Q & A: Family-Based Therapy

Q. I’m aware that family-based treatment using the Maudsley approach has been receiving considerable attention as an effective treatment for adolescent patients with anorexia nervosa. Is there any way of knowing early on exactly which patients and families are unlikely to benefit from this approach, so that other approaches might be instituted earlier? (EH, Portland)

A. From the earliest research on family-based treatment (FBT) it was clear that some families were unsuited or simply not able to effectively initiate and sustain the level of commitment and involvement required for effective FBT. It’s also been clear that certain patient characteristics are associated with lower likelihood of success using this approach.

The large majority of patients enrolled in these studies have come from intact families, or families where a parent has at least one other strong sustaining adult ally as a co-participant. Families that are unwilling or unable to participate in FBT are clearly ruling themselves out early. Patients with higher degrees of obsessionality don’t do as well as those who are less obsessional. Finally, a recent two-site FBT study involving 65 adolescent patients with anorexia nervosa (AN) reported that remission of AN with regard to weight recovery by session 20 was predicted by a gain of at least 2.88% of their ideal body weight by session four (Doyle PM et al, IJED 2010; 43: 659). That is, patients who achieved less than this degree of weight gain by session four were less likely to remit by session 20. Male patients and those with shorter lengths of illness were more likely to remit, as were those who had subclinical forms of the disorder. No good data exist to suggest that patients who don’t do well in FBT will necessarily do any better using any other available approach. It remains to be seen whether treatment-resistant patients who languish and fail to gain weight via FBT despite a good family effort might do better in structured inpatient programs.  

— JY