Psychotherapy Brown Bag

Family-based treatment for adolescent eating disorders: A detailed discussion of the data

by Michael D. Anestis, M.S.

Back in April, I wrote an article on PBB discussing the empirical support for various treatments for anorexia nervosa (AN).  The bulk of the article focused on family-based treatment (FBT) for child and adolescent AN, as this treatment has the greatest degree of research supporting its utility for this particular diagnosis.  In recent months, I have had a number of pleasant interactions with the folks at Maudsley Parents (http://www.maudsleyparents.org; follow @JaneCawley on Twitter) and have come away from those conversations feeling compelled to spread the word about the data on this matter.

If you have not read my prior FBT article, I would recommend consulting it for a detailed description of the nature and structure of the treatment.  Additionally, I would recommend reading Lock and le Grange (2005) for a summary of the nature of the treatment and earlier research supporting its efficacy in the treatment of eating disorders (see our References page for the entire citation).  That being said, the context within which to view the utility of this treatment is one of hope amidst frustration.  Empirical support for treatments for AN is elusive and, as a result, many look upon our ability to treat the disorder with a mix of emotions ranging from anger to despair.  Fortunately, results of FBT, which was designed at the Maudsley Hospital in London, have offered reason for greater optimism, at least with respect to adolescents.  The goal of today's article is to provide a greater degree of detail regarding the data supporting the efficacy and effectiveness of FBT in the treatment of eating disorders in order to help readers develop a clearer sense of why many clinicians and researchers believe we are seeing the beginning of a better age in the treatment of previously treatment resistant diagnoses.

FBT Controversy

The rationale for discussing this data stems from a the fact that some controversy - or at least some concern - surrounds FBT.  The early empirical work on this approach, as one might expect, was conducted by a single research group comprised of the researchers who developed the treatment.  As such, good science dictates that independent replications by researchers not associated with treatment originators at a location outside the Maudsley Hospital are needed in order to optimize confidence in the results.  Fortunately, such data now exist.  Additionally, some individuals find it troubling that FBT involves parents assuming control of the adolescent's eating behaviors for the first six months of treatment, as early theoretical models of AN centered around the idea that the disorder represents a misguided search for autonomy from an enmeshed family (e.g., Minuchin et al., 1978).  Loeb and colleagues (2007) noted that FBT takes an atheoretical stance on the origins of AN and focuses instead on what approaches are most likely to increase the chances of recovery.  Along these lines, they utilize the family as a resource for guidance and authority in treatment and their results make it difficult to argue with that decision.  Other criticisms of FBT center on the relatively brief nature of the treatment (one year) and its outpatient nature, as most treatment models for AN involve a chronic course involving frequent inpatient hospitalizations.  In this case, the data are all that matters, and I will present empirical evidence indicating that individuals not only recover at a high rate through FBT, but maintain these gains at long term post-treatment follow-ups.  Finally, some critiques of FBT stem from the fact that its methods do not easily map onto a standard theoretical orientation (e.g., psychodynamic, cognitive behavioral).  As a scientist, I find this critique baffling.  Although much of my training is from the CBT perspective, my devotion is to empirical investigation not CBT in particular, and if a treatment not associated with my typical theoretical viewpoint demonstrates efficacy and/or effectiveness through rigorous scientific investigations, it is unclear how the theoretical orientation of the treatment is relevant.  Think of it this way: if somebody discovered a cure for a previously incurable form of cancer and that treatment did not involve any dangerous side effects or unethical procedures, would it matter to you whether the treatment was consistent with what you expected from it?  If it would - which is reasonable - I suspect it would nonetheless matter much less than the fact that it works.

Okay, so let's discuss the evidence indicating that FBT not only works, but works outside of the Maudsley hospital itself and results in long-term improvements.  This review will focus on recent research performed outside of the Maudsley Hospital, but please note that prior research on this treatment exists as well.

Loeb et al., 2007

In an open trial conducted in a university clinic, 20 male and female adolescents (ages 12-17) were treated with manualized FBT.  All participants either met full criteria for AN or were subthreshold.  Subthreshold AN required that the participant meet the weight loss criteria (below 85% of expected body weight) but only have missed one or two menstrual periods rather than the three required for amenorrhea or that the participant miss the weight cutoff but lose enough weight to qualify for amenorrhea.  As such, subthreshold AN did not represent "mild" cases.  Participants in this study exhibited a significant increase in body weight and a significant decrease in dietary restraint and eating concerns.  They did not, however, exhibit statistically significant improvements in shape or weight concerns or depression symptoms.  Depression symptoms at baseline were mild, however, so improvement on that factor was not a primary aim of treatment.  Only two of the 20 participants self-initiated early termination from treatment, meaning that FBT did a solid job of overcoming the attrition issues that plague AN treatment.

On the whole, these findings were fairly strong.  They demonstrate that the manualized form of FBT can be implemented in a setting outside of the Maudsley hospital with a decent degree of success.  The lack of improvement on weight and shape concerns is an issue; however, the fact that the participants improved substantially on the more dangerous symptoms of AN is important to consider as well.  Additionally, the small sample size vastly diminished the statistical power of the analyses, rendering it difficult to detect even moderate sized effects.  As such, a larger sample size could help reduce fears of false negatives.

le Grange, Crosby, Rathouz, & Leventhal (2007)

In this study, the authors examined the utility of FBT in the treatment of bulimia nervosa (BN).  In prior articles, we have discussed the evidence supporting the utility of a number of other treatments for BN, including CBT, interpersonal psychotherapy, and dialectical behavior therapy (as well as the lack of evidence for other treatments such as equine assisted psychotherapy).  Here, the authors presented compelling data indicating that FBT can be useful in treating BN as well.

