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Family Therapy Models and Theories

Family therapy approaches. A number of different family therapies have been used to treat anorexia, although all seek to change the power structure within the family by empowering parents, preventing alliances that cross generations, and reducing tensions and problems between parents. Note that this approach contrasts markedly with the cognitive behavioural interventions described above which encourage autonomy and personal control over eating.

Structural family therapy One of the fi rst family approaches to treating anorexia was reported by Minuchin et al.. They reported an 85 per cent success rate, although this has been viewed with some caution as it was based on a series of case reports with relatively young and ‘intact’ families rather than data from controlled trials. More recently, Russell et al.followed a similar therapeutic approach which focused on the underlying stresses within the family. The approach had three tasks. The fi rst involved engaging the family in the therapy process. They termed the second part the refeeding phase. In this, the family was observed eating together to identify relationships, communication of support, and rules about food and eating. At this time, the ‘identifi ed patient’ and their siblings were encouraged to align, in order to reinforce appropriate boundaries within the family. The fi nal stage involved changes in the family system, including return of control over eating to parents, working to support cooperation between parents, and stopping alignments or collusion between one or other parent and the person with the eating disorder. Russell et al. compared the effectiveness of this approach with that of individual supportive therapy in the treatment of people with both anorexia and bulimia. Their fi ndings were somewhat disappointing. Although many of the people with anorexia achieved signifi cant weight gain, most participants achieved only modest gains on more general measures of outcome. At one-year follow-up, 23 per cent of the participants were rated as having a ‘good’ outcome, 16 per cent had a ‘moderate’ outcome and 61 per cent had a ‘poor’ outcome.

Family therapy proved more effective than individual therapy on measures of weight, menstrual functioning and psychosocial adjustment for participants whose problems began before the age of 19 years and where the duration of problems was less than three years. Individual therapy proved marginally more effective than family therapy for older participants.

Behavioural family therapy

Behavioural family therapy combines systemic and behavioural therapy approaches. The goals of therapy begin with restoration of weight. Strategies to achieve this include changing eating habits and cognitive therapy to minimize body image distortions, fear of fatness, and feelings of ineffectiveness. Family interaction patterns such as confl ict avoidance, enmeshment and over-protectiveness are also targeted. Therapy follows three phases. First, control over eating is taken away from the individual and given to the parents, to restore the family hierarchy. Parents are taught and encouraged to implement a behavioural weight-gain programme for their child, including making meals, regulating exercise and establishing consequences for following or not following the plan. Once weight gain has been achieved, therapy moves to the second stage.

This combines three elements:

cognitive restructuring of distorted body image and unrealistic food beliefs working with the family to alter enmeshment, coalitions and inappropriate family hierarchies gradually giving control over eating to the person with the eating disorder.

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