By Chris Thornton - Clinical Director of The Redleaf Practice
and Dr. Stuart Murray - Director of Family Therapy at The Redleaf Practice
and Dr. Stuart Murray - Director of Family Therapy at The Redleaf Practice
This post is based on the paper “Do the Components of Manualized Family-Based Treatment for Anorexia Nervosa Predict Weight Gain?” by Ellison and colleagues. Just to note that Rani was a former intern of Chris and most of the other coauthors are friends, mentors and colleagues of both of us. Andrew Wallis also provides fortnightly supervision in MFBT at The Redleaf Practice.
The MFBT treatment posits 5 key features that are seen to be central to the efficacy of the treatment.
This study looked at the effect of these features on the outcome as measured by weight change. The authors developed a scale they called the Core Treatment Objectives Clinician Rating Scale (CTOCRS) which was completed after every MFBT session by the therapist (which does introduce some potential bias into the study). They also investigated the role of the therapeutic alliance in outcome.
What the study found:
Although MFBT was not compared to another therapy it is pleasing to see yet another study indicating the efficacious nature of this approach to therapy.
The key features of MFBT are those which drive weight gain and adolescent recovery from AN. Indeed, greater parental control, consistency, externalization of the illness and reduced criticism were directly related to favourable treatment outcome. More specifically, parental control of AN behaviours was the single-most significant predictor of treatment outcome. This adds to the increasing body of evidence demonstrating that the core components of MFBT are indeed important. The only component that was not associated with weight gain was sibling support, although this is indirectly associated with greater weight gain. Greater sibling support generally allows parents to exert greater parental control and take a firmer stance with the AN, knowing that their symptomatic child is well supported by siblings.
Related to our previous blog on the moderating variables in MBFT, it is interesting to look at the papers findings about drop out. Drop out was not predicted by age, weight at entry to the hospital, or illness severity as measured by the EDI-3. The only predictor of drop out was lower levels of parental control. So again, severity and age should not be seen as contraindications to MFBT.
The data seems to suggest that the relationship between the parents and the therapist is important. Interestingly there is a gender difference here. Mother-therapist alliance was more important than parental alliance overall and predicted greater weight gain and less drop out. A stronger father-therapist alliance paradoxically predicted less weight gain. These results are noted as preliminary and are difficult to derive a clinical meaning from, especially in light of the finding that parental unity was important in weight gain.
To quote the paper; "Of all the core components of the FBT, parental control over AN behaviour was found to be the strongest predictor of outcome. This finding matches a qualitative study (unpublished), where parents believed that taking control of recovery was one of the most important aspects of FBT (p4).” Later, ... “the finding that parental control is the central predictor of change is important when considering potential augmentations to FBT" (p5)
All core features of MFBT acted to increase parental control and thus are still central foci of treatment in FBT. This included sibling support.
A take home message from this paper for me is that you need to beware of adaptions of MFBT, particularly if those adaptions are in anyway related to undermining parental control over the anorexic behaviour. The family-wide difficulties encountered in successful MFBT based treatment, and the level of anxiety generally experienced by all involved often means that clinicians may be invited to endorse less challenging forms of treatment.This is reflected in the complexity of delivering MFBT in a multidisciplinary setting as this increases the potential for members of the team to inadvertently undermine the parents capacity to get their child well. It is not only important that parents be united, it is vital that teams stay united in the face of Anorexia.
The MFBT treatment posits 5 key features that are seen to be central to the efficacy of the treatment.
- Parental Control - the extent to which parents take a zero tolerance to all AN behaviour, and make decisions based on extinguishing the AN from their family.
- Externalisation of the illness - to separate the patient from the illness allowing the parents to take a firmer stance with respect to the AN and decrease criticism of their child during the battle with AN.
- Structural realignment within the family - AN impacts upon all members of families in different ways. Structural realignment focuses the parents in working as a decisive and collaborative team, as well as strengthening the relationship between siblings.
- Parental consistency in order to maximise parental control.
- Sibling support of the patient in order to decrease emotional distress in the patient and to free the parents up to take control of the eating.
This study looked at the effect of these features on the outcome as measured by weight change. The authors developed a scale they called the Core Treatment Objectives Clinician Rating Scale (CTOCRS) which was completed after every MFBT session by the therapist (which does introduce some potential bias into the study). They also investigated the role of the therapeutic alliance in outcome.
What the study found:
Although MFBT was not compared to another therapy it is pleasing to see yet another study indicating the efficacious nature of this approach to therapy.
The key features of MFBT are those which drive weight gain and adolescent recovery from AN. Indeed, greater parental control, consistency, externalization of the illness and reduced criticism were directly related to favourable treatment outcome. More specifically, parental control of AN behaviours was the single-most significant predictor of treatment outcome. This adds to the increasing body of evidence demonstrating that the core components of MFBT are indeed important. The only component that was not associated with weight gain was sibling support, although this is indirectly associated with greater weight gain. Greater sibling support generally allows parents to exert greater parental control and take a firmer stance with the AN, knowing that their symptomatic child is well supported by siblings.
Related to our previous blog on the moderating variables in MBFT, it is interesting to look at the papers findings about drop out. Drop out was not predicted by age, weight at entry to the hospital, or illness severity as measured by the EDI-3. The only predictor of drop out was lower levels of parental control. So again, severity and age should not be seen as contraindications to MFBT.
The data seems to suggest that the relationship between the parents and the therapist is important. Interestingly there is a gender difference here. Mother-therapist alliance was more important than parental alliance overall and predicted greater weight gain and less drop out. A stronger father-therapist alliance paradoxically predicted less weight gain. These results are noted as preliminary and are difficult to derive a clinical meaning from, especially in light of the finding that parental unity was important in weight gain.
To quote the paper; "Of all the core components of the FBT, parental control over AN behaviour was found to be the strongest predictor of outcome. This finding matches a qualitative study (unpublished), where parents believed that taking control of recovery was one of the most important aspects of FBT (p4).” Later, ... “the finding that parental control is the central predictor of change is important when considering potential augmentations to FBT" (p5)
All core features of MFBT acted to increase parental control and thus are still central foci of treatment in FBT. This included sibling support.
A take home message from this paper for me is that you need to beware of adaptions of MFBT, particularly if those adaptions are in anyway related to undermining parental control over the anorexic behaviour. The family-wide difficulties encountered in successful MFBT based treatment, and the level of anxiety generally experienced by all involved often means that clinicians may be invited to endorse less challenging forms of treatment.This is reflected in the complexity of delivering MFBT in a multidisciplinary setting as this increases the potential for members of the team to inadvertently undermine the parents capacity to get their child well. It is not only important that parents be united, it is vital that teams stay united in the face of Anorexia.
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