A Unique Treatment Program for Couples

A group at the University of North Carolina has developed a unique program for helping patients and their partners deal with anorexia nervosa (AN). “Uniting Couples in the Treatment of Anorexia Nervosa,” or UCAN, is a couple-based cognitive behavioral therapy intervention for the treatment of AN (Int J Eat Disord 2010; published online before print).

As Cynthia M. Bulik, PhD, and colleagues report, a substantial proportion of people presenting for treatment are in committed relationships. Patients also often emphasize the importance of their partners in the recovery process. In one study of 70 women treated for 10 years, the one factor patients felt contributed most to their recovery was having a supportive partner. Many other studies have attested to the importance of other factors, including communication and sexuality.

The UCAN program is based on the perspective that although one member of a couple has AN, the disorder occurs in an interpersonal and social context. The partner without AN is a central part of that environment. Partners often do not know how to help, and at times may inadvertently exacerbate the problem. By including the partner in the intervention, the program provides an additional source of support, to reinforce appropriate eating and other health-related behaviors while avoiding punishment.

First, an understanding of the couple’s experiences

The UCAN program has several phases. The first step is understanding the couple’s experience of AN, providing psychosocial education about the disorder and the recovery process, and teaching the couple effective communication skills. In the initial stages, the therapist does an extensive assessment of the couple’s relationship history, both partners’ experience of AN, and evaluates how AN has influenced and been influenced by the couple’s relationship.

Next, viewing the couple’s interactions around AN

The second phase targets the couple’s relations and interactions around the eating disorder. The couple is guided through consideration of the various features of AN they feel are most challenging, such as restricting food, binge eating, or secrecy. The couple uses their communication skills to develop ways to respond to these challenges more effectively as a team. For example, the couple is encouraged to consider how the partner can support the patient when eating meals without adopting a role as strict “monitor” or by making inappropriate comments on what the patient has not eaten or “should” be eating. The therapist guides the couple through an analysis of their relationship patterns around the eating disorder. Eventually the couple use their decision-making skills to develop a more effective approach to eating together as a couple/family, both within and outside the home.

The second phase then broadens the focus of treatment to features the couple find challenging in the recovery process, including body image and sexual issues as they relate to the eating disorder. Body image distortions and body dissatisfaction can be two of the most vexing features of AN for the partner, and it is important that the couple build a greater sense of understanding and empathy for each other’s body image. The therapist then guides them to more effective ways to communicate or interact around body image. Body image work is then a natural entree into the couple’s physical relationship.

Final phase: working on relapse prevention

The final phase brings treatment to a close by discussing relapse prevention and helping the couple plan steps after the UCAN program ends. The couple receives psychoeducation about the process of recovery and relapse prevention, including slips versus relapses and high-risk situations for the patient and couple. The couple is then asked to use their decision-making skills to develop effective ways to respond to selected high-risk situations, with the goal of avoiding slips and relapses. Finally, the couple is asked to brainstorm ways to work as a team against AN in the future.

The program was developed for individuals in committed relationships who are living together as an interdependent couple. Patients and partners can be of any sex or sexual orientation. And, since UCAN addresses difficult AN-related and relationship issues, both partners need to be able to commit to the entire course of 22 sessions and to be certain of support by the therapist at particularly challenging points during treatment.

Challenges

In relationships with high levels of distress, the patient with AN may have difficulty sharing intimate details about AN with his/her partner if it does not feel safe and if the couple frequently has negative interactions. In addition, some partners can find it difficult to have empathy about the disorder and to support the patient. However, giving the couple a specific target area to work on can provide an opportunity for them to learn to work as an effective team.

Individual factors also influence the ease with which treatment proceeds. Often conditions such as depression and anxiety disorders or symptoms that co-occur with AN are an inevitable target of treatment. The authors have found that the support of a skilled UCAN therapist and a quick response from the full treatment team can help the couple and the patient through difficult times in treatment.