Couples Therapy Helps Combat Anorexia Nervosa

Therapists find success by enlisting
support of intimate partners.

A cognitive-behavioral therapy, couples-based intervention for adults with anorexia nervosa (AN) is providing a pathway for both the patient and his/her partner to work together in the treatment process. Typically partners are not included in the treatment of patients with AN, and inpatient treatment models may include partners at admission and discharge only or in family weekends or family meetings. Such sessions are also usually aimed at families rather than partners, and provide information only. According to researchers at the University of North Carolina, excluding partners from treatment perpetuates a culture of secrecy and “no-talk zones” around many aspects of AN; this secrecy helps perpetuate the disorder.

Guided by the evidence that family-based interventions are beneficial in the treatment of both adults and adolescents with AN, Dr. Cynthia Bulik and colleagues at the University of North Carolina, Chapel Hill, developed Uniting Couples in the Treatment of AN, or UCAN (J Cogn Psychother 2012; 26:19). As Dr. Bulik and colleagues have noted, family members and partners are often deeply challenged to understand how their loved ones can starve right before their eyes. The devastating and often long-term effects of the disease also pose incredible stress for caregivers. The disease produces social isolation and increased dependence upon families and partners. Partners must deal with difficult eating behaviors, when their partner refuses to eat, purges, has a relapse, and/or lapses into silence and secrecy. The stigma of AN and the cost of treatment also take a huge toll on relationships. Partners report a wide array of emotional responses, including grief, shame, anxiety, depression, and guilt.

Over time, there has been a huge reversal in the way family members are viewed in the treatment of AN patients. Whereas families were once thought to be a cause for the eating disorder, and family members were thus excluded from treatment, programs such as the Maudsley approach now actively involve families in treatment. Parents now take initial control of re-nourishment of their child, and the approach is also being tested in older adolescents and young adults. However, the authors point out, while this model may work well for parents and children, it has the potential in an intimate relationship to create power struggles and may disrupt equal partnerships. The couples-based intervention takes a different form.

First, a foundation for addressing AN

In the first phase, UCAN treatment begins by helping the couple build a supportive foundation for addressing AN effectively as a team by (1) understanding the couple’s own experience of AN; (2) providing psychoeducation about AN and the process of recovery; and (3) teaching the couple effective communication skills. The therapist assesses the couple’s relationship history and both partners’ experience with AN, and analyzes how the eating disorder has influenced and been influenced by the couple’s relationship. The findings are discussed with both members of the couple to help create a comprehensive and shared understanding of AN.

In the next phase, the therapist helps the couple develop an effective support system for the individual work that must be accomplished. The couple is guided to consider which features of AN they find most challenging and then learn how they can use their communication skills to respond to such challenges more effectively as a team. One example would be to have the partner sit with the patient and develop more positive interactions around eating, rather than having the partner act as a “food monitor. As the authors note, the body image work (for both patient and partner) during this phase provides a natural entrée in to the couples’ physical relationship. The last phase concentrates on bringing treatment to a close, with an emphasis on relapse prevention and the next steps in the AN recovery process-the goal is to help the couple develop effective responses to use when a slip or full relapse occurs.

Partners show dedication in the face of enormous stress

During the UCAN study, the authors were heartened by the dedication that partners showed, such as gaining weight as they attempted to “eat with” the patient, hoping that this would encourage her to eat more. Others stopped exercising because their partner would be envious of the time the partner spent at the gym or tempted to compete to exercise more. Occasionally, the stress of the secrecy, distrust, and distance proved to be too much, and the relationship could not recover. This was an argument for earlier intervention, according to the authors. Couples also have very different degrees of ease as working as a team to face the challenges of AN, say the authors. When there is a high degree of stress in a relationship, negative, critical comments can affect whether the partner with AN is comfortable or even willing to share intimate details about her AN. Giving such couples a specific targeted area to address as a couple can give them a chance to learn to work together as an effective team.

Finally, a complicating factor that must be weighed is the fact that many patients with AN are not motivated to recover or at least have a high degree of ambivalence about making changes in their eating behavior. This is difficult enough in individual therapy but becomes even more complicated in a couples- based intervention. If the patient does not wish to change, the partner’s major role-helping the patient with AN make changes becomes even harder. A skilled therapist can help by addressing such issues and helping avoid control and power issues related to eating. Working with a full treatment team is also helpful for dealing with the many comorbidities so common in AN.