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Ending treatment, discussion of future