups: 40% of those in both groups recovered at follow-up, but guided self-help was more cost-effective than family therapy in that study.

The second study compared family therapy with individual therapy in 80 adolescents with bulimia nervosa or partial bulimia nervosa.

 Family therapy was found to be superior to individual therapy at the end of treatment and follow-up. Rates of recovery (as defined above) at follow-up were 30% for those in family therapy and 10% for those who received individual therapy.

CBT has been adjusted for adolescents with bulimia nervosa with the addition of a focus on adolescent developmental issues, parental involvement, using age-appropriate examples, and improving the therapeutic alliance.

 Although no randomized clinical trials using these additional foci have been conducted, case series data suggest that CBT adjusted for adolescents who have bulimia nervosa was effective and led to recovery rates of approximately 50% in a clinical sample.

A number of medication treatment studies for adults with bulimia nervosa suggest that some antidepressant medications are useful for managing bulimia nervosa.

 However, when compared with CBT, medications are less effective but are more cost-effective.

 The single study of antidepressant treatment in adolescents with bulimia nervosa was a pilot study of 10 participants that found that the medication was well tolerated and led to clinical improvements in binge eating and purging.

 presents a summary of treatment options for children and adolescents with anorexia nervosa or bulimia nervosa. There are no systematic studies of treatment for children and adolescents who received selective eating, FAED, or another EDNOS diagnosis. A report on the use of behavioral desensitization and shaping in an inpatient milieu for the management of a somatization disorder similar to FAED suggests that this approach may be useful in severe cases.

There are few systematic studies that compare the relative merits of different types of treatment settings for children and adolescents with eating disorders.

 Two randomized clinical trials in adolescents compare inpatient treatment with outpatient treatment.

The first study compared an inpatient stay of several months in a specialty service with outpatient family and individual therapy.

 At the end of treatment and follow-up, there were no differences in outcome. A more recent study compared specialized inpatient treatment for adolescents with anorexia nervosa with specialized outpatient CBT for adolescents with anorexia nervosa and usual outpatient care.

 Again, no differences were found at 1-year follow-up; however, specialized CBT was the most cost-effective.

There are no systematic studies that compare day programs or other intensive outpatient treatments with outpatient care, although there is evidence that such programs are becoming more common.

 However, one study compared a high dose with a low dose of outpatient family treatment for adolescents with anorexia nervosa and found that at the end of treatment and at 4-year follow-up, those adolescents who received the lower dose did as well as those who received twice as much treatment for twice as long.

 Taken together, these findings suggest that treatment for adolescents with anorexia nervosa does not require intensive intervention for psychiatric improvement.

Although the psychiatric treatment of adolescents with anorexia nervosa may generally be conducted on an outpatient basis, management of the medical consequences of severe malnutrition as a result of anorexia nervosa often requires medical hospitalization.

 A number of academic and medical associations have published guidelines for the medical management of these disorders in children and adolescents, and they identify acute medical complications associated with significant weight loss, including bradycardia, hypotension, and refeeding syndrome.

There are a number of treatment studies of child and adolescent eating disorders that are under way. It is hoped that these studies will provide important guidance on how to improve outcomes in this population.

At the University of Chicago and Stanford University, a study of 120 adolescents with anorexia nervosa that compares a developmentally focused individual treatment (adolescent-focused therapy [AFT]) with family therapy is nearing completion. This study is a large-scale comparison of 2 major and divergent approaches to managing anorexia nervosa. AFT concentrates on individuation, autonomy, and self-mastery to overcome the preoccupations and inappropriate avoidance that characterize the symptoms of anorexia nervosa.

 Family therapy, in contrast, employs parents to directly manage the adolescent’s weight restoration and only secondarily examines adolescent developmental issues in the family context.

 The results of this study should be available soon.

Another large study of adolescent anorexia nervosa is being conducted at 7 sites in the US and Canada. The study compares family therapy (as described above) with a systemic family approach aimed at family dynamics rather than empowering parents to effect weight change in their anorexic child.

 Results will shed light on the specific role of family involvement in the treatment of adolescents with anorexia nervosa.

A study that compares family therapy, individual supportive therapy, and CBT for adolescents with bulimia nervosa is just getting under way at the University of Chicago and Stanford University. When completed, it will be the largest study of adolescent bulimia nervosa undertaken. It will provide information on whether individual supportive therapy, CBT, or family therapy is the most effective approach for the disorder and will help identify patients who might benefit differentially from one treatment.

While clinicians await the results of these trials, the current evidence suggests that for adolescents with eating disorders, the best available treatment is family therapy aimed at helping parents manage their child’s eating disorder symptoms.

 While the evidence for the superiority of this form of family therapy over other treatments is still limited, the data suggest that it is effective in many cases. Family therapy also appears to be useful clinically in nonresearch populations, and manualized versions of the approach are available.