This study was a randomized controlled trial (RCT) comparing FBT to supportive psychotherapy in the treatment of adolescent BN.  80 participants were randomly assigned to one of the two treatments and the results for the two approaches were compared immediately post-treatment and at a six month follow-up.  Immediately following treatment, more individuals in the FBT condition (39%) were binge-purge abstinent than in the supportive psychotherapy group (18%).  Abstinence rates decreased somewhat at 6-month follow-up, but again individuals in the FBT group were more likely to be binge-purge abstinent.  Post-treatment analyses also revealed that individuals in the FBT group exhibited significantly greater reductions in objective binge episodes, subjective binge episodes, all compensatory behaviors, dietary restraint, weight concerns, shape concerns, eating concerns, and global eating disorder symptoms.  The two groups did not differ in degree of improvement on self-esteem or depression.

Clearly, these results are very promising.  The authors utilized strong methodology (RCT) to compare two active treatments and FBT demonstrated superior efficacy in a wide range of eating disorder related outcomes.  FBT was not compared to any empirically supported treatments for BN, so of course caution should be used in interpreting the degree to which FBT offers as much promise as those treatments; however, this study does provide a rationale for budding confidence and future research.

Rhodes, Baillee, Brown, & Madden (2008)

In another RCT, Rhodes and colleagues (2008) sought to examine whether the addition of a parent-to-parent consultation early in treatment would improve outcomes in the treatment of AN.  20 families were randomly assigned to standard FBT and FBT with the added parent component.  Results indicated that the addition of the parent-to-parent consultation was associated with significantly greater weight restoration in AN patients.

Paulson-Karlsson, Engstrom, & Nevonen (2009)

In the most recent study I could find on this matter, Paulson-Karlsson, Engstrom, and Nevonen (2009) tested the efficacy of FBT in the treatment of AN in a hospital in Sweden.  32 female adolescents who met criteria for AN and their parents received FBT.  At 36-month follow-up, 75% of the participants were in full remission.  In addition to the elimination of their eating disorder symptoms, the participants reported experiencing less distance from their families and a less chaotic familial environment.  The lack of a comparison group obviously renders this study far from perfect, but the results are nonetheless highly impressive.

Summary thoughts

The above mentioned studies do not represent the entirety of the work in this area, but they provide a fairly comprehensive glimpse at the evidence supporting the utility of FBT in the treatment of adolescent eating disorders, particularly with respect to AN. Skepticism regarding treatments is a healthy scientific mindset and clearly we at PBB demonstrate this rather regularly when we discuss treatments for which evidence is lacking.  That being said, skepticism towards the utility of FBT for eating disorders appears unwarranted based upon the data.  Concern that symptom improvements are not more substantial are entirely legitimate; however, the complete lack of empirically supported alternatives for this particular subset of individuals renders the gains seen through FBT highly meaningful.  As Daniel le Grange (2006) said in a commentary replying to an article criticizing the positive views of FBT (Bergh et al., 2006): "it makes little sense to dump the car that starts every other morning before you have purchased a new and potentially more reliable model!"  In other words, FBT represents progress - impressive progress at that - with a population for whom we previously had no treatments with strong empirical support.  Its imperfections do not render it useless or irrelevant, nor do they bestow upon less supported treatments any measure of enhanced efficacy.  FBT marks an emerging dawn after a long dark stretch devoid of strong treatment research on AN.  We should embrace these results even as we challenge them, test alternatives, and strive for something better.

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If you would like to learn more about family-based treatment, we recommend the following items, all of which are available through our online store of scientifically-based psychological resources:

• Treatment Manual for Anorexia Nervosa: A Family-Based Approach by James Lock, Daniel le Grange, Stewart Agras, and Christopher Dare

• Eating with Your Anorexic: How My Child Recovered Through Family-Based Treatment and Yours Can Too by Laura Collins

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Tell me about your mother: straightening out the role of family in the etiology, maintenance, and treatment of eating disorders

by Joye C. Anestis

As most of our parents have pointed out to us (most likely when we were angst-y teenagers), being a parent can be pretty rough - sleepless nights, mountains of worry, little in the way of gratitude, and often the majority of the blame if something goes awry in a child's life.  It's a wonder we continue to have kids!  Historically, the world of clinical psychology has done little to ease parents' burdens.  In fact, many researchers and therapists have increased that burden by promoting the idea that mental illness in the child is the direct result of misbehavior by a parent (usually the mother).  Some psychologists continue to espouse this idea even in the face of ample evidence to the contrary.  This is especially the case for eating disorders, where theories of "anorexogenic" parenting flourish in some circles.   "Anorexogenic" family patterns are similar to now discredited theories of "schizophrenogenic" and "autistogenic" mothers - the basic idea is that particular styles of interaction among family members play a specific role in the etiology and maintenance of mentally ill behavior.  In short, eating disorders are the direct result of some parental mistake.  Thankfully, the Academy for Eating Disorders (AED) has published a position paper elucidating the role of family in eating disorders.

Before I get into the meat of this position paper, I want to make two comments.  First of all, mental illnesses are complex constructs - anyone who has ever had one or ever attempted to treat one can attest to that.  Identifying one single cause (such as parenting style) is difficult, if not impossible.  Most of the well-validated theories of causation in clinical psychology acknowledge a multitude of factors which interact to produce disordered behavior in an individual, factors such as genetic variables, individual personality traits, specific environmental experiences, and individual beliefs about those experiences.  Simply blaming the parents seems to me to do a disservice to the complex and unique people and constructs that clinical psychologists face.  While the simplest theories are often considered the best (Occam's razor), there are situations in which danger arises from being overly simplistic in determining causation - the danger in this instance, alienating and condemning parents who might be valuable resources in treatment. Keep in mind that I am speaking of being overly simplistic in determining cause...it has been well-established that the simpler treatments are often the best.  The second thing I want to point out is that the family-based theories implicated in the AED position paper differ greatly from other family variables that we have discussed in terms of other mental illnesses.  For example, expressed emotion has been identified as a factor that exacerbates schizophrenia and bipolar disorder.  This is a  hostile and critical family interaction style that influences patient outcome...it is not believed to cause these disorders, which have clear biological bases.  By being critical of the role of family in the development of eating disorder, neither I nor the authors of this position paper are arguing that family interaction styles have no effect on behavior.  What we do argue is that family factors are not enough, other factors play a larger role, and that it is more prescient to focus our energy on using family members as allies to help young people recover from eating disorder than to assign blame on the parents.

