The Effects of a Multiple Family Therapy on Adolescents with Eating Disorders: An Outcome Study GELIN* ZOE SILVANA FUSO† STEPHAN HENDRICK* SOLANGE COOK-DARZENS‡ YVES SIMON†
Multiple Family Therapy (MFT) has gained increasing popularity in the treatment of eating disorders and many programs have been developed over the past decade. Still, there is little evidence in the literature on the effectiveness on MFT for treating eating disorders. The present study examines the effects of a particular model of Multiple Family Therapy on eating disorder symptoms, quality of life, and percentage of Expected Body Weight (%EBW) in adolescents with eating disorders (ED). Eighty-two adolescents with ED, aged between 11 and 19 years, were assessed before and after treatment using the Eating Disorders Inventory 2 (EDI-2), the Outcome Questionnaire 45 (OQ-45) and %EBW. Results showed a significant increase in %EBW between the beginning and end of treatment, with a large effect size. 52.4% of patients achieved an EBW above 85%. Symptoms relative to all EDI dimensions (except for bulimia) significantly decreased during treatment. The three dimensions related to quality of life assessment also improved over the course of MFT. At the end of treatment, 70.7% of patients had a total OQ-45 score below clinical significance. This study suggests that Multiple Family Therapy may benefit adolescents with eating disorders, with improvement on several outcome measures (%EBW, ED symptoms, and quality of life). However, the lack of a comparison group entails caution when drawing conclusions. Keywords: Multiple Family Therapy; Eating Disorders; Adolescents; Outcome; Treatment Effectiveness Fam Proc 54:160–172, 2015
A
norexia nervosa (AN) is a serious mental and behavioral disorder with significant psychiatric and medical morbidity (Klump, Bulik, Kaye, Treasure, & Tyson, 2009). The prevalence of anorexia nervosa is estimated to be up to 0.9% in young females (Smink, van *Systemic and Psychodynamic Clinical Psychology Department, University of Mons, Mons, Belgium. † Centre Th erapeutique du Trouble Alimentaire de l’Adolescent (CTTA), Centre Hospitalier Le Domaine, Braine l’Alleud Belgium. ‡ Child and Adolescent Psychiatry Department, Robert Debre Hospital, Paris, France.
Correspondence concerning this article should be addressed to Zo e Gelin, Systemic and Psychodynamic Clinical Psychology Department, University of Mons, Place du Parc 18, Mons 7000, Belgium. E-mail: zoe. [email protected]. The CTTA (Therapeutic Centre for Adolescents suffering from Eating Disorders) is a pilot-project funded by the Belgian Federal Public Service—health, food chain safety, and environment. We would like to thank the parents’ association Miata for its support and the team of the CTTA for collecting data. 160
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Hoeken, & Hoek, 2012). Moreover, AN is known to have the highest mortality rate of any mental illness (8–10%) (Franko et al., 2013). It is the position of the Academy for Eating Disorders that the origins and maintenance of eating disorders (ED) can be influenced by family factors, while standing firmly against any etiological model in which families are to blame for the development of the ED (Le Grange, Lock, Loeb, & Nicholls, 2010). APA and NICE practice guidelines strongly recommend including families in the treatment of children and adolescents with ED (Eisler, 2005; Yager et al., 2012) and using family interventions that directly address the ED (NICE, 2004). Family therapy approaches have been applied to AN for more than 40 years (Eisler, Lock, & Le Grange, 2010). In a review of family therapy for adolescents with AN, Gardner and Wilkinson (2011) identified six randomized, controlled trials (RCT), some of which suggested that family therapy might be more effective than individual psychotherapy in terms of physical improvement and reduction of cognitive distortions (Eisler et al., 1997; Retzlaff, von Sydow, Beher, Haun, & Schweitzer, 2013; Robin, Siegel, Koepke, Moye, & Tice, 1994; Robin et al., 1999; Russell, Szmukler, Dare, & Eisler, 1987). More specifically, family therapy appears to be particularly effective for recent-onset AN in adolescents (Russell et al., 1987). However, the authors concluded that the evidence in favor of family therapy over individual therapies is on the whole weak due to small sample sizes and the significant risk of bias. Yet, in a recent RCT, Lock et al. (2010) found that family therapy is superior to individual therapy in facilitating full remission at 6–12 month follow-up for adolescents suffering from ED. Originally inspired by the works of Minuchin and colleagues at the Philadelphia Child Guidance Clinic and by the strategic family therapy movement developed by Selvini and colleagues in Milan, the Maudsley family therapy approach is a specific form of family therapy that has achieved a solid evidence base and therefore