The Family Journal

http://tfj.sagepub.com/

Anorexia Nervosa: Treatment in the Family Context

Dana Heller Levitt
The Family Journal 2001 9: 159
DOI: 10.1177/1066480701092010

The online version of this article can be found at:

http://tfj.sagepub.com/content/9/2/159

Published by:

http://www.sagepublications.com

On behalf of:

International Association of Marriage and Family Counselors

Additional services and information for The Family Journal can be found at:

Email Alerts: http://tfj.sagepub.com/cgi/alerts

Subscriptions: http://tfj.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

Citations: http://tfj.sagepub.com/content/9/2/159.refs.html

Downloaded from tfj.sagepub.com by Guadalupe Perez Lezama on September 25, 2010

 v Literature Review—Theory
THE FAMILY
Levitt / ANOREXIA
JOURNAL:
NERVOSA:
COUNSELING
TREATMENT
AND THERAPY FOR COUPLES AND FAMILIES / April 2001
Anorexia Nervosa: Treatment
in the Family Context
Dana Heller Levitt
University of Virginia
The prevalence of eating disorders is on the rise, and many treatment
modalities are being developed and investigated to demonstrate
their efficacy. One form of treatment for anorexia nervosa that con-
tinues to be developed is family therapy. In the following article, an-
orexia nervosa and its prevalence are defined, theories of its
development are discussed, and family therapy interventions that
have been applied to the treatment of the disorder are outlined.
A s family dynamics are frequently cited as an element in
the development and maintenance of eating disorders,
family therapy is frequently a form of treatment. Anorexia
nervosa, one of the eating disorders, is among the deadliest of
psychiatric disorders. Treatment in this context, therefore,
requires careful planning and examination of both validated
therapeutic interventions as well as the disorder itself.
ANOREXIA NERVOSA
The diagnostic characteristics of anorexia nervosa include
the following: (a) refusal to maintain body weight at or above
85% of that expected for one’s age and height, (b) intense fear
of gaining weight or becoming fat, (c) body image distur-
bance, and (d) the absence of at least three consecutive men-
strual periods for females (American Psychiatric Association
[APA], 1994). Females, in particular those between 15 years
and 24 years of age, are most vulnerable to developing
anorexia nervosa (leGrange, 1999; Robin, Bedway, Siegel, &
Gilroy, 1996). Although it is becoming more widespread
internationally, anorexia still tends to be most prevalent in
industrialized societies such as the United States and Europe
(APA, 1994). Prevalence rates among females in late adoles-
cence and early adulthood are estimated to be 0.5% to 1%.
These rates are indicative of only those who meet all of the
diagnostic criteria and do not include those who meet and are
more appropriately diagnosed with an eating disorder not oth-
erwise specified or disordered eating (APA, 1994).
People with anorexia generally diet persistently to lose
weight, which results in a weight loss of at least 15% of their
THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES, Vol. 9 No. 2, April 2001
© 2001 Sage Publications, Inc.
Downloaded from tfj.sagepub.com by Guadalupe Perez Lezama on September 25, 2010
body weight (Robin et al., 1996). Because of the severe
weight loss, anorexia has high morbidity and mortality rates.
Fifteen percent or more of the people followed up to 20 years
or longer following treatment die of causes related to anorexia
nervosa (leGrange, 1993).
DEVELOPMENT OF
ANOREXIA NERVOSA
The cause of anorexia remains unclear in many respects
(Lackstrom & Woodside, 1998). What is certain is that no sin-
gle etiological factor can be identified in its development
(Robin et al., 1996). Rather than attempting to identify a sin-
gle cause, clinicians and researchers are urged to remember
that the “development of an eating disorder is much too com-
plicated a process to blame on any particular factors or peo-
ple” (Thode, 1994, p. 62). Thode (1994) suggested address-
ing and considering the larger sociocultural system, family
system, and the physiological and emotional systems of the
person with the symptom in both etiology and treatment.
Although many family variables are suggested to contribute
to the development of anorexia, the family itself is not blamed
as the cause of the disorder in one of its members (Eisler,
1993). Anorexia describes the patient only and not the family,
shunning such terms as the anorectic family (Minuchin,
Rosman, & Baker, 1978). Usually developed in the launching
stage of the family (Thode, 1994), there is often a disturbance
in the identified client’s autonomy (leGrange, 1993). Fam-
ilies with a child with anorexia generally have highly
enmeshed patterns of interaction (Minuchin et al., 1978).
Such child- oriented families often also contain unexpressed
parental conflict or overinvolved parent and child relation-
ships (leGrange, 1993).
In response to the enmeshed and overinvolved family pat-
terns, the child with anorexia seeks proximity in the form of
interpersonal contact (Minuchin et al., 1978). The systems
work of Minuchin et al. (1978) posited that a child may
develop anorexia for rewards of love and approval by being
thin or needy. Likewise, they state that such children are
159-163
159
160 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / April 2001
dependent on parental approval and develop an obsessive
concern for perfection, often equated with thinness. Anorexia
can be a way to present oneself as weak, incompetent, and in
need of family support, which ensures that the child will be
the center of attention or may deflect parental conflict. As