So I step off the soapbox and return to the empirical data...what does the data tell us about the influence of families in the etiology, maintenance, and treatment of eating disorders in young people?  The AED position paper, written by Le Grange, Lock, Loeb, & Nicholls, does an excellent job of succinctly summarizing this issue (look for it on the AED website, as well as in the International Journal of Eating Disorders).

Family Factors in the Etiology of Eating Disorders

Research on family risk factors is sparse, but no data to date support the assertion that families are causal in the development of eating disorders (mothers everywhere breathe a sigh of relief).  Both the retrospective/cross-sectional studies and prospective/longitudinal studies that have been conducted possess severe limitations.

• Cross-sectional research: A variety of risk factors have been implicated in the development of eating disorders including: inappropriate parental pressures; early-life "overprotective/high-concern" parenting behaviors; parental indifference, family discord, lack of parental care, and greater adversity; significant change in the family structure in the year before eating disorder onset; high parental expectations, low parental contact, and more family criticism about shape and weight; and more parental problems such a separation, arguments, criticism, high expectations, over-involvement, under-involvement, low affection, and critical comments about shape, weight, or eating.  Le Grange et al. note that, due to the methodological limitations inherent in cross-sectional studies (i.e., causation cannot be proven with this type of study), the findings most likely indicate that these parental/family factors are risk factors of psychopathology in general and are not specific to eating disorders.  Furthermore, it is most likely that these risk factors interact with more specific biological vulnerabilities that ultimately give rise to particular phenotypes of disordering eating (Klump et al., 2009).
• Longitudinal research: The prospective studies on this topic are inconclusive.  Three have found family variables to be important and three have not.  Again, the authors note that these studies lack the methodological rigor necessary to fully answer the questions at hand (problems include lack of psychiatric controls to determine specificity of the associations found, lack of adequate statistical power, and use of assessments with questionable reliability and validity).   Prospective, longitudinal studies are the only way this causal question can be answered, but so far no answers have arisen.
• The Role of Genetics: The role of genetics in the development of eating disorders, on the other hand, has been more clearly elucidated, and evidence continues to mount that heritable influence underlie both anorexia and bulimia.  I find it interesting that genetic factors do highlight a family influence for eating disorder development, but it is a very different type of influence than the one promoted by theories of "anorexogenic" parenting.  Importantly, no single gene or genomic region has been reliably implicated; however, again it is highly likely that a multitude of risk factors, genetic, environmental, psychological, cultural, etc., interact to influence susceptibility to eating disorders.

The Role of Parents in the Resolution of Eating Disorders

Involving family members in the treatment of eating disorders has been covered on PBB before (family-based treatment for anorexia and incorporating family in treatment for children & adolescents), so I won't repeat what we've already said.  I will just note that family involvement in treatment of eating disorders in young people (especially anorexia) appears to be useful in reducing both psychological and medical morbidity.  Furthermore, family inclusion in treatment is acceptable to both parents and patients, resulting in lower attrition rates.  The literature here is stronger for anorexia than for bulimia (but other treatment options exist for bulimic patients). The position paper does not go into great detail describing the evidence for these treatments, as most of their energy was spent discrediting theories which blame parents for creating eating disorders in their children.  For more information on this topic, see previous PBB articles on these treatments, browse our bookstore for resources, and download some essential IJED articles for free.

It is the conclusion of the AED position paper that families should be included in the treatment of most young people with eating disorders.  Their take-home point is that utilizing family members as an asset in the treatment process should take precedence over assigning blame for the disorder.  Parents feel enough guilt on their own without psychologists telling them that their child's problems are all their fault.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Negative family interactions impact relapse rates in bipolar disorder: Defining "expressed emotion" and attempting to reduce its occurrence

by Michael D. Anestis, M.S.

Few people would disagree that living with bipolar disorder is extremely difficult.  Even though most individuals experience manic episodes as exhilarating while they last, the repercussions of these episodes tend to result in extremely negative emotions and significant problems once the mania recedes.  Additionally, the depressive episodes experienced by many bipolar individuals can be debilitating and dangerous.  That being said, less attention is generally paid to the fact that living with somebody else who has bipolar disorder is also a difficult experience.  For the spouses and families of an individual with bipolar disorder, the consequences of bipolar symptoms can be painful, costly, and disheartening.  Some individuals are able to maintain a positive outlook in such situations and remain close to their ailing loved one.  Others, however, find such outcomes more difficult to attain.

One of the most important variables to consider when discussing the relationship between a mentally ill individual and his or her loved ones is expressed emotion (EE).  EE is defined as critical, hostile, or emotionally overinvolved attitudes towards and interactions with a relative diagnosed with a mental illness (Hooley, Rosen, & Richters, 1995).  This definition is admittedly broad; however, a substantial amount of research has been conducted on EE and results have consistently indicated that high levels of EE predict poorer outcomes for a host of mental illnesses, including schizophrenia and mood disorders (Barrowclough & Hooley, 2003; Butzlaff & Hooley, 1998).  In other words, the more critical family members are towards a mentally ill relative, the more likely that individual is to relapse and exhibit a negative outcome. 

With respect to bipolar disorder, EE has been shown to be unrelated to manic relapse, but significantly related to depressive relapse.  In fact, even when controlling for symptom severity, high levels of EE predicted a five-fold increase in the likelihood of depression relapse in individuals with bipolar disorder (Yan, Hammen, Cohen, Daley, & Henry, 2004).  So, while EE does not appear to have any impact on manic episodes, high levels of EE in family members predicts subsequent relapses of depression for individuals with bipolar disorder.

In 2008, Lori Eisner and Sheri Johnson of the University of Miami published a study in Behavior Therapy that looked at the utility of an intervention aimed at reducing EE in individuals with a family member diagnosed with bipolar disorder.  They noted that, despite the negative outcomes associated with EE, it persists in large part due to prominent misconceptions regarding the nature of mental illness in general and disorders such as bipolar disorder in particular.  Individuals with high levels of EE tend to believe that the symptoms of mental illness are within the control of the mentally ill individuals (Barrowclough, Johnston, & Tarrier, 1994) and, as such, become highly angered when their loved one fails to prevent him or herself from exhibiting those symptoms.  This viewpoint leads the high EE individual to make frequent judgmental, critical comments to the loved one and to become emotionally overinvolved in their loved one's life. 

