Chapter 49 Family Therapy and Marital Therapy for Eating disorders

Print: Chapter 49. Family Therapy and Marital Therapy http://www.psychiatryonline.com/popup.aspx?aID=262397&print=yes…

1 of 10

10/05/2009 17:35

Print Close Window

Daniel Le Grange, James D. Lock: Chapter 49. Family Therapy and Marital Therapy, in Gabbard’s Treatments of

Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc.

DOI: 10.1176/appi.books.9781585622986.262393. Printed 5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part IX. Eating Disorders >

Chapter 49. Family Therapy and Marital Therapy

INTRODUCTION

Several psychosocial treatments for bulimia nervosa (BN) have been explored, while only modest

efforts have been devoted to the exploration of such treatments for anorexia nervosa (AN). Among

these interventions are family therapy and marital therapy, both of which have received little

enquiry in BN, while family therapy in particular has received much more attention in AN. Findings

from the few published studies for adults with AN are inconclusive, but involving parents in

treatment has allowed a more optimistic picture to emerge for adolescent AN.

FAMILY THERAPY FOR EATING DISORDERS

Family therapy is frequently recommended as the treatment of choice for eating disorders among

adolescents and (to a lesser extent) among adults (American Psychiatric Association 2000; National

Institute for Clinical Excellence 2004). For the most part, this treatment has its roots in structural

family therapy and strategic family therapy (Dare and Eisler 1997). In structural family therapy as

developed by the Philadelphia group, AN symptomatic behaviors are viewed as maintaining

pathological family processes, or the “psychosomatic family,” which is characterized by avoidance

of conflict, overprotectiveness, rigidity, and enmeshment (Minuchin et al. 1978). Interventions aim

to enhance parental authority, challenge inappropriate alignments between siblings and parental

figures, and encourage sibling subsystem development (Liebman et al. 1974; Rosman et al. 1977).

Minuchin et al. (1978) hypothesized that the specific family context of a psychosomatic family is

required for the eating disorder to develop (Minuchin et al. 1978). While these authors emphasized

that their model was not simply an account of a “family etiology” for AN but highlighted the

evolving interactive nature of the process, they still suggested that the resulting “psychosomatic

family” was a necessary condition for the development of AN. Consequently, the treatment

proposed by the Philadelphia group was primarily designed to alter family functioning as a way of

treating AN.

In comparison, strategic family therapy is more limited in focus, because it addresses exclusively

the impact of AN symptoms on the patient and family. It does not presume a pathological family

process per se but instead subscribes to an “agnostic” theoretical understanding of the illness

(Haley 1973; Selvini Palazzoli 1974; Selvini Palazzoli and Viaro 1988). Nonetheless, this approach

to family treatment also views the family as deeply resistant to outside interventions, and in an

effort to overcome this posited resistance, therapists take a nondirective approach that encourages

family members to explore, observe, and suggest changes among themselves. Although structural

and strategic approaches are the basic forms of family therapy provided for AN, more recently

narrative family therapy (White 1987; White and Epston 1990), which aims to externalize the

illness, has also been incorporated in family therapy for AN.

Using elements of many of these early family therapy techniques, clinical researchers at the

Maudsley Hospital in London devised a treatment approach specifically tailored to the needs of

adolescents with AN (Dare and Eisler 1997; Russell et al. 1987). This approach has evolved into a

highly practical intervention, which initially focuses exclusively on problems related to improving

eating and promoting weight gain in the adolescent with AN under the parents’ direction. This form

of family therapy contains several aspects of Minuchin’s approach, including attention to family

structure and use of a family meal. However, consistent with strategic family therapy, the Maudsley

approach views the family positively, and the therapist takes a consultative rather than an

authoritarian role. Also similar to strategic family therapy, the Maudsley approach focuses only onPrint: Chapter 49. Family Therapy and Marital Therapy http://www.psychiatryonline.com/popup.aspx?aID=262397&print=yes…

2 of 10

10/05/2009 17:35

problems in family structure that complicate the parents’ efforts in restoring their adolescent’s

weight. Also, in a strategy derived from narrative family therapy, the therapist continually

reinforces the separation of the patient from the illness (externalization) in order to keep parents

from blaming either themselves or their child for AN. During the initial stages of treatment, the

family and the therapist review the patient’s progress and discuss what was effective and perhaps

less effective during the previous week’s efforts to change eating and weight-loss behaviors.

