Anorexia Nervosa (AN) is a grave health condition that causes high rates of morbidity and death. Steinhausen (2002), who conducted a review of 119 outcome studies, discovered that the prognosis of anorexia nervosa among adult patients was generally poor from the 1950s to early 2000. Full recovery from the illness, which entails the lack of all clinical symptoms of the illness, was only in 46.9% of the sufferers. Only 33.5% of the patients showed some improved outcomes, with some outstanding symptoms. 20.8% of the sufferers developed the illness chronically. The mortality rate of the adult sufferers was found to be between 5% and 10%. Steinhausen (2002) also discovered that adolescents suffering from anorexia nervosa faired better than adult patients. The adolescents recorded a higher recovery rate of 57.1%. 25.9% of the adolescents in his study showed improvements, while 16.9% developed the illness chronically. These sufferers also reported lower mortality than the adults ranging from 3.2% to 8.2% (cited in Eisler et al., 2007).
There are many different treatment interventions that have been used to treat adolescents suffering from anorexia nervosa. The interventions range from individual-based programs to group and family-based interventions. Nevertheless, family-based therapy has attracted a lot of attention from the scholarly and clinical spheres due to its perceived effectiveness in treating anorexia nervosa among adolescents. An increasing number of studies are being conducted to examine and assess the effectiveness of family-based therapy. The logic behind it is that anorexia nervosa particularly as it pertains to adolescents is an illness that affects not only the sufferer but also the other members of the family. As a result, any treatment that is aimed at the adolescent sufferer should also incorporate the entire family.
The main purpose of this paper is to conduct a literature review of studies that have been conducted to examine the role of family-based therapy in treating adolescents suffering from anorexia nervosa. Specifically, this paper will review two clinical studies and three research studies. The focus of this paper on adolescents lies on the intact that anorexia nervosa usually develops in adolescents and persons in their early adulthood. In addition, the condition becomes more difficult to treat and manage in sufferers in their adulthood but easier to treat in adolescents. The consequences are also more severe in adults than in adolescents. The focus on adolescents is therefore important because it will enable clinicians, parents, and sufferers to manage it before it progresses into adulthood. It is hoped that this literature review will reveal existing literature gaps in the area of family-based therapy for anorexic adolescents. It is also hoped that the review will provide clinicians with important information pertaining to the assessment, counseling, teaching, and leadership/administration of adolescents suffering from anorexia nervosa.
Analysis of Underserved Population
Description of population
The population of this study consists of adolescents suffering from anorexia nervosa. Adolescents refer to persons between the age of 13 and 19 years. The condition is predominant in female adolescents and only about 10% of the total sufferers are male.
Incidence of anorexia nervosa among adolescents
It has been estimated that approximately one percent of adolescent females and 0.1 percent of adults suffer from anorexia nervosa at some point in their lives. However, the incidence of anorexia nervosa is greatest in females aged between 15 and 22 years (Eisler, Simic, Russell & Dare, 2007)
Related health and social systems problems
The onset of anorexia nervosa in adolescents has been linked to the development stage of the sufferers. Adolescence is a stage at which individuals are in need of acceptance particularly from their peers. Feelings of discontent with body images and the need to belong are rife in this stage. It is also the stage in which children have greater conflicts with their parents due to the need to have more control over their lives. As a result, psychological illnesses such as anorexia nervosa begin to affect adolescents. The illness is indeed a manifestation of many emotional and psychological needs of the sufferer such as the need for attention from parents, the need to have an identity, and the need to be accepted by their peers.
Besides the psychological causes of anorexia nervosa, the illness has also been linked to cultural factors particularly the cultural values that promote thinness as the ideal body image and size. This happens through the media which tends to portray thin women as ideal mainly through advertisements. This portrays a distorted self-image particularly among individuals who are not thin. Third, anorexia nervosa in some cases is a manifestation of social problems such as family conflicts and marital disputes. Children growing up in such an environment may resort to starvation as a coping mechanism or as a means of diverting the parents’ attention from their current problems (Whitney & Eisler, 2005).
