Current Thinking about Family
Therapy and Systemic Interventions
with Eating Disorders
Facilitator: Lesley Novelle
Workshop format
• explore common themes across current
research studies and any gaps
• explore facets of multi-disciplinary working
within a systemic frame
• Consider from a family perspective
What it is not?
• The answer!
• Comprehensive , looking at what families
might say within the literature and the
approach , Method, Technique of current
studies, not looking any further afield than
systemic texts (at this point)
Context
• Year one of a four year taught Doctorate, produce a
comprehensive literature review before development
of a research proposal
• Family Therapy team as part of MDT approach
• Providing justification for further study (or changing
the focus)
• Why am I interested?
• Please share what interested you in coming today
NICE Guidance and Junior Marsipan
• Systemic invitation not just in terms of family
interventions but also working together as
“systems of concern”.
Search Strategy
• Key words:
– Eating (disorder), Anorexia, Bulimia (very tight) EBSCO, Psychinfo
• Only systemic journals, results from:
– Journal of Family Therapy
– Family Process
– Australian and New Zealand Journal of Family Therapy
– Journal of Marital and Family Therapy
– Journal of Feminist Family Therapy
– American Journal of Family Therapy
– Contemporary Family Therapy
Systemic Literature
Some key ideas emerging from the texts:
• Using families as a resource
• Considering both conjoint family work and
separating out different sub systems.
• Multi-modal, multi-family groups
• Strengthening parental position and decision making
• Externalising the Eating problem
• Long term and tricky 3-4 years duration
Some statistics
• USA (Hudson et al , 2007) Downs and Blow (2013)
– 1.2% individuals experience Anorexia Nervosa
– 2% experience Bulimia Nervosa
– 5.5% Binge Eating Disorder
– Little evidence to suggest that families “cause”
eating disorders, some evidence to suggest family
patterns can maintain. Eating disorders can
dominate family functioning and intensify
previous patterns.
Quote
“The impact of the illness on the family is
immediately evident through the influence
that the symptoms hold within the household.
Just as issues around food, eating and weight
dominate the sufferer’s thoughts and
behaviours, food may also take a predominant
role within family life and interactions”
Whitney and Eisler (2005, p,577) in Downs and
Blow (2013)
Emerging from the development of the last
18 years in particular
WHICH MODELS?
Maudsley model
• Inspired by the work of Salvador Minuchin
(1975, 1978), Palazzoli et al (1978), in Downs and Blow (2013) Primarily focused on
Anorexia Nervosa
• Three tasks:
– Gaining and maintaining family co-operation by intensifying the need to treat
the disorder. (removing blame and shame)
– Assess the organisation of the family, what alliances, boundary and control
techniques are used
– Establish interventions to help the family in the creation of change
• Three Phases
– Getting parents to work together, empowering to gain control over weight
gain and weight restoration
– Focus on helping adolescent to begin to eat on own
– Family work to help young person to gain back control of thier eating (life)
Multi-family groups
• No quantitative studies but a number of case study write ups.
• Multiple family groups, four families in one study Colahan and
Robinson (2002)
• Multiple interventions with all four families, using roles in
family, treatment modalities and shared mealtimes.
• Adaptation of Maudsley model looking at parent to parent
support as adjunct.
• Downs and Blow (2013) suggest this as an area for further
study.
Family Based Treatment
• Girz et al (2013)
Adolescent day treatment (Canada)
– Parents check in with FT after weekend
– FT holds conversation with parents after weekly team
rounds
– Re-entry meeting if extra support needed
– Parents and children weekly FT sessions
– Parents and children attend MFT evening
– Parents involved in setting family transition plans (food
and non-food related)
Conjoint or Separated Family
Therapy
• Discussion in the literature about family based interventions and their
delivery. Eisler et al (2000) (not published in FT literature)
• Links to some of the earlier work with a psychoanalytic/systemic theory
base.
• 40 adolescent “patients” assigned to either:
• Conjoint: Family and young person
• Separated: Parent (and siblings?), young person separate.
• Outcomes:
– High levels of maternal criticism- Separated Family Therapy, better outcomes
– Symptomatic change was more evident in the Separated Family Therapy whereas
emotional change was more highly reported in the Conjoint Family Therapy.
– Also significant changes in family measure of expressed emotion and critical comments
between parents and young people were significantly reduced as was so between
parents. Warmth between parents increased.
Family members voices
• Weak or quiet with some exceptions
• Located in questionnaires and outcome
measures
• What is their narrative?
• Downs and Blow (2013) , lack of literature
about the role or support of siblings
Exercise
• This may be quite a challenging and emotional
exercise, please look after yourself and one
another and only share what you feel you would
like to share.
• There will be people in the room who have
experienced eating problems, please be mindful.
• Purpose of exercise is to:
• Allow room to hear a family perspective
• To consider any incoherence
• To consider the best next steps from a family based
intervention perspective.
Vignette
• Family: White British, Young woman aged 14,
Mother aged 41, Father aged 45 , younger
brother aged 12
• Primary care group: Practice nurse, GP ,
Health Visitor, School
• Camhs team: Care co-ordinator, family
therapist, Psychiatrist, MAT practitioner, 3rd
sector support organisation.
