Research into the treatment of adolescents with eating disorders has concentrated on the inpatient management of patients with AN. Common strategies are intensive nutritional rehabilitation and psychosocial interventions for patients and their families over several weeks or months. Although the outcomes of reported trials (often uncontrolled) have been highly variable, a majority of treated patients appear to achieve a normal body weight upon discharge from an inpatient program. However, many patients demonstrate a chronic fluctuating course in their eating disturbance over time. Studies of the treatment of adolescents with AN concur that family involvement forms a vital part of the process. In addition to traditional family therapy (FT), family group psychoeducation (FGP) has been introduced as a family-oriented treatment in recent years. FGP is a more cost-effective intervention than FT because up to 7 families can attend a group led by 2 therapists. Our plan was to introduce this group program to our Adolescent Eating Disorders Program as a way of involving families in the care of their adolescents. Before doing so, however, we wanted to compare the impact of both methods over a 4-month period on adolescents with AN who were admitted as inpatients, then treated on an outpatient basis.
Procedures in Treatment Groups: Family Therapy
Subjects assigned to the FT group received 8 sessions of family therapy (every 2 weeks) over the 4-month study period. These 45-minute sessions were attended by the patient and her parents and siblings, as agreed on in early sessions. The therapists were 2 social workers and 1 psychiatrist with 4-10 years of experience in the conduct of family therapy with adolescent eating-disordered patients. The main objective of the therapy was to encourage parents to take an active role in the management of the disorder. The therapy supports the goals of weight restoration and normalization of eating behavior. It also focuses on strengthening the parenting couple through direct, open communication within the family. Lastly, FT tries to distinguish eating disorder symptoms from normal adolescent strivings and expectable parent-adolescent conflicts. The therapy identifies and supports the development of autonomy and maturation in the adolescent within an accommodating family system.
Family Group Psychoeducation
Subjects assigned to the FGP treatment arm received 8 sessions of family psychoeducation every 2 weeks over the 4-month study period. Psychoeducation is the process of giving information about the nature of a disorder in order to foster attitudinal and behavioral change in recipients. Its principal objective is to educate patients and their parents about the nature of eating disorders and to offer a group opportunity to discuss how the family can implement change. Adolescents and parents attended 90-minute classes led by a dietitian, an occupational therapist, and a psychiatric nurse. These staff members had 2-6 years of direct experience in treating adolescents with eating disorders. In the first 45 minutes of each class, the dietitian and psychiatric nurse group leaders presented information to the families on a series of topics: the multidetermined nature of eating disorders, physical and psychological sequelae, regulation of weight and the consequences of dieting, normal adolescent growth and development, normal eating, body image and self-esteem, relationship issues for adolescents and families, and coping with change. Information was drawn from various sources. During the second 45 minutes, adolescents and parents broke up into separate groups to discuss the information. The adolescent group was led by the occupational therapist.
Standard Medical Treatment: Medical treatment on the inpatient ward is guided by a strict protocol that ties the adolescent's activity level to medical stabilization. Upon admission, the patient is prescribed bed rest, cardiac monitoring, and intravenous support until she is medically stable. Initially, the food supplement Ensure is used to provide nutrition. It ensures achieving one of our major goals for inpatients: a steady weight gain of 1.4 kg per week. This rate of weight gain is predictable and controlled, avoids refeeding syndromes, and lessens anxiety about food choices--all important principles in weight restoration for hospitalized adolescents with eating disorders. As the patient improves, food is gradually added to the diet. We strive to help the patient first reach a weight of 80% of IBW, a measure of relative medical safety, and then 85% to 90% of IBW before discharge from the inpatient unit. These weight targets have been determined by consensus among our medical staff.
Standard Psychosocial Treatment: Psychosocial treatments in the inpatient unit include individual management, various group therapies, and milieu therapy all designed to help patients and families deal with the intense feelings, especially anxiety and anger, associated with weight gain. Once our study subjects became medically stable, met their weight goals, and, in conjunction with their families, had increased confidence, they and their families were discharged to the Eating Disorders Program's outpatient clinic. The remainder of their FT or FGP sessions were continued on an outpatient basis until the end of the 4-month study period. Psychosocial treatments in the outpatient clinic also included brief meetings for the patient or her parents with pediatric and nursing staff, focusing on medical monitoring and supporting a weight gain of 1 kg per month.
