Evaluation of Family Treatment Models for Eating Disorders

James Lock


Curr Opin Psychiatry. 2011;24(4):274-279. 

In This Article

Why Family Interventions for Children and Youth with Eating Disorders?

There are few treatment studies for eating disorders in children and adolescents, but, among those that have been conducted, family interventions have figured prominently in most of them. This is in distinct contrast to the lack of any family interventions included in RCTs for adult eating disorders. The main reason for this is that most researchers studying adults did not consider this as an option for adults, whereas, for developmental reasons, including family members in treatment appears reasonable for younger patients.[24] However, it should be noted that exclusion of families from treatment of child and adolescent eating disorders was the mainstay of treatment for almost a century after anorexia nervosa was first described in the medical literature. Families, and parents in particular, were seen as causing, exacerbating, and interfering with recovery.[25,26] As a result, the mainstay of treatment was hospitalization that excluded or severely curtailed family involvement. Even in outpatient treatment, emphasis was placed on the adolescent's need for separation, individuation, and autonomy. From this perspective, the symptoms of anorexia nervosa were evidence of conflicts and ambivalence about achieving these developmental tasks.[27–29]

There is evidence of familial aggregation of eating disorders, and heritability estimates range from 30 to 60% according to a recent comprehensive review on this subject. However, there is little systematic evidence supporting the view that families cause eating disorders.[30] Nonetheless, beginning in the late 1970s, Minuchin et al.[31] developed the theory of the psychosomatic family – enmeshed, rigid, avoidant, and overprotective – to describe a risky family constellation for anorexia nervosa. Studies to date have not supported this theory. However, Minuchin and colleagues devised the first family approach to anorexia nervosa – structural family therapy – and presented the first case series data demonstrating that involving the family in treatment could be helpful. Other family therapy approaches for anorexia nervosa were developed.[32,33] However, the approach created by investigators at the Maudsley Hospital (i.e., FBT) in the 1980s is the only one to be systematically investigated to date.[34]

When the Maudsley group began their work, there was no clear guiding theory behind the strategies they developed. Instead, experience with families, nursing staff, and a belief that outpatient treatment was preferable to inpatient intervention were guiding principles. However, more recently, Eisler[35] has suggested that this approach addresses accommodations the family has inadvertently made to the problems that anorexia nervosa has introduced to the family. As a result of these unwitting accommodations, families are ineffective in making necessary changes to address the behaviors that maintain eating disorders. Family therapy aims to help them identify these ineffective accommodations and find ways to help the family to change them.

When the first RCT examining treatments focused exclusively on adolescents with anorexia nervosa was published in 1987,[10] there was no manual describing the approach. Lock et al.[36,37] manualized the approach and named it FBT. By manualizing the approach, FBT could be consistently and reliably delivered in many sites and tested using more rigorous methods. In the manualized format, the treatment consists of three distinct phases. The first phase focuses on helping parents take charge and manage severe dieting and over-exercise; the second phase transitions control of these behaviors gradually back to the adolescent in an age-appropriate manner; and the third phase focuses on the impact of anorexia nervosa on adolescence. Sessions last about 1 h and involve the entire family. Between 10 and 20 sessions over a 6–12-month period are typically needed for FBT.