Potential causes of the illness or family and individual factors that are not directly interfering with

the task at hand are not explored. Once the adolescent approaches a healthier weight (~90% of

ideal body weight) and is eating without difficulty with parental support, the therapist aims to

assist the family in returning control of eating-related behaviors to the adolescent. The therapist

next turns to more general adolescent issues, providing an opportunity for the therapist and family

to evaluate the impact of AN on adolescent development and on any challenges that adolescent

tasks (e.g., sexuality, autonomy, leaving home) have on the patient and family. This final part of

treatment is generally brief, lasting no more than a few sessions over several months. This

family-based approach to treating AN has been published in manualized form (Lock et al. 2001).

More intensive forms of family therapy, especially for those who do not respond to outpatient

single-family therapy alone, have also been explored in the form of multiple-family groups (MFGs)

(Dare and Eisler 2000). This approach builds on the effectiveness of such formats for family

intervention with other serious disorders (e.g., schizophrenia) but utilizes the same general

principles of parental empowerment while focusing only on the specific problems related to AN as

used in the Maudsley single-family approach. In this group format, families meet together for a

long weekend wherein they build a supportive community that helps to depathologize families

while providing opportunities to experiment with behavioral change. Having the availability of

expert consultants and the opportunity to share experiences with other families confronting similar

problems allows for an intensive learning environment under relatively controlled and supportive

conditions. Following the initial long weekend, families again meet as a group for daylong sessions

over the ensuing months to help each other with the dilemmas that AN is presenting to their

families. In practice, single-family sessions are also provided for families that participate in MFGs.

In this way, MFGs may be best considered as an attempt to boost the efficacy of single-family

therapy for more resistant or challenging cases.

The use of family therapy for BN is more limited. Application of the Maudsley type of family therapy

is currently being explored. Again, the same general approach of parental empowerment and

responsibility without psychopathologizing parents or families is utilized when using this family

approach with adolescents with BN. Progression through family-based treatment in an adolescent

with BN was outlined in a recent case study (Le Grange et al. 2003). These authors indicate how

family-based treatment for this patient population differs from that in adolescent AN in a number of

ways: 1) the emphasis is on regulating eating and curtailing purging as opposed to weight

restoration; 2) the treatment is more collaborative between the adolescent and her or his parents,

whereas in AN parents take charge of refeeding; 3) the secretiveness of BN as well as the guilt and

shame that it causes is acknowledged, as opposed to the emaciated state of the AN sufferer that is

often viewed with pride; and 4) both parents and therapist have to confront the challenges of

comorbid illnesses in BN, which more easily derail treatment than is the case in AN.

Although cognitive-behavioral therapy (CBT) for BN in adults is commonly practiced in an

individually based format, the use of a family-supported version of CBT for adolescent BN is being

explored. Because adolescents with BN are often less motivated for treatment, do not control their

eating situations (e.g., they do not buy their own food, do not control when meals are taken), and

are cognitively more immature than adults with BN, there are good clinical and developmental

reasons to involve parents in CBT for this population (Lock 2002). Perhaps the most significant

adjustment that can be made to CBT for adolescent BN to address these developmental differences

between adults and adolescents is the addition of a parental component (Lock 2005). Parents can

help ensure timely participation in therapy, can be educated about how their stocking of foods and

timing of meals affect binge-eating and purging behaviors, can be used to help the adolescentPrint: Chapter 49. Family Therapy and Marital Therapy http://www.psychiatryonline.com/popup.aspx?aID=262397&print=yes…

3 of 10

10/05/2009 17:35

disrupt binge-eating and purging behaviors by being present to discourage them, and can learn how

interactions with their son or daughter may at times trigger binge-eating or purge behavior.

EMPIRICAL SUPPORT FOR FAMILY THERAPY FOR EATING DISORDERS

Despite this clear account of various types of family therapy for a range of eating disorders, there is

surprisingly little systematic research on the efficacy of this modality for eating disorders (Le

Grange and Lock 2005). Nonetheless, the first of these limited inquiries involving family therapy

was from the Child Guidance Clinic in Philadelphia and exerted considerable impact on ensuing

treatment efforts in AN (Minuchin et al. 1978). Minuchin and colleagues, working primarily along a

structural family therapy approach with mostly adolescent patients with short-duration AN,

reported remarkably high rates of success in that 86% of these patients were recovered at time of

follow-up. Since the work of Minuchin’s team, a number of small case series examining various

types of family therapy have been reported (Dare 1983; Herscovici and Bay 1996; Le Grange and

Gelman 1998; Martin 1985; Mayer 1994; Stierlin and Weber 1987, 1989; Wallin and Kronwall 2002),

as well as three larger case series that used a manualized approach for family-based treatment

(Lock and Le Grange 2001; Le Grange et al. 2005; Loeb et al. 2004). Overall, these case series

studies support family therapy as an effective treatment, at least for adolescents with AN.

