Mental health across the lifespan

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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 multifamily 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

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INTRODUCTION

In this article, we provide a critical review of the evidence for eating disorder-focusedfamily 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: [email protected] 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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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 accumulating for the efficacy of multifamily therapy formats, 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

1Eating 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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the cause of the problem; expecting the parents to take a lead in managing their child’s eating in the early stages of treatment; externalizing the eating disorder; and a shifting of focus on to adolescent and family developmental life cycle issues in the later stages of treatment (Eisler, Wallis, and Dodge, 2015). While the treatment has been manualized by a number of research teams, the different treatment manuals all adhere to the core princi- ples just outlined (for more detailed discussion see Eisler, Wallis, and Dodge, 2015). In this article, we describe the treatment as operationalized in the Maudsley service manual (Eis- ler, Simic, Blessitt, Dodge & team, 2016).

In our conceptualization, the treatment is an integrative four-phase systemic treatment model delivered by a therapist in the context of a specialist multidisciplinary eating disor- ders team setting. In Phase 1, Engagement and development of therapeutic alliance, the child is assessed alongside their parent/s. The assessment process has a strong multidisci- plinary focus that includes a psychiatric frame (confirming the diagnosis, identifying coex- isting problems such as anxiety, depression, or self-harm), a medical/pediatric frame (evaluating medical and physical risks that have to be managed safely), an individual psy- chological frame (exploring motivation to change, identifying cognitive and temperamen- tal characteristics of the young person), as well as a family systems frame (developing a systemic formulation and identifying areas of family strengths and resilience), but the assessment is also the beginning of the process of engagement between therapist and fam- ily. The therapeutic engagement should include all family members including the young person even though they may often appear to be a reluctant participant at first. The thera- pist offers information about AN and the physiological as well as psychological effects of starvation (Keys, Brozek, Henschel, Mickelson, & Taylor, 1950), highlighting the fact that many of the phenomena associated with eating disorders are characteristic of anyone in a state of starvation. The providing of expert information thus becomes part of the process of externalizing the illness reinforced by “externalizing conversations” (White & Epston, 1990), with the aim of developing a therapeutic ethos of nonblame and guilt reduction. The inclusion of a medical examination at assessment helps to engender an appropriate atmosphere of concern, promotes a message to the parent/s that they need to act urgently to reverse the effects of starvation, and contributes to the development of a safe base for treatment. During the final part of the assessment, a meal plan is presented to the parents as a ‘prescription’ for recovery. The family is reassured that the therapist will work along- side them, beginning with a family meal within the next week where further advice and information will be provided by the therapist. Weekly appointments are the norm during the early stages of treatment while parent/s and patient struggle with the demands of feeding and weight restoration.

In Phase 2, Helping families manage the eating disorder, the therapist continues to encourage parents to take a lead in managing their child’s eating, while emphasizing the temporary nature of this role. The child is weighed by the therapist at the start of each session with the focus of therapy then being dictated by the weight trajectory. Therapeutic tasks in this phase will include detailed exploration of what happens at mealtimes, explor- ing parental roles, increasing parents’ sense of agency, for instance through challenging beliefs about the impossibility of parental action, and sharing examples of what other fam- ilies have done to overcome similar difficulties. While much of the focus is on how the par- ents can help their child, it is important for the therapist to maintain a good engagement with the young person, discussing broader goals that can be achieved as physical health is gradually restored.

With most families this phase tends to have a fairly behavioral focus, and relational issues that are raised are noted as important but left to be “addressed at a later stage when the physical concerns have been resolved”. With a minority of families progress at this stage is, however, more problematic and broader issues need to be addressed with the

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family. Most commonly this slower progress happens in the context of a more complex individual and/or family presentation (Simic et al., 2016). This will tend to include higher levels of comorbidity, the young person may be emotionally dysregulated and the clinical picture may include episodes of self-harm and a binge/purge rather than a pure restricting presentation. At a relational level, there is often increased negativity or hostility and inse- cure patterns of attachment (Jewell et al., 2016). Attachment and emotion-focused family interventions (Diamond, Diamond, & Levy, 2014; Robinson, Dolhanty, & Greenberg, 2015) may be usefully employed to overcome the impasse that can develop at this stage.

Therapy moves to the third stage, Exploring issues of individual and family develop- ment, once weight restoration has largely been achieved or is well under way. This marks a move in therapy toward handing back age-appropriate responsibility to the patient and supporting parent/s to re-focus on their individual needs and those of other family mem- bers. The presence of an eating disorder, like any other serious and life-threatening condi- tion, can cause great disruption to family organization (Eisler, 2005). These effects are explored and addressed during this phase of treatment. The move to Phase 3 is generally also marked by a change in the nature of the therapeutic alliance. In the early stages of treatment, the therapeutic alliance tends to be characterized by dependence on the thera- pist, reinforced by the therapists’ expertise, willingness to give advice, and share experi- ences of successful strategies that other families have employed. The family’s dependency on the therapist in the early stage of treatment parallels the temporary increased depen- dency of the young person on the parents that the therapy advocates. Just as at the later stage of therapy the parents are encouraged to start handing back responsibility to the young person (and the young person is encouraged to reassert their wish for indepen- dence), the therapy also needs to address the dependent relationship of the family on the therapist.