has become a treatment of choice for adolescent AN (Loeb & Le Grange, 2009; Watson & Bulik, 2013). In this approach, it is assumed that adolescents suffering from ED are not in a position to make decisions about food and eating (Wallis et al., 2013). Hence, parents are encouraged to temporarily take responsibility for refeeding their child, thus preventing the repeated relapses that can result from hospitalization (Lay, Jennen-Steinmetz, Reinhard, & Schmidt, 2002). Parents are also invited to distinguish between their daughter and her illness, using “externalization” techniques and minimalizing expressed emotions of criticism and hostility (Rhodes, Gosbee, Madden, & Brown, 2005). Adaptations from the original “Maudsley Model” have been made over the years, evolving toward the consolidation of single-family practice in the US (Lock & Le Grange, 2012; Lock, Le Grange, Agras, & Dare, 2001), and toward augmentations and further developments in the United Kingdom, including the emergence of a Maudsley-based Multiple Family Therapy (MFT) model (Eisler, 2005; Rhodes et al., 2005). Although MFT represents a relatively new approach to the treatment of ED, it has gained increasing popularity over the past decade (Cook-Darzens et al., 2005). Following a fairly narrow definition of MFT, we can describe it as a therapeutic method that brings together several families affected by the same pathology. However, the term also refers to specific treatment paradigms that are anchored in various theoretical models (psychoanalytical, systemic, cognitive-behavioral, etc.), yielding specific treatment packages with specific principles and techniques. MFT was developed by Laqueur (Laqueur, Laburt, & Morong, 1964; Raasoch & Laqueur, 1979), and subsequently by McFarlane (2002), for the treatment of schizophrenic patients. Over the past 20 years, MFT has become a popular treatment for a great variety of conditions. It has been proven effective for conditions such as schizophrenia (Dixon et al., 2001; Dyck, Hendryx, Short, Voss, & McFarlane, 2002; Dyck et al., 2000), Fam. Proc., Vol. 54, March, 2015
162 /
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depression (Fristad, Goldberg-Arnold, & Gavazzi, 2003; Lemmens, Eisler, Buysse, Heene, & Demyttenaere, 2009; McDonell & Dyck, 2004), and obsessive compulsive disorders (Barrett, Healy-Farrell, & March, 2004). MFT has also been applied to a wide spectrum of chronic medical illnesses (Lopez-Larrosa, 2013), including chronic pain (Lemmens, Eisler, Heireman, Van Houdenhove, & Sabbe, 2005) and cancer (Steinglass, Ostroff, & Steinglass, 2011). The application of this form of treatment to ED was initially developed by two clinical and research teams as an intensive day treatment: Scholz and Asen (Asen, 2002; Asen & Scholz, 2010; Scholz, Rix, Scholz, Gantchev, & Th€omke, 2005) in Dresden, and the Maudsley team led by Dare and Eisler (2000) in London. Both teams adapted the Maudsley model to a MFT format, with the initial aim of bringing about recovery in patients who did not benefit from the single-family Maudsley approach (Dare & Eisler, 2000; Rhodes et al., 2005). At the same time, more systemically oriented models of outpatient MFT were developed in France for adolescents with severe ED (Cook-Darzens et al., 2005) and in England for AN adults (Colahan & Robinson, 2002). The rationale for MFT is that similarities and differences between families help them feel less stigmatized and isolated, create solidarity, and allow learning from other families’ experiences. It also allows them to share different perspectives and experiences with each other (Asen & Schuff, 2006). Overall, three distinct MFT models tend to dominate the European field of ED treatment: the Maudsley-oriented model, the systemic model, and the psycho-educational model. While single family therapy has been judged as possibly effective and may be wellrecognized for the treatment of ED, there is presently little solid evidence in the literature on the effectiveness of MFT, in spite of its popularity. Thus, the impact of MFT needs further examination and testing through quantitative assessments to expand evidence-based practices to Multiple Family Therapy for eating disorders (Downs & Blow, 2013).
Objective The aim of the present study was to evaluate the effectiveness of a Maudsley-oriented MFT program developed at the Therapeutic Centre for Adolescents suffering from Eating Disorders (CTTA) in Belgium. This research focused on the evolution of percentages of Expected Body Weight (%EBW), eating disorder symptoms, and quality of life between initiation and termination of treatment. The lack of a control group is a major limitation of the study. However, this exploratory treatment/outcome study is intended as a first step in the investigation of this program.
METHODS This study was approved by the University of Mons–Faculty of Psychology and the Education Ethics Committee.
