Avoid being ‘tyrannised’ by the evidence: Reflections on family-based treatment in adolescent anorexia nervosa

Murray et al. (2012) have argued forcibly for a ‘united and consistent’ team approach in the use of family-based treatment (FBT; Lock et al., 2010) for adolescents and children with anorexia nervosa. This position is, I think, irrefutable. As in applying any therapeutic program, all members of the team need to be in agreement and supportive of each other. This is particularly so in the care of people with anorexia nervosa who struggle with resistance to change. Ego-syntonic features of the illness are strong and ambivalence in therapists can easily undermine an already fragile therapeutic engagement. FBT is demanding of time and persons and is at the least challenging if not at times confronting for families. For most, it is, however, likely to be successful, and to be at least as effective as any other approach. Properly applied it has all the features Frank (1972) listed as common to an effective psychotherapy; namely, an intense, emotionally charged confiding relationship with a helping person, a rationale for the therapy, including an explanation of the patient’s cause for distress and method for relieving it, new information concerning the patient’s problem(s) and alternate ways of dealing with it/them, strengthening expectations of help, provision of success experiences and facilitation of emotional arousal.

Mindful of Frank (1972), it is important not to forget that other family approaches have also been evaluated in young people with anorexia nervosa and, as is not uncommon, it has been difficult to demonstrate that any one therapy is superior to another. (Interpersonal psychotherapy for depression or bulimia nervosa is a good example of a ‘control’ psychotherapy that has emerged to be an active therapy.) Following the seminal trial by Russell et al. (1987), randomised controlled trials (RCTs) have been conducted in anorexia nervosa comparing different forms and intensities of family therapy as well as comparing family therapy to individual therapies or ‘treatment as usual’-type conditions. With two exceptions, RCTs have generally failed to demonstrate that one form or intensity of family therapy is superior to another form in adolescents with anorexia nervosa. Lock et al. (2005) reported that at follow-up 20 sessions were favoured over 10 sessions of FBT in subgroups of those with more severe symptoms and non-intact families. Similarly, in a subgroup analysis, Eisler et al. (2000) reported separated therapy (where parents are seen apart from the child) to be favoured over conjoint therapy in families where maternal criticism was high. RCTs (e.g. Godart et al., 2012; Lock et al., 2010; Robin et al., 1999) have been more supportive of family therapy when compared with individual therapies in adolescents (but not adults) with anorexia nervosa. However, only one of these RCTs was of FBT (Lock et al., 2010) and the individual therapy conditions were not active evidence-based controls.

The research finding differences in outcomes across subgroups indicates that different approaches may be more or less successful with different families. As Tolstoy said, ‘every unhappy family is unhappy in its own way’. Murray et al. (2012) rightly caution against avoiding FBT and misjudging families as the cause rather than part of the solution to the child’s illness. However, for diverse reasons, FBT is not appropriate for all families. Access and financial and other barriers to FBT continue to be problematic for many. Involvement of the parents is likely a key factor, but is engagement of the whole family necessary? For example, a recent study points to parental control but not sibling support in effecting change in FBT (Ellison et al., 2012).

There is agreement that FBT requires further testing head-to-head against other active child and adolescent therapies (Lock et al., 2010). Different models of family-based interventions that show promise, such as group-based multifamily therapy (Fairbairn et al., 2011), are also being developed and trialled. The field would benefit from further research efforts investigating what is common amongst effective therapies for adolescent anorexia nervosa and modifications or variations of FBT that improve its accessibility and broaden its applicability. In the meantime, clinicians need to remain open to adapting or modifying treatment if indicated. This does not diminish the importance of team cohesion.

See Viewpoint by Murray et al., 2012, 46(11): 1026–1028