 At the same time, there is undoubtedly an important role for other therapies, including individual therapy for adolescents with anorexia nervosa and bulimia nervosa, especially in situations where family therapy is not an option.

Medications for eating disorders in children and adolescents should be reserved for those with comorbid conditions (eg, anxiety, depression) or for those who are not responsive to psychosocial treatments. The use of medication for the treatment of adolescents with anorexia nervosa-even for comorbid conditions-might best be deferred until weight is normalized to help ensure that anxiety, obsessive-compulsive behaviors and thoughts, and depressed affect are not primarily nutritionally or behaviorally based.

Among the many challenges clinicians face is developing specific expertise in treating child and adolescent eating disorders. Most eating disorder specialists focus on treating adults, and few have sufficient training or appreciation of developmental differences in younger patients who have an eating disorder. Furthermore, many nonspecialist clinicians have little training in the treatment of eating disorders, particularly in family therapy. Although there are regional centers of excellence in the treatment of child and adolescent eating disorders, these are few in number and are located mostly in urban centers. Reliance on hospital and residential treatment is, in part, a result of these limitations of trained professionals. Efforts to address these disparities by integrating eating disorder treatment training in clinical training programs, use of distance learning, and distance therapy are needed.

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Eating disorders are serious and potentially life-threatening, associated with severe food restriction, overexercise, malnutrition, and distorted thinking about body shape and weight or binge eating and purging behaviors.

Eating Disorders in Children and Adolescents

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.

 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,

 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.

Family therapy, one of the few treatments for AN that has been systematically examined, may show the most promise, especially for adolescent patients.

 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. Gull

 called families the "worst attendants" and Charcot referred to parents as a pernicious influence on their offspring with AN.

 The clinical recommendation arising from these observations was to remove the parents from involvement in their child's care in a maneuver sometimes called 

. Other experts have justified excluding or minimally involving families when treatment targets the individual developmental needs of adolescents, including autonomy, assertiveness, and self-control.

 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.

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.

 A parent guide has also been written to support parents in learning about this form of family treatment.

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.

Parents are encouraged to find solutions to the problems of food refusal and weight loss-inducing behaviors. Usually this entails helping the parents agree on a strategy to increase the amounts and types of food their child is eating and to limit the child's physical activity. Thus, in the first part of the FBT program, parents learn to get organized, become consistent, and be persistent without getting angry and frustrated with their child.

At the beginning of treatment, FBT is highly focused on eliminating food refusal and promoting weight gain. Issues related to family or individual processes are deferred unless they directly interfere with weight restoration. Once weight is restored and the adolescent is eating more regularly, control of eating is returned to the adolescent. After the adolescent demonstrates sufficient ability to eat normally and maintain a normal weight, therapy turns to more general issues of adolescent development and family process.

The major innovation of putting parents in control of weight restoration sets FBT apart from other therapies for AN. Like parents of children with autism, schizophrenia, and other illnesses, parents of children with AN have long felt blamed, responsible, and guilty for their children's illness. As a result, they felt powerless to help their children.

FBT aims to diminish these sentiments and powerlessness in several ways. First, parents are reminded that there is no known cause for AN. The approach further empowers parents by encouraging them to directly challenge and disrupt the severe dieting and overexercise associated with AN as they would any other dangerous adolescent behavior (eg, alcohol or drug use, truancy, or recklessness). The issue of adolescent control is reformulated to help parents see that extreme dieting and the resulting malnutrition are evidence that their child needs help and should not be left to his or her own devices regarding eating behavior.

There are only 5 randomized controlled outpatient trials of psychological treatment for adolescents with AN (

 These trials were conducted over the past 20 years and comprised about 200 participants. All of these trials involved FBT in some form. Taken together, these studies suggest that family therapy is acceptable, feasible, and effective. In fact, dropout rates were modest (between 10% and 15%), in contrast to treatment studies of adults with AN, where dropout rates of 40% or more effectively made randomized outcomes difficult to analyze and interpret.

 Outcomes of adolescents in these studies suggest that between 70% and 80% do well in FBT in terms of weight restoration, normalization of eating-related thoughts and behaviors, and psychosocial functioning. In comparison, outcomes in adult studies report 30% to 40% recovery rates.

Studies comparing FBT with other approaches are few and small in scale. Although the results available suggest that FBT may be superior in adolescent participants, definitive conclusions about comparative outcomes await further study.

 Interestingly, studies of adults with AN who were treated with FBT are less convincing; in such cases, FBT may be no better than individual therapy.

Long-term outcomes of adolescent patients treated with FBT suggest that the improvements obtained during treatment are enduring. Two studies have demonstrated that both weight restoration and eating-related thoughts and behaviors continue to be improved at follow-up 4 to 5 years later.

 However, although the majority of these adolescents have recovered from their eating disorder and are working or are in school, about a quarter of them have other mental health problems, including depression and anxiety disorders.	