Participants The MFT program proposed at CTTA has been designed for families with an adolescent who meets the following criteria for inclusion: (1) a DSM-IV diagnosis for anorexia nervosa or bulimia; (2) an age between 11 and 19 years. Individuals are excluded if they have comorbid diagnoses of multi-impulsive conduct psychosis, drug or alcohol dependence, obesity, severe personality disorder, autistic disorder, psycho-organic disorder, if they were acutely suicidal, or suffered from an intellectual deficiency. A multifamily group is formed as soon as there are at least 5–6 families available for treatment and the therapists do not www.FamilyProcess.org
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attempt to match family structure or dynamics with a particular group profile. Between September 2006 and October 2011, 82 patients and their parents participated in 15 different MFT groups. These 82 adolescents constitute our present study sample.
Treatment The MFT program of the Therapeutic Centre for Adolescents suffering from Eating Disorders (CTTA) lasts approximately 11 months and works on an outpatient basis. It includes 21 days of therapy spread over 12 monthly treatment modules1 organized as blocks of days. A typical day of therapy starts at 9 am. It involves different therapeutic activities (either in the form of separate sessions2 of parents and adolescents or in the form of a joined session). Snack times, lunch, and family relaxation times are important parts of the day’s activities. A day of therapy ends around 4 pm. The multidisciplinary therapeutic team is comprised of two female psychologists trained in behavioral cognitive therapy, two female psychiatric nurses, one female dietitian, and one male psychiatrist also trained in behavioral cognitive therapy and with 20 years of experience in the treatment of eating disorders. Five of them have been working in this program since its inception in September 2006 and thus have 7 years of experience working as MFT therapists. One therapist is new to the team, with 1 year of experience as a MFT therapist. The treatment is explained in detail in a manual developed by the clinician’s team (Simon et al., n.d.). Each session of therapy is based on a technical data sheet. The therapy is based on three premises, as developed by Hendrick (2007): (1) families have expertise and therapy aims to activate family competence; (2) therapy is limited in time; and (3) relationships are at the centre of therapy. Related to these premises, several therapeutic principles are formulated, focused on family organization and functioning in adolescent ED and depending on the current phase of treatment. Psycho-educational talks or discussions about ED, nutrition, meals, work on parental competence and adolescence are an important part of the treatment as well as techniques that place the family at the centre of the group. Indeed, different sessions are designed to invite the family to reflect, in front of the group, on its organization and experience, using family sculptures, genograms, and family discussions. Two treatment days are devoted to siblings who are invited to the MF group. The therapist’s role is to be an expert in the disease and its treatment and to guide families toward the activation of their skills. The therapist is directive, gives information, approves and encourages families to express their emotions, sensations, and perspectives during sessions with regard to eating, as well as family satisfaction or dissatisfaction. The treatment is divided into three phases, similar to those delineated in the Maudsley program. During the first phase (lasting 5 months), treatment focuses on the adolescent’s eating behaviors with the aim of restoring a healthy weight. Parents take total control and responsibility for feeding their child and managing the ED symptoms. However, the adolescent remains in control of his/her life regarding social activities, in accordance with his/her age level. The therapeutic team invites the parents to progressively adopt more coherent and firm attitudes regarding eating behaviors. The first treatment module lasts five consecutive days. Each of the next treatment modules included in the first phase lasts 2 days. During the second phase (a monthly 1-day treatment module, over 3 months), control of eating is progressively given back to the adolescent, in accordance with his/her weight, age, and developmental level. Family functioning and intrafamily relationship patterns are now addressed. Attention is focused on areas of family dissatisfaction that 1 2
They are organized on a monthly basis. A day of therapy is divided into different sessions.
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existed prior to the onset of the ED. The expression of problems is encouraged but problem-solving techniques are secondary to the quality of the communication within the family. During the third phase (a monthly 1-day treatment module, over 4 months), the emphasis is placed on the psychosocial and psychological development of each individual family member. The parental couple and the adolescent are invited to reflect upon the reorganization of their family and personal life to improve their well-being. The adolescent is encouraged to become more independent and to develop a healthy relationship with his/ her parents while the family progressively prepares itself for future separation.