Ending treatment, discussion of future plans and discharge is the final phase of treat- ment. The therapist in Phase 4 may encounter parental anxiety which is out of step with their child’s progress and therefore sessions in this phase include discussions about relapse prevention, tolerance of uncertainty, reviewing the course of recovery, and some reflection on the expertise of parents and child to manage future difficulties.

Multifamily Therapy for Anorexia Nervosa (MFT-AN)

MFT-AN draws on the four-phase treatment model in a group therapy for 5–7 seven families at one time. MFT-AN commences with an introductory afternoon comprising a lecture highlighting the psychological and physical consequences of starvation. Par- ents and young people then meet a ‘graduate family’—a family who have previously been through the MFT-AN process—who share their experiences of the group. This meeting is followed by four intensive days of therapy with up to five follow-up days over the following 6 to 9 months. The intensive nature of the treatment has been described as creating a ‘hothouse effect’ (Asen & Scholz, 2010), which makes it a pow- erful context for mutual learning, reducing the sense of isolation and stigma and increasing a sense of hope and the likelihood of change. In addition to the program of therapeutic sessions (see Simic & Eisler, 2015, for details), families also have their meals and snacks together in communal areas, providing multiple opportunities for in vivo learning and support.

Family Therapy for Bulimia Nervosa (FT-BN)

FT-BN differs somewhat from the FT-AN model. FT-BN sessions are far more likely to feature separated sessions, with the therapist meeting the young person and par- ent/s on their own at least early on in treatment. Greater attention is focused on

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building a therapeutic engagement between the therapist and the young person in order to ensure that issues of motivation to change and building trust within the fam- ily can be addressed early on. Early sessions with parents provide psychoeducation, practical parenting skills, and coaching with an emphasis on reducing criticism, blame, and guilt. Validation skills are promoted as a way of supporting future change. Early separated interventions in FT-BN provide a foundation for later conjoint ses- sions, when issues of communication and collaboration can be enhanced to support behavioral change.

Multifamily Therapy for Bulimia Nervosa (MFT-BN)

MFT-BN shares some similarities with MFT-AN, with similar benefits arising from the group process as described above. It provides a group learning opportunity but with ses- sions spaced weekly over 4 months, allowing for a slower process of change, and providing space for reflection and practice of the skills learned. Similarly to FT-BN, initial group meetings have more separate parallel sessions with young people and the parents. The shared context of the MFT group allows parents to feel that they are not alone in dealing with the frustrations and difficult behaviors of their child. Alongside systemic tasks and exercises, elements of both Dialectical and Cognitive-Behavioral approaches are combined to address the unique needs of this patient group (Stewart, Voulgari, Eisler, Hunt, & Simic, 2015).

EFFICACY RESEARCH

The eating disorders field provides a challenging context in which to conduct research. The relative rarity of AN means that multiple sites are often needed to recruit sufficient numbers into an RCT (Watson & Bulik, 2013). In the case of BN, recruitment to studies can also be problematic, as help-seeking is typically delayed by 4–5 years (Turnbull, Ward, Treasure, Jick, & Derby, 1996), meaning that many adolescents with BN are not present- ing to services until adulthood. A further challenge for research is that the urgent medical risks presented by eating disorders, particularly AN, mean that providing a wait-list con- dition in any efficacy trial raises important ethical issues (Watson & Bulik, 2013). This means that treatments under investigation have to go up against other credible, bona fide treatments. This provides a sterner test of efficacy, but provides a methodological chal- lenge in a field with few established treatments.

Relative Efficacy of FT-AN

Three RCTs have investigated the efficacy of family therapy as compared with individ- ual therapy for AN. The first of these, by Russell, Szmukler, Dare, and Eisler (1987), was conducted at the Maudsley Hospital in London, and involved a sample of 57 participants with AN and 23 participants with BN. Participants included both adolescents and adults, and they were divided into four subgroups: one group with BN, and three groups with AN grouped by duration of illness and age at onset of illness. These subgroups were then ran- domized to family or individual therapy. After 1 year of treatment, in the subgroup of AN participants aged under 19 at illness onset and an illness duration of less than three years (n = 21), 90% of those receiving family therapy achieved better categorical outcomes (based on weight, menstruation status, and presence of bulimic behaviors) compared to 18% of those receiving individual therapy. These differences persisted at 5-year follow-up (Eisler et al., 1997). The findings of this influential study are compromised by a number of limitations. Firstly, the lack of manualization of the treatments delivered means that the study would no longer meet criteria for inclusion as evidence for an empirically supported

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treatment (Lock, 2015). Secondly, the sample size for the group which showed superior efficacy of FT-AN is very small. Thirdly, the supportive individual therapy arm was not a bona fide therapy, as it lacked a theoretical model of change or clear focus for treatment.

