Evolving Treatments for Adolescents with Anorexia Nervosa: The Role of Families in Recovery
By James Lock, M.D., Ph.D.
Anorexia nervosa most often begins during adolescence. Unfortunately, a young person who starts to starve herself or himself may not at first realize that anorexia nervosa is a serious psychological illness that causes severe and debilitating emotional and physical problems. What's more, our understanding of how to treat adolescents with anorexia nervosa is still quite limited.
Although the cause of anorexia nervosa is unclear, severe dieting and weight loss are often associated with struggles to cope with the escalating psychological and social demands of adolescence. A preoccupation with food and weight may be a way to avoid or be distracted from these seemingly impossible demands. On the other hand, it appears that prolonged severe dieting and weight loss themselves are behaviors that, once firmly entrenched, perpetuate the distorted beliefs around eating, food, and body image that are common to anorexia nervosa. It is therefore unclear whether treatment should begin by focusing on the anxieties around adolescence or should initially address the severe dieting and weight loss.
Two Standard Treatment Approaches
Two standard approaches for outpatient treatment are generally considered. The most common of these is individual psychodynamic therapy, which usually assumes that the root cause relates to developmental anxieties about the physical changes associated with puberty, the social demands of adolescence, and the developmental task of separating from parents. Treatment involves exploring and attempting to resolve the young person's anxieties related to these issues while encouraging him or her to eat sensibly and gain weight. Parents may be included in such treatments, but they are usually asked to support the adolescent's independence and refrain from trying to change behaviors related to food and weight.
The other approach that is commonly used is family therapy. This treatment examines ways in which the family may be a factor in the development or perpetuation of the young person's illness and looks at ways the family can help to resolve any conditions that may have contributed to it. The therapist targets family processes, including inappropriate alliances within the family, communication problems, conflict or avoidance of conflict, and suppression of individuation and separation among family members, particularly the adolescent. The family may discover that the symptoms of anorexia nervosa help to maintain dysfunctional adaptations by diverting attention away from family difficulties. When these dysfunctional patterns are addressed, the young person will no longer feel pressure to save the family from facing its problems by using anorexia to avoid age-appropriate developmental tasks.
The Maudsley Approach
In contrast to these two standard approaches, both of which take direct aim at anorexia nervosa's supposed psychological roots, stands a different form of family treatment developed initially at the Maudsley Hospital in London. This approach, which evolved from procedures used in family therapy models, focuses on family management of the symptoms of anorexia nervosa rather than on presumed pathological features of the patient or family.
In the Maudsley approach, treatment is highly focused on behavioral change around eating and weight gain rather than on the causes of the anorexia nervosa. Therapists using this approach emphasize the importance of changing eating patterns and increasing weight as the first step in recovery. They also strongly advise parents that their support and commitment are of critical importance, and that they can and must take up the task of re-feeding their child. In helping parents address severe dieting, purging, over exercise, and other related problems of anorexia, the Maudsley approach is highly practical. Weekly sessions include a review of weight progress and of the success or failure of strategies parents attempted during the week to increase intake and prevent weight loss. In the ensuing discussions the therapist consults with the parents and the adolescent about how to improve their strategies, while looking for every opportunity for encouragement in any areas of success. Thus, the therapist depends on the leverage that parents have with their children to effect behavior change. For this reason, parents and the family as a whole are consistently viewed in a positive light regarding both their intentions and their attempts to find solutions to the predicament they must face as a result of anorexia nervosa having afflicted their child.
By not blaming the parents or seeing them as the cause of the anorexia nervosa, parents are relieved of the guilt that often encumbers families and interferes with their ability to take definitive action to help their child. Further, the therapist illustrates the impact the illness has on the young person and on the many ways she or he has been affected physically, emotionally, and socially. By externalizing the illness and blaming it instead of the adolescent for the problems that the family is experiencing, the groundwork is laid for both the parents and their son or daughter to take action against a common adversary rather than fight one another.
Using these principles, family treatment consists of three phases, which take place over a 6- to 12-month period. The focus of the first phase is helping the parents take up the task of re-feeding their adolescent. Parents are educated about the seriousness of the illness and its dire medical and psychological consequences. Next, parents are encouraged and supported in the use of their authority, skill, love, and knowledge of their child to effect changes in eating behaviors. This can take many forms, but usually includes a period of time during which parents prepare all meals and monitor their child's eating and exercise behaviors. This often means keeping the child home from school and taking off time from work for a few weeks. During this phase the therapist helps the parents stay on task and avoid other distractions while also providing encouragement and support.
The second phase begins when the adolescent is approaching normal weight and eating behaviors have become more normal. During this phase, the parents slowly begin to turn over control of eating and related behaviors back to their teenager. The therapist helps parents identify when they feel ready and safe to begin this process and reviews the strategies they employ in this transition. Often, because the adolescent is learning and experimenting with greater independence while still suffering anorexic thoughts, weight gain may slow for a period. However, as the adolescent is out of immediate physical danger, this can be tolerated to allow for slower mastery of the eating under their own control. Toward the end of phase 2, the treatment turns to the relationship between eating and adolescent issues. For example, therapy may focus on the difficulties faced when eating at social events, on dates, and at school. Once the adolescent has achieved full control of eating and anorexia nervosa is not part of the daily struggle for either the adolescent or parents, the third phase of treatment begins. The aim of this phase is to help the parents and the patient make sure that any hurdles that may have developed as a result of anorexia nervosa are overcome. For example, due to the illness, the adolescent may have fallen behind in school, become socially isolated, or grown more dependent on the parents. The therapist assists the family to identify and address these issues and then terminates treatment.
Which Approach to Choose?
Unfortunately, empirical support that might give families some guidance in choosing an appropriate treatment approach is very limited. The best available evidence currently supports the Maudsley approach to family treatment. The Maudsley group has published three small studies that examined family treatment in randomized trials. In one study, a subgroup of adolescents who had been ill with anorexia nervosa for less than a year responded more favorably to family treatment than to individual therapy, and this difference had been maintained at a 5-year follow-up.
Two additional studies examined whether family treatment was best conducted by meeting with the entire family together, or if focusing on the parents while supporting the child separately was more effective. Overall, these studies did not detect that either strategy was superior unless the parents were highly critical of their child, in which case, it was better to focus on them separately. One small U.S. study compared family therapy similar to the Maudsley approach to an individual psychodynamic psychotherapy. Initial outcomes favored family treatment, though at follow-up no differences remained between the two treatment groups.
It appears that including parents and families is important in the treatment of adolescents with anorexia nervosa. It also seems that giving parents direct control over the management of disordered eating and other behaviors associated with anorexia nervosa is an effective strategy for helping adolescents with this disease. In published follow-up studies from the Maudsley group, overall out comes suggest that up to 90% of adolescents who received family treatment using this model recovered. In contrast, studies of the overall prognosis of anorexia nervosa suggest that fewer than 50% would be expected to recover.
In Conclusion . . .
Nonetheless, it remains unclear whether family treatment is the best approach for this particular population. Other alternatives, such as traditional family therapy and individual psychodynamic therapy, have not been rigorously examined. Systematic comparisons of these various approaches are needed if we are to advance our understanding about what treatments are most effective. In the meantime, families would be well advised to consider treatment along the lines of the Maudsley approach, as the data supporting this method appear promising.