BOOK REVIEW: Treatment Manual for Anorexia Nervosa: A family-based approach
Reprinted from Eating Disorders Review
January/February 2001 Volume 12, Number 1
©2001 Gürze Books
(J. Lock, D. Le Grange, W. S. Agras, and C. Dare. New York: Guilford Press, 2000, 279 pp, $35.00)
When a new treatment manual for anorexia nervosa appears, we should all take notice. When the treatment manual is based on empirically supported and validated methods, we should applaud. When the treatment manual based on empirically validated methods is the first of its kind?in this case a family therapy approach?we should all run out to purchase a copy, read it, and incorporate the methods into our thinking and practices.
Among the few published evidence-based studies concerning psychotherapeutic interventions for anorexia nervosa, that of Dare, Eisler, Russell and their colleagues at the Maudsley Hospital in London has certainly achieved the highest ranks. That research, which examined the efficacy of family therapy for younger patients with anorexia nervosa, incorporated some of the concepts of earlier family theorists such as Minuchin, Madenes, Palazzoli and their co-workers, and went beyond them to develop controlled studies examining the impact of family therapy on anorexia nervosa.
Building on that work, and incorporating the work of Robins, Lock and his colleagues, who are using the manual as the basis for ongoing research at Stanford, have given us an extremely welcome review of the rationale for a family therapy approach and a guidebook for achieving a meaningful intervention. Focused largely on adolescent anorexia nervosa patients living at home, the treatment entails approximately 20 visits over one year. The primary treatment team ideally consists of a knowledgeable clinician and a co-therapist. An associated consulting team includes a primary care physician, usually a pediatrician, a nutritionist, and other specialists as needed. The lion's share of the work falls to the family in the home under the guidance, support, and supervision of the treatment team.
Treatment is designed to occur in three phases. The basic philosophy is pragmatic and "agnostic" regarding the efficacy of family therapy for younger patients with anorexia nervosa—families are not blamed for the patient's disorder. Here's the bottom line: The first phase, usually requiring 3 to 5 months, compels the parents to re-assume parental control over the patient's eating. The family's perspectives about the eating disorder and their actions toward the adolescent are prescribed by the treatment. Parental authority and sib-sib boundaries are re-established and reinforced. The family is obligated to find solutions that work for them—to devise a way to see to it that the patient eats and that a healthy weight is restored. They are to treat the patient with dignity and respect, acknowledging her point of view and experience, and making clear distinctions between the patient, who is cherished, and her disease, which is objectified and battled. During this time other family conflicts and disagreements related to the impact of the eating disorder and other issues are deferred.
Phase II begins once the patient accepts the family's demands that she eat and as weight is being restored. At this time, control over eating and weight is restored to the patient, and the other family issues can be addressed. In Phase III, the team and family focus on the adolescent's development, particularly upon needs for increasing autonomy and separation from the family, getting back on track, and helping the family to focus on non-eating-disorders issues.
The manual addresses many practical issues, including dealing with noncompliant families and with hospitalized patients, and how the approaches described here still apply to weight-restored patients. The early treatment sessions are spelled out in great detail, and rich case vignettes are used to illustrate treatment phases. Many common questions posed by families and intercurrent difficulties likely to be experienced are anticipated and discussed.
To sum up, every clinician who works with adolescents with eating disorders will want to own and study this book. It's an extremely welcome addition. We can expect that the ongoing research based on this manual will produce refinements and modifications in the years to come. Until future editions incorporate those changes, this manual is likely to become a standard for the field.