Brief Strategic Family Therapy

Most patients with anorexia nervosa (AN) have positive responses to family therapy, but much still remains to be learned about how such therapeutic changes occurs after family therapy. French researchers sought to identify the elements that stimulate such change after brief strategic family therapy. Specific areas they targeted included variables involved in the mechanisms leading to improvement of nutritional and psychological status.

Dr. Karyn Doba and colleagues conducted a 6-month study follow-up study of 10 female AN patients and their parents, studying the duration of conflictual communications and nonverbal behavior estimated by eye contact (PLOS ONE August 2013 8:e70389). The researchers compared their baseline findings with those at the end of 5 to 6 sessions of family-based treatment. The duration of conflictual communication (i.e., interactions between persons who express opposing interests, views or opinions) and of affiliative  communication (nonverbal behavior estimated by eye contact) were compared between the first and last sessions of family-based treatment using nonparametric statistical tests.

The 10 families included the father (mean age: 49.4 years), the mother (mean age: 43 years), and the patient with AN (mean age: 20 years). At the time of the study, all patients lived at home with both parents. All patients had restrictive-type AN, and had a mean body mass index (BMI, kg/m²) of 13.9. They subjects had their eating disorders for a mean of 2.9 years and all were currently receiving antidepressant medication. The family therapy sessions were conducted by one of two therapists over a period of from 5 to 6 months and usually involved a single session once a month. Each session was 1 hour long and was videotaped. Treatment was terminated depending on the mutual decision of family members and the therapist.

Semi -structured interviews were used to evaluate the patient’s illness and psychosocial functioning. In addition, the patients’ nutritional status, menstrual function, mental state, psychosexual adjustments, and psychosocial adjustment were measured with the Morgan and Russell Scale.   At the end of the family treatment, each patient’s overall outcome was classified as good, intermediate, or poor. Patients whose menstrual period returned when there was no evidence of bulimic behavior and whose weight was within 15% of the average body weight (20 kg/m² were rated as having a good outcome; those who reached a normal weight without the return of menstruation or who reported bulimic symptoms were given an intermediate outcome rating; patients whose BMI was below 18 kg/m² were classified as having a poor outcome.

Family interactions were assessed offline using the videotaped sessions from the beginning of treatment and at the last session. Verbal communications between family members were rated for the degree of conflictual/nonconflictual content. Conflictual communications included opposition of someone else or a disagreement between two persons, confrontation with another person, or sarcasm, blame, disapproval, and critical comments. Non-conflictual communications included agreement with another person, avoiding strategies, and expression of solidarity and positive appreciation.

Four of the six patients had a good outcome

Four patients had a fairly good outcome and six had an intermediate outcome. At the end of BSFT, there was a statistically significant increase in average weight, nutrition, psychosocial, and psychosexual functioning. When the researchers compared affiliative nonverbal behavior at the first and last sessions, they could find no differences. Conflictual communication between the patient and her father had increased by the final session, but this was not the case for the mother. Thus, only the patient and her father significantly modified their conflictual nonverbal behavior during the study.

The authors note that families of AN patients have been characterized by a lack of emotional expressiveness, especially in the case of conflicts, and also by lack of conflict resolution. Their observation that an increase in conflictual communication correlated with improvement in BMI suggested that conflict management is a clinically meaningful index of family functioning in cases of AN. However, the authors also suggest that a longer period of treatment might enhance the benefits of treatment.