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Current Thinking about Family Therapy and Systemic Interventions with Eating Disorders


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Title: Current Thinking about Family Therapy and Systemic Interventions with Eating Disorders

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

  • 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
  • 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
  • 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.

  • 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 sufferers 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)

Which Models?
  • Emerging from the development of the last 18
    years in particular

Maudsley model
  • Inspired by the work of Salvador Minuchin
  • (1975, 1978), Palazzoli et al (1978), in Downs
    and Blow (2013) Primarily focused on Anorexia
  • 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
  • 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
  • Focus on helping adolescent to begin to eat on
  • 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
  • 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
  • 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

  • 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.

  • 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.

  • 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.

  • What was it like doing the exercise, is everyone
  • What next steps emerged, talk from each group to
    the other groups in turn?
  • What dilemmas, concerns, exciting ways forward

Six instructions
  • 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
  • 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
  • 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
  • Collaborative adaptable engagement with current
  • Score- measuring progress across a number of

  • How we intervene
  • Structured family therapy- reflecting team
  • Family input in home-purpose?
  • Consultation
  • Educational and practical input
  • Explore needs of all family members
  • Use of a reflecting team approach
  • Individual work in the presence of
  • Joint team approach to care planning- are we
    stronger than the eating problem

  • Collaboration and transparency re goals/contract-
  • 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
  • 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

  • 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.
  • 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. 727-736
  • 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.3551 pp.102-120
  • Minuchin, S., Baker, B.L., Rosman, B.L., Milman,
    L., Todd, T.C., (1975) A conceptual model of
    psychosomatic illness in childrenfamily
    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
  • Palazzoli. S.M. (1978), Self-Starvation from
    individual to Family Therapy in the Treatment of
    Anorexia Nervosa. Trans. Pomerans, A. New York
    Jason Aronson.

  • Grey literature
  • Junior MARSIPAN Management of Really Sick
    Patients under 18 with Anorexia Nervosa. Royal
    College of Psychiatrists, College report, January
    2012 http//
    68.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//
    a/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