Whitney and Eisler (2005) conducted a study whose aim was to investigate the ways families of adolescents suffering from anorexia nervosa may be affected and distorted by the eating disorder. The study is based on the theory of “family reorganization” initially proposed by the author. Whitney and Eisler (2005) argue that an illness such as anorexia nervosa reorganizes the sufferer’s family in six major ways. First, the illness takes the center stage in the family. The family gets obsessed with issues of food, eating, and weight which take predominance in the family’s daily interactions. Family members are forced to give up their pleasurable activities such as hobbies so as to address the needs of the sufferer. Second, the family of the sufferer becomes focused on the “here-and-now” rather than on the future. They develop a sense of urgency. Mealtimes become a struggle for the family rather than a time for social interaction. Family members are forced to take control and put everything on hold so as to care for their ailing child. Sensitive families will avoid confrontation between the families at all costs because they perceive it to be disastrous. Due to the un-conducive environment at home, some family members will avoid mealtimes by for instance staying late at work or choosing the mealtime to go to the gym (Whitney & Eisler, 2005).
The third process involves the restriction of the available patterns of family interaction processes. At the early stages of the recognition of the illness, family members are likely to make all efforts to help the sufferer, by educating themselves about the illness and encouraging the sufferer to eat. However, as the illness progresses and the family members realize that their efforts are not helpful, they may become frustrated, guilty and even critical of the sufferer. Such feelings often add to the strain of the family and aggravate the condition. Fourth, anorexia nervosa often reveals the functioning of the family – such as marital woes and parental problems – even before the onset of the illness and may be blamed as a contributing factor to the illness. Fifth, as the illness takes center stage in the family, the other needs of the family become neglected. Other siblings feel sidelined by the illness, parents feel guilty for not paying attention to their other children and the needs of the parents particularly as a couple are neglected. Lastly, the presence of anorexia nervosa leads the family to feel helpless, devastated and lacking a sense of control over the condition. The members may feel guilty and become self-critical for their inability to help the sufferer.
The study by Whitney and Eisler (2005) has several limitations. The researchers based their review on studies that used small samples and qualitative data. The study also focuses on the early stages of anorexia nervosa and therefore more research studies need to be done on family reorganization as the illness moves through different stages. Nevertheless, the study has important clinical implications. Clinicians should be very sensitive when dealing with families of anorexic adolescents because such families are usually very sensitive and harbor feelings of guilt, helplessness and inadequacy. The clinicians should thus avoid strengthening such feelings and instead promote feelings of hope, encouragement and empowerment of the families. They should also encourage the family to adopt safe risks as a way of minimizing the feelings of helplessness and unsupportive interactions among the family members.
Lock and Grange (2005) conducted a study to describe the theory and empirical support of family therapy for families with anorexic adolescents. The researcher asserts that family therapy is one of the most recommended treatments for families with such sufferers. Despite this, there is a literature gap in the effectiveness of family therapy. The earliest studies that supported the effectiveness of family therapy are Minuchin et al. (1978) and Stierlin & Weber (1989) which were based on the Maudsley approach to family therapy (cited in Lock & Grange, 2005). These studies founded that adolescents suffering from anorexia nervosa showed better results when treated using family therapy than when treated using individual therapies. In yet another study by Robin et al. (1999) the researchers used a form of family therapy known as behavioral family systems therapy which is similar to the Maudsley model (cited in Lock & Grange, 2005). The researchers found that at the end of the treatment period, the participants in the family therapy group had improved status in terms of increased weight gain and return of menses.
The study by Lock and Grange (2005) is limited in that it has reviewed very few studies. However, the study has significant clinical implications. The review shows that family therapy can be valuable in assisting adolescents suffering from anorexia nervosa and other eating disorders. Specifically, families can benefit from therapies that incorporate parental re-feeding techniques. The findings also suggest that family members have a potential role to play in helping their member suffering from an eating disorder. Nevertheless, before clinicians can implement a family therapy, they need to establish whether the approach is acceptable to the sufferer. This is because the adolescent stage is a stage of greater autonomy and therefore any efforts at undermining such autonomy – through control over eating and weight issues – may not be received well.