Only 13 randomized clinical trials of psychotherapeutic interventions for AN have been published

(Le Grange and Lock 2005). Many of these studies were directed at adolescents, and most involved

some form of family therapy. The first of these was conducted at the Maudsley Hospital in London

and evaluated two psychological treatments: family therapy and individual supportive therapy

(Russell et al. 1987). This study included 80 consecutive admissions of all ages to the Maudsley

Hospital. Thirty-six of these patients had an illness onset at or before age 18 years. Twenty-one

patients (mean age at entry: 15.3 years) had an illness duration of less than 3 years

(short-duration AN), and 15 (mean age at entry: 20.6 years) had an illness duration of more than 3

years (long-duration AN). All patients were initially admitted to the inpatient unit for an average of

10 weeks of weight restoration before randomization to outpatient follow-up treatment. After 1

year of outpatient treatment, adolescents with short-duration AN had significantly better outcomes

with family therapy than did their counterparts who were initially assigned to individual treatment.

There were no differences in outcome between treatments for adolescent patients with

long-duration AN. However, for adolescents with short-duration AN, family therapy continued to

significantly outperform individual therapy. At 5-year follow-up, 90% (9 subjects) of those patients

originally assigned to family therapy and 36% (4 subjects) of those assigned to individual therapy

could be considered recovered according to Morgan Russell criteria (Eisler et al. 1997; Morgan and

Russell 1988). An important limitation of this study is the small number of adolescent subjects

(n = 21) who were treated and assessed at follow-up. This is too limited a number on which to base

with confidence more general treatment recommendations. However, given the limited number of

positive findings for the treatment of AN, the promising findings of this approach provide support

for the need to examine it in further studies using a larger number and range of subjects.

A form of family therapy similar to the Maudsley treatment developed by Robin et al. (behavioral

family systems therapy) (Robin 2003) was compared with an active individual therapy

(ego-oriented individual therapy) aimed at encouraging assertiveness, mastery, and increased

confidence among adolescents with AN in a small (N = 37) randomized clinical trial from Wayne

State University (Robin et al. 1994, 1999). After 18 months of treatment, family therapy was found

to have produced greater weight gain and higher rates of resumption of menstruation compared

with individual therapy. However, at 1-year follow-up posttreatment, there were no differences

between the two groups. Thus, although it is not possible to attribute the overall outcomes (about

80% did well) of this study solely to the two psychotherapies used, given that the patients in this

study also received a significant amount of dietary advice and that a number were hospitalized

during treatment, there appears to be a differential benefit favoring family treatment in terms of

more rapid response.

Family therapy has received much less attention in the adult literature, with only two studiesPrint: Chapter 49. Family Therapy and Marital Therapy http://www.psychiatryonline.com/popup.aspx?aID=262397&print=yes…

4 of 10

10/05/2009 17:35

specifically testing the efficacy of family therapy, and both of these were conducted at the

Maudsley Hospital (Dare et al. 2001; Russell et al. 1987). The Russell et al. (1987) study was the

first controlled trial of family therapy involving adult AN patients. Thirty-six patients (mean age at

start of treatment: 20.6 years) were randomly assigned to either family or individual therapy upon

discharge from the hospital. Family therapy showed no benefit over individual therapy, and it

appeared there was a trend in favor of individual therapy in a subgroup of patients with adult-onset

AN (mean age at onset: 24.6 years) as opposed to early-onset AN (mean age at onset: 14.3 years).

While this trend did not hold at 5-year follow-up, there was some suggestion that patients with

adult-onset AN had better psychological adjustment (as assessed via structured interview

[Morgan-Russell Outcome Assessment Schedule]) in individual therapy than they did in family

therapy (Eisler et al. 1997).

The same group (Dare et al. 2001) conducted the only other published trial for adult AN that

involved family therapy. In contrast to the first Maudsley study, this trial was administered on an

outpatient basis only and designed to assess the effectiveness of three specific psychotherapies

versus “usual care.” Eighty-four adult patients were randomly allocated to family therapy (of the

Maudsley type described above), focal psychotherapy, cognitive analytic therapy, or usual care. At

the end of treatment, patients showed modest symptomatic improvements, with family therapy and

focal psychotherapy achieving superior results compared to the control treatment. However, there

was no difference between the three specific psychotherapies. This result could be correct, but it

could also be due to the study’s methodological limitations (e.g., not using manualized treatments;

having insufficient power to detect differential therapeutic effects). Consequently, definitive

conclusions from these studies about the superior efficacy of family therapy compared with other

specific therapies for this age group require further study.