Assessment From the time of admission to the end of the treatment, all patients were routinely assessed by the therapeutic team. Percentage of Expected Body Weight (%EBW) was used to monitor weight changes pre- and post-treatment. One hundred percent of EBW for a given participant was calculated as the 50th percentile of BMI for exact age and height, based on his or her height, age, and gender (% EBW = BMI/50th percentile BMI for age and height 9 100) (Le Grange et al., 2012). Weight thresholds were calculated using weight charts for the Belgian Flemish population (Laboratorium voor Antropogenetica, 2004). As part of the current study, the adolescents further completed the Eating Disorder Inventory-2 (EDI-2) and the Outcome Questionnaire-45 (OQ-45). EDI-2 evaluates how ED symptoms evolve with MFT (Garner, Olmstead, & Polivy, 1983). It is a self-reporting questionnaire used in research and clinical settings to assess ED symptoms and psychological features (Clausen, Rosenvinge, Friborg, & Rokkedal, 2011). EDI-2 is comprised of three subscales directly related to ED symptoms: drive for thinness, bulimia, and body dissatisfaction. It also includes eight more general psychological features related to ED: ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, maturity fears, asceticism, impulse regulation, and social insecurity. The scale reliably discriminates between patients and nonclinical controls (Clausen et al., 2011). OQ-45 (Lambert et al., 1996) assesses patients’ quality of life. It is a 45-item self-report measure that tracks and assesses patient outcome in a therapeutic setting. It is a well-established measure that has been widely validated (Okiishi, Lambert, Nielsen, & Ogles, 2003). Each item is scored on a 5-point Likert scale. Higher values (scores range from 0 to 180) confirm pathology. OQ-45 provides a total score (63 and above indicates symptoms of clinical significance) as well as three subscale scores: symptomatic distress, interpersonal relationships, and social roles.
Statistical analyses Statistical analyses were performed after the completion of the treatment and were carried out using the Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, USA) version 21. Each outcome variable provided data at two points in time: pretreatment and posttreatment. Statistical analysis of the outcome was conducted on an intention-to-treat basis, and any data available from dropouts were included. For continuous data, a maximum likelihood approach (EM algorithm) was used to deal with missing data (Rubin, 1991). For the purposes of our analyses, significance values used throughout the study were set at .05, and all tests were two-tailed. We used descriptive statistics to characterize the sample with respect to demographic and clinical features. Continuous variables without a normal distribution (Shapiro–Wilk test) were reported as medians and interquartile ranges (IQR) and compared using the Wilcoxon signed-rank test. When normality was demonstrated, the continuous variables were presented as mean and standard deviation (SD) and were compared using the Student’s t-test for paired samples. Effect sizes were also calculated (Cohen d or r, as www.FamilyProcess.org
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appropriate) for each result to facilitate the interpretation of clinical significance. Cohen d was calculated for normally distributed variables (%EBW and OQ45). r (calculated as r = z/square root of N) was used for EDI measures.
RESULTS Available Data Of the 82 patients and their families who started MFT, 7 (8.5%) dropped out during treatment. Regarding %EBW measures, 82 patients were seen pretreatment and 79 posttreatment (3.66% missing data; 1 dropout and 2 completers). Regarding OQ-45 measures, the questionnaire was implemented after the beginning of data collection. Thus, the first two groups of MFT did not complete it at the beginning of treatment: 71 patients were seen pretreatment (13.42% missing data; 1 dropout and 10 completers) and 77 posttreatment (6.1% missing data; 2 dropouts and 3 completers). As for EDI-2 measures, our sample included 81 patients pretreatment (1.22% missing data; 1 completer) and 77 posttreatment (6.1% missing data; 2 completers and 3 dropouts). Among these patients, 21 completed the EDI-1. Therefore, for the three clinical dimensions added in EDI-2 (asceticism, impulsivity, and social insecurity), our sample included 61 patients (25.66% missing data).
Participants Demographics and clinical baseline characteristics are presented in Table 1.
Percentage of Expected Body Weight At the end of treatment, 52.4% of the patients had an EBW above 85%, 24.4% of whom were above 95%. Results showed significant improvement in the %EBW between pre- and posttreatment, mean difference: 9.85 10.65, t(81) = 8.38; p < .001. At the end of treatment, mean EBW was 86.75% 11.20. Analysis of effect size showed a large effect size (d = 0.925) (see Table 2 for the effects of MFT on %EBW).
TABLE 1 Demographics and Clinical Baseline Characteristics
Characteristics Age, years, mean (SD) Male, N Diagnosis, N AN purging subtype AN restrictive subtype BN %EBW, mean (SD) Previous hospitalizations, N Previous therapeutic treatments, N Other than single family therapy Single family therapy Intact family, N Duration of illness—less than a year, % Hospitalizations during treatment, N Treatment duration, months, mean (SD)
Note. Diagnosis is based on DSM-IV.