Robin et al. (1999) conducted a small RCT (n = 37) comparing family therapy and indi- vidual therapy in the treatment of adolescents (aged 11–20) with AN. The behavioral fam- ily systems therapy (BFST) used by Robin and colleagues had many similarities with the approach developed at the Maudsley (Eisler, Wallis, and Dodge, 2015; Robin et al., 1999). The comparison treatment consisted of Ego-Oriented Individual Therapy (EOIT), a treat- ment derived from psychodynamic principles. The therapist saw adolescents on a weekly basis, and met with parents fortnightly, although unlike in the family intervention, the parents were encouraged not to get directly involved in the management of mealtimes. BFST resulted in significantly greater increases in body mass index (BMI) at end of treat- ment (BFST mean change 4.7; EOIT mean change 2.3) and at 1-year follow-up (BFST 5.5; EOIT 3.2). Approximately two-thirds of the adolescents reached the target weights (set individually by their pediatrician) at end of treatment with no differences between the treatment arms. Significantly more girls in the BFST group (94%) than in EOIT (64.4%) had resumed menstruation by the end of treatment.

The largest efficacy trial comparing FT-AN and individual work was conducted by Lock et al. (2010). About 121 adolescents with AN were randomized either to a manu- alized family therapy based on the Maudsley approach, referred to as Family-Based Treatment (FBT), or to an individual therapy referred to as Adolescent-Focused Ther- apy (AFT), a modification of EOIT used in Robin et al.’s (1999) study. At the end of treatment, there was no statistical difference between the two treatments in terms of rates of full remission, although FBT was statistically superior in terms of partial remission, participants’ BMI percentile, and hospitalization rates. FBT was signifi- cantly superior in terms of rates of full remission at 6-month (FBT = 40% vs. AFT = 18%) and 12-month follow-up (FBT = 49%; AFT = 23%). Full remission was defined as a participant achieving a minimum of 95% expected body weight adjusted for sex, age, and height, and scores within one standard deviation of community norms for self-reported eating pathology.

Relative Efficacy of FT-BN

There have been three RCTs of FT-BN. Le Grange et al. (2007) compared family therapy (using a modification of their FBT manual) with supportive psychotherapy in a sample of 80 adolescents. FBT-BN emerged as significantly superior at end of treat- ment (39% binge-and-purge abstinence vs. 18% in the supportive therapy arm). At 6- month follow-up, abstinence rates had reduced in both groups (29% for FBT-BN vs. 10% for supportive therapy), but FBT-BN retained its superiority over supportive ther- apy. However, the assessment of treatment response was not blind to treatment condi- tion, thus posing a risk of bias. A further test of the efficacy of FT-BN was provided by Schmidt et al. (2007), in a comparison with guided self-care CBT (n = 85). In this study, there were no significant differences between groups on the primary outcome, abstinence from bingeing and purging, either at 6 months (end of treatment) (FT-BN 13%; CBT 19%), or at follow-up at 12 months when abstinence rates stood at 41% for the FT-BN group, and 36% for the CBT group. However, the CBT group had an ear- lier reduction in binge frequency. Schmidt et al. (2007) highlight a low rate of recruit- ment because of some of the older adolescents’ unwillingness to involve their parents in the treatment, but adolescents who received FT-BN continued to make more improvements after the end of treatment than those seen on their own. Treatment costs were significantly lower for the CBT arm.

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In the most recent RCT, Le Grange et al. (2015) compared FBT-BN, CBT, and support- ive psychotherapy in a sample of 130 adolescents. Recruitment rates were structured in such a way that more adolescents were randomized to FBT-BN (n = 51) and CBT (n = 58) than the supportive psychotherapy arm (n = 20). Compared to CBT, abstinence rates were higher for FBT-BN at end of treatment (39% for FBT-BN vs. 20% for CBT) and at 6-month follow-up (44% for FBT-BN vs. 25% for CBT). At 1-year follow-up, there were no differ- ences between groups. Rates of hospitalization were significantly lower for FBT-BN. The risk of bias is reduced in this study as compared with the earlier Le Grange et al. (2007) study, due to the use of independent assessors.

Efficacy Trials Comparing Different Forms of FT-AN

Four studies have compared the efficacy of different forms of FT-AN. Le Grange, Eisler, Dare, and Hodes (1992) conducted a pilot RCT comparing conjoint FT-AN, in which family members were seen together for therapy, with separated FT-AN, in which adolescents and parents were seen separately by the same therapist. This small study (n = 18) found no significant differences between the two forms of treatment. Eisler et al. (2000) conducted a larger RCT (n = 40) comparing separated and conjoint FT-AN, replicating the finding that overall neither was superior, either at end of treatment or at five-year follow-up. The lack of difference between the two treatment arms was important because it challenged the prevailing theoretical assumptions of the model, as the findings further undermined the idea that family members needed to be seen together, in order to intervene in family patterns that might be illness-maintaining. Moreover, while at aggregate level there was no difference between treatment arms, families rated as high in maternal criticism—an aspect of the measure expressed emotion (EE) (Leff & Vaughn, 1985) —achieved signifi- cantly better outcomes when offered separated FT-AN, a finding that was sustained at 5- year follow-up (Eisler, Simic, Russell, and Dare, 2007).