Eisner and Johnson further noted that prior attempts to develop interventions based on psychoeducation have succeeded in increasing relatives' understanding of mental illness, but have failed to actually reduce EE (Fristad et al., 2003; Simoneau et al., 1999).  As such, their goal was to create an alternative approach that not only emphasized psychoeducation, but also sought to diminish EE directly by teaching high EE individuals acceptance skills capable of disarming the intense surges of emotions that likely lead to critical comments and interactions.  The authors based this component of their intervention on Christensen and Jacobson's (2000) integrative behavioral couple therapy (IBCT), which works to reduce bitter interactions between romantic couples.

The study sample consisted of 42 adults from 32 different families.  All participants had at least one relative who had a lifetime history of at least one full manic episode as determined through a semi-structured diagnostic interview (SCID-IV; First, Spitzer, Gibbon, & Williams, 1997).  Participants had the option of attending one full-day seminar (9am - 4pm) or two evening seminars (5:30pm - 9pm).  Only the family members themselves attended the workshop(s).  The family members with a history of manic episodes did not attend, as prior research has indicated that this can have negative effects on participants' willingness to openly share information and engage in the treatment (Reilly, Rorbaugh, & Lackner, 1988).  The intervention itself consisted of modules focusing on the following material:

• Providing education on the nature of bipolar disorder
• Helping family members understand and contextualize the responses of their relatives
• Addressing the impact of criticism on the course of bipolar disorder
• Defining acceptance and discussing its relevance to bipolar disorder
• Discussing ways to implement acceptance in their lives and practicing these skills in session

The rationale for this study was strong and the intervention itself seemed promising; however, the results were not consistent with what the authors anticipated.  In the end, the clients were very happy with the intervention and exhibited an increased knowledge regarding bipolar disorder.  The intervention was less successful in its other aims though, as levels of anger and criticism did not decrease post-treatment.  Unfortunately, this is consistent with prior work and seems to indicate that EE is very difficult to change.  Obviously, given the strong negative impact of EE on the course of bipolar disorder and other mental illnesses, it is pivotal that other researchers and clinicians work to develop empirically supported interventions capable of actually reducing EE.  Given that the entire treatment consisted of either one full day or two half-day sessions, the brevity of the intervention may have had an impact on the outcome.  Perhaps if the intervention included brief follow-up sessions in which the participants could problem solve regarding areas in which they have had a difficult time integrating material into their daily lives, the treatment would be more effective.

So what does all of this mean?  First of all, the anger, frustration, and sense of being overwhelmed experienced by individuals with relatives diagnosed with bipolar disorder is entirely understandable.  The research on EE is not blaming family members for their loved ones' illnesses nor are they saying that they are not entitled to their feelings.  Instead, the research on EE simply tells us that frequent critical, harsh interactions with individuals diagnosed with mental illnesses can have a highly negative impact on outcomes.  Consequently, maintaining the viewpoint that mentally ill individuals have complete control over their symptoms seems counterproductive and unlikely to result in desired outcomes.  Whether or not an individual wants harsh criticism to be effective in changing behaviors, the evidence indicates that it is not.  The acceptance-based approach tested by Eisner and Johnson (2008) seems philosophically appealing; however, the results of their study indicated that is not an effective solution either, at least as the intervention is currently packaged. 

If you would like to learn more about expressed emotion or other relevant topics, we encourage you to consult our online store, which provides a long list of resources based on rigorous scientific studies.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Using cognitive-behavioral therapy to prevent depression in adolescents at high risk

by Joye C. Anestis

In clinical psychology, we most often deal with healing mental disorders after they have reared their ugly heads.  The majority of interventions written about on PBB target full-blown mental illnesses, as do the therapies considered to be empirically-supported treatments (ESTs).  However, many researchers focus their energy on the other side of the disorder spectrum and are working to develop preventative treatments for individuals known to be at high-risk for developing a specific mental illness (e.g., people with significant genetic risk).  Certainly, some would argue that developing ways to prevent mental illness should be the primary imperative for the clinical psychology (& other mental health) field.

Much of the prevention literature targets children and adolescents who are at high risk for eventually developing a mental disorder.  The method of defining high risk individuals depends on the mental illness being studied, but familial risk is probably the most common indicator.  Children and adolescents with a parental history of certain mental illness (e.g., depression, bipolar disorder, schizophrenia) are at a higher risk of developing that disorder.  The study at hand (Garber et al., 2009, recently published in JAMA) focused on preventing depression in a sample of adolescents with a parental history of depression.   In 2001, Clark and colleagues reported that a group cognitive-behavioral (CB) prevention program was more effective than usual care for the prevention of depression in adolescents whose parents had a history of depression.  Garber et al. (2009) attempted to replicate these findings, hypothesizing that those in the CB program would have a lower incidence of depressive episodes and show a better outcome on continuous measures of depressive symptomatology.  They also investigated whether other factors, such as current parental depression, current participant depression, and participant history of a mood disorder, moderated the effect of the intervention.

The sample: As is common in randomized controlled trials, individuals had to meet detailed exclusion criteria in order to participate in the study.  Adolescents had to have at least 1 parent/caretaker who had a major depressive in the past 3 years, or 3+ episodes or 3+ cumulative years in a major depressive or dysthymic episode in the adolescent's lifetime.  Additionally, the adolescents had to be 13-17 years old and have current subsyndromal depressive symptoms, a prior depressive episode that was in remission for at least 2 months, or both.  Adolescents were also excluded if they had a current mood disorder diagnosis, were currently taking an antidepressant, had received more than 8 sessions of CBT for depression, or had a biological parent with bipolar I disorder or schizophrenia.  Siblings could be included, and the randomization protocol ensured that siblings were assigned to the same condition.  In all, 316 adolescents (58.5% female) participated, spread across 4 study sites (Nashville, Pittsburgh, Portland, and Boston). 