Fam. Proc., Vol. 54, March, 2015
Patients 16.03 (1.46) 2 9 69 4 76.99 (9.75) 10 23 0 57 74.4 17 9.85 (1.69)
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TABLE 2 Effects of MFT on %EBW, Quality of Life (OQ-45), and ED Symptoms (EDI-2)
Pretreatmenta % EBW OQ-45 Symptomatic distress Interpersonal relationship Social roles Total score EDI-2 Drive for thinness Bulimia Body dissatisfaction Ineffectiveness Perfectionism Interpersonal distrust Interoceptive awareness Maturity fears Asceticism Impulse regulation Social insecurity
Posttreatmenta
Testb
p-value
Effect sizec
76.99 9.75
86.75 11.20
8.38
Multiple Family Therapy (MFT) has gained increasing popularity in the treatment of eating disorders and many programs have been developed over the past decade. Still, there is little evidence in the literature on the effectiveness on MFT for treating eating disorders. The present study examines the effects of a particular model of Multiple Family Therapy on eating disorder symptoms, quality of life, and percentage of Expected Body Weight (%EBW) in adolescents with eating disorders (ED). Eighty-two adolescents with ED, aged between 11 and 19 years, were assessed before and after treatment using the Eating Disorders Inventory 2 (EDI-2), the Outcome Questionnaire 45 (OQ-45) and %EBW. Results showed a significant increase in %EBW between the beginning and end of treatment, with a large effect size. 52.4% of patients achieved an EBW above 85%. Symptoms relative to all EDI dimensions (except for bulimia) significantly decreased during treatment. The three dimensions related to quality of life assessment also improved over the course of MFT. At the end of treatment, 70.7% of patients had a total OQ-45 score below clinical significance. This study suggests that Multiple Family Therapy may benefit adolescents with eating disorders, with improvement on several outcome measures (%EBW, ED symptoms, and quality of life). However, the lack of a comparison group entails caution when drawing conclusions. Keywords: Multiple Family Therapy; Eating Disorders; Adolescents; Outcome; Treatment Effectiveness Fam Proc 54:160–172, 2015
A
norexia nervosa (AN) is a serious mental and behavioral disorder with significant psychiatric and medical morbidity (Klump, Bulik, Kaye, Treasure, & Tyson, 2009). The prevalence of anorexia nervosa is estimated to be up to 0.9% in young females (Smink, van *Systemic and Psychodynamic Clinical Psychology Department, University of Mons, Mons, Belgium. † Centre Th erapeutique du Trouble Alimentaire de l’Adolescent (CTTA), Centre Hospitalier Le Domaine, Braine l’Alleud Belgium. ‡ Child and Adolescent Psychiatry Department, Robert Debre Hospital, Paris, France.
Correspondence concerning this article should be addressed to Zo e Gelin, Systemic and Psychodynamic Clinical Psychology Department, University of Mons, Place du Parc 18, Mons 7000, Belgium. E-mail: zoe. [email protected]. The CTTA (Therapeutic Centre for Adolescents suffering from Eating Disorders) is a pilot-project funded by the Belgian Federal Public Service—health, food chain safety, and environment. We would like to thank the parents’ association Miata for its support and the team of the CTTA for collecting data. 160
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Hoeken, & Hoek, 2012). Moreover, AN is known to have the highest mortality rate of any mental illness (8–10%) (Franko et al., 2013). It is the position of the Academy for Eating Disorders that the origins and maintenance of eating disorders (ED) can be influenced by family factors, while standing firmly against any etiological model in which families are to blame for the development of the ED (Le Grange, Lock, Loeb, & Nicholls, 2010). APA and NICE practice guidelines strongly recommend including families in the treatment of children and adolescents with ED (Eisler, 2005; Yager et al., 2012) and using family interventions that directly address the ED (NICE, 2004). Family therapy approaches have been applied to AN for more than 40 years (Eisler, Lock, & Le Grange, 2010). In a review of family therapy for adolescents with AN, Gardner and Wilkinson (2011) identified six randomized, controlled trials (RCT), some of which suggested that family therapy might be more effective than individual psychotherapy in terms of physical improvement and reduction of cognitive distortions (Eisler et al., 1997; Retzlaff, von Sydow, Beher, Haun, & Schweitzer, 2013; Robin, Siegel, Koepke, Moye, & Tice, 1994; Robin et al., 1999; Russell, Szmukler, Dare, & Eisler, 1987). More specifically, family therapy appears to be particularly effective for recent-onset AN in adolescents (Russell et al., 1987). However, the authors concluded that the evidence in favor of family therapy over individual therapies is on the whole weak due to small sample sizes and the significant risk of bias. Yet, in a recent RCT, Lock et al. (2010) found that family therapy is superior to individual therapy in facilitating full remission at 6–12 month follow-up for adolescents suffering from ED. Originally inspired by the works of Minuchin and colleagues at the Philadelphia Child Guidance Clinic and by the strategic family therapy movement developed by Selvini and colleagues in Milan, the Maudsley family therapy approach is a specific form of family therapy that has achieved a solid evidence base and therefore has become a treatment of choice for adolescent AN (Loeb & Le Grange, 2009; Watson & Bulik, 2013). In this approach, it is assumed that adolescents suffering from ED are not in a position to make decisions about food and eating (Wallis et al., 