Family Therapy for Child and Adolescent Eating Disorders: A Critical Review

• Author: Tom Jewell,Mima Simic,Catherine Stewart,Ivan Eisler,Esther Blessitt
• Published date: 01 September 2016
• Date: 01 September 2016
• DOI: http://doi.org/10.1111/famp.12242

Family Therapy for Child and Adolescent Eating

Disorders: A Critical Review

TOM JEWELL*

ESTHER BLESSITT

†

CATHERINE STEWART*

,†

MIMA SIMIC

†

IVAN EISLER

†

Eating disorder-focused family therapy has emerged as the strongest evidence-based treat-

ment for adolescent anorexia nervosa, supported by evidence from nine RCTs, and there is

increasing evidence of its efficacy in treating adolescent bulimia nervosa (three RCTs). There

is also emerging evidence for the efficacy of multif amily therapy formats of this treatment,

with a recent RCT demonstrating the benefits of this approach in the treatment of adolescent

anorexia nervosa. In this article, we critically review the evidence for eating disorder-focused

family therapy through the lens of a moderate common factors paradigm. From this perspec-

tive, this treatment is likely to be effective as it provides a supportive and nonblaming context

that: one, creates a safe, predictable environment that helps to contain anxiety generated by

the eating disorder; two, promotes specific change early on in treatment in eating disorder-

related behaviors; and three, provides a vehicle for the mobilization of common factors such

as hope and expectancy reinforced by the eating disorder expertise of the multidisciplinary

team. In order to improve outcomes for young people, there is a need to develop an improved

understanding of the moderators and mediators involved in this treatment approach. Such

an understanding could lead to the refining of the therapy, and inform adaptations for those

families who do not currently benefit from treatment.

Keywords: Family Therapy; Common Factors; Adolescence; Eating Disorders; Anorexia

Nervosa; Bulimia Nervosa

Fam Proc 55:577–594, 2016

INTRODUCTION

In this article, we provide a critical review of the evidence for eating disorder-focused

family therapy (Eisler, Le Grange, & Lock, 2015) for children and adolescents. We will

look at the evidence as it pertains to anorexia nervosa (AN) and bulimia nervosa (BN), the

two disorders that have been most studied in the child and adolescent population. AN is a

disorder characterized by significantly low weight, dietary restriction, intense fear of

weight gain and distorted body image, and consists of restricting and binge/purge sub-

types (American Psychiatric Association, 2013). BN is characterized by a similar fear of

*Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK.

†

South London and Maudsley NHS Foundation Trust, London, UK.

Correspondence concerning this article should be addressed to Tom Jewell, Section of Family Therapy,

Box PO73, Institute of Psychiatry, King’s College London, De Crespigny Park, Denmark Hill, London,

SE5 8AF. Email: tom.1.jewell@kcl.ac.uk

This study was supported by National Institute of Health Research (NIHR) Clinical Doctoral Research

Fellowship, Tom Jewell, CDRF-2014-05-024. The views expressed are those of the author and not neces-

sarily those of the NIHR.

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Family Process, Vol. 55, No. 3, 2016 ©2016 Family Process Institute

doi: 10.1111/famp.12242

weight gain, as well as binge eating followed by compensatory behaviors such as vomiting

or laxative abuse. Using DSM-5 criteria (American Psychiatric Association, 2013), the life-

time prevalence of AN is 1.7%, while for BN it is 0.8% (Smink, van Hoeken, Oldehinkel, &

Hoek, 2014).

The evidence for treatment of child and adolescent eating disorders has been reviewed

extensively in recent years. Systematic reviews have concluded that family therapy for ado-

lescent anorexia nervosa (FT-AN)

1

has strong evidence of efficacy (Lock, 2015; Watson &

Bulik, 2013), with higher rates of recovery at 6- and 12-month follow-up as compared to

individual therapy (Couturier et al., 2013a), 2013; Downs & Blow, 2013; Lock, 2015; Watson

& Bulik, 2013). FT-AN is the recommended treatment for adolescent AN in clinical guideli-

nes for a number of countries, such as the United States (American Psychiatric Association,

2006) and United Kingdom(National Institute for Clinical Excellence, 2004), and is the only

well-established treatment available for this population (Lock, 2015). The evidence for psy-

chosocial treatments of BN is more limited, but family therapy for adolescent bulimia ner-

vosa (FT-BN) has been found to be superior to cognitive behavior therapy (CBT) in a recent

randomized clinical trial (RCT; Le Grange, Lock, Agras, Bryson, & Jo, 2015). Previous stud-

ies of FT-BN have shown it to achieve comparable outcomes to CBT (Schmidt et al., 2007)

and superior outcomes to supportive psychotherapy (Le Grange, Crosby, Rathouz, & Leven-

thal, 2007). Evidence is also accumulatingfor the efficacy of multifamily therapyformats, in

which several families with a child with an eating disorder come together for intensive

group treatment (Eisler et al., in press; Simic & Eisler, 2015).

In this article, we will review the evidence for eating disorder-focused family therapy

through the lens of the common factors paradigm (Sprenkle, Davis, & Lebow, 2009; Wam-

pold, 2010). This perspective emphasizes the importance of variables which apply across

all therapeutic models, such as client and therapist factors, therapeutic alliance, therapist

allegiance to the treatment model, and the mobilization of client hope or expectancy. As

these common factors have been argued to account for a much greater proportion of vari-

ance in outcome than the specific model employed in treatment (Asay & Lambert, 1999),

the common factors paradigm lends itself to a critical appraisal of the evidence for any

empirically supported treatment—particularly claims of greater efficacy relative to other

treatments. While the common factors paradigm has sometimes led to polarized debates

about the relative merits of common factors as compared with specific models and tech-

niques, it is possible to take a ‘moderate common factors’ position: that is, both accepting

that common factors are key ingredients to successful psychotherapy, and yet remaining

open to the possibility that specific aspects of a treatment model or particular techniques

can be superior for particular difficulties or subgroups of clients (Sprenkle et al ., 2009). In

this article, we will be adopting just such a position in our review of the evidence.

DESCRIPTION OF THE TREATMENT

Family Therapy for Anorexia Nervosa (FT-AN)

The core features of FT-AN include the following: a clear focus on working with the fam-

ily to help their child recover, coupled with a strong message that the family is not seen as

1

Eating disorder-focused family therapy has been variously referred to as the Maudsley approach, the

Maudsley Model of family therapy, or Family-Based Treatment (FBT), but these terms can be ambiguous

as they are also sometimes used to refer specifically to a particular treatment manual. For consistency and

clarity, in this article we will use the term ‘eating disorder-focused family therapy’ (FT-AN or FT-BN) as

an umbrella term, and then describe adaptations of this approach for anorexia nervosa (FT-AN) and buli-

mia nervosa (FT-BN), including both single and multi-family therapy formats. In this article we use terms

such as FBT or BFST (Behavioral Family Systems Family Therapy for anorexia nervosa) to refer specifi-

cally to studies using particular manualized forms of this treatment.

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