Conclusions: Our sample included 25 severely ill adolescents who, on the day of their initial assessment, required hospital admission because of significant medical compromise resulting from their restriction of nutrition and fluids. Consequently, they may not be representative of the many young people who suffer a less severe or partial form of the illness.
This study had 2 main limitations. First, it lacked a control group in which no family intervention was carried out. However, we know from the literature as well as from our own clinical experience that without the involvement of the parents and family as therapeutic allies, weight gain is extremely difficult to achieve. Moreover, most of our subjects were ambivalent about admission to hospital but agreed to participate, in part because of the pressure exerted by their parents, whose cooperation was necessary for treatment to proceed. Although the presence of a nofamily control group for comparison would have reinforced the evidence of parents' importance as treatment allies, a group excluding parents from treatment would not have received approval from the hospital's ethics review board.
A second limitation was the difficulty in recruiting subjects, mainly because parents did not wish their children randomized to a relatively "new" treatment when they were so ill. Consequently, our study sample was small.
Although these limitations may weaken their validity, our results did show that weight was restored during the 4 months of treatment in both the FT and FGP groups. At the same time, however, after either form of intervention the only change in any of the psychosocial variables measured was on the patient's self-report of family functioning (FAM-III). At time 1 the FAM-III results in both groups indicated that the patients rated family functioning within the normal range. At time 2, the FAM-III results in both groups suggested that the patient perceived an increase in family dysfunction, although seeing functioning as still within the normal range. This change may have occurred because family members began to confront the issue of eating disorder in the patient.
While both forms of family intervention supported weight gain, determining exactly how this occurred is unclear. Neither patients nor parents observed psychological changes on measures of specific and nonspecific eating disorder pathology. We might speculate that both parents and patients felt strong enough support from the family treatment groups to accept the weight gain program passively without undergoing much psychological change. It is also possible that the intense anxiety created by the medical admission, which required bed rest along with cardiac monitoring and intravenous support, created a crisis that promoted the alliance of parents with the team. This in turn may have enabled patients to accept the weight gain program in a way they would not have done otherwise. During the inpatient admission, 76% of the necessary weight gain occurred.
Weight restoration is vital in young people with AN because the consequences to adolescent psychological function as well as physical growth and development can be profound if the starved state is prolonged. Growth retardation, poor bone and brain development, depression, obsessive compulsive symptoms, and social withdrawal are a few of the medical and psychological consequences. Time pressure exists to restore weight and medical stability. On the other hand, more than one-half of these adolescents were readmitted to the inpatient ward either during or immediately after the study period, suggesting that the lack of psychosocial change contributed to a resumption of intake restriction after discharge. This is a situation well known to clinicians working with this population, While we recognized that psychological change lags behind the restoration of weight and menstrual functioning, and the illness itself has a long and chronic course, we were still surprised that patients and parents noted so little change, in light of the intensive psychological treatments delivered to both treatment groups.
Several explanations are possible. First, the patients in our study are among the most severely ill of the population of adolescents with AN and thus likely the most highly resistant to change. This suggests that 4 months may be too short a time to produce measurable psychological change. Second, the rate of weight gain may have been too rapid for these young people, resulting in passive weight gain with no real involvement of the patient in her recovery. Third, the role of family therapy or family group psychoeducation may be to provide support for weight gain and nothing more. Fourth, but least likely, is that family involvement has no impact on psychosocial change, regardless of how it is delivered. In any event, our findings show that weight gain was achieved with family group psychoeducation. FGP appears to be a cost-effective, clinically useful method of involving the parents as treatment allies to support weight gain during the first months of treatment for severely ill anorexic adolescents.
- Geist, Rose; Heinmaa, Margus; Stephens, Derek; Davis, Ron; Katzman, Debra K; Comparison of Family Therapy and Family Group Psychoeducation in Adolescents With Anorexia Nervosa; Canadian Journal of Psychiatry, Mar2000, Vol. 45 Issue 2, p173
Reflection Exercise #9
The preceding section contained information
about using family therapies to help treat Anorexia Nervosa. Write
three case study examples regarding how you might use the content of this section
in your practice.
What are two methods for involving families in the treatment of a client with Anorexia Nervosa? Record the letter of the correct answer