2013). Hence, parents are encouraged to temporarily take responsibility for refeeding their child, thus preventing the repeated relapses that can result from hospitalization (Lay, Jennen-Steinmetz, Reinhard, & Schmidt, 2002). Parents are also invited to distinguish between their daughter and her illness, using “externalization” techniques and minimalizing expressed emotions of criticism and hostility (Rhodes, Gosbee, Madden, & Brown, 2005). Adaptations from the original “Maudsley Model” have been made over the years, evolving toward the consolidation of single-family practice in the US (Lock & Le Grange, 2012; Lock, Le Grange, Agras, & Dare, 2001), and toward augmentations and further developments in the United Kingdom, including the emergence of a Maudsley-based Multiple Family Therapy (MFT) model (Eisler, 2005; Rhodes et al., 2005). Although MFT represents a relatively new approach to the treatment of ED, it has gained increasing popularity over the past decade (Cook-Darzens et al., 2005). Following a fairly narrow definition of MFT, we can describe it as a therapeutic method that brings together several families affected by the same pathology. However, the term also refers to specific treatment paradigms that are anchored in various theoretical models (psychoanalytical, systemic, cognitive-behavioral, etc.), yielding specific treatment packages with specific principles and techniques. MFT was developed by Laqueur (Laqueur, Laburt, & Morong, 1964; Raasoch & Laqueur, 1979), and subsequently by McFarlane (2002), for the treatment of schizophrenic patients. Over the past 20 years, MFT has become a popular treatment for a great variety of conditions. It has been proven effective for conditions such as schizophrenia (Dixon et al., 2001; Dyck, Hendryx, Short, Voss, & McFarlane, 2002; Dyck et al., 2000), Fam. Proc., Vol. 54, March, 2015
162 /
FAMILY PROCESS
depression (Fristad, Goldberg-Arnold, & Gavazzi, 2003; Lemmens, Eisler, Buysse, Heene, & Demyttenaere, 2009; McDonell & Dyck, 2004), and obsessive compulsive disorders (Barrett, Healy-Farrell, & March, 2004). MFT has also been applied to a wide spectrum of chronic medical illnesses (Lopez-Larrosa, 2013), including chronic pain (Lemmens, Eisler, Heireman, Van Houdenhove, & Sabbe, 2005) and cancer (Steinglass, Ostroff, & Steinglass, 2011). The application of this form of treatment to ED was initially developed by two clinical and research teams as an intensive day treatment: Scholz and Asen (Asen, 2002; Asen & Scholz, 2010; Scholz, Rix, Scholz, Gantchev, & Th€omke, 2005) in Dresden, and the Maudsley team led by Dare and Eisler (2000) in London. Both teams adapted the Maudsley model to a MFT format, with the initial aim of bringing about recovery in patients who did not benefit from the single-family Maudsley approach (Dare & Eisler, 2000; Rhodes et al., 2005). At the same time, more systemically oriented models of outpatient MFT were developed in France for adolescents with severe ED (Cook-Darzens et al., 2005) and in England for AN adults (Colahan & Robinson, 2002). The rationale for MFT is that similarities and differences between families help them feel less stigmatized and isolated, create solidarity, and allow learning from other families’ experiences. It also allows them to share different perspectives and experiences with each other (Asen & Schuff, 2006). Overall, three distinct MFT models tend to dominate the European field of ED treatment: the Maudsley-oriented model, the systemic model, and the psycho-educational model. While single family therapy has been judged as possibly effective and may be wellrecognized for the treatment of ED, there is presently little solid evidence in the literature on the effectiveness of MFT, in spite of its popularity. Thus, the impact of MFT needs further examination and testing through quantitative assessments to expand evidence-based practices to Multiple Family Therapy for eating disorders (Downs & Blow, 2013).
Objective The aim of the present study was to evaluate the effectiveness of a Maudsley-oriented MFT program developed at the Therapeutic Centre for Adolescents suffering from Eating Disorders (CTTA) in Belgium. This research focused on the evolution of percentages of Expected Body Weight (%EBW), eating disorder symptoms, and quality of life between initiation and termination of treatment. The lack of a control group is a major limitation of the study. However, this exploratory treatment/outcome study is intended as a first step in the investigation of this program.
METHODS This study was approved by the University of Mons–Faculty of Psychology and the Education Ethics Committee.
Participants The MFT program proposed at CTTA has been designed for families with an adolescent who meets the following criteria for inclusion: (1) a DSM-IV diagnosis for anorexia nervosa or bulimia; (2) an age between 11 and 19 years. Individuals are excluded if they have comorbid diagnoses of multi-impulsive conduct psychosis, drug or alcohol dependence, obesity, severe personality disorder, autistic disorder, psycho-organic disorder, if they were acutely suicidal, or suffered from an intellectual deficiency. A multifamily group is formed as soon as there are at least 5–6 families available for treatment and the therapists do not www.FamilyProcess.org
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/ 163
attempt to match family structure or dynamics with a particular group profile. Between September 2006 and October 2011, 82 patients and their parents participated in 15 different MFT groups. These 82 adolescents constitute our present study sample.