Because of the promising results of family therapy of the Maudsley type with adolescent AN, a

number of studies have used this type of family therapy with adolescent populations to refine the

treatment. For example, it was postulated that the degree of overt family criticism as exhibited

through Expressed Emotion ratings might influence treatment response. It was postulated that

those families with higher degrees of criticism would do better when parents were treated

separately (separated family therapy) from their children. Two studies comparing family therapy

with the whole family present versus separated family therapy have been published (Eisler et al.

2000; Le Grange et al. 1992). Indeed, with high levels of criticism, separated family therapy was

superior to whole family therapy. However, overall results for these two studies were similar, and

regardless of type of family treatment, approximately 70% of patients responded favorably to

family intervention. Further, preliminary results from a 5-year follow-up have been reported by

Eisler et al. (2003) showing that irrespective of the type of family treatment, 75% of patients were

recovered.

It has also been suggested that family therapy could be a highly efficient treatment requiring only a

relatively brief course. This is an important issue because of the high cost of treatment in this

population as well as the demands that family therapy places on those who participate in it (Lock

2003; Striegel-Moore et al. 2000). Preliminary support for this idea came from a study wherein

adolescents treated for 6 months with fewer than 10 sessions appeared to have good outcomes (Le

Grange et al. 1992). An outpatient study of adolescent AN (N = 86) compared different intensities

of the Maudsley treatment using a manualized form of the intervention (Lock et al. 2005).

Short-term (10 sessions over 6 months) and long-term (20 sessions over 12 months) treatments

were compared in randomized clinical trials. Overall, the outcomes of the patients treated with

either form of family therapy did well, with 95% reaching normal weight thresholds at the end of

treatment. The authors concluded that the short-term course appeared to be just as effective as the

long-term course of family therapy for adolescents with short-duration AN. However, it was also

noted that there might be important moderators that influence how much treatment is needed.

Patients who had nonintact families or who had very high levels of obsessive-compulsive features

related to eating and weight appeared to do better with the year-long treatment regimen.

The role of family therapy in inpatient settings is not well understood, though it is commonlyPrint: Chapter 49. Family Therapy and Marital Therapy http://www.psychiatryonline.com/popup.aspx?aID=262397&print=yes…

5 of 10

10/05/2009 17:35

provided. Only one study has been reported that compared family therapy aimed at family dynamic

and structural issues to family group psychoeducation in an inpatient setting (Geist et al. 2000).

However, because nearly half of the family treatment occurred in the context of an inpatient

setting, the effects of the specific interventions are difficult to evaluate. Nevertheless, the majority

(76%) of weight gain occurred prior to discharge from the hospital, with equivalent treatment

effects observed with both family interventions.

Two studies have examined the acceptability of family therapy of the Maudsley type to patients and

parents. Because this form of family therapy is highly demanding of parents and families and

because the adolescent with AN is initially not allowed to make independent decisions about her

eating and weight-related behaviors, the question of acceptability is particularly salient. The initial

report by Le Grange and Gelman (1998) was a qualitative description that supported the idea that

this form of family treatment was ultimately acceptable. A larger study of patient satisfaction

employing both quantitative and qualitative evaluations provides additional empirical support for

this notion (Krautter and Lock 2004). In this study, adolescents and parents alike rated the

effectiveness of the treatment and the therapeutic alliance with the therapists very highly. Still,

however, almost 30% expressed a desire for individual therapy in conjunction with family therapy.

Two groups, one at the Maudsley Hospital (Dare and Eisler 2000) and another in Germany (Scholz

and Asen 2001), have taken preliminary steps to develop an intensive MFG program for adolescents

with AN and their families. As this work is still in a developmental stage, only preliminary findings

can be offered here. Both research groups have reported notable symptomatic improvements in

several cases, including increased weight, return of menstruation, stabilization of eating, reduction

of binge eating and vomiting, and decreased laxative abuse. Dropout rates at both centers have

been low; parents and a majority of the adolescent patients (80%) regard working together with

other families in a day hospital setting as “helpful” and “desirable” (Scholz and Asen 2001). Similar

results were reported by the London group (Lim 2000). In particular, parents who participated in

the MFG day program reported that this treatment was helpful because of its collaborative nature

and the sharing of ideas with other families about how to cope with their common predicament.