A recent RCT by Le Grange et al. (2016) (n = 107) compared conjoint FBT with a manu- alized form of separated FBT, which they name Parent-Focused Treatment (PFT). In PFT, a nurse weighs the adolescent, assesses medical stability, and provides brief supportive counseling, with the total individual contact time limited to 15 minutes. The adolescent’s weight and any other pertinent information is then communicated to the therapist, who then sees the parents for 50 minutes with a similar treatment focus to that used with the whole family in FBT. Remission, defined as in the Lock et al. (2010) study, was higher in PFT than in conjoint FBT at end of treatment (6 months) (43% vs. 22%), but did not differ statistically at 6- or 12-month follow-up. Lower parental EE predicted higher rates of remission in both study arms, but in contrast to the Eisler et al. (2000, 2007) studies, treatment response in families with high EE did not differ according to treatment. While the study further undermines the idea that conjoint sessions are a necessary ingredient of successful treatment, the findings also demonstrate the benefits of conjoint treatment for certain patient groups. For instance, patients with higher eating disorder-related obses- sionality benefited more from FBT than PFT, in keeping with previous findings suggest- ing that conjoint treatment is more beneficial to this group of patients as compared to separated treatment (Eisler et al., 2000) or individual work (Lock et al., 2010). Finally, Lock, Agras, Bryson, and Kraemer (2005) have investigated dose of treatment, comparing outcomes of short (10 sessions over 6 months) versus long forms (20 sessions over 12 months) of FBT. In this study of outpatient treatment (n = 86), there were no signifi- cant differences in outcomes between the two treatment arms. The study suggests that there are a number of treatment ‘responders’ for whom FBT works well within a short duration of time. For this group, increased contact hours appear to confer no additional benefit. However, nonintact families, and families where the young person had high levels

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of eating disorder-related obsessionality, benefited significantly more from the longer form of treatment.

Efficacy of FT-AN Compared with Generic Family Therapy Approaches

From a moderate common factors perspective, an obvious question to ask is whether the efficacy of FT-AN is due to specific ingredients of the model, or whether an alternative family therapy model might achieve equivalent outcomes. Thus far only one RCT, con- ducted by Agras et al. (2014), has been designed to help answer this question. This study of outpatient treatment (n = 164) compared two forms of manualized family therapy: FBT and Systemic Family Therapy (SyFT—Pote, Stratton, Cottrell, Boston, & Shapiro, 2001). The latter was a ‘generic’ form of family therapy, not specifically designed for treating ado- lescent AN. At end of treatment, there were no significant differences between treatments in terms of the primary outcome measures of percentage of ideal body weight and remis- sion. However, participants receiving FBT gained weight faster early on in treatment, spent fewer days in hospital, and treatment costs were lower, suggesting overall advan- tages of FBT. The study therefore provides support for the view that therapists adhering to a FT-AN treatment manual will achieve superior results overall as compared to those utilizing a more generic approach.

Interpreting the findings of this study is complicated by two potential confounding vari- ables: the eating disorder expertise of clinicians, and the role of specialist service contexts. Participants in both arms of the Agras et al. study were seen in specialist eating disorder services by therapists with an average of 6 years of experience of working with eating dis- orders. SyFT did not preclude a focus on the eating disorder, and given the treatment con- text and the therapists’ expertise, it is understandable that many families brought the discussion of the child’s eating disorder to therapy as a treatment priority. As a result, the two forms of family therapy investigated may have been more similar than it would other- wise seem (Blessitt, Voulgari, & Eisler, 2015).

These issues are illustrated by Godart et al.’s (2012) RCT conducted in France (n = 60), which investigated whether family therapy improved outcomes in adolescents treated in hospital. The family therapy model used in the study was not FT-AN, but a more generic approach in which family dynamics were conceptualized as being involved in the development and maintenance of the eating disorder. Adolescents receiving family therapy achieved significantly better outcomes compared with those receiving treatment as usual. Consequently, we can surmise that family therapy can have a beneficial impact on outcome even if the FT-AN model is not used. However, given that again the study was conducted by therapists with significant eating disor- ders expertise in a specialist service, it does not follow that family therapists without eating disorders expertise, working in nonspecialist services, can achieve equivalent results. The impact of service context is discussed in more detail later in this article.

Efficacy of MFT-AN and MFT-BN

Currently, one RCT has been conducted examining the efficacy of MFT-AN (Eisler et al., 2016) This UK study (n=169) compared outcomes for families receiving single family FT-AN as compared with MFT-AN. At end-of-treatment (12 months), categorical treat- ment outcomes were significantly better for those families who received MFT-AN (76% in the good or intermediate outcome categories) as compared with FT-AN (58%). At 6-month follow-up, families who received MFT-AN fared better than those receiving FT-AN, with a significantly higher weight, although the difference in categorical outcome was no longer significant. A strength of this RCT is that it was a pragmatic study with minimal exclusion criteria conducted across six treatment centers in and around London. Whilst this study

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suggests that the addition of a multi-family intervention improves outcomes, the authors are cautious in the conclusions, noting among other things that families in the MFT-AN arm also received single family therapy sessions, and that total therapist contact time was higher for families in this treatment arm.