such, the goals of family therapy are to change the enmesh-
ment, over- involvement, rigidity, and conflict-avoidance pat-
terns in the family system of the person with anorexia
(leGrange, 1993).
FAMILY INTERVENTIONS
Family therapy has been established as the treatment of
choice for adolescents who have a duration of illness less than
3 years (Rathner, 1998). One investigation shows that 85% of
patients who had been treated with family therapy for
anorexia had recovered at the time of follow-up 1.5 years to
7 years later (Minuchin et al., 1978). Compared to individual
therapy, family therapy has been proven more effective for
younger patients with an early onset and short duration of
anorexia (Russell, Szmukler, Dare, & Eisler, 1987). Other
studies conclude that there is little difference between family
and individual therapy for persons with anorexia, with the
caveat that family therapy may not be universally effective
(Eisler, 1993).
Despite these findings, few studies have examined what
specifically about family therapy is effective in treating
anorexia. The most prevalent outcome studies are in the areas
of behavioral family systems therapy and structural family
therapy. These forms are similar in many respects, primarily
because of their roots in systemic family therapy. A third
form, the constructive family therapy approach, is presented,
given its implications for future research.
Behavioral Family Systems Therapy
As its name suggests, Behavioral Family Systems Therapy
(BFST) combines elements of behavioral and systems ther-
apy for families with an adolescent who has anorexia. Family
hierarchy and developmental level are considered and
addressed through behavioral modification and cognitive
work (Robin et al., 1996). The goals of this form of therapy
begin with restoration of the individual’s weight and health.
The goals are accomplished through the following: (a) chang-
ing eating habits; (b) addressing body image distortions and
the fear of fatness; (c) modifying self image, feelings of inef-
fectiveness, depressed affect, anxiety, and perfectionistic and
obsessional personality styles. Maladaptive family interac-
tion patterns, such as conflict avoidance, enmeshment, and
overprotectiveness, are targeted at the outset of therapy
(Robin et al., 1996).
BFST follows three phases of treatment after initial assess-
ment (Robin et al., 1996; Robin, Siegel, & Moye, 1995). First,
control over eating is taken away from the individual and
given to parents. The explanation for this change in control, to
Downloaded from tfj.sagepub.com by Guadalupe Perez Lezama on September 25, 2010
restore the family hierarchy, is given and the therapist
acknowledges the difficulties parents face with such a task.
Parents are coached to develop and implement a behavioral
weight-gain plan for their child, including making meals, reg-
ulating exercise, and establishing consequences for following
the plan. Once weight begins to approach a more healthful
point, therapy begins to focus on nonfood related issues. It is
in this phase that cognitive restructuring of distorted body
image and unrealistic food beliefs take place. Strategic inter-
ventions to alter enmeshment, triangulation, coalitions, and
family hierarchy are implemented. The therapist also works
with the family to identify the role that anorexia plays in
maintaining family homeostasis. In the final treatment phase,
control over eating is gradually returned to the adolescent.
The adolescent is taught healthful ways to maintain weight, as
this remains the primary treatment goal. Problem-solving
communication skills are introduced to the family so that
anorexia is not used as a means of communication. As part of
such training, conflict-resolution and family-interaction
issues are addressed. The adolescent’s individuation is fos-
tered even as the parents’ marital dyad is strengthened in
preparation for launching. In addition to continued efforts at
weight management and communication, changing distor-
tions and misconceptions takes place in this phase before
treatment is terminated.
Robin et al. (1995) tested the efficacy of BFST in a sample
of female adolescents ranging in age from 12 to 19 years. All
of the women had developed anorexia within 12 months of the
study and lived at home. The women in this study were ran-
domly assigned to BFST or individual therapy described as
supportive and solution focused. Therapists conducting both
forms of therapy used manuals to standardize treatment. Ses-
sions lasted 60 to 75 minutes and took place over an average
of 15.9 months. At follow-up 1 year after termination, both
forms of treatment had positive affects on maintaining body
mass index, restoration of menses, and family interactions. It
was thus concluded that BFST is an effective form of therapy
with female adolescents with anorexia and their families.
This study has limitations in generalizing results to all appli-
cations of BFST. The participants came from primarily
two-parent families and were older adolescents. BFST
requires the commitment of the parents’ effort and to work as
a team and therefore may be best applied with highly moti-
vated and otherwise intact families.
Structural Family Therapy
Like BFST, structural family therapy interventions studied
have foundations in systems theory. Systems therapy focuses
on stress in the family rather than the individual, believing
that the experience of one member has an affect on all mem-
bers (Thode, 1994). The primary treatment goal is likewise to
restore the weight in the family member with anorexia, which
may take from 10 to 14 weeks (leGrange, 1993, 1999).