These results suggest that MFGs are acceptable to families and likely feasible treatments for further

study.

In comparison with AN, there are few systematic accounts of family therapy for adult or adolescent

1. Because there is considerable overlap in symptomatology between adolescent AN and BN (Le

Grange and Lock 2002; Le Grange et al. 2004), as well as developmental factors concerning the

younger age and dependency of adolescents, family therapy has also been considered for

adolescents. In one small case series from the Maudsley group, Dodge et al. (1995) found that

adolescents with BN improved under a family treatment model. Additional support for family-based

treatment for adolescent BN comes from adolescent AN studies in which adolescents with

binge/purge type AN treated with this approach improved to the same degree as purely restrictive

patients (Eisler et al. 2000; Lock et al. 2005). Many adolescents report that parental involvement is

helpful to them when it is supportive rather than judgmental and critical. It is possible that

family-based treatment may contribute to a reduction of the shame and guilt that commonly

co-occur with BN through reminders to parents that the adolescent’s symptomatic behaviors are

due to an illness rather than to self-indulgence and willfulness. Finally, a few studies have

described single cases of family therapy for adults with BN (Madanas 1981; Roberto 1986; Root et

1. 1986; Wynne 1980), and two studies of family therapy give a clear account of this treatment

(Russell et al. 1987; Schwartz et al. 1985). However, findings for both of these studies were

inconclusive.

The use of family members in CBT for BN in adolescents is still under investigation; however, two

preliminary reports suggest that the approach may be useful. There is one report of a case series

(N = 34) wherein parents were involved in CBT for adolescents with BN (Lock 2005). Although this

case series does not allow conclusions about the specific contributions of parents, the outcomes of

the group were comparable to those seen in adult CBT, with an abstinence rate of 56%, an

improvement in binge eating and purging in 78% (from a mean of 15.5 episodes per week to 3.4Print: Chapter 49. Family Therapy and Marital Therapy http://www.psychiatryonline.com/popup.aspx?aID=262397&print=yes…

6 of 10

10/05/2009 17:35

episodes per week), and a dropout rate of only 18%. In a separate study, 7 adolescents who

received family-facilitated CBT reported significant reductions on all four subscales of the Eating

Disorder Examination, suggesting that family-supported CBT for adolescent BN leads to

psychological as well as behavioral change (Schapman-Williams et al. 2006).

MARITAL THERAPY FOR EATING DISORDERS

The majority of adolescent eating disorder patients live with their families of origin, whereas adult

patients present with a greater variety of living arrangements (e.g., many adults live on their own,

with their family of origin, or with a spouse, partner, or friend). Woodside et al. (2000) argue that

an increasing number of adult patients are married or live in committed relationships. However,

compared with data on adolescents and their families, much less information is available about the

treatment of adult patients who are in committed relationships (e.g., Van den Broucke and

Vandereycken 1989; Woodside and Shekter-Wolfson 1991). The available research tends to focus

on the quality of the marital relationship (e.g., Van den Broucke et al. 1995, 1997; Woodside et al.

1993), whereas adult patients living with their families of origin have received scant attention.

Reports on marriages of patients with eating disorders describe troubled relationships either due to

the eating disorder or otherwise to a relationship wherein the eating disorder might have arisen in

an attempt to bring some resolution to the troubled relationship. In addition to the difficulties in

these marital relationships, researchers offer a poor prognosis in the event of the resolution of the

eating disorder (Woodside et al. 2000).

Most studies have presented a mixed picture of marital relationships for adult eating disorder

patients. Van den Broucke et al. (1995), using an observational measure of communication

patterns, found that eating disorder couples, compared to maritally distressed and maritally

nondistressed couples, had generally better communication and more self-disclosure compared to

the other two groups (Van den Broucke et al. 1995). A group from Japan (Kiriike et al. 1996, 1998)

reported that marital distress was a significant trigger in more than 70% of cases in which eating

disorder onset occurred after the marriage had begun. These findings led Woodside et al. (2000) to

examine marital satisfaction and intimacy among couples in which one member has an eating

disorder. These authors administered the Waring Intimacy Questionnaire (WIQ; Waring and Reddon

1983) at admission and again at discharge to a group of patients and their spouses who attended a

day hospital program. Self-reported marital dissatisfaction of eating disorder patients was at least

partially alleviated with symptomatic improvement. However, treatment of one member of the

couple may not necessarily lead to less marital dissatisfaction in the other member of the couple.

