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Vol.22, No.10, October 2006 - Parents: Are they a help or hindrance in the treatment of anorexia?

Parents are often uncertain, and understandably so, about how to respond to their son or daughter when they develop anorexia nervosa (AN). They are confused by the symptoms, which seem at first an innocent enough exploration of dieting common to many adolescents, but that then rapidly become startling bizarre and deadly. They are confused by how their child, who previously was amiable and compliant, becomes withdrawn, irritable and defiant, especially around eating. And they are particularly confused about what professionals tell them: don't get involved, let her decide, you can only make things worse.

The parent-as-impediment approach
Starting with William Gull in 1876, who observed families to be the "worst attendants" for their children suffering from AN, to Salvadore Minichin's specific formulations characterizing such families as psychosomatic (enmeshed, overprotective, rigid and conflict avoidant), parents in particular have been regarded as likely to be the cause of the problem with few positive resources to recommend them. Thus when adolescents with AN were treated, regardless of the approach or setting, it has been common for parents and families to be excluded from care and viewed as the source of the problem.

In practice this has meant that when adolescents were treated in inpatient settings, parental visits were highly restricted. In many cases, parents were not permitted contact of any kind with their child for extended periods. Such "parentectomies" were viewed as providing an opportunity to break the pathological hold of family processes believed to have caused AN. In this same spirit, individual outpatient therapies justified the exclusion of parents often to the point of not communicating even the most basic information about medical progress. When families and parents were involved, it was through family therapy aimed at correcting presumed pathological family processes.

For the most part, the source of these views was theoretical rather than empirical. Earliest treatments evolved in the era when psychoanalysis dominated psychiatric practice. AN was seen as representing the regressed outcome of a severely dysfunctional relationship with parents around sexual desire and anxiety. Consistent with this view, patients were treated individually and encouraged to examine the destructive forces operating within their relationship with their parents. Later on, Minuchin's influential work recast the blame so as to involve the entire family's structure and interactions. His claims, like those of the psychoanalysts, have held continued appeal to therapists in spite of the fact that there is little systematic evidence to support either position.

Other approaches hold that it's developmentally appropriate to exclude parents from treatment of their adolescent son or daughter. That is, adolescents are seeking autonomy and need to separate from their families. Although this is doubtless an important process in Western culture specifically, it ignores compelling evidence that parents remain a key resource to adolescents and without them their chances of successful adulthood is diminished.

Compounding this problem, despite the obvious seriousness both medically and psychologically of AN, there are few studies to guide treatment. Only a handful of randomized clinical treatment trials of psychotherapeutic interventions for AN have been published and these are small in size and many suffer from fairly serious methodological limitations. This lack of evidence has left therapists with little guidance and has contributed to the persistent hold of theoretically driven rather than empirically driven approaches to AN.

Embracing a parent-positive approach
Interestingly, what evidence we do have generally favors an approach that runs completely counter to existing theories about parents and families as the incompetent culprits that cause AN. This evidence is based on a series of family therapy studies that began in the 1980s at the Maudsley Hospital in London and have continued there and elsewhere. The approach advocated in these studies is a form of family therapy aimed at empowering families, particularly parents, to address the problems AN is causing for their child and family. Specifically, parents are disabused of the notion that they have caused AN, thus reducing guilt and the resultant fear of taking action to address it.

Further, parents learn how they can take decisive action to disrupt behaviors such as restrictive dieting, purging, and excessive exercise to forestall the eminent and future severe medical and psychological problems with chronic AN. Most importantly, parents are encouraged through consultative problem solving within the family context, to find solutions to these problems and to persist in struggling against the powerful hold they have on their family. Data from the studies that have used this "parent positive" approach suggest that it is acceptable and effective.

Nonetheless, parents still arrive for treatment informed through scores of books and articles, information gathered from the internet, and consultations from therapists and physicians that they somehow caused the illness and that they are helpless in the face of it. We clearly need to provide a more balanced view of how parents can be involved. In our short book (Lock and Le Grange, 2005; see References) we have endeavored to employ the basic approach used by the Maudsely group to reeducate parents about AN, anchored by the following ideas:

Parents should take immediate and decisive action to forestall both the immediate medical problems associated with severe malnutrition (i.e., bradycardia, hypothermia, orthostatic hypotension) and chronicity. Parents must view themselves as necessary and important contributors to improvements in their child's recovery regardless of whether their child's treatment is in hospital or outpatient and whether individual or family based. And, most importantly, parents should refuse to be excluded from their child's care. In a society where anxious parenting has become the norm, we hope this book will help parents to start off seeking care with more confidence and with an understanding of the kinds of roles they can play to be help their child with AN.

It is generally not reasonable to think that a parent should have expertise in how to manage AN without expert consultation and support. The illness is challenging even for those with many years of experience. However, professionals may sometimes be surprised by the ingenuity and skills parents can provide through the unique leverage that parental love and investment in their children allows.

It remains to be seen whether family therapy that sees the family as a resource to the adolescent's recovery from AN will ultimately prove to be the most efficacious approach. Studies are at last underway to determine this. But what is already quite evident is that it is not necessary to exclude families and particularly parents from treatment. Instead, it appears that they are a help rather than a hindrance.


James Lock, M.D., Ph.D., is Associate Professor of Child Psychiatry and Pediatrics at Stanford University School of Medicine. He is board certified in child and adolescent psychiatry and directs the eating disorder program for children and adolescents at Lucile Packard Children's Hospital. He has current and past research support from the National Institutes of Health for the study of psychological and psychopharmacological treatments for eating disorders.

References:
Lock, J, Le Grange, D, How to Help Your Teenager Beat An Eating Disorder, Guilford Press, 2005.
Lock, J, Le Grange, D, Agras, S, Dare, C, Treatment Manual of Anorexia Nervosa: A Family-Based Approach, Guilford Press, 2001.



The Brown University Child and Adolescent Behavior Letter, October 2006
Reproduced with permission of John Wiley & Sons, Inc.
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James Lock, M.D., Ph.D., is Associate Professor of Child Psychiatry and Pediatrics at Stanford University School of Medicine. He is board certified in child and adolescent psychiatry and directs the eating disorder program for children and adolescents at Lucile Packard Children’s Hospital. He has current and past research support from the National Institutes of Health for the study of psychological and psychopharmacological treatments for eating disorders.
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