Multi-Family Therapy for Anorexia Nervosa

A Treatment Manual

Mima Simic, Julian Baudinet, Esther Blessitt, Andrew Wallis, Ivan Eisler

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000427585
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Multi-Family Therapy for Anorexia Nervosa is a treatment manual that details an empirically supported and innovative treatment for this disorder.

This book provides a detailed description of the theory and clinical practice of MFT-AN. The treatment draws on the Maudsley Family Therapy for Anorexia Nervosa model as well as integrating other psychological and group frameworks. Part I details the theoretical concepts, MFT-AN structure, content and implementation, including clinically rich and detailed guidance on group facilitation, therapeutic technique and troubleshooting when the group process encounters difficulties. Part III provides step-by-step instructions for the group activities in the initial four-day intensive workshop and for the subsequent follow-up days that occur over a further six to eight months.

The book will serve as a practical guide for both experienced and new clinicians working with children and adolescents with eating disorders and their families, in utilising multi-family therapy in their clinical practice.

Part I Theory, structure and techniques

Chapter 1: What is multi-family therapy?

Multi-family therapy has a long history going back to the work of Laquer (Laquer et al., 1964) and has been used to treat a range of psychological difficulties including psychosis, mood and anxiety disorders, alcohol and substance misuse as well as school and behavioural problems in children and young people (Gelin et al., 2018). There is also a growing literature on the use of multi-family therapy for eating disorders primarily for adolescent anorexia nervosa (Simic & Eisler, 2015) but also adult anorexia nervosa (Tantillo et al., 2020; Wierenga et al., 2018) and adolescent bulimia nervosa (Stewart et al., 2019). Multi-family therapy for adolescent anorexia nervosa (MFT-AN) was developed as an alternative treatment to inpatient admission for young people who are struggling with anorexia nervosa or other restrictive eating disorders. Since its development in the 1990s (Dare & Eisler, 2000; Scholz & Asen, 2001) it has been used in different formats and range of treatment settings across the world (Gelin et al., 2018; Cook-Darzens et al., 2018). MFT-AN can be delivered in a variety of formats. In this manual we will be describing a specific intensive format, based on the structure and content first developed at the Marlborough Family Day Unit in London (Asen et al., 2001), which has been modified for adolescent anorexia nervosa and has been shown to be efficacious in a randomised controlled trial (Eisler et al., 2016a).

The treatment aims to help improve outcomes for young people with an eating disorder and their families. It brings together families who are struggling with similar difficulties with the aim of increasing knowledge and support, building solidarity to reduce feelings of isolation and changing treatment context by providing multiple sources of information and increasing intensity.

MFT-AN draws on principles from a number of psychological theoretical frameworks, including group psychodynamic therapy, cognitive behavioural, and systemic therapy as well as Maudsley Family Therapy for Anorexia Nervosa (FT-AN). MFT-AN consists of five to eight families (all with a young person suffering with anorexia nervosa, atypical anorexia nervosa or avoidant/restrictive food intake disorder) and a therapeutic team. Ten MFT days are offered over the course of six to eight months and consists of working together as a group for up to 10 full days of treatment. Treatment starts with an introductory afternoon prior to four full consecutive days of therapy. These four consecutive days are then followed by four to six one-day follow-ups. The MFT group is a closed group and the expectation is that families attend both the intensive consecutive days and subsequent one-day follow-up meetings. Follow-up days are initially more frequent, but then their frequency gets spread out, with typically a two-to three-month gap between the last two meetings.

Young people and their families who join the MFT group, are expected to be in different phases of treatment, in different stages of their illness with variable levels of motivation towards recovery. Variability has certain advantages and allows families and young people who are early in treatment or who have not made much progress, to witness that change is possible.

This manual is written in two parts. The first part outlines the MFT treatment model including a description of the MFT-AN structure and content, how change is expected to occur, therapeutic techniques, team functioning, and troubleshooting when the group process encounters difficulties. The second part of this manual outlines the structure and content of MFT activities, with detailed instructions, feedback of each activity, and comments we have received from families we treated. The clinical activities described in this manual continue to evolve both as part of our own clinical practice as well through the contribution of a large number of teams that have participated in MFT trainings delivered by the Maudsley Centre for Child and Adolescent Eating Disorders¹. The activities described in this book are just a selection of activities we use when facilitating MFT-AN.

Who is this manual for?