Therefore, in terms of treatment, it would appear as if the marital relationship does have an impact

on the course of the disorder. Van den Broucke and Vandereycken (1989) argued that attention

should be paid to the characteristics of the marital relationship, which includes the relationship

between the onset of the relationship and the onset of the disorder as well as the timing of the

marriage. In planning marital therapy, it would also be important to evaluate the mutual

interdependency between the partners. Finally, as communication about intimate matters may be

problematic, specific attention should be paid to communication skills training. Specifically, the

therapist ought to establish the extent to which interaction patterns are related to the development

and/or maintenance of the eating disorder (Van den Broucke and Vandereycken 1989).

CONCLUSION

The few published controlled studies involving adolescents with AN suggest that family therapy is

helpful in younger patients with a short duration of illness and that long-term hospitalization is not

a requirement for recovery for many of these patients. Given the current data, albeit limited,

between 60% and 70% of patients will have reached a healthy weight by the conclusion

of treatment. At 5 years posttreatment, a majority of patients will have fully recovered (Eisler et al.

1997). Further research in a much larger sample of patients is required to confirm these findings.

Little is known regarding the role of parents and families in the treatment for adolescents with BN,

although preliminary evidence suggests that family involvement may be helpful with this group as

well. The picture for adult patients with eating disorders is much less encouraging—only twoPrint: Chapter 49. Family Therapy and Marital Therapy http://www.psychiatryonline.com/popup.aspx?aID=262397&print=yes…

7 of 10

10/05/2009 17:35

controlled treatment trials included family therapy, with rather disappointing results. Likewise,

research in marital therapy for patients in committed relationships is scant, and outcome in

treatment is guarded at best.

REFERENCES

American Psychiatric Association: Practice guideline for the treatment of patients with eating

disorders (revision). Am J Psychiatry 157 (suppl 1):1–39, 2000

Dare C: Family therapy for families containing an anorectic youngster, in Understanding Anorexia

Nervosa and Bulimia: Report of the IVth Ross Conference on Medical Research. Columbus, OH, Ross

Laboratories, 1983, pp 28–37

Dare C, Eisler I: Family therapy for anorexia nervosa, in Handbook of Treatment for Eating

Disorders. Edited by Garner DM, Garfinkel P. New York, Guilford, 1997, pp 307–324

Dare C, Eisler I: A multi-family group day treatment programme for adolescent eating disorders.

European Eating Disorders Review 8:4–18, 2000

Dare C, Eisler I, Russell G, et al: Psychological therapies for adults with anorexia nervosa:

randomised controlled trial of outpatient treatments. Br J Psychiatry 178:216–221, 2001 [PubMed]

Dodge E, Hodes M, Eisler I, et al: Family therapy for bulimia nervosa in adolescents: an exploratory

study. Journal of Family Therapy 17:59–77, 1995

Eisler I, Dare C, Russell GF, et al: Family and individual therapy in anorexia nervosa: a 5-year

follow-up. Arch Gen Psychiatry 54:1025–1030, 1997 [PubMed]

Eisler I, Dare C, Hodes M, et al: Family therapy for adolescent anorexia nervosa: the results of a

controlled comparison of two family interventions. J Child Psychol Psychiatry 41:727–736, 2000

[PubMed]

Eisler I, Le Grange D, Asen E, et al: Family interventions, in Handbook of Eating Disorders. Edited by

Treasure JL, Schmidt U, van Furth E. Chichester, UK, John Wiley & Sons, 2003, pp 291–310

Geist R, Heinmaa M, Stephens D, et al: Comparisons of family therapy and family group

psychoeducation in adolescents with anorexia nervosa. Can J Psychiatry 45:173–178, 2000

[PubMed]

Haley J: Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson. New York, Norton,

1973

Herscovici C, Bay L: Favorable outcome for anorexia nervosa patient treated in Argentina with a

family approach. Eating Disorders 4:59–66, 1996

Kiriike N, Nagata T, Matsunaga H, et al: Married patients with eating disorders in Japan. Acta

Psychiatr Scand 94:428–432, 1996 [PubMed]

Kiriike N, Nagata T, Matsunaga H, et al: Single and married patients with eating disorders.

Psychiatry Clin Neurosci 52 (suppl):S306–S308, 1998

Krautter T, Lock J: Is manualized family based treatment for adolescent anorexia nervosa

acceptable to patients? Patient satisfaction at end of treatment. Journal of Family Therapy

26:65–81, 2004

Le Grange D, Gelman T: The patient’s perspective of treatment in eating disorders: a preliminary

study. South African Journal of Psychology 28:182–186, 1998

Le Grange D, Lock J: Bulimia nervosa in adolescents: treatment, eating pathology, and comorbidity.