The intervention: Participants were randomly assigned to either the treatment group or a control group, but the randomization procedure ensured that the 2 groups were equivalent on age, sex, race-ethnicity, and inclusion criteria.  The treatment group (n = 159) received the CB preventative intervention.  It consisted of 8 weekly 90-minute sessions (the acute phase) and 6 monthly sessions (the continuation phase) in mixed-sex groups of 3-10 adolescents.  During the acute intervention, the participants were taught cognitive restructuring skills to identify and refute unrealistic and negative thoughts, as well as problem-solving skills.  During the continuation sessions, cognitive restructuring and problems-solving were reviewed and some new skills were taught (e.g., relaxation, behavioral activation).  At weeks 1 and 8 of the acute sessions, the parents attended the sessions to learn the general topics and skills being covered, as well as the rationale behind them.  For the usual care control condition, all enrollees, regardless of randomized condition, were allowed to begin or continue nonstudy mental health or other health care service.  Such service use was documented.  Assessments of parents and adolescents were conducted before the intervention, immediately after the intervention (month 3), and after the continuation phase (9 months after baseline).

The results: Overall, the prevention programs worked.  The treatment group developed new depressive  episodes at a significantly lower rate than the control group,and self-reported depressive symptoms declined at a significantly greater rate for those in the CB program.  Next, the investigators examined several factors to see if they moderated the effect of the treatment.  Interesting, current parental depression significantly moderated the effect of the prevention program, meaning that the prevention program was significantly better at preventing a depressive episode if a parent was not currently depressed.  When a parent was currently depressed, rates of incident depression (i.e., new episodes) in the youths did not significantly differ between the 2 groups.  Within the prevention group, those whose parents were currently depressed had a significantly higher rate of incident depression than those whose parents were not currently depressed.  This difference did not exist in the control group.  The adolescents' own depressive history and depressive symptoms did not impact the outcome.

This study by Garber et al. builds on the literature showing the group CB intervention are effective in preventing the development of depression in adolescents who are at high risk for the disorder.  Not only is this an important finding on the utility of CB techniques in holding a pernicious illness at bay, but adds to the growing literature supporting certain group treatments. Group treatments are more cost-effective for clients and are highly attractive to managed care companies, making it imperative for researchers to develop and examine the efficacy of these programs.  An important caveat to Garber et al.'s overall results is the finding that the prevention program is most effective when their participants' parents are not currently depressed.  This finding is consistent with previous findings showing a relationship between parental symptom improvement and child functioning (Gunlicks & Weissman, 2008).  Garber et al. suggest that future studies should examine a combined or sequential parent and adolescent treatment/prevention program, an initiative that would be fascinating and possibly very helpful.  On a pragmatic note, I imagine that such a program would be more cost-effective (certainly more so than waiting until the adolescent has been struggling with depression for many years).  Additionally, I wonder if incorporating a child into the parental treatment would also be highly motivating for the parent, thus perhaps increasing the efficacy of CBT for depression.  I would be very interested to read about that study.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Improving relationships: the empirical status of marital enrichment programs

by Joye C. Anestis

The empirically-supported treatment (EST) movement has focused primarily on diagnosible mental illnesses and related conditions.  Thus, treatments for other problems have not been systematically quantified according to accepted standards for ESTs.  One of the more common reasons for people to seek psychotherapy is for maintain or improve their relationships, and marital enrichment or enhancement programs have been developed to help couples achieve that goal.  It is important to note that marital enrichment programs differ from marital therapy programs intended for those experiencing more severe distress, typically those receiving marital enrichment or enhancement services are in more functional relationships but are wishing to improve their quality (Jakubowski et al., 2004).  Although marital enrichment programs are not included in formal lists of ESTs, enough research has been conducted on them to determine their empirical status.  In 2004, Jakubowski, Milne, Brunner, and Miller examined the marital enrichment literature to determine where these programs lie on the continuum of ESTs.  They found 4 programs which can be considered "efficacious" (i.e., an EST) based on the APA Task Force standards (at least 2 randomized controlled trials conducted by 2 independent research teams, treatment is manualized), 3 found to be "possibly efficacious" (only one randomized controlled study or studies done by only one research team), and 6 were considered "empirically untested" (programs with some outcome research but no randomized controlled trials).  It is important to note that many more marital enrichment programs exist but treatment outcome data is not available for them.  Below, I summarize Jabukowski et al.'s findings, as well as provide a brief update where available.

Efficacious

• PREP (Prevention and Relationship Enhancement Program): PREP is a skills-based program with 4 primary goals: to teach couples better communication and conflict management strategies (in fact, one of my favorite PREP books is called Fighting for Your Marriage), to assist couples in identifying and evaluating expectations, to facilitate understanding of and decisions reflecting commitment, and to increase positive bonding.  It can be conducted with individual couples, in groups, and in self-study by couples.  A number (at least 7) of randomized controlled trials (RCTs) have demonstrated the efficacy of this program.  Gains associated with PREP include increased positive communications when compared with couples in control groups, increased spouse confidence in the relationship, increased communication and problem-solving skills, lower rates of divorce, greater relationship satisfaction, decrease in the intensity of problems, and greater sexual satisfaction.
  • Update since Jabukowski et al. (2004): 2 studies published since 2004 have demonstrated the efficacy of a computerized adaptation of PREP (ePREP; Braithwaite and Fincham, 2007, 2009).  Interestingly, these studies also showed that improving relationship functioning via ePREP also alleviates symptoms of depression and anxiety.
• Relationship Enhancement (RE): Relationship enhancement aims to teach couples self-disclosure skills with a focus on feelings, behaviors, and eliminating blaming statements.  It also teaches listening skills.  RE can be taught in an all-day workshop or in weekly group meetings (2 hours a week, 10-15 weeks).  A large body of research indicates the benefit of RE for a number of outcomes, including increases in couple self-disclosure and empathy and improved marital communication and satisfaction (see Accordino & Guerney, 2003, for a review of the RE outcome research).
• The Couple Communication Programs (CC): Couple Communication strives to develop clear and open communication between partners in order to increase awareness of the self and partner, the relationships, and the rules of conflict.  CC is conducted in group format, meeting 2 hours a week for 4 weeks.  The efficacy of CC has been examined in a number of studies, with overall findings indicating that CC is superior to no treatment and is effective in improving communication skills (see Butler & Wampler, 1999, for a recent meta-analysis).  The long-term effects of CC are questionable, however, with studies demonstrating a consistent trend toward skill deterioration.
• Strategic Hope-Focused Enrichment:  This is a more eclectic approach to marital enrichment, focused on promoting love and faith in each other and increasing couple motivation to work together to improve their relationships.  It consists of 5 1-hour sessions.  RCTs have demonstrated that this protocol can imporve marital satisfaction and communications and overall quality of life.

