The clinical and empirical aspects of MFT for eating disorders

1. The clinical and empirical aspects of MFT for eating disorders Ivan Eisler Kings College, Institute of Psychiatry, Child and Adolescent Eating Disorders Service SLAM London, April 2010

2. Evidence for the effectiveness of family therapy for adolescent anorexianervosa

3. Outcome of family therapy in adolescent AN Open follow-up studies of family therapy in adolescent anorexia nervosa Minuchin et al 1978 Dare, 1983 Martin, 1985 Stierlin & Weber 1989 Mayer, 1994 Herscovici & Bay 1996 Le Grange et al 2005 Lock et al 2007 RCTs of family therapy in adolescent anorexia nervosa Russell et al 1987; Eisler et al 1997 Le Grange et al 1992; Squire-Dehouck 1993 Eisler et al 2000; Eisler et al in 2007 Robin et al 1994; Robin et al 1999 Ball & Mitchell 2005 Lock et al 2005; Lock et al 2006 Lock et al 2010 Eisler et al 2010

4. Russell et al 1987 Family therapy Individual therapy

5. Robin et al 1999 Family therapy Individual therapy

6. Lock et al (in press) Family therapy Individual therapy

7. Outcome of family therapy in adolescent AN • By end of treatment 50-75% reach a healthy weight • At follow-up 75-90% are well • FT leads to significantly better weight gain than individual therapy • Differences between family therapy and individual therapy continue for up to 5 years • Relapse rates following successful FT are generally low (< 10%) • Different types of family may benefit more from particular types of family intervention Open follow-up studies of family therapy in adolescent anorexia nervosa Minuchin et al 1978 Dare, 1983 Martin, 1985 Stierlin & Weber 1989 Mayer, 1994 Herscovici & Bay 1996 Le Grange et al 2005 Lock et al 2007 RCTs of family therapy in adolescent anorexia nervosa Russell et al 1987; Eisler et al 1997 Le Grange et al 1992; Squire-Dehouck 1993 Eisler et al 2000; Eisler et al in 2007 Robin et al 1994; Robin et al 1999 Ball & Mitchell 2005 Lock et al 2005; Lock et al 2006 Lock et al 2009

8. Intensive multi-family group therapy for adolescent anorexia nervosa

9. Families and eating disorders • The myth of the “psychosomatic family” • The family as a resource • Family reorganisation around illness

10. Family life and eating disorder • The central role of the symptom in family life • Narrowing of time focus on the here-and-now. • Restriction of the available patterns of family interaction processes. • The amplification of aspects of family function • Diminishing ability to meet family life-cycle needs • The loss of a sense of agency (helplessness) Eisler, I. (2005) The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa. Journal of Family Therapy, 27, 104 – 131. Whitney J. & Eisler I. (2005) Theoretical and empirical models around caring for someone with an eating disorder: The reorganization of family life and inter-personal maintenance factors. Journal of Mental Health,14, 575 – 585

11. Family Therapy for Adolescent ANGeneral principles • Treatment with the family vs treatment of the family • Identifying strengths and mobilization of family as a resource • Central focus on helping family to find solutions • The role of information giving • Expertise in eating disorder vs expertise in family

12. Family Therapy for Adolescent ANGeneral principles • Challenging disabling family beliefs, perceptions and meanings (e.g. beliefs about guilt and blame) • Blocking the central role of the symptom in the family organization • Reinforcing of the family adaptation processes that enable developmentally appropriate family life-cycle changes

13. Intensive MFG programme for adolescent anorexia nervosa • Initial assessment of the patient and the family • Introductory evening • Four day intensive programme (10.00 - 16.00) • 5 – 7 one day follow-up meetings over 9 months • Individual family therapy sessions between meetings depending on need • Follow-up of individual and family as needed

14. Introductory evening • Welcome • Staff introductions • Description of aims and structure of 4 day programme • Presenting details of snacks and lunch times • Psycho-educational talk on the effects of a starvation • In smaller groups e.g. parents group and YP group, people introduce themselves to each other and meet “graduate” family members from previous groups. • Q&A

15. Tuesday 9.30 – 10.00 MFG staff meeting 10.00-11.00 Multi family introduction [interactional – e.g get families to introduce one of the families who they met at the Introductory evening, exploring expectations from the MFG. 11.00 – 11.30 Morning Snack +weighing of the AN young people 11.30 – 12.45 Parents: lunch that day planning Young people (YP): ‘Portraying anorexia’ (draw, model or write something that symbolizes anorexia for you/your family) 12.45 - 2.00 Multi Family Lunch/observing YP’s eating patterns, how parents mange YP’s eating, intervening to promote change in patterns 2.00 – 3.00 Extensive feed back on first lunch experience of all families to each other (separate groups observing) 3.00 – 3.30 Afternoon Snack 3.30 – 4.30 Reflections on the ‘portrayals of anorexia’ and pros and cons of staying anorexic

16. Friday 9.30 – 10.00 MFG staff meeting 10.00 - 11.00 Individual Families: Time line – how might things look in the year ahead. 11.00 – 11.30 Morning Snack + weighing of YP 11.30 – 12.45 Joint discussion of time charts 12.45 - 2.00 Multi-Family Lunch 2.00 - 3.00 Reconstituted family groups: Developing survival toolkits for mothers, fathers and young people 3.00 – 3.30 Afternoon Snack 3.30 – 4.30 Multi-family Group: Feedback from families and discussion of future plans

17. Exploring patients’ and parents’ perspectives of multi-family therapy

18. Qualitative study Participants • 16 patients (1 male) • 18 mothers • 10 fathers Measures • Individual interviews • Open-ended questions about the helpful and unhelpful aspects of multi-family day treatment • Completed 2 - 4 weeks after the initial treatment block • Overall participants described a helpful and positive treatment experience

19. Support network for patients and parents For parents: • Being understood • Reducing guilt and isolation • Sense of belonging • Feelings of reciprocity For patients: • Reducing isolation

20. Perceived changes in the patients/main themes • Realisation of A.N and understanding of the seriousness of the illness. • Talking openly with other people in the group in a way that family may have not been able for sometime. • Empathising with parents and siblings

21. Perceived changes in the parents/main themes • Gaining insight into the illness • Reality checking • Empathy • Belief that they can do something to help their child recover • Strengthening the parental role • Permission to exercise parental authority • Hope/optimism and determination re future without AN • Increased sense of self efficacy • Improved relationships/communication within the family

22. Pre-treatment assessment Three month assessment End of treatment assess. Six month FU assessment Multi Centre trial of Adolescent Anorexia Nervosa Referral to Maudsley, St Georges, Blackwater valley, Vincent Sq, Royal Free (+Dresden) Refuse randomisation Agree to randomisation Multi-family group treatment Single family therapy N=84 N=83

23. Eisler et al (in preparation) Family therapy Multi-family therapy

24. Benefits of intensive MFG • Bringing together families with shared experiences • Focusing on the impact the problem has had on family life • Rediscovering family strengths and resilience to enable parents take s central role in tackling their daughter’s eating problems • Creating new and multiple perspectives and helping families to take an observational stance • Offering expertise in the context of a highly collaborative therapeutic relationship • To address problematic family interactions and communications, that have developed around the eating problems