South African Psychiatry Review 5:19–22, 2002

Le Grange D, Lock J: The dearth of psychological treatment studies for anorexia nervosa. Int J Eat

Disord 37:79–81, 2005Print: Chapter 49. Family Therapy and Marital Therapy http://www.psychiatryonline.com/popup.aspx?aID=262397&print=yes…

8 of 10

10/05/2009 17:35

Le Grange D, Eisler I, Dare C, et al: Evaluation of family treatments in adolescent anorexia nervosa:

a pilot study. Int J Eat Disord 12:347–357, 1992

Le Grange D, Lock J, Dymek M: Family-based therapy for adolescent with bulimia nervosa. Am J

Psychother 67:237–251, 2003

Le Grange D, Loeb KL, Van Orman S, et al: Bulimia nervosa: a disorder in evolution? Arch Pediatr

Adolesc Med 158:478–482, 2004

Le Grange D, Binford R, Loeb KL: Manualized family-based treatment for anorexia nervosa: a case

series. J Am Acad Child Adolesc Psychiatry 44:41–46, 2005

Liebman R, Minuchin S, Baker L: An integrated treatment program for anorexia nervosa. Am J

Psychiatry 131:432–436, 1974 [PubMed]

Lim C: A pilot study of families’ experience of a multi-family group day treatment programme.

Unpublished M.Sc. dissertation, Institute of Psychiatry, Kings College, University of London, 2000

Lock J: Treating adolescents with eating disorders in the family context: empirical and theoretical

considerations. Child Adolesc Psychiatr Clin North Am 11:331–342, 2002 [PubMed]

Lock J: A health services perspective on anorexia nervosa. Eating Disorders 11:197–208, 2003

[PubMed]

Lock J: Adjusting cognitive behavior therapy for adolescents with bulimia nervosa: results of a case

series. Am J Psychother 59:267–281, 2005 [PubMed]

Lock J, Le Grange D: Can family based treatment of anorexia nervosa be manualized? J Pyschother

Pract Res 10:253–261, 2001 [PubMed]

Lock J, Le Grange D, Agras WS, et al: Treatment Manual for Anorexia Nervosa: A Family-Based

Approach. New York, Guilford, 2001

Lock J, Agras WS, Bryson S, et al: A comparison of short- and long-term family therapy for

adolescent anorexia nervosa. J Am Acad Child Adolesc Psychiatry 44:632–639, 2005 [PubMed]

Loeb KL, Walsh BT, Lock J, et al: Open trial of family based treatment for adolescent anorexia

nervosa. Poster presented at: American Academy of Child and Adolescent Psychiatry Annual

Meeting, Washington, DC, October 19–24, 2004

Madanas C: Strategic Family Therapy. San Francisco, CA, Jossey-Bass, 1981

Martin F: The treatment and outcome of anorexia nervosa in adolescents: a prospective study and

five year follow-up. J Psychiatr Res 19:509–514, 1985 [PubMed]

Mayer R: Family Therapy in the Treatment of Eating Disorders in General Practice. London, Birkbeck

College, University of London, 1994

Minuchin S, Rosman B, Baker L: Psychosomatic Families: Anorexia Nervosa in Context. Cambridge,

MA, Harvard University Press, 1978

Morgan H, Russell G: Clinical assessment of anorexia nervosa: the Morgan-Russell outcome

assessment schedule. Br J Psychiatry 152:367–371, 1988 [PubMed]

National Institute for Clinical Excellence: Core interventions in the treatment and management of

anorexia nervosa, bulimia nervosa and related disorders. Clinical Guidelines #9. London, National

Institute for Clinical Excellence, 2004, pp 1–15

Roberto L: Bulimia: the transgenerational view. J Marit Fam Ther 12:231–240, 1986

Robin A: Behavioral family systems therapy for adolescents with anorexia nervosa, in

Evidence-Based Psychotherapies for Children and Adolescents. Edited by Kazdin A, Weisz J. New

York, Guilford, 2003, pp 358–373

Robin A, Siegel PT, Koepke T, et al: Family therapy versus individual therapy for adolescent femalesPrint: Chapter 49. Family Therapy and Marital Therapy http://www.psychiatryonline.com/popup.aspx?aID=262397&print=yes…

9 of 10

10/05/2009 17:35

with anorexia nervosa. J Dev Behav Pediatr 15:111–116, 1994 [PubMed]