Because of the high cost of managing AN, one of the more exciting findings is that FBT can be a remarkably efficient therapy. In its chronic form, AN is highly intractable to known interventions, often requiring long-term and intensive interventions.

 However, many younger and less chronically ill adolescent patients appear to respond favorably with the relatively short treatment protocols of family therapy.

Based on a review of existing studies of FBT for adolescents with AN, the duration of treatment ranged from 6 months to 18 months, with most treatment durations falling between 6 months and 12 months.

 Intensity of treatment (number of sessions provided during the treatment period) ranged from 9 sessions to 31 sessions over a 12-month period.

 In these studies, the weighted (by number of patients in study) mean number of sessions per year was 14.85.

 Outcome did not appear to vary as a result of the intensity or duration of treatment, since participants who were treated for as few as 9 sessions over 6 months did as well as those who were treated for 47 sessions over 18 months.

In a randomized clinical trial designed to examine the effect of intensity and duration, Lock and colleagues

 found no differences in any outcome measure between those randomly allocated to receive 10 sessions over 6 months and those receiving 20 sessions over 12 months. However, for patients with severe obsessions and compulsions related to eating behaviors or for those who came from nonintact families, longer treatment appeared to be more effective. Overall, the findings of this study provide substantive support that a brief course of treatment is as effective as a longer course in adolescents who are treated with FBT. These results highlight the advantage of employing parents in FBT not only in terms of promoting recovery but also clinical efficiency and cost-effectiveness.

Two studies have examined patient and family views of FBT.

 Both studies found that patients and families thought FBT was helpful and successful, but approximately one third of the adolescents in one study reported a desire for individual treatment in addition to FBT.

 These studies suggest, somewhat surprisingly given the ego-syntonic nature of AN, that adolescents as well as their parents not only accept FBT but also develop strong therapeutic relationships with the therapist.

For example, in one study, early patient therapeutic alliance in FBT facilitated early weight gain, and early parental therapeutic alliance helped prevent dropping out of treatment.

 There is another noteworthy finding: the study found early weight gain was a better predictor of end of treatment psychological recovery and of end of treatment therapeutic alliance than early therapeutic alliance.

 This underscores the importance of early behavioral response both to the process of therapeutic engagement and to ultimate outcome in FBT for adolescent AN.

FBT appears to work best with adolescents who have uncomplicated, short-duration AN. Comorbid psychiatric illness and family problems appear to increase dropout rates as well as decrease response rates.

 Although systematic studies of the mechanisms of the therapeutic action of FBT have yet to be conducted, improvement in comorbid psychiatric symptoms and family pathology early in treatment is associated with increased response rates. In addition, as is common with many treatments for eating disorders, early response, such as weight gain in a patient with AN, also increases the likelihood that the patient will recover.

Two studies have also found that FBT can be delivered in a separated form, wherein the parents are seen separately from their child for therapy focused on weight restoration.

 This form of FBT may be preferable in cases in which there is a high degree of overt criticism (eg, high levels of expressed emotion) of the child.

Concluding thoughts and future directions

Since Dare and Eisler's first published studies of FBT more than 20 years ago, a collection of both uncontrolled and controlled studies have been conducted using this approach.

 Although none of these studies are definitive, together they produce considerable evidence in support of FBT for adolescent AN. This has been recognized in the National Institute for Clinical Excellence in the United Kingdom evidence-based practice report, in the Agency for Healthcare Research and Quality recommendations and, most recently, in the new practice guidelines for the treatment of eating disorders by the American Psychiatric Association.

Nonetheless, there is a clear need for more definitive comparative studies. Funded by the National Institutes of Health, a randomized controlled trial comparing FBT to a developmentally tailored individual treatment for adolescents with AN is currently under way at the University of Chicago and Stanford University. Studies comparing FBT to other forms of family therapy for AN in adolescents are being initiated in other centers, including Cornell University, Washington University, Lauriette Psychiatric Clinic and Hospital, Sheppard Pratt Health System, and the University of Toronto. We hope that these larger-scale studies will  identify the best treatments, as well as help to determine the best therapy for each individual.

New directions for studying FBT include assessing the utility of the approach for adolescents with bulimia nervosa, evaluating FBT's effects on young adults living at home or with relatives, as well as assessing the integration of the approach in more intensive treatment settings such as day programs, intensive outpatient programs, and inpatient programs. Other therapy formats, particularly family group formats, are also being developed.

A particular challenge common to many evidence-based treatments is efficient and effective dissemination of the approach to clinicians in practice. Training professionals and future professionals in FBT remains a limiting factor in making this approach available to patients outside of specialty centers.

The long-standing controversy concerning whether parents should be involved in the treatment of their adolescent children with AN appears to be resolving. The studies of family treatment conducted thus far clearly support actively including parents in the treatment of their adolescent children with AN. Parents and other family members are an important resource, especially for these younger patients in crisis. Most important, by using family treatment it appears to be possible to forestall the evolution of more chronic, often intractable, and devastating forms of AN.

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