The potential benefit of MFT-AN is also indicated by several smaller studies. For instance, Salaminiou, Campbell, Simic, Kuipers, and Eisler (2015) report good or interme- diate outcomes achieved by 6 months in 62% of the 30 families receiving MFT-AN. Gabel, Pinhas, Eisler, Katzman, and Heinmaa (2014), in a case-matched comparison, reported higher weight gain in adolescents receiving MFT-AN as compared to treatment as usual. Finally, Marzola et al. (2015) reported a brief treatment adaptation of MFT-AN, in which treatment was delivered over five full consecutive days. A follow-up of between 2–5 years of 74 patients showed that nearly 90% had achieved full or partial remission.

Research findings on the efficacy of MFT-BN are currently scarce. Stewart et al. (2015) have described the development of a MFT-BN group delivered in an outpatient context over 20 weeks in 1.5-hour-long sessions. Preliminary findings reported in their paper (n = 10) suggest that the group reduces eating pathology and depression, and increases adaptive coping skills. Thus MFT-BN currently shows promise, but further research is needed with larger samples and comparison groups.

FINDINGS ON IMPLEMENTATION AND SERVICE CONTEXT

Implementation Studies

A small number of studies have looked at the implementation of FT-AN (see Couturier and Kimber, 2015, for a recent review). Three small dissemination studies investigated whether clinicians who were unfamiliar with FT-AN could be trained in the approach over two days, following which their clinical outcomes were evaluated. In all three studies, clin- ical outcomes improved (Couturier, Isserlin, & Lock, 2010; Loeb et al., 2007; Tukiewicz, Pinzon, Lock, & Fleitlich-Bilyk, 2010). Two larger retrospective studies conducted by Wal- lis, Rhodes, Kohn, and Madden (2007) and Hughes et al. (2014) provide evidence of sub- stantial reductions in rates of hospitalization, readmission, and the length of hospital admissions following the adoption of FT-AN by children’s hospitals in Sydney and Mel- bourne.

Service Context as a Possible Common Factor in the Treatment of Eating Disorders

One of the main limitations of all the studies discussed above is that they do not take into account the potential impact of therapist eating disorders expertise and the role of specialist service context, which can be seen as common factors across all the treatment studies conducted thus far in the adolescent eating disorder field.

The findings of a naturalistic study by House et al. (2012) shed some light on these issues. The study compared all adolescents with an eating disorder in London over a two- year period, whose treatment followed different referral and treatment pathways that were determined by local commissioning arrangements that either allowed direct referral from primary care physicians to a specialist outpatient eating disorders service or followed a stepped care model with initial referrals going to the local generic child and adolescent mental health services (CAMHS). There were considerable differences between those who had access to the specialist care pathway compared to those whose initial referral was to generic CAMHS teams. The specialist pathway had 2–3 times higher case identification rates, two and a half times lower rates of hospital admissions during the first 12 months following referral, and considerably greater consistency of care with one treatment provi- der. While this does not provide direct evidence for the effectiveness of FT-AN (although

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this was the main treatment mode in the specialist services), it suggests that other factors are operating, such as referrers’ expectation, clinician confidence, the availability of a spe- cialist eating disorders multidisciplinary team that is able to manage complex cases from the start, and the mobilization of expectancy effects (Eisler, Wallis, and Dodge, 2015), which RCTs do not account for but which appear to have a major impact on outcome.

A related finding comes from a study by Murray, Griffiths, and Le Grange (2014). This small study (n = 29) found that collegiate alliance—the perceived alliance between case- involved professionals—predicted dropout from FBT, and was negatively correlated with eating pathology at end of treatment. One possible explanation for this could be that sup- port from a likeminded multidisciplinary team may be important in FT-AN due to the emotional challenges that clinicians can experience in using this approach. Couturier et al. (2013b) conducted interviews with FBT therapists, from which it emerged that clini- cians can feel anxious about certain therapeutic tasks, such as weighing the patient and completing family meals. Kosmerly, Waller, and Robinson (2015) found that greater clini- cian anxiety was associated with therapists being less likely to weigh the client at the beginning of a session. Similarly, Robinson and Kosmerly (2015) found just under a third of FBT therapists in their study reported that clinicians’ own emotions negatively influ- enced treatment decisions. Thus, one of the things which specialist teams may provide is an environment in which therapists can receive supervision and support, thereby strengthening treatment fidelity (Couturier & Kimber, 2015), and also attending to the emotional challenges which may lead to poorer clinical outcomes.

PREDICTORS, MODERATORS, AND MEDIATORS OF OUTCOME

Predictors of Outcome

Short duration of illness and younger age both predict better outcomes in FT-AN (Agras et al., 2014; Eisler et al., 2000; Lock, Couturier, Bryson, & Agras, 2006), as does a lower level of emaciation at the start of treatment (Eisler et al., 2000). Adolescents with lower levels of eating disorder pathology had higher rates of recovery in studies by Eisler et al. (2000) and Agras et al. (2014). In the latter study, intact families and adolescents without binge–purge symptoms also fared better.