Treatment has the following two component foci: the
symptom and the underlying stresses contributing to the
development of anorexia. Parents are primarily concerned
with their child’s weight restoration. Family members are
enlisted for support and to allow the individual to take charge
of eating. They are encouraged to no longer make eating and
food a power struggle and to act as if eating is normal. The
family is likewise asked what they believe the family will be
like if the focus or concern (anorexia) in the family were to
change. This question sets the stage for the second focus of
therapy in which the underlying stresses contributing to the
development of anorexia are addressed. Family rules for deal-
ing with stress are pointed out and changed. In addition, trian-
gles that place the person with anorexia in a stressful situation
are eliminated and the responsibility for conflict is returned to
the more appropriate parties (Thode, 1994).
Structural family therapy with anorexia has three tasks
(Russell et al., 1987). First, the family’s cooperation must be
secured and maintained. The physical dangers of anorexia are
often highlighted on first contact with the family to engage
them in treatment (Dare, Eisler, Russell, & Szmukler, 1990;
leGrange, 1999; Russell et al., 1987). While taking a problem-
solving approach with the family, it is especially important to
abate their self-blame for the anorexia to harness the family’s
energy for treatment (Russell et al., 1987).
Once engaged in treatment, the family is then observed to
assess their organization. Also referred to as the refeeding
phase, the family is observed eating together to identify rela-
tionships, communication of support, and rules about food
and eating (leGrange, 1999; Russell et al., 1987). Part of this
refeeding and assessment task includes aligning the identified
patient with siblings to reinforce boundaries and assess alli-
ances within the family.
The third task of structural therapy includes interventions
to continue managing symptoms and produce effective
changes in the family system (Russell et al., 1987). Such
interventions emphasize the need for parental support, con-
sistency, and cooperation to facilitate healthy adolescent or
young adult relationships. Control of eating is gradually
returned to parents when the illness is no longer the basis of
communication. Rationalization, psychodynamic interpreta-
tions, behavioral strategies, manipulations, and homework
between sessions may be applied to foster individuation and
to strengthen the marital dyad in preparation for the chil-
dren’s departure from home (leGrange, 1999; Russell et al.,
1987).
The Maudsley Hospital in London has adopted a similar
three-phase structural approach in their family treatment
model (Dare et al., 1990; Eisler, 1993; leGrange, 1993;
leGrange, Eisler, Dare, & Russell, 1992; Russell et al., 1987).
First, a family meal takes place in which direct observation of
family patterns and parental control of their child’s symptoms
occurs. The second phase involves the adolescent’s surrender
to parental demands to increase food intake, which success-
Downloaded from tfj.sagepub.com by Guadalupe Perez Lezama on September 25, 2010
Levitt / ANOREXIA NERVOSA: TREATMENT 161
fully changes the family’s mood. Finally, when the adoles-
cent achieves a stable weight and self-starvation ceases, a
more healthful relationship with parents is established, dem-
onstrating that anorexia need not be the basis for interactions.
Family treatment takes place weekly and supplements inpa-
tient care that focuses on weight and health restoration
(leGrange, 1993). Compared to family counseling, in which
the parents are seen by the therapist separately from the child
or adolescent and therefore no direct observation takes place,
outcome studies of the program show that both symp-
tom-focused forms of treatment were effective (leGrange et
al., 1992). The similarities in conjoint family therapy with the
entire family and family counseling with the parents
alone—united parental stance to control eating and weight
gain, lack of blame on the family, and weight gain as the pri-
mary goal—may contribute to the comparable results of the
two modalities.
In a controlled trial of structural family therapy compared
with individual treatment (Dare et al., 1990; Eisler, 1993;
Russell et al., 1987), it was concluded that family therapy may
not be universally effective (Eisler, 1993). The individual
treatment used as a control in this study was described as sup-
portive and symptom focused (Dare et al., 1990). Eighty indi-
viduals over the span of 4 years were randomly assigned to
individual treatment or family therapy at Maudsley Hospital.
The age range of these individuals was 14 to 55 years, with the
age of onset spanning ages 9 to 50. The duration of illness
likewise had a broad range, from 3 months to 14 years. Partic-
ipants were contacted for follow-up 1 year after treatment ter-
minated. The results of the follow-up studies show that family
therapy was more effective with patients who had early onset
(before age 18) and short duration of anorexia (3 months or
less). It was likewise concluded that family therapy was more
effective with younger patients who were more likely to be
living with their parents at the time of illness and treatment.
Individual therapy was more effective for patients older than
age 18. The overall results showed that both family and indi-
vidual therapy were effective but that some criteria, including
age and duration of illness, make family therapy more appro-
priate and effective than individual therapy.
In another report of the Maudsley program, different treat-
ment modalities were established to study the effectiveness of
structural family therapy (Crisp et al., 1991). Ninety patients
were randomly assigned to one of the following four groups:
(a) inpatient treatment only, (b) outpatient individual and
family psychotherapy plus dietary counseling, (c) outpatient
group psychotherapy plus dietary counseling, or (d) no fur-
ther treatment. Family therapy held a systems approach and
attended to the establishment of appropriate boundaries,
enmeshment and conflict-avoidance strategies, and issues
surrounding the use of food and weight to communicate in the
