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What Works?

Family therapy for adolescents with anorexia nervosa

Ronald S. Manley, PhD, RPsych, Pat Roles, MSW, BCAT

Reprinted from "Treatments for Young People" issue of Visions Journal, 2006, 3 (1), p. 17-18

Anorexia nervosa is a devastating illness that affects around 0.3% of young women (or about one in every 200 girls).1 Boys are affected as well. Sufferers of this illness have a strong fear of becoming fat and may even believe they are fat when they are actually underweight. This distortion of body image is real for them. Individuals with anorexia nervosa try to keep a low body weight through restricting food, over-exercising or through purging food after eating (making themselves vomit, or using laxatives).

This illness most often develops during the early to mid teens, a time of life brings great change. Changes include physical, social and emotional growth and development, shifts in peer relationships, emerging sexuality, greater independence from family, a move to high school or leaving school at graduation. Overwhelmed by these demands, some children with risk factors, such as low self-esteem, may develop an eating disorder as a way of attempting to cope with these pressures and changes. The illness is a way of communicating to others that something is not working for them in their life.

Treatment requires a team approach, which can include doctors, psychologists, social workers, nurses and nutritionists. Treatment approaches have changed greatly over the years. There used to be a reliance on behavioural approaches, such as a reward system where the individual earned privileges for weight gained. Now, efforts are directed more toward working on motivation to recover and self-responsibility for recovery.

Why family therapy?

These young people live in the context of their family. The family, therefore, can be an important resource in supporting the young person in their difficult process of gaining weight and becoming psychologically healthy.

Family therapy is the process of a therapist meeting with a patient and family members to help the family work together to solve the problem, since anorexia affects the whole family. This may include counselling with parents alone.

Family therapy is not aimed at the family as the cause for an eating disorder. Parents often feel blamed and do much soul-searching about what they did or did not do that may have resulted in the eating disorder. Sometimes parents’ fears overwhelm them, interfering with their ability to support their child effectively. It is important to enlist family members, in a non blaming way, to work together with the treatment team so they can understand how to support their daughter or son through the process of recovery. Family members also need to look after themselves during this often lengthy recovery process.

Maudsley approach?

Research in the family therapy field has provided very encouraging results in answering the question: how can we best support an adolescent with anorexia nervosa in getting better? Some such early research took place at the Maudsley Hospital in London, England.

Adolescents have been found to do better with family therapy than with individual therapy.5 In the Maudsley approach, family members are supported to work directly with their daughter or son in encouraging them to eat, rather than being encouraged to “back off” from actively trying to get their child to eat. Control over eating is not returned solely to the adolescent until she/he has achieved a healthy weight. Only then does the therapy directly address issues less closely related to the eating behaviour itself.

One review reported that, of patients who were assessed five years following treatment, three quarters were found to have a good outcome

The same review reports on another study that compared two types of family therapy: 1) involving the child in the family therapy, and 2) involving only the parents. The fi ndings showed no difference in the outcome.2 This result suggests that working with the parents alone is as important as involving the child in the process. It is essential that parents be able to work with one another and be consistent in their approach to their child, even if the parents are separated or divorced.

What’s new in family therapy?

The family-based treatment for anorexia developed at the Maudsley Hospital has been developed into a manual for therapists.2,3,6,7 This is important because it means the treatment has been standardized and so allows researchers to study it more carefully. Standardization also means the therapy can be adopted in a variety of treatment centres, since the manual outlines how the treatment should proceed.

More recently, a type of therapy called multiple-family day treatment has emerged as part of the Maudsley approach.2,4 This type of family therapy is conducted with several families at one time, and views the family as an important resource in helping their adolescent to regain weight. Families meet together over several days, as opposed to the more traditional once-aweek family therapy approach. They hear about and share stories, discover more about their own resources and focus on solutions. These are experiences that empower families.2,4 Improvements with this approach have been reported in a number of areas, such as gaining weight and binge eating and purging less. It is particularly noteworthy that the drop-out rate has been low. Both patients and parents have provided good feedback about this treatment.

A proposal has recently been made to consider the multiple-family therapy situation as a “community of concern”8 and to enhance this therapy with practices taken from narrative therapy. Narrative therapy9 is an approach that helps people redefi ne their relationship to the problem through “restorying” (the client constructs a new, empowering and preferred story about themselves and their life). An example of incorporating a narrative therapy strategy would be to expand the traditional family therapy format by having parents who have already gone through treatment be consultants to families who are in treatment.

Where are we now?

At this time we can say more clearly, although not conclusively, that family therapy is the “treatment of choice” for children and younger adolescents with a short duration of anorexia.2,3,7 While we also need to study other treatments for comparison with the results of family therapy,3 it is clear that we need to welcome family members as part of the overall treatment team for youth with anorexia nervosa. For an illness that is so devastating to patients and their families, the favourable outcomes of this treatment approach are welcome news indeed.

About the Authors

Ron is Clinical Director of the Eating Disorders Program at BC Children’s Hospital, and Clinical Assistant Professor in the Department of Psychiatry at UBC

Pat is Social Worker and a family therapist in the Eating Disorders Program at BC Children’s Hospital, and is Clinical Coordinator in the BCCH Social Work department

  1. Gowers, S. & BryantWaugh, R. (2004). Management of child and adolescent eating disorders: The current evidence base and future directions. Journal of Child Psychology and Psychiatry, 45(1), 63-83

  2. LeGrange, D. (2005). The Maudsley family-based treatment for adolescent anorexia nervosa. World Psychiatry, 4(3), 142-146.

  3. LeGrange, D. & Lock, J. (2005). The dearth of psychological treatment studies for anorexia nervosa. International Journal of Eating Disorders, 37, 79-91

  4. Lock, J. (2006). Update on Maudsley type family therapy for eating disorders. The Renfrew Centre Foundation Perspective, Winter, 19-20.

  5. Russell, G.F., Szmukler, G.I., Dare, C. et al. (1987). An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44(12), 1047-1056

  6. Lock, J., LeGrange, D., Agras, W.S. et al. (2001). Treatment manual for anorexia nervosa: A family based approach. New York: Guilford Publications.

  7. LeGrange, D. (2004). Family-based treatment for adolescent anorexia nervosa: A promising approach? Clinical Psychologist, 8(2), 56-63

  8. Rhodes, P., Gosbee, M., Madden, S. et al. (2005). ‘Communities of concern’ in the family-based treatment of anorexia nervosa: Towards a consensus in the Maudsley model. European Eating Disorders Review, 13(6), 392-398

  9. White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.

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