In RCTs for BN, the following have been found to predict higher rates of abstinence at end of treatment: being male, milder eating pathology, lower baseline depression scores, and higher family cohesion (Le Grange, Crosby, & Lock, 2008; Le Grange et al., 2015).

Moderators

Our understanding of moderators and mediators is necessarily limited to those vari- ables that have been chosen for data collection in published RCTs. Unsurprisingly, adoles- cent eating pathology has been one of the most commonly used measures in the field. One particular aspect of eating pathology—eating disorder-related obsessionality—has fre- quently emerged as a moderator of treatment in FT-AN. For adolescents with high obses- sionality, outcomes have been better when the family have been offered a longer course of treatment (Lock et al., 2006). Conjoint treatment also appears more helpful for this group of patients, as compared to individual therapy (Lock et al., 2010) or separated forms of FT-AN (Eisler et al., 2000; Le Grange et al., 2016). However, adolescents with high obses- sionality benefited less from FBT as compared with SyFT, a more generic manualized FT approach (Agras et al., 2014). As adolescents with high obsessionality had higher baseline levels of eating pathology, depression, anxiety, and compensatory behaviors, the findings suggest that a broader treatment focus within family therapy may be beneficial to adoles- cents with high levels of comorbidity.

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Other findings on moderation are that adolescents with AN with binge–purge symp- toms benefited more from a longer course of FBT, as did nonintact families (Lock et al., 2006). In BN, participants with lower family conflict and lower eating pathology scores responded better to FBT-BN compared to CBT (Le Grange et al., 2008, 2015).

The possible role of EE as a moderator of treatment effectiveness in FT-AN has received particular attention over the years. Pilot studies of FT-AN found that a high level of EE (particularly maternal criticism) toward the adolescent was highly predictive of poor engagement in family therapy (Szmukler, Eisler, Russell, & Dare, 1985) and poor treat- ment outcome (Dare et al., 1995; Le Grange et al., 1992). As previously discussed, Eisler et al. (2007) found that high EE at baseline predicted poorer outcomes at 5-year follow-up for those in conjoint family therapy. More recently, Rienecke, Accurso, Lock, and Le Grange (2016) found that patients with mothers rated high in hostility by observers gained more weight in individual therapy than FBT. Furthermore, higher paternal criti- cism is associated with poorer outcomes regardless of treatment (Le Grange et al., 2016; Rienecke et al., 2016).

Forsberg et al. (2015) have suggested that the inconsistent findings on EE might reflect an underlying third variable. We have suggested elsewhere (Jewell et al., 2016) that a concept such as attachment, which overlaps theoretically and empirically with that of EE (Green, Stanley, & Peters, 2007; Scott, Briskman, Woolgar, Humayun, & O’Connor, 2011), may help to explain the differential response to FT-AN. The ability to tolerate strong nega- tive affects is a marker for secure attachment (Fonagy, Bateman, & Luyten, 2012). Some parents and adolescents with insecure attachment representations may therefore have a lower threshold for tolerating the emotional arousal that is likely engendered in the early weeks of FT-AN. If adolescents and/or parents become highly emotionally aroused during family therapy sessions, they may be more likely to interpret material arising from the session—such as comments by family members—in negative terms, such as criticism or blame. This may also be the case during emotionally charged interactions in the family home, particularly family mealtimes, making the task of helping the young person increase their food intake more demanding. More fundamentally, the meaning given to the parental task of managing their child’s eating may differ according to family members’ attachment representations. Adolescents with secure attachment may be more likely to accept parental supervision of their eating as an act of care. By contrast, adolescents with a preoccupied attachment style (Shmueli-Goetz, Target, Fonagy, & Datta, 2008), who tend to be caught up in past grievances, may ‘push back’ at such parental supervision, experi- encing it not as caring but controlling and nagging. Similarly, parents who themselves have unresolved attachment issues are more likely to lack confidence in themselves as parents (Jones, Cassidy, & Shaver, 2014) and may respond to their child’s rejection of help by increasing their own negativity. In such cases, conceptualizing the therapeutic task as ‘putting parents in control’ may in fact be counter-productive.

Potential Mediators of Treatment

Currently, no formal mediators have been identified in studies of eating disorder-focused family therapy. This is a serious barrier to improving treatment, as an understanding of mediators could inform adaptations to the model, allowing for active components to be intensified while redundant elements could be discarded (Kazdin & Weisz, 1998).

What does the available evidence suggest might be a plausible mediator? Several lines of research provide support for the importance of parental variables. In a study by Ellison et al. (2012), clinicians rated parents on variables which are seen as key to change in the Lock, Le Grange, Agras, and Dare (2001) treatment manual, such as parental control and unity, in a sample of 59 adolescents receiving FBT. Higher scores on these variables

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predicted adolescent weight gain, with the strongest predictor being parental sense of being in control over AN. However, change in these variables across time was not assessed. By contrast, Robinson, Strahan, Girz, Wilson, and Boachie (2013) found that parental self-efficacy increased over the course of FBT, and that increases in parental self- efficacy over treatment were correlated with reductions in adolescent eating pathology. From a clinician perspective, parental empowerment is also seen as key ingredient of FBT (Dimitropoulos, Freeman, Lock, & Le Grange, 2015), although this might be seen as some- what circular in that empowerment is a key theme within the treatment model.