Possibly Efficacious

• Couple Commitment and Relationship Enhancement (Couple CARE): Couple CARE is based on PREP (described above).  The difference is that Couple CARE is a "flexible delivery" program (i.e., promotes ease of access) and emphasizes self-directed learning.  One RCT has been conducted on Couple CARE, showing increased relationship enhancement and stability.
• Association for Couple in Marriage Enrichment (ACME): ACME programs strive to improve relationships through a variety of activities (e.g., role playing) using experiential learning and group processes (see Association for Couples in Marriage Enrichment, 1993, for more information).  ACME appears to be less structured than other interventions, focusing on the process of martial enrichment and not an exact format (Dyer & Dyer, 1999).  This lack of standardization makes it hard to study empirically.  The one RCT conducted, however, demonstrated positive outcomes for couples.
• Couple Coping Enhancement Training (CCET): CCET aims to prevent marital distress.  It combines CBT with with theories of stress, coping, & social reciprocity.  The one RCT conducted demonstrates CCET's ability to improve marital satisfaction adn quality and decrease parenting stress.
  • Update since Jabukowski et al. (2004): Ledermann, Bodenmann, & Cina (2007) recently published a new RCT with distressed couples with preadolescent children.  Positive effects were noted immediately upon completion of the program but these gains were not maintained at 6-month and 1-year follow-ups.

Empirically Untested (please see Jakubowksi et al., 2004, for more information)

• Structured Environment
• Marriage Encounter
• Practical Application of Intimate Relationship Skills (PAIRS)
• Imago Relationship Therapy
• Traits of a Happy Couple
• Saving Your Marriage Before It Starts

Apparently there is a rich array of programs to choose from when assisting couples improve their relationships.  4 programs, as of now, are considered empirically supported - with several others in need of a bit more research before we can draw firm conclusions about its empirical status.  Clinical psychologists do not often see clients primarily for relationship problems (individuals are more likely to seek counseling psychologists or marriage and family therapists for such concerns); however, clients being treated for mental illness often are having concurrent relationship difficulties that might need additional treatment.  It is prudent for clinical psychologists to have some facility with marital enhancement protocols, as in some cases additional couples therapy may be warranted. 

Treatment Manuals for some of the Efficacious Programs Listed Above
Fighting for Your Marriage: Positive Steps for Preventing Divorce and Preserving a Lasting Love (New & Revised)
Hope-Focused Marriage Counseling: A Guide to Brief Therapy
Relationship Enhancement Therapy: Healing Through Deep Empathy and Intimate Dialogue

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively - May 2009 Psychotherapy Brown Bag featured article

By Les Gordon, M.A., LMFT & Katie Gordon, Ph.D.

Part 1: Why It’s Important (Katie Gordon, Ph.D.)

Simply put, it’s important to include family members in the treatment of children and adolescents because it leads to better mental health outcomes. Parents are often valuable resources in therapy, and their active involvement in the treatment process can go a long way to reduce their child’s suffering and mental health problems. Multisystemic therapy (MST) for adolescent conduct disorder is a clear example of the potentially powerful and positive impact family members can have on clinical outcomes. In one particularly impressive MST study, Schaeffer and Borduin (2005) followed up adolescent felons who were randomly assigned to either MST or individual therapy 14 years prior. They found that those who received MST were 4 times less likely to be re-arrested, 2.5 times less likely to be arrested for a violent crime, and averaged ~62 less incarcerated days per year than those who received individual therapy.
    In a review article on the status of treatments with family components (e.g., parental psychoeducation, parent training), Diamond and Josephson (2005) presented evidence that including parents in treatment for other childhood/adolescent mental health problems, including substance-use related problems, anxiety disorders (particularly if one or both parents have anxiety also) and attention-deficit/hyperactivity disorder (ADHD) tends to lead to better outcomes than treatments that do not include parents (note: parental involvement does not appear to affect core symptoms of ADHD, but reduces associated behavior problems) . Since the 2005 review, more evidence has emerged that a specific type of family-based treatment (FBT) is superior to supportive individual therapy for bulimia nervosa in adolescents (le Grange, Crosby, Rathouz, & Leventhal, 2007), findings that are in line with those that Mike Anestis presented on FBT for adolescents with anorexia nervosa earlier this week. Involving family in the treatment of adults is beyond the scope of this article, but it is worth mentioning that there is empirical support for manual-based family treatments for adults with substance use disorders (e.g., Fals-Stewar & O’Farrell, 2003), bipolar disorder (Rea et al., 2003), and schizophrenia (Pharoah et al., 2006).
    Despite the evidence that including family members in treatment can be very beneficial, some clinicians may still feel reluctant, and parents may fear that they will be blamed if they participate. This may be due, in part, to historical or even folk explanations of mental disorders. For example, beliefs that certain mental illnesses are caused by having an absentee father (e.g., having “dad issues”) or an uncaring mother (e.g., “the refrigerator mother” or “the schizophrenogenic mother”) may linger in the minds of parents and even clinicians, despite a lack of evidence to support these theories. Part 2 of this article highlights the importance of directly addressing these types of issues by assuring parents that the purpose of their involvement is not to place blame, but rather, to enlist them as essential, helpful collaborators in their child’s treatment. It may be particularly important to assure parents of this early on, given evidence that parental therapeutic alliance predicts retention rates and outcomes in therapy for children and adolescents (e.g., Shelef et al., 2005). A second, perhaps more common, reason clinicians may feel reluctant to include families in therapy might be that they feel unsure about having the appropriate skills and/or feel intimidated about being “outnumbered” by clients in the therapy room. The purpose of Part 2 of this article is to normalize these feelings of uncertainty, and to outline some practical tips for including family members in treatment.