Paulson-Karlsson (2009) carried out an investigation to assess the results of family-based therapy for female adolescents suffering from anorexia nervosa aged between 13 and 18 years. Specifically, the researcher wanted to determine if there are changes in the sufferers before treatment and 18 to 36 months follow-up. The participants were selected from an eating disorder outpatient clinic, at the Queen Silvia Children’s Hospital in Sweden. The study included only those patients diagnosed as suffering from anorexia nervosa and not any other eating disorder. The mean of the participants was 15 years, mean BMI was 16.2, all of them had amenorrhea, and 15% of them were pre-menarcheal. The treatment model used in the study was a combination of two family-based therapies – a separated family therapy (SFT) and conjoined family therapy (CFT). Each family was treated by psychotherapists experienced in eating disorders. The therapy was conducted in three distinct phases. The first phase involved both family and individual sessions and focused on the management of anorexia nervosa. The second phase involved the parents taking less control of the illness and more focus on the family members’ unique needs including their own. The last phase had even less focus on the eating disorder and mainly involved sessions with regular family therapy. Analysis of data (BMI, menstruation, phobia for weight, attitudes towards body shape and size, anxiety at meals and body dissatisfaction) was done using statistical means – mean, median, and Wilcoxon’s matched-pairs signed-ranks test – from the pre-treatment period to the 18- and 36-month follow-up. From the analysis, Paulson-Karlsson (2009) found that the 72% of the participants had recovered from their illness at the 18-month follow-up while 78% had recovered at the 36-month follow-up. The patients also showed positive outcomes in general psychopathology at the 18- and 36 month follow-up except for perfectionism, fears of maturity and externalizing problems. In addition, the therapy resulted in an improved family climate whereby the distance between the patients and their family members decreased while closeness increased.
The limitations of the study by Paulson-Karlsson (2009) include the use of a small sample which may negatively affect the generalizability of the findings to the entire population. Second, the follow-up periods were relatively short and this may have had a significant effect on the outcome. Future studies should therefore use relatively longer follow-up periods to determine ay changes in the outcome of the therapies used in this study. Nevertheless, the findings have significant clinical implications. Clinicians dealing with patients of anorexia nervosa should adopt a treatment approach that incorporates both individual and family interventions.
Pereira, Lock and Oggins (2006) conducted a study to examine the effectiveness of therapeutic alliances in forecasting the dropout, response and aftermath in a group of adolescents suffering from anorexia nervosa. The researchers recognized that therapeutic alliance play a crucial role in determining the outcome of treatments but its role in treating psychological illnesses such as anorexia nervosa is still not clear. The participants used in this study included 41 adolescents aged between 12 and 18 years who were treated using family-based therapy for one year in 20 sessions in a randomized clinical trial. The trail made a comparison of this group to another group of 6-months’ treatment in 10 sessions. The two groups had no baseline differences but the longer period of treatment of the former group permitted the investigation of early and late therapeutic alliance. The FBT as described earlier is doe in three distinct phases. The measures that were used in this study include: weight, eating disorder and working alliance inventory. Data analysis was done through analysis of variance and Pearson’s correlations.
Pereira, Lock and Oggins (2006) found that therapeutic alliance plays an important role in treating anorexia nervosa. Dropout of the sufferers was found to be determined by parental therapeutic alliance especially as it relates to therapeutic goals. However, dropout was not found to be determined by adolescent therapeutic alliance. The agreement of parents with the therapeutic goals may show their dedication to the treatment, their agreement with the type of therapy being implemented and their willingness to help in the re-feeding process. All these may encourage the adolescent to stay on in the therapy. On the other hand, the weight of the adolescents was found to be correlated with adolescent therapeutic alliance. The explanation for this is two-fold: first, adolescents who were committed to their therapeutic alliance were more likely to gain weight early on; and adolescents who gained weight early on were motivated to stay on and develop effective relationships with their therapists. The researchers also found that adolescents who had higher weight and eating concerns at baseline showed less consensus in early and late sessions as well as failed to develop strong collaborations with their therapists.
