This paper is a literature review and discussion of how family therapy approaches anorexia nervosa. The premise for most of the research conducted using family based therapy is a theory by Salvador Minuchin and Mara Selvini from the 1970s that states in order for a sufferer of anorexia nervosa to recover the "family's structure or style of management [of problems] needs to be corrected." (Lock, & Grange, 2001) A compilation of peer reviewed journal studies as well as other reviews of anorexia nervosa family therapy treatment will be used to illustrate the effectiveness of family therapy for persons under the age of 19 suffering from anorexia nervosa. The literature will also show that more experimental studies are needed in this area of eating disorders, due to the lack of substantial research for eating disorders and their treatment methods. However, since family therapy has been used to treat anorexia, positive outcomes have been seen in areas of body weight, psychological symptoms, overall recovery many years after treatment, and family support when compared to individual therapies. However, for persons over the age of 19 traditional therapies are still lacking in significant recovery rates.
Anorexia nervosa is a variation of eating disorders that can plague both men and women. Anorexia is defined as "extreme emaciation" and the refusal to maintain a healthy body weight (Oltmanns, & Emery, 2010). Sufferers of this condition always have an unhealthy body image, also known as "a disturbed perception of the body," often feeling that there is nothing wrong with their bodies when they might weigh only 95 lbs (Oltmanns, & Emery, 2010). The third defining characteristic of anorexia is a "distorted body image," in which sufferers will usually see themselves as bigger than they are, no matter how emaciated they may appear (Oltmanns, & Emery, 2010). Also, anorexics will have an intense fear of gaining weight, which stems from their extreme use of control, which poses severe risks to therapy whose main purpose is to get anorexics to gain weight and remove them from any harm of death or brain damage (Oltmanns, & Emery, 2010). The final symptom of anorexia is Amenorrhea, or the cessation of the menstrual cycle, although a consideration of dropping this last criteria from the Diagnostic Manual has been recommended by some clinicians because some anorexics do menstruate (Oltmanns, & Emery, 2010). Prevalence for this disorder is approximately 5.1% among young women in the generalized population (Oltmanns, & Emery, 2010), which adds to the alarming fact that anorexia nervosa has severe negative consequences like interfering with puberty, breast development, cerebral abnormalities, severe depression (Hodes, Eisler, & Dare, 1991), with a mortality rate of 6-10% for adolescents (Lock, & Grange, 2001).
These alarming statistics only exacerbate the sad fact that so little is being studied about effective therapies for eating disorders. When 5.1% of young women could possibly develop a disorder that have such a high mortality rate, and such a high risk of causing severe developmental trauma to the body, obviously more research needs to be conducted. With what research has been conducted since the 1980s, family therapy seems to be the best method for treatment and recovery, but only for adolescents (Rhodes, 2003). According to Rhodes (2003), whose article outlines the Maudsley Model, those sufferers over the age of 18 or 19 are better off being treated with an individual program, but recovery statistics over a protracted period are still low. Family therapy seems to work so well with young adults because of its premise that the anorexic is not just by themselves with their disorder, but an individual who is part of a cohesive group as well (Nichols, & Shwartz, 2001). This form of therapy allows each member of the group to be directly honest about his or her feelings, while "developing a greater family cohesiveness," (Nichols, & Shwartz, 2001) which can serve to fix any problematic dynamics that might be found in families with a sufferer of anorexia, as well as allowing the family to be part of the treatment. However, as expressed before, family therapy works best with young adults, and one reason why it may not work with older teenagers is because the family has less power over their behavior and choice and the disorder has become more complex by this point (Nichols, & Shwartz, 2001).
In an article written by Paul Rhodes (2003) about the pioneering model for family systems approaching treatment with anorexics, Rhodes expands on the Maudsley Model's theory, application, and support it has received since its conception in the 1980s. Developed by Christopher Dare at the Maudsley hospital in London along with his colleagues, they were very influences by emerging theories that anorexia could act as a sort of "homeostasis" for the dysfunctional family, with the tension and disputes functioning in a cyclical manner. Dare ran a successful clinical trial of the treatment on 80 patients (Rhodes, 2003).
The resulting therapy follows a three step program; in the first phase the family all comes in for therapy with the child who is anorexic, and the therapist will ask pointed questions about how severe it is, how are they dealing with it now, how do they feel about it, etc. (Rhodes, 2003). Then, the therapist will ask the parents to form a team whose goal is to get the child to eat and to gain weight, which essentially amounts to the parents trying to get their child to eat just a little more than they normally would (Rhodes, 2003). This phase is known as "refeeding" and is very important not only to the child, but also to the parents who must always portray a unified front in getting their child to eat more, as well as the therapist who is monitoring the dynamic within the family and watching closely for High Expressed Emotion (EE), which can stress the family (Rhodes, 2003). The second phase is developing a new and trusting relationship with the child and giving them more responsibility to choose and eat food by themselves without prompting from the parents, and careful planning is used when the child will be away from the home during any mealtimes (Rhodes, 2003). When refeeding is a success and the child has gained weight and is back in control of feeding themselves, therapy now enters its third phase which consists of healing the family dynamic, talking about sensitive issues like sexuality or social friendships; parents are also asked to replace any negative feelings or criticisms with open communication and listening (Rhodes, 2003).
In a follow-up study conducted by Leslie Sim et al. (2004) in which Sim and her team replicated the Maudsley Model with two cases, a thirteen-year-old boy and an 18-year-old girl, and found that despite different sexes and ages the Maudsley Model was successful even when the cases were subject to both individual therapy and then family therapy. Previous to the family therapy model being used to treat anorexia, individual therapy was used which consisted of a collection of professionals working on one single case (such as a regular therapist, a group therapist, a family therapist, a psychiatrist, and a nutritionist), which has come to be known as "traditional treatment" for anorexics (Sim, et al. 2004). With Sim's (2004) case studies both patients improved greatly in body weight, although it is unknown if the psychological preoccupations with food, diet and body perception improved as well, as these issues were not the focus.
In a thorough study completed by Eisler, et al. (2005), and its five-year followup study by Eisler, Simic, Russell, and Dare (2007), has demonstrated the full effectiveness of family based therapy for anorexics. In the first study by Eisler, et al. (2005), 40 participants were used for the research, who on average were 15 years of age, had been ill for at least one year, were on average 25% underweight, and another 25% were bingeing and/or purging. Results showed that most showed vast improvement with their weight and how they felt psychologically, with a small percentage that dropped out, did not do well with treatment, or some developing bulimic symptoms. For those who did not do well it was more likely that they had been to treatment previously, or had been ill for a longer period of time. The obvious outcome for all four variations of the family therapy used for this study was that when parents were allowed to partake in the refeeding phase of therapy, recovery was more likely to take place than if they were not allowed to participate at all. One variation of family therapy was to see the patient on an individual basis as well as with the family present, which seem to have inconclusive results, but fared better than if the parents were not involved at all, which certainly speaks to mounting evidence that having the parents involved in the core therapy is extremely beneficial to full recovery.