Part 2: How to Do It Effectively (Les Gordon, M.A., LMFT)

As a family therapist for 25 years, I can’t imagine any conceptualization of child or adolescent psychological problems that does not include careful examination of the family process. The assessment of family dynamics throughout treatment allows for deeper understanding of the presenting problem, and the factors that maintain it. With this in mind, I hope that these hints will be helpful to clinicians working with children, adolescents and their families.

1.  Start early by asking family members to attend the initial assessment session. Set up a 1.5-2 hour meeting for an initial assessment, not counting any paperwork you’ll have them fill out. I usually set up an initial session fee that is somewhat less than two hours but more than the one hour standard fee. Introduce yourself to each member of the family in the waiting room, making a bit of small talk. Depending on the age of the child(ren), I also make sure to have some toys or games ready for them as well, as it can help with engaging the client and building rapport. Notice the affect, attitudes, and body language of all member of the family. I try to gather basic information, such as the child’s age, presenting problems, and the family member names prior to the first session. This is done through a 10-minute phone consultation when the clients first seek out your professional services. Although a good office manager can save you the trouble of this conversation, I believe it is highly beneficial to actually speak to the family and establish some initial rapport and connection. You may also be able to determine whether this is a case that you are qualified to accept. I have referred prospective clients out at this point due to my lack of expertise with their particular problems, insurance issues, and/or some other issue.

2.  Appreciate the differences between assessment and treatment. The first few sessions are primarily assessment, and therefore clinicians need to avoid jumping in to the rescue of the family. This is the time to observe, ask questions, and detail how the family functions.  The family dynamics will quickly appear without much prompting. For example, if there is a toddler who is playing while the clinician is speaking with the parents, you can observe who redirects the child, the patience levels, and the type of words and physical actions used during interactions with the child. With older children and adolescents, you can observe where they sit, how close to either parent they are, how active they are in conversation, how affectionate, along with mood and communication patterns. If clinicians interrupt and direct too tightly at this point, you could miss important observations into the family’s true form and style.

3.  Set the rules up immediately. After you introduce yourself and explain a little bit about how you work and your philosophy, encourage them to ask any questions they may have at that point. This is the time to disclose a bit more about your experience as a therapist.  Did you work in schools? Hospitals? What brought you into the counseling profession? If you have any sense of humor (hopefully) this is the time to be wise, gentle, and humorous.  If you have no sense of humor, then perhaps a political science major may have been more appropriate. I usually state at this time that I was a childrearing expert at one time-- immediately after graduate school and prior to the births of my three children. I want them to know that I am a parent and have experienced the full effects of having a job, being in a relationship, and raising children who were all not perfect every moment of every day (except my co-author).  This builds an alliance of immeasurable importance with the parents because they feel that they will be understood rather than judged.
    Explain how therapy works and in general what they can expect. I usually say that I will meet with the child/adolescent alone some to most of the time, go through confidentiality, and leave some time at the end of each session for parents to join us. As some occasions warrant – we may spend a whole session together as a family.

4.  Practice helps a family therapist more than anything. If you are an intern or student, or a newly supervised licensee, then seek out as much family work as you can. Avoid that feeling in the pit of your stomach that you may be outnumbered or overwhelmed in session. Embrace the unknown - understanding that expertise is the result of hundreds of hours of practice. Find a supervisor who likes systemic and family therapy and get their assistance. Read a Satir or Minuchin book or article. I am reminded that when I did workshops in my thirties with these esteemed family therapy pioneers, I went immediately back into my practice and attempted one of Satir’s techniques with a very dysfunctional family. It was a total flop except for the insight I gained about myself as a young family therapist. Of course, I missed the point that these famous family therapists had years of experience in conducting family therapy!

5.  After assessment is complete, and the clinician has established a respectful and workable relationship with the family it is time to actually do what they are paying you to do… provide treatment. Of course, treatment recommendations depend on your observations and conclusions regarding family and individual diagnosis(es). Clinicians may find it helpful to devote a part of a session to review their opinions with the family, outline treatment protocols, and get consent for treatment. The consenting family is a less problematic family. Some disorders (e.g., anxiety disorders) may require less family involvement than others (e.g., oppositional-defiant disorder, which typically has a greater impact on the entire family’s functioning).  At times, sibling conflict may be so important that I’ll decide to have a separate meeting with the siblings.

6.  With regards to treatment considerations, families typically have developed a series of rigid responses to disciplinary situations without really understanding that there are other ways to interact. Many clinicians use the react vs. response techniques to educate families. I basically tell parents that any strategic and planned response is superior to simply reacting, so it’s imperative to discuss how to handle conflict. During this period of introducing new patterns of responses, clinicians are likely to find different degrees of unwillingness or inability to make changes. We often think the clients are being resistant and treat it as such. However, most failure at this point is due to parental insecurity and the results of years of habitualized reactions. The gentle, supportive, and educational approach is usually more successful, and may keep the client engaged at a time when they want to give up. Most importantly- go slowly and pick only one behavior to change at a time. This may be as simple as disengagement, time-out, or rehearsed verbalizations such as “I’m too upset now to decide what to do, let me go chill for 15 minutes, and we’ll meet back here to finish our discussion.” Remind parents that change is difficult, but simply making the attempt sends a message of support and love to their children.
A most valuable therapeutic technique in family therapy is positive practice.  This is when the client and/or their family role play the new response to repetitious conflicts first in the clinician’s office then at home.  Remember-- it is highly unlikely for an individual to apply a new technique in the middle of the apex of a stressful moment when they have reacted to it in the same way for months or years. Our brains just don’t function that way. The more they rehearse the responses in times of calm the greater the likelihood of success when they really need it. This also builds up rapport and teamwork within the family.