family system. The results of this study showed that progress
was observed 1 year later in all cases where the patient
received treatment. Outpatient treatment produced a slightly
162 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / April 2001
slower rate of weight gain, although this was comparable
1 year later. Thus, it was concluded that family therapy was
effective with this group of persons with anorexia, although
the amount that may be attributed to family therapy alone (as
opposed to dietary counseling or other factors) cannot be
ascertained (Crisp et al., 1991).
Working With the Family:
Constructive Family Therapy
Minuchin et al. (1978) have a historically successful
approach to working with families with a person with
anorexia. Following their work, the use of a healthy family
structure as a comparison for families with adolescents with
anorexia was introduced as a popular approach to working
with such families (Vandereycken, 1987). Yet, the results of
their work must be read with caution. Although they report
that more than 85% of their patients recovered from anorexia
(Minuchin et al., 1978), bias in the selection of the partici-
pants (younger, short duration of treatment, and from intact
families) and bias in the fact that the researchers carried out
treatment confound the results.
A more constructive approach to family therapy has been
suggested that is less adversarial and more complementary of
the family’s strengths than behavioral and systems therapy
with anorexia nervosa. The constructive approach comes
from a position of strength and resource, observing the family
for well-being rather than deficiencies (Vandereycken, 1987).
Rather than trying to tackle resistance, therapy is viewed as a
series of crises and addresses the changes that both the indi-
vidual and family fear. This cooperative approach has the
notion of “working with instead of against” the family system
(Vandereycken, 1987, p. 463).
Vandereycken’s (1987) constructive family therapy treat-
ment program is tripartite. Treatment is time limited, usually
lasting 3 months, with intensive aftercare provided. Multifac-
eted treatment includes group psychotherapy with other fami-
lies, behavioral contracting, occupational and art therapy, and
psychomotor treatment. Finally, constructive treatment is
family oriented and provides educational guidance, parent
counseling groups, and individual family therapy when indi-
cated to optimize the success of families and the member with
anorexia. Treatment must be flexible depending on the indi-
vidual and family, with a caution against stereotyping the
needs and profiles of families with children with anorexia
(Vandereycken, 1987). Although the constructive approach
was developed in response to the systems and behavioral fam-
ily therapies employed for families with anorexia nervosa, no
empirical evidence as yet exists to demonstrate its efficacy.
CONCLUSION
Several theoretical frameworks and interventions are used
to treat anorexia nervosa in a family context. The primary
goal of treatment is to restore weight and health. Family ther-
Downloaded from tfj.sagepub.com by Guadalupe Perez Lezama on September 25, 2010
apy is suggested as a preferred and effective form of treatment
for anorexia nervosa, yet little has been provided to explain
this rationale. Despite the wealth of literature, family inter-
ventions with empirical evidence exist primarily for behav-
ioral family systems therapy and structural therapy, and even
these are few. Results are primarily drawn from two large
studies of the effectiveness of family therapy with this popu-
lation. Ethical standardization and controlled study of treat-
ment effectiveness are difficult, particularly when dealing
with a life-threatening illness such as anorexia nervosa. Fur-
ther studies to delineate the specific interventions within the-
oretical frameworks that are most effective are needed for
therapists to develop appropriate treatment plans when work-
ing with families with members with anorexia. Furthermore,
it is important to recognize how systems beyond family play a
part in the development and treatment of anorexia. Consistent
with the principles of family therapy, the person’s entire con-
text must be considered as important elements that may have
relevance to and significant affects in making changes and
gathering strength to put anorexia under control.
REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical man-
ual of mental disorders (4th ed.). Washington, DC: Author.
Crisp, A. H., Norton, K., Gowers, S., Halek, C., Bowyer, C, Yeldham, D.,
Levett, G., & Bhat, A. (1991). A controlled study of the effect of therapies
aimed at adolescent and family psychopathology in anorexia nervosa.
British Journal of Psychiatry, 159, 325-333.
Dare, C., Eisler, I., Russell, G. F., Szmukler, G. I. (1990). The clinical and the-
oretical impact of a controlled trial of family therapy in anorexia nervosa.
Journal of Marital and Family Therapy, 16(1), 39-57.
Eisler, I. (1993). Family therapy for anorexia nervosa. In M. Hodes &
S. Moorey (Eds.), Psychological treatment in disease and illness
(pp. 209-222). London: Gaskell.
Lackstrom, J. B., & Woodside, D. B. (1998). Families, therapists and family
therapy in eating disorders. In W. Vandereycken & P.J.V. Beumont (Eds.),
Treating eating disorders: Ethical, legal and personal issues (pp. 106-
126). New York: New York University Press.
leGrange, D. (1993). Family therapy outcome in anorexia nervosa. South
African Journal of Psychology, 23, 174-179.
leGrange, D. (1999). Family therapy for adolescent anorexia nervosa. Jour-
nal of Clinical Psychology, 55, 727-739.
leGrange, D., Eisler, I., Dare, C., & Russell, G.F.M. (1992). Evaluation of
family treatments in adolescent anorexia nervosa: A pilot study. Interna-
tional Journal of Eating Disorders, 12, 347-357.
Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic families:
Anorexia nervosa in context. Cambridge, MA: Harvard University Press.
Rathner, G. (1998). A plea against compulsory treatment of anorexia nervosa
patients. In W. Vandereycken & P.J.V. Beumont (Eds.), Treating eating
disorders: Ethical, legal and personal issues (pp. 179-215). New York:
New York University Press.