Treatment The MFT program of the Therapeutic Centre for Adolescents suffering from Eating Disorders (CTTA) lasts approximately 11 months and works on an outpatient basis. It includes 21 days of therapy spread over 12 monthly treatment modules1 organized as blocks of days. A typical day of therapy starts at 9 am. It involves different therapeutic activities (either in the form of separate sessions2 of parents and adolescents or in the form of a joined session). Snack times, lunch, and family relaxation times are important parts of the day’s activities. A day of therapy ends around 4 pm. The multidisciplinary therapeutic team is comprised of two female psychologists trained in behavioral cognitive therapy, two female psychiatric nurses, one female dietitian, and one male psychiatrist also trained in behavioral cognitive therapy and with 20 years of experience in the treatment of eating disorders. Five of them have been working in this program since its inception in September 2006 and thus have 7 years of experience working as MFT therapists. One therapist is new to the team, with 1 year of experience as a MFT therapist. The treatment is explained in detail in a manual developed by the clinician’s team (Simon et al., n.d.). Each session of therapy is based on a technical data sheet. The therapy is based on three premises, as developed by Hendrick (2007): (1) families have expertise and therapy aims to activate family competence; (2) therapy is limited in time; and (3) relationships are at the centre of therapy. Related to these premises, several therapeutic principles are formulated, focused on family organization and functioning in adolescent ED and depending on the current phase of treatment. Psycho-educational talks or discussions about ED, nutrition, meals, work on parental competence and adolescence are an important part of the treatment as well as techniques that place the family at the centre of the group. Indeed, different sessions are designed to invite the family to reflect, in front of the group, on its organization and experience, using family sculptures, genograms, and family discussions. Two treatment days are devoted to siblings who are invited to the MF group. The therapist’s role is to be an expert in the disease and its treatment and to guide families toward the activation of their skills. The therapist is directive, gives information, approves and encourages families to express their emotions, sensations, and perspectives during sessions with regard to eating, as well as family satisfaction or dissatisfaction. The treatment is divided into three phases, similar to those delineated in the Maudsley program. During the first phase (lasting 5 months), treatment focuses on the adolescent’s eating behaviors with the aim of restoring a healthy weight. Parents take total control and responsibility for feeding their child and managing the ED symptoms. However, the adolescent remains in control of his/her life regarding social activities, in accordance with his/her age level. The therapeutic team invites the parents to progressively adopt more coherent and firm attitudes regarding eating behaviors. The first treatment module lasts five consecutive days. Each of the next treatment modules included in the first phase lasts 2 days. During the second phase (a monthly 1-day treatment module, over 3 months), control of eating is progressively given back to the adolescent, in accordance with his/her weight, age, and developmental level. Family functioning and intrafamily relationship patterns are now addressed. Attention is focused on areas of family dissatisfaction that 1 2
They are organized on a monthly basis. A day of therapy is divided into different sessions.
Fam. Proc., Vol. 54, March, 2015
164 /
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existed prior to the onset of the ED. The expression of problems is encouraged but problem-solving techniques are secondary to the quality of the communication within the family. During the third phase (a monthly 1-day treatment module, over 4 months), the emphasis is placed on the psychosocial and psychological development of each individual family member. The parental couple and the adolescent are invited to reflect upon the reorganization of their family and personal life to improve their well-being. The adolescent is encouraged to become more independent and to develop a healthy relationship with his/ her parents while the family progressively prepares itself for future separation.