The study by Pereira, Lock and Oggins (2006) is limited in various ways. First, the families that took part in this study were willing to participate in FBT and therefore they may have had the motivation to succeed in the treatment. This may affect the ability of the findings to be generalized to the population especially to families which are not willing to take part in FBT. Second, the families that took part in the study had a fairly higher socioeconomic status as compared to the general population. This may also have had a significant influence on the outcomes. However, the findings of the study have strong clinical implications. The findings imply that FBT is usually successful in enhancing therapeutic alliance because of its unique intervention strategies. The use of these intervention strategies to promote therapeutic alliance could therefore assist in identifying ways through which treatment, acceptability and viability of FBT could be improved.
Eisler, Simic, Russell and Dare (2007) conducted a study based on the increasing evidence that family therapy is a successful intervention for adolescents suffering from anorexia nervosa. The aim of their study was to establish the long-term effects of two forms of family-based therapy, namely: the conjoint family therapy and the separated family therapy. The study involved following up 40 patients over a 5-year follow-up period. The participants had been treated either using the conjoint family therapy or the separated family therapy. Out of the 40 patients, only two refused to be reassessed. Data were collected through face-to-face interviews (29 participants), telephone interviews (6 participants) and questionnaires/parental interviews (6 participants). Data collected included personal assessment of mood swings, self-esteem and obsession, as well as family assessment. The data were analyzed through paired t-tests, ANOVA, ANCOVA, and the Fisher Exact test or McNemar test.
Eisler, Simic, Russell and Dare (2007) found that at 5-year follow-up. 75% of the participants had no symptoms of anorexia nervosa and no death had occurred. Second, the rate of relapse following recovery was found to be relatively low (8%) compared to other studies (Steinhausen, Seidel, & Winkler Metzke, 2000; Lay, Jennen-Steinmetz, Reinhard, & Schmidt, 2002) which found a relapse rate of 25-30% (cited in Eisler et al., 2007). Third, the researchers found that only three patients developed symptoms of anorexia bulimia and only one to the degree that necessitated a clinical diagnosis. This number is significantly lower compared to other studies which reported the development of anorexia bulimia in 30% of the patients. It was also found that a history of hospital admission prior to the study significantly affected the outcome. This could be because of the fact that adolescents who are treated as inpatients are likely to be severely ill with serious personal factors that may hinder their effective participation in outpatient treatment interventions.
The limitations of this study include the lack of manualized treatments as is the case in most randomized clinical trials. Second, the researchers used a relatively small sample which may have affected the outcomes and which may hinder the ability of the findings to be generalized to the population. Third, the researchers were not able to obtain relapse data from all the participants and this may have influenced the relatively low relapse rate found. Despite these limitations, the findings imply that family therapy is an effective intervention for treating adolescents suffering from anorexia nervosa. Although the study found little difference between CFT and SFT, the results indicate that CFT is not so effective in families having high levels of expressed emotions. This implies that it is unwise to use CFT in such families early on when parents are critical of their child. However, CFT can be used later on in treatment when the family has become better engaged with the illness.
Directions and Implications for Clinical Practice/Role of Advanced Practice Nurse
The review conducted of the five studies has great implications for clinicians dealing with patients of anorexia nervosa. In the area of assessment, clinicians need to be very sensitive about the needs of the patients as well as of their families. The literature review has revealed that adolescents are at a very vulnerable stage of development and desire a greater level of autonomy than was afforded during their childhood. Therefore before the implementation of an intervention that is likely to undermine their level of autonomy – family-based therapy – the clinicians need to assess the patients and determine if the approach would be acceptable to them. Failure to do this would render the family-based therapy ineffective.
The literature review has provided various recommendations for clinicians and psychologists handling anorexia nervosa among adolescents. The studies have reveled that families of adolescents with anorexia nervosa also suffer along with their child. Parents as well as siblings harbor feelings of guilt, resentment, helplessness, criticism and failure as they go through every stage of the illness. As a result, the therapists handling the patient should be sensitive to the family as well and avoid reinforcing such negative feelings. Instead, they should be encourage and support the family and provide it with more effective alternatives of managing their anorexic child.