This manual is written for mental health professionals of varying background and discipline, including but not limited to family therapists, psychologists, social workers, nurses, psychotherapists, psychiatrists and dietitians. MFT can be delivered effectively by clinicians who are not trained family therapists, but it is generally helpful if teams offering MFT include individuals with systemic training. As a minimum, it is important that clinicians planning to facilitate MFT-AN are familiar with the concepts of the Family Therapy for Anorexia Nervosa (FT-AN). FT-AN is an evidence based, four phase treatment that supports the young person and family to return to physical and psychological health by working together in a developmentally sensitive manner. Good understanding, clinical experience and training in the FT-AN model is a prerequisite for anyone planning to offer the MFT-AN intervention. MFT-AN training is also available and is strongly recommended prior to commencing the treatment as it provides a solid grounding in the theory as well as the practical elements of running MFT. The training also addresses managing the complex group process, which is unique to MFT and important to consider.

Evidence for MFT-AN

The evidence base for MFT-AN continues to emerge and rests on the shoulders of the 40 plus years of research into family therapy for restrictive eating disorders. Family therapy with an eating disorder focus is now well established as the first-line treatment for children and adolescents (Jewell et al., 2016). A number of recent national treatment guidelines (UK: NICE, 2017; Canada: Couturier et al., 2020; Australia: Hay et al., 2014) recommend family therapy, with the UK and Canadian guidelines including MFT in their recommendations.

Effectiveness

The most recent and largest study of MFT-AN (N=169; Eisler et al., 2016a) is a randomised trial from the UK, which compared MFT-AN with FT-AN. The MFT group also had FT-AN sessions as clinically indicated in between MFT group sessions. The study was conducted in community-based specialist eating disorders services with therapists who were not especially selected for the study but those providing routine care, making this a real-world trial of the model. Results indicated better primary outcomes for the MFT group at 12 months after treatment commenced, with 76% meeting either an intermediate or good outcome using the Morgan Russell criteria (Russell et al., 1987) compared with 58% in the control group. As expected, there were clinically significant improvements for both groups over time with improved weight, eating disorder psychopathology and mood. There were no statistically significant differences on these measures between groups, except the MFT group had gained significantly more weight at 18 months after treatment commenced. There was no difference between the groups in the number of FT-AN sessions over the 12 months of treatment. A second multicentre randomised controlled trial (Carrot et al., 2019) has recently been registered and is aiming to recruit 150 participants comparing MFT and systemic family therapy and will be the first study to compare MFT to a non-eating-disorder-focused family therapy.

A smaller comparison study and a number of case series have also investigated the effectiveness of MFT-AN. Gabel et al. (2014) in Toronto compared the addition of MFT-AN to treatment as usual for 25 patients with a retrospective matched control group from the same service. Treatment as usual consisted of inpatient and outpatient treatment as indicated and also included individual and family therapy. The patients in the MFT group had significantly higher weight than those receiving treatment as usual after 12 months and also had significantly greater improvements in eating disorder psychopathology and mood.

A number of open studies provide additional support for MFT-AN. Salaminiou et al. (2017) reported on 30 patients in the UK who received MFT-AN. There was a significant improvement in weight with 62% in a normal weight range after six months of treatment and two thirds no longer meeting the criteria for a restrictive eating disorder. Improvements in the patient’s mood, self-esteem and eating disorder psychopathology were also reported. A case series from Belgium (Gelin et al., 2015) of 82 patients also reported significant weight gain over 12 months of treatment, as well as psychological improvements. Other case series from Denmark (Hollessen et al., 2013); USA (Marzola et al., 2015); Sweden (Dennhag et al., 2019) and Czech Republic (Mehl et al., 2012) also report significant weight gain and/or psychological improvements or improved quality of life after MFT. While there is some variability in the structure and treatment dose in these studies the physical and psychological improvement for patients is consistent.

Treatment acceptability and feasibility

MFT studies consistently report positive parent and patient satisfaction with MFT (Eisler et al., 2016a; Dawson et al., 2018). Qualitative responses reported in these studies reflect planned MFT targets, such as increased understanding of their young person’s illness, improved parental capacity, self-efficacy and reduced isolation, although challenges are also reported, and young people do not rate the treatment as highly as their parents (Eisler et al., 2016a). Also notable is MFT’s low dropout rate, which varies between reports, but is generally less than 10% (Eisler et al., 2016a; Gelin et al., 2018).

Mechanisms of change

Mechanisms of change in MFT require further research, however, qualitative feedback while limited, seems to match the hypothesised mechanisms. An innovative study (...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• List of figures
• List of tables
• List of quick reference boxes
• List of abbreviations
• Acknowledgements
• Part I Theory, structure and techniques
• Part II MFT activities
• References
• Appendix I: List of activities by theme
• Appendix II: List of activities by format
• Index