Treatment Manual for Anorexia Nervosa: A Family-Based Approach, by James Lock, Daniel Le Grange, W. Stewart Agras, and Christopher Dare, New York, NY, The Guilford Press, 2001, 270 pp, $35.00.
As the authors of this book point out, anorexia nervosa is one of the most common and most serious medical and psychiatric conditions facing adolescents today. They quote studies showing the risk of death from complications of anorexia at from 6 to 15%, with half of these fatalities from suicide. Any of us involved in the treatment of eating disorders will confirm that getting teens to eat in an inpatient setting is the easy part. The real problem is having them eat at home.
The authors write from experience. Christopher Dare, the senior person on this team, has been treating eating disorders at the Maudsley Hospital in London for decades. This book could have easily been subtitled "The Maudsley Method." His is a family-centered approach, adopted from the structural family therapy of Salvador Minuchin but given a tender, humane touch. Lock and Agras work at Stanford, where eating disorder treatment has been prominent for just as many years, and Le Grange trained with Dare in London before taking the position as Director of the Eating Disorders Program in the Department of Psychiatry at the University of Chicago.
Therapists in the field have long known that it is essential to involve the family in the treatment of adolescents with eating disorders. It is one thing to know this and another to know just what to do. This book tells us what to do. But before offering a step by step description of the treatment, the authors review the theoretical basis of their approach and summarize the number of controlled clinical trials that support their claims of superior outcome. Basically, with the family-centered approach described here, restrictive-type anorexia responds to treatment in about 6 to 12 months approximately 65% of the time.
The most important feature of this treatment approach is the emphasis on forming a partnership with parents and empowering them to help their child eat. Many eating disorder treatment facilities, even ones that claim a family-oriented philosophy, take the stance (overtly or covertly) that the parents are at least part of the problem. Lock and his team look to the parents as the solution. They consciously encourage parents to have their child eat more at home by using whatever means the parent feels will be most effective. This emphasis on empowerment contrasts with strategies that separate the teen from the parents as a response to omnipresent control struggles and the adolescent's need for individuation. The authors of this book argue that normal individuation has come to a complete halt in conjunction with the starvation and can resume only when the parents assert appropriate limits around food and eating.
Several other themes in the treatment include (1) food is medicine, (2) weight gain is the measure of increasing health, and (3) it is best to externalize the illness. The externalization allows everyone to understand that it is the anorexia that is making the child behave in uncharacteristic ways, such as being willful and deceitful, in contrast to the perfect little girl the family used to enjoy. The authors are fully aware that parents of teens with eating disorders are sometimes critical, rejecting, and inconsistent. They know that differentiation between parents and teen is often a painful issue. They offer detailed descriptions of dealing with inconsistency, for example, while still empowering parents to help their children eat. And they give adequate emphasis on the later stages of therapy, when normal individuation attempts replace the eating disordered behaviors.
If this were a treatment manual submitted as part of a National Institutes of Mental Health grant, it would run about 20 pages. The authors do include the schematized version of their treatment broken into phases and sessions devoted to issues prominent in each phase. What makes the book useful to nonresearchers is the detailed description of each session and the interspersed examples of family dialogue taken from real family therapy treatment that demonstrates each point along the way.
The authors make it clear that they feel that their method is applicable to adolescent restrictive-type anorexia and not to eating disorders of young adults or to long-standing bulimia. Nevertheless, adults with eating disorders usually began restricting in adolescence and were ineffectively treated. Early, aggressive treatment is the best way to prevent long-term sequelae, and treatment with a family-based approach has been demonstrated to be most effective. Now that this book is in the public domain, therapists can no longer say that they know that they should involve the family but just don't know what to do. There are many other books written for parents and families struggling with this difficult illness. This work was designed to be most valuable to psychotherapists, and it succeeds well in this mission.
Thomas A. Roesler, M.D.
Division of Child and Family Psychiatry; Brown Medical School; Providence, Rhode Island