Second, the review has shown that an intervention for treating anorexic adolescents is more effective if therapeutic alliances – both parental and the adolescent – are formed. Indeed, healthy relationships between the therapists and the family as well as between the therapists and the sufferers are a strong determining factor in the recovery process of anorexic adolescents. Clinicians should thus implement ways which would enhance such alliances.
Counseling of families with an anorexic adolescent should also take into consideration the effectiveness of using a combination of separated family therapy and the conjoint family therapy. However, caution should be taken in this approach particularly in families with conflicts. Such families should be treated using the separated family therapy approach until when they have matured in the understanding and management of the illness. When this is achieved, the clinician can use the conjoint family therapy.
The findings from the literature review have significant implications for clinical education programs. Such programs should incorporate units that sensitize students as well as practicing clinicians on the role of family-based therapy in addressing anorexic adolescents. Besides education programs, teaching can also be done through training programs, seminars and workshops. Through such programs, students and practicing clinicians dealing with anorexic adolescents can learn more about family-based therapy: its effectiveness, implementation, applicability to patients with different characteristics. This can be facilitated by the dissemination of findings from studies that have so far been conducted in this area.
Leadership and administration
Leadership plays an important role in clinical practice. The implementation of family-based therapy in treating anorexic adolescents can only be accomplished through the support from the leaders and managers of healthcare centers. Support from leadership/management is illustrated by their willingness to embrace the approach and their support in staff development. Staff development can be done through the provision of advanced educational opportunities, training, workshops and seminars.
Directions and Implications for Evidence Based Nursing Research: Areas for Further Study
The few studies reviewed in this paper have significant implications for clinicians. However, the studies have limitations that may have influenced their outcomes. It is necessary for future studies to be carried out that address these limitations. The major limitations found include:
The use of a small sample of participants or studies
All the research studies reviewed above have used relatively small samples of participants. The problem with using a small sample lies in the inability of the findings to be generalized to the entire population. Issues of bias also arise from using small samples. The samples may therefore not be a true representation of the target population. The clinical studies reviewed also used a small number of studies which may have influenced the inferences made. Future studies should be conducted using a bigger sample size or a larger number of studies to eliminate problems of lack of representation.
The use of a short follow-up period
The use of a short follow-up period has also been identified in this review. The length of the follow-up period plays a significant role in the outcomes of a study. Shorter time periods are highly likely to have more positive outcomes in the patients as compared to longer follow-up periods because the effects of the treatment intervention are still clearly evident. Future studies should therefore be carried out using relatively longer follow-up periods to determine any changes in the outcomes of the therapies used by clinicians.
The use of homogenous samples
The use of homogenous samples – for instance the use of families who are willing to participate in a family-based therapy and families with higher socioeconomic status – has also been identified in this review. Homogenous samples are likely to portray distinct characteristics. The sample also creates difficulties in generalizing the results to the target population. Future studies should be conducted using heterogeneous samples. The results would not only enable the researchers to identify any differences in the population but they would also be able to be generalized to the population without any biasness.
Inability to obtain useful data from all participants
This problem was evident in the study conducted by Eisler et al. (2007). The researchers were unable to obtain relapse data from all the participants. This limitation may have influenced the low relapse rate found. Future studies can be carried out which will ensure that necessary data are collected from all participants.
This study has been conducted to as a review of current studies focusing on family-based therapy as an intervention for treating adolescents suffering from anorexia nervosa. The review has shown that family-based therapy is indeed an effective intervention for addressing the illness because it addresses the unique needs of all the family members rather than just the needs of the sufferer. Family-based therapy teachers the entire family not only how to manage and care for the ill member but also how to address the oft-neglected needs of the other family members. In this approach, the sufferer is assisted to live a healthy normal life without losing much of her autonomy. Despite these positive outcomes revealed from the literature review, many limitations are inherent in the studies. These can be addressed by future studies which would help in further ascertaining the effectiveness of the family-based therapy.
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