Assessment From the time of admission to the end of the treatment, all patients were routinely assessed by the therapeutic team. Percentage of Expected Body Weight (%EBW) was used to monitor weight changes pre- and post-treatment. One hundred percent of EBW for a given participant was calculated as the 50th percentile of BMI for exact age and height, based on his or her height, age, and gender (% EBW = BMI/50th percentile BMI for age and height 9 100) (Le Grange et al., 2012). Weight thresholds were calculated using weight charts for the Belgian Flemish population (Laboratorium voor Antropogenetica, 2004). As part of the current study, the adolescents further completed the Eating Disorder Inventory-2 (EDI-2) and the Outcome Questionnaire-45 (OQ-45). EDI-2 evaluates how ED symptoms evolve with MFT (Garner, Olmstead, & Polivy, 1983). It is a self-reporting questionnaire used in research and clinical settings to assess ED symptoms and psychological features (Clausen, Rosenvinge, Friborg, & Rokkedal, 2011). EDI-2 is comprised of three subscales directly related to ED symptoms: drive for thinness, bulimia, and body dissatisfaction. It also includes eight more general psychological features related to ED: ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, maturity fears, asceticism, impulse regulation, and social insecurity. The scale reliably discriminates between patients and nonclinical controls (Clausen et al., 2011). OQ-45 (Lambert et al., 1996) assesses patients’ quality of life. It is a 45-item self-report measure that tracks and assesses patient outcome in a therapeutic setting. It is a well-established measure that has been widely validated (Okiishi, Lambert, Nielsen, & Ogles, 2003). Each item is scored on a 5-point Likert scale. Higher values (scores range from 0 to 180) confirm pathology. OQ-45 provides a total score (63 and above indicates symptoms of clinical significance) as well as three subscale scores: symptomatic distress, interpersonal relationships, and social roles.
Statistical analyses Statistical analyses were performed after the completion of the treatment and were carried out using the Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, USA) version 21. Each outcome variable provided data at two points in time: pretreatment and posttreatment. Statistical analysis of the outcome was conducted on an intention-to-treat basis, and any data available from dropouts were included. For continuous data, a maximum likelihood approach (EM algorithm) was used to deal with missing data (Rubin, 1991). For the purposes of our analyses, significance values used throughout the study were set at .05, and all tests were two-tailed. We used descriptive statistics to characterize the sample with respect to demographic and clinical features. Continuous variables without a normal distribution (Shapiro–Wilk test) were reported as medians and interquartile ranges (IQR) and compared using the Wilcoxon signed-rank test. When normality was demonstrated, the continuous variables were presented as mean and standard deviation (SD) and were compared using the Student’s t-test for paired samples. Effect sizes were also calculated (Cohen d or r, as www.FamilyProcess.org
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appropriate) for each result to facilitate the interpretation of clinical significance. Cohen d was calculated for normally distributed variables (%EBW and OQ45). r (calculated as r = z/square root of N) was used for EDI measures.
RESULTS Available Data Of the 82 patients and their families who started MFT, 7 (8.5%) dropped out during treatment. Regarding %EBW measures, 82 patients were seen pretreatment and 79 posttreatment (3.66% missing data; 1 dropout and 2 completers). Regarding OQ-45 measures, the questionnaire was implemented after the beginning of data collection. Thus, the first two groups of MFT did not complete it at the beginning of treatment: 71 patients were seen pretreatment (13.42% missing data; 1 dropout and 10 completers) and 77 posttreatment (6.1% missing data; 2 dropouts and 3 completers). As for EDI-2 measures, our sample included 81 patients pretreatment (1.22% missing data; 1 completer) and 77 posttreatment (6.1% missing data; 2 completers and 3 dropouts). Among these patients, 21 completed the EDI-1. Therefore, for the three clinical dimensions added in EDI-2 (asceticism, impulsivity, and social insecurity), our sample included 61 patients (25.66% missing data).
Participants Demographics and clinical baseline characteristics are presented in Table 1.
Percentage of Expected Body Weight At the end of treatment, 52.4% of the patients had an EBW above 85%, 24.4% of whom were above 95%. Results showed significant improvement in the %EBW between pre- and posttreatment, mean difference: 9.85 10.65, t(81) = 8.38; p < .001. At the end of treatment, mean EBW was 86.75% 11.20. Analysis of effect size showed a large effect size (d = 0.925) (see Table 2 for the effects of MFT on %EBW).
TABLE 1 Demographics and Clinical Baseline Characteristics
Characteristics Age, years, mean (SD) Male, N Diagnosis, N AN purging subtype AN restrictive subtype BN %EBW, mean (SD) Previous hospitalizations, N Previous therapeutic treatments, N Other than single family therapy Single family therapy Intact family, N Duration of illness—less than a year, % Hospitalizations during treatment, N Treatment duration, months, mean (SD)
Note. Diagnosis is based on DSM-IV.
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Patients 16.03 (1.46) 2 9 69 4 76.99 (9.75) 10 23 0 57 74.4 17 9.85 (1.69)
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TABLE 2 Effects of MFT on %EBW, Quality of Life (OQ-45), and ED Symptoms (EDI-2)
Pretreatmenta % EBW OQ-45 Symptomatic distress Interpersonal relationship Social roles Total score EDI-2 Drive for thinness Bulimia Body dissatisfaction Ineffectiveness Perfectionism Interpersonal distrust Interoceptive awareness Maturity fears Asceticism Impulse regulation Social insecurity
Posttreatmenta
Testb
p-value
Effect sizec
76.99 9.75
86.75 11.20
8.38