Instructions
• Form in to groups as identified. Do not confer
until all of boxes completed.
• Using paper with six boxes follow instructions
read out and make a mark or representation in
each box which represents the instruction.
• Now share your thoughts and experiences of the
exercise in the group paying particular attention
to feelings and then next steps (boxes 4 and 6).
• Agree how you will feedback to the larger group.
Feedback
• What was it like doing the exercise, is
everyone ok?
• What next steps emerged, talk from each
group to the other groups in turn?
• What dilemmas, concerns, exciting ways
forward emerge?
Six instructions
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Family -mark the paper to represent relationship with your daughter/Sister.
Drawing lines, dots and squiggles.
Goal: mark the paper to represent your goal with this person. Where do you see
yourself headed?
Obstacle: marks the paper to represent what is getting in the way of achieving the
goal.
Counter –transference- mark the paper to represent her feeling about young
person.
Theories- mark the paper to represent what you know theoretically about this
situation. What are the possible causes and context of your struggle?
Next steps- mark the paper to represent what their next steps will be with this
work. What do they envisage in the future?
Early family intervention
• Focus on preventing further weight loss/destructive
behaviours.
• Support parents; work with parental authority and
responsibility.
• Strike a balance between making it clear that the
eating problem is unwelcome and acknowledging
that it is functional
• Use family and individual strengths
• Keep young person linked to their world
Family Therapy, what we are discovering
Approach
• Consider who is the client Dare (1997)
• In involving parents and other family members what “approach” do
you have
• Contract ( bearing in mind safety and motivation for change)
• Family culture respected
• Current goals
• Life cycle issues
• Privacy and transparency
• What is the impact on siblings, what is the forum for them to share
• Both directive and collaborative? (outcome from narrative in studies
about different experiences of treatment)
• Clear and well co-ordinated , regular care plan reviews
• Collaborative adaptable engagement with current system
• Score- measuring progress across a number of domains
Methods
How we intervene
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Structured family therapy- reflecting team
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Family input in home-purpose?
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Consultation
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Educational and practical input
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Explore needs of all family members
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Use of a reflecting team approach
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Individual work in the “presence of”
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Joint team approach to care planning- are we stronger
than the eating problem
Techniques
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Collaboration and transparency re goals/contract- write
Engagement- key area and linked to approach/careful attention to contract
Voices to be heard
Explore resilience and strengths
Teach, role play, enact, play, toys and tech
CBT
Develop rituals for talking, building on family strengths
Develop a genogram as a tool
Outcome measures
Timing- when and how to intervene
Within sessions– Sculpting
– Externalising
– directives/coaching
– enactment
– intensification
Some ideas about ways forward
• Remember that Anorexia is very powerful and
can organise us all to do things we might
otherwise not consider e.g. feelings, actions
• Use people close to the person experiencing
the problem as a resource. “System of
Concern”
• Consider the risk and the dilemmas associated
with “consent”- but be open to possibilities
References
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Journal articles:
Colahan, M. Robinson, P.H., (2002) Multi-family groups in the treatment of young adults with eating
disorders. Journal of Family Therapy, Vol 24, pp. 17-30
Downs, K.J. and Blow, A.J., (2013) A substantive and Methodological review of the family-based
treatment for eating disorders: the last 25 years of research. Journal of Family Therapy.
Vol.35:51:p3-28
Eisler, I., Dare C., (2000) Family Therapy for Adolescent Anorexia Nervosa: The results of a
Controlled Comparison of Two Family Interventions. Journal of Child Psychiatry, Vol.41, pp. 727736
Griz, L., Robinson, A.L., Foroughe, M., Jaspewr, K., Boachie, A., (2013) Adapting family-based
therapy to a day hospital programme for adolescents with eating disorders: preliminary outcomes
and trajectories of change. Journal of Family Therapy, Vol.35:51 pp.102-120
Minuchin, S., Baker, B.L., Rosman, B.L., Milman, L., Todd, T.C., (1975) A conceptual model of
psychosomatic illness in children:family organisation and family therapy. Archives of General
Psychiatry, Vol.32, pp. 1031-1038
Minuchin, S., Rosman, B.L, Baker, B.L, (1978) Psychosomatic Families: Anorexia Nervosa in Context.
Cambridge, M.A.: Harvard University Press.
Palazzoli. S.M. (1978), Self-Starvation: from individual to Family Therapy in the Treatment of
Anorexia Nervosa. Trans. Pomerans, A. New York: Jason Aronson.
References
Grey literature
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Junior MARSIPAN: Management of Really Sick Patients under 18 with Anorexia
Nervosa. Royal College of Psychiatrists, College report, January 2012
http://www.rcpsych.ac.uk/files/pdfversion/CR168.pdf accessed 28.8.13
National Institute for Clinical Excellence: Eating disorders Core interventions in the
treatment and management of anorexia nervosa, bulimia nervosa and related
eating disorders Clinical Guideline
http://www.nice.org.uk/nicemedia/live/10932/29218/29218.pdf accessed 29.7.13
• Burnham, J. (1992). Approach, Method, Technique: Making Distinctions
and Creating Connections. Human Systems: The Journal of Systemic
Consultation and Management. Vol 3, p3-26
• See hand out for references over last 20 years