Robin, A. L., Bedway, M., Siegel, P. T., & Gilroy, M. (1996). Therapy for
adolescent anorexia nervosa: Addressing cognitions, feelings, and the
family’s role. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treat-
ment for child and adolescent disorders: Empirically based strategies for
clinical practice (pp. 239-259). Washington, DC: American Psychologi-
cal Association.
Robin, A. L., Siegel, P. T., & Moye, A. (1995). Family versus individual ther-
apy for anorexia: Impact on family conflict. International Journal of
Eating Disorders, 17, 313-322.
Russell, G.F.M., Szmukler, G. I., Dare, C., & Eisler, I. (1987). An evaluation
of family therapy in anorexia nervosa and bulimia nervosa. Archives of
General Psychiatry, 44, 1047-1056.
Downloaded from tfj.sagepub.com by Guadalupe Perez Lezama on September 25, 2010
Levitt / ANOREXIA NERVOSA: TREATMENT 163
Thode, N. (1994). A family systems perspective on recovery from an eating
disorder. In B. P. Kinoy (Ed.), Eating disorders: New directions in treat-
ment and recovery (pp. 61-79). New York: Columbia University Press.
Vandereycken, W. (1987). The constructive family approach to eating disor-
ders: Critical remarks on the use of family therapy in anorexia nervosa
and bulimia. International Journal of Eating Disorders, 6, 455-467.
Dana Heller Levitt is a doctoral candidate in counselor education at
the University of Virginia. Her clinical interests are in the areas of
body image, eating disorders, and issues pertinent to women.
Research interests include body image and eating disorders, clinical
supervision, and counselor training.