7.  To paraphrase Virginia Satir, “There is only one argument that ever exists- and that is whose definition of what is going on is going to be accepted”. Family therapists the world over have found such wisdom in this simple proclamation which has profound effects on how we view psychotherapeutic treatment. We clinicians often get drawn into conflicts with families about who is right--they actually present their arguments to us and ask us to make a decision after all the evidence is presented! I usually comment that I forgot to wear my robes this day, and therefore I cannot judge effectively. Unless it’s allowing children to play with matches or play in traffic, I try to encourage parent-oriented solutions.
    As a result, family therapists often teach communication skills as a vital part of therapy.  Remember, parents have almost no training in parenting, and the communications skills that feel natural to many clinicians do not feel natural at all for some families. The basics of communication skills training include: using “I feel...” rather than “you…” statements, timing the discussion of problems right (e.g., not while watching TV or in the middle of the night), and how we to divide time between listening and speaking. It also may help to highlight the goal of effective communication-- do we want to be right or be happy (and resolve the problem)?  There are many effective communication programs available. A couple that I prefer are Defiant Children, Second Edition: A Clinician's Manual for Assessment and Parent Training and The Parent's Handbook: Systematic Training for Effective Parenting .
    It is also essential to teach parents to listen to children and adolescents during non-crisis times. Sometimes, direct interaction between parents and children only occurs when something is going wrong. Of course, this is upside down. The more we listen to our children in non-conflict situations, the better the communication is during the conflict situations. Perhaps the most efficacious time for practicing good communication is during therapy, because there is a supportive, experienced person to assist them and because most people, even children, know that therapy is a time for sharing important thoughts and feelings.  I often joke that it’s my sofa that does everything- as soon as their bottom hits the cushion they start emoting! Outside of the office the best times to communicate with children is away from distractions and for short periods of 5- 15 minutes.  I believe short walks are also effective times for communication because, symbolically, both people are walking in the same direction, towards the same goal. Communicating while walking can also reduce the amount of eye contact and body language being negatively interpreted by the other person (which can lead to conflict).

8.  There are some common problems which tend to derail effective treatment if the clinician does not respond effectively:

-   Adolescents (ages 15-19) do not always want their parents involved in treatment. They may feel that their confidentiality and trust in the clinician is compromised, because they feel that the clinician sides with parents during conflicts. In this situation, referring the parents to another clinician for parent skills training may be appropriate. It is particularly convenient if they see a clinician in the same practice, or you have established a good working relationship with the clinician, so that you can work together to treat the family. Every once in a while a family session can be more effective with the two clinicians conducting co-therapy.

-   Parents may expect quick results and improvements despite presenting with serious problems. This is best dealt with by reminding parents that these problems didn’t develop overnight, and therefore cannot be solved easily. Also, remind parents of the treatment plan and highlight the small improvements that they may not have noticed or remember. Also, if too much time has passed with little or no positive results, it’s prudent to meet with the family, and admit that the current treatment plan does not seem to be effective. Developing additional or alternate plans is advised in this situation. This may include increasing the number of sessions per week, referral for further psychological testing, a medication consult, etc.

-   One or more individuals may take over the session and diminish the clinicians’ ability to direct traffic effectively. This may include excessive arguing, aggression, and threats or physical attacks towards each other. This almost always occurs because the clinician tries to get the family to use a level of communication that they are not ready or skilled enough to use. An experienced family therapist practices smaller and less emotionally-laden topics before moving onto the big issues. It is also necessary to carefully consider the mood of the client or their family on that particular day. If the clinician reads significant disturbance or aggression, it may be better to speak with that person individually and ask them if they are okay with a family session that day.
    Humor and empathy are usually effective in discharging anger. No one can truly be angry with someone who clearly understands and articulates their perspective.  Often, it is the job of the family therapist to rephrase a family member’s statement in a way that is less threatening and more accurate. Asking permission to do this and asking if you spoke correctly allows the client to still feel in control. If a conflict starts to accelerate I may say “ Oops, I’m sorry I forgot to wear my striped referee’s jersey today” or “Folks, if you wait about an hour then you can argue for free once you go home- it’s too expensive to fight here.” Sometimes you might just have to insist that one or all the parties take a time out in another room or outside.  Many times, I have had an adolescent or parent storm out of session and come back on their own within five minutes, because they really want to be a part of treatment.

-   Seldom, a parent, due to his or her own issues (e.g., a diagnosable mental disorder), is unable to improve much of their skill set, and does not contribute in a positive way to their child’s treatment. A clinician may then employ “damage control,” and try to teach the son or daughter how to responsibly and functionally get their needs met in their lives, even if that parent is unable to assist them.

-   In some situations, a clinician may feel that a family or one of its members display such callous and obstructive behaviors that it is necessary to discharge them from treatment. Make the discharge in compliance with the ethics of your license and/or practice, making sure to provide them with referrals for treatment elsewhere (it’s best not to refer them to colleagues that you like!).

    In conclusion, family therapy can be a vital and effective assessment and treatment modality that requires a certain set of skills. There are a number of workshops, books, classes, and supervision experiences that can assist you in acquiring these skills once you have determined the value of family therapy as it fits into your practice.

If you are interested in learning more about integrating family into the treatment of children and adolescents, we recommend the following products, all of which are available through the Psychotherapy Brown Bag online store:

• The Parent's Handbook: Systematic Training for Effective Parenting
  

• Defiant Children, Second Edition: A Clinician's Manual for Assessment and Parent Training

• Bipolar Disorder, Second Edition: A Family-Focused Treatment Approach

• Treating Bulimia in Adolescents: A Family-Based Approach
  

• Multisystemic Treatment of Antisocial Behavior in Children and Adolescents

Les Gordon, M.A., has been a Licensed Marriage & Family Therapist and an educator for over 25 years, and currently has a private practice in Coral Springs, Florida.
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Katie Gordon, Ph.D. is an Assistant Professor of Psychology at North Dakota State University. She received a year of training in family-based treatments for eating disorders at the University of Chicago.