Robin A, Siegel PT, Moye AW, et al: A controlled comparison of family versus individual therapy for

adolescents with anorexia nervosa. J Am Acad Child Adolesc Psychiatry 38:1482–1489, 1999

[PubMed]

Root M, Fallon P, Friedrich WN: Bulimia: A Systems Approach to Treatment. New York, Norton, 1986

Rosman B, Minuchin S, Liebman R, et al: A family approach to anorexia nervosa: study, treatment

and outcome, in Anorexia Nervosa. Edited by Vigersky RA. New York, Raven, 1977, pp 341–348

Russell G, Szmukler G, Dare C, et al: An evaluation of family therapy in anorexia nervosa and

bulimia nervosa. Arch Gen Psychiatry 44:1047–1056, 1987 [PubMed]

Schapman-Williams AM, Lock J, Couturier J: Cognitive-behavioral therapy for adolescents with

binge eating syndromes: a case series. Int J Eat Disord 39:252–255, 2006 [PubMed]

Scholz M, Asen KE: Multiple family therapy with eating disordered adolescents. European Eating

Disorders Review 9:33–42, 2001

Schwartz R, Barrett M, Saba G, et al: Family therapy for bulimia, in Handbook of Psychotherapy for

Anorexia Nervosa and Bulimia. Edited by Garner D, Garfinkel P. New York, Guilford, 1985, pp

280–310

Selvini Palazzoli M: Self-Starvation: From the Intrapsychic to the Transpersonal Approach. London,

Chaucer, 1974

Selvini Palazzoli M, Viaro M: The anorectic process in the family: a six-stage model as a guide for

individual therapy. Fam Process 27:129–148, 1988

Stierlin H, Weber G: Anorexia nervosa: lessons from a follow-up study. Family Systems Medicine

7:120–157, 1987

Stierlin H, Weber G: Unlocking the Family Door: A Systemic Approach to the Understanding and

Treatment of Anorexia Nervosa. New York, Brunner/Mazel, 1989

Striegel-Moore R, Leslie D, Petrill SA, et al: One-year use and cost of inpatient and outpatient

services among female and male patients with an eating disorder: evidence from a national

database of health insurance claims. Int J Eat Disord 27:381–389, 2000 [PubMed]

Van den Broucke S, Vandereycken W: The marital relationship of patients with an eating disorder: a

questionnaire study. Int J Eat Disord 8:541–556, 1989

Van den Broucke S, Vandereycken W, Vertommen H: Marital intimacy in patients with an eating

disorder: a controlled self-report study. Br J Clin Psychol 34:67–78, 1995

Van den Broucke S, Vandereycken W, Norré J: Eating Disorders and Marital Relationships. New

York, Brunner/Mazel, 1997

Wallin U, Kronwall P: Anorexia nervosa in teenagers: changes in family function after family

therapy at 2-year follow-up. Nord J Psychiatry 56:363–369, 2002 [PubMed]

Waring E, Reddon J: The measurement of intimacy in marriage: the Waring Intimacy Questionnaire.

J Clin Psychol 39:53–57, 1983 [PubMed]

White M: Anorexia nervosa: a cybernetic perspective. Family Therapy Collections 20:117–129, 1987

White M, Epston D: Narrative Means to Therapeutic Ends. New York, WW Norton, 1990

Woodside D, Shekter-Wolfson L: Family treatment in the day hospital, in Family Approaches in

Treatment of Eating Disorders. Edited by Woodside D, Shekter-Wolfson L. Washington, DC,

American Psychiatric Press, 1991, pp 87–106

Woodside D, Shekter-Wolfson L, Brandes J, et al: Eating Disorders and Marriage: The Couple in

Focus. New York, Brunner/Mazel, 1993Print: Chapter 49. Family Therapy and Marital Therapy http://www.psychiatryonline.com/popup.aspx?aID=262397&print=yes…

10 of 10

10/05/2009 17:35

Woodside DB, Lackstrom JB, Shekter-Wolfson L: Marriage and eating disorders: comparisons

between patients and spouses and changes over the course of treatment. J Psychosom Res

49:165–168, 2000 [PubMed]

Wynne L: Paradoxical interventions: leverage for therapeutic change in individual and family

systems, in The Psychotherapy of Schizophrenia. Edited by Strauss T, Bowers S, Downey S, et al.

New York, Plenum, 1980, pp 191–202

Copyright © 2009 American Psychiatric Publishing, Inc. All Rights Reserved.