Two studies have illuminated change processes in MFT-AN using qualitative data. Engman-Bredvik, Suarez, Levi, and Nilsson (2016) interviewed 12 parents, and reported that parents valued the role of the group in reducing parents’ perceptions of blame and stigma arising from having a child with AN. Parents also spoke of gaining increased com- petence in their parental roles, which was attributed to learning gained through meeting other parents. Similar themes emerged from Voriadaki, Simic, Espie, and Eisler’s (2015) study of parents and adolescents who attended MFT-AN. Key themes included the impor- tance of feeling less alone, and more hopeful about recovery, as a consequence of meeting other families. Adolescents reported becoming more accepting of the idea that they had a problem. These findings suggest that, at least in MFT-AN, change is happening rapidly, and that the development of hope—a crucial common factor—appears to be mobilized by the treatment context.

Indeed, one of the challenges for FT-AN research is that change can take place very rapidly when the approach is successful. Weight gain achieved by the fourth treatment session—usually 1 month after the start of treatment—is a predictor of good outcome at end of treatment (Doyle, Le Grange, Loeb, Doyle, & Crosby, 2010; Le Grange, Accurso, Lock, Agras, & Bryson, 2014). Similarly, in FBT-BN, early change in binge eating and purging among adolescents is a good predictor of response at the end of treatment (Le Grange et al., 2008). This has important implications in the search for treatment media- tors. As by definition, a mediator must change value following the start of treatment (Kraemer, Wilson, Fairburn, & Agras, 2002), mediators may be operating very early in treatment. Thus, a challenge for future research is both to conceptualize what changes, and to capture it empirically. Variables such as parental self-efficacy may operate as medi- ators in some families but not others, and it is plausible that change mechanisms may be different in families who respond early to treatment as compared with families where change takes longer to achieve. To explore these issues, it will be necessary to conduct pro- cess studies using multiple time-points for data collection, particularly within the early phase of treatment. A further hypothesis is that the first assessment appointment may be a key precipitant of change for some families. If true, future research could measure expec- tancy effects by asking families to evaluate their views on attending the service, and hopes for recovery, prior to attending the first appointment.

Therapeutic Alliance

The role of the therapeutic alliance in psychotherapy outcomes has perhaps received more attention than any other common factor. However, findings on alliance in FT-AN thus far do not tell a simple story partly because different measures have been used in dif- ferent studies including both observational and self-report measures and partly because adolescent and parent alliance ratings appear to predict different aspects of outcome. Isserlin and Couturier (2012) using an observational measure of alliance found that par- ental alliance predicted engagement in treatment and early behavioral change, whereas adolescent alliance was positively linked to remission in eating disorder cognitions at the end of treatment. Similar findings using a different observational measure of alliance are

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reported by Pereira, Lock, and Oggins (2006), although in this case adolescent alliance predicted both psychological change and early weight gain, whereas parental alliance pre- dicted engagement in treatment. Ellison et al. (2012) also report a positive association between parental alliance and posttreatment weight gain, and a negative association with dropout. Somewhat surprisingly the study found differences between maternal and pater- nal alliance ratings, with maternal alliance predicting greater weight gain and lower drop- out, and paternal alliance predicting less weight gain.

Complex findings have also emerged from two studies of alliance using data from Lock et al.’s (2010) study of FBT versus individual therapy. In the first study, observer-rated alliance predicted partial, although not full remission, at end of treatment, for both FBT and individual therapy (Forsberg et al., 2013). In a more recent study, Forsberg et al. (2014) found no association between parental alliance rated at session 4 and remission at end of treatment. Given the previously discussed finding that many adolescents achieve early weight gain, it is hard to unpick the temporal ordering of alliance and weight gain; it is certainly plausible that weight gain itself will have a positive impact on alliance and dis- entangling the impact of alliance on outcome may therefore be difficult.

The mixed findings on alliance and outcomes in FT-AN point to a potentially complex relationship between these variables. If our hypothesis that meaningful change in FT-AN may happen as early as the first assessment session, and that common factors such as hope/expectancy effects contribute to this, then perhaps the alliance to an individual clini- cian may need to be considered alongside of the impact of the service context on the family members’ views—particularly their trust or belief in the treatment center as a credible institution. A useful conceptualization is offered by Fonagy and Allison (2014), who have applied the notion of epistemic trust to the process of psychotherapy. Epistemic trust refers to an individual’s willingness to consider new knowledge from another person as trustworthy, generalizable, and relevant to the self (Fonagy & Allison, 2014), and thus draws attention to the relational context in which learning takes place (Landrum, Eaves, & Shafto, 2015).

The expert multidisciplinary team context in which the initial assessment occurs may play a key role in enhancing the developing alliance with the therapist, providing a safe base for treatment and promoting the development of epistemic trust. The knowledge that the team as a whole have of the nature of eating disorders and the way they impact family life resonates with the family’s experiences and gives them a sense of being understood and supported. This contributes to the perceived credibility and trustworthiness of the therapist and supports the development of the therapeutic alliance. However, the develop- ment of epistemic trust may not proceed in a straight-forward fashion in all cases; inse- cure attachment and emotion regulation difficulties in particular may mitigate against the development of such trust, at least in part due to the hypothesis proposed earlier in this paper. If epistemic trust is a precondition for learning, then this may be a useful orga- nizing principle for treatment. Specific interventions, such as therapists coaching parents during the family meal, may succeed or fail based on the extent to which trust has been developed. For families who do not develop such trust early in treatment, it may be fruitful for the therapist to consider alternative ways by which this may be achieved. Viewed from this perspective, seeing parents and adolescents separately, or offering a multifamily ther- apy group, provide new contexts for the development of epistemic trust and change.

DISCUSSION

Eating disorder-focused family therapy has become firmly established as an empirically supported treatment, with evidence of superior efficacy relative to individual approaches in both AN and BN (Couturier et al., 2013a; Le Grange et al., 2015; Watson & Bulik,

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2013). Nevertheless, caution is needed here. While there is evidence of treatment efficacy from well-designed RCTs, to date there have been no replication studies conducted inde- pendently of model developers. As a result, it is possible that allegiance effects may account for the apparent superiority of family therapy. Moreover, other potentially viable treatments for adolescent anorexia nervosa such as CBT (Dalle Grave, Calugi, Doll, & Fairburn, 2013) have not been compared directly with FT-AN, and it is possible that they could be equally effective. It is important to note that even in comparisons of family versus individual approaches, the treatments often have a great deal in common with each other. Parental involvement has been described as a sine qua non of child and adolescent eating disorders treatment (Lask, 2000). In line with this view, most of the ‘individual’ treat- ments that have been studied included at least some collateral parent sessions. This means that parents still had the benefit of the expectancy effects that might accrue both from seeing a therapist who presents a clear model of treatment, and also through contact with other professionals such as pediatricians. Given that a treatment which excluded parents completely would be in many instances ethically problematic, and unacceptable to many families, it may be fruitless to frame the debate in terms of family and individual approaches being in opposition to each other. While from a research point of view it is per- fectly legitimate to ask questions about the relative efficacy of each treatment, in clinical practice treatments will often be combined and family and individual therapy will then be seen as complementary components of treatment.

In clinical settings outside of an RCT, children and adolescents will often receive indi- vidual time with therapists quite routinely. In FT-BN, individual sessions are built into the treatment model, which makes use of elements drawn from CBT. Similarly, in both MFT-AN and MFT-BN, group sessions for adolescents on their own make up a significant proportion of the therapeutic program. However, FT-AN currently lags behind in its con- ceptualization of when adolescents should be seen on their own, or what the therapeutic aims of individual therapy should be. For families who currently do not respond to treat- ment, adaptations to FT-AN, potentially involving separated adolescent and parent ses- sions, are in need of theoretical elaboration and empirical validation. Meanwhile, for adolescents with comorbidities, the third stage of FT-AN (once weight restoration is well underway) may constitute an ideal time in which to add adjunctive treatments, such as CBT. For both adolescent AN and BN, the key questions for the field are: For whom does the current treatment work? What alternatives or additions should be offered for those who do not benefit? And can the treatment model be improved so that adolescents achieve higher rates of remission?

CONCLUSION

Based on the available evidence, we can conclude that the most successful treatments of child and adolescent eating disorders have the following general features in common; they:

• actively mobilize the family as a key treatment resource to promote changes in eating disorder behaviors early on in treatment;

• provide a coherent model of treatment (ideally operationalized in a treatment manual) that allows a degree of consistency in the way treatment is provided, while providing enough flexibility to tailor the treatment to the specific needs of individual families; and

• are delivered by clinicians with significant expertise in eating disorders, where possible within a specialist multidisciplinary team context; this provides a setting which engen- ders a sense of safety and trust in which adolescents and parents can take on new learn- ing and new behaviors.

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Although the existing treatment manuals specify the ingredients that should form the con- tent and process of treatment, the empirical evidence to support our understanding of which ingredients are necessary and how they bring about change is still limited. Developing an understanding of the mechanisms of change and the factors that moderate how these operate in different individuals and different families is therefore a key priority for research.

As many have argued previously, improving our understanding of moderators and mediators signposts when and how treatments need to be modified, or what additional or alternative therapies might need to be offered when the standard treatment is not suffi- cient. They also, however, offer a new perspective on the debate about the role of common factors in therapy. Some common factors, such as temperament, may not be amenable to change but interact with the specific treatment factors and therefore act as moderators. Others, such as therapeutic alliance, may both interact with specific treatment factors and be amenable to change and can be understood as part of what mediates change. We suggest that a moderate common factors position—both seeking to understand the com- monalities between treatments, and yet open to the idea that different treatment approaches can have distinctive effects, and may also interact in specific ways with differ- ent common factors—offers a coherent base from which to begin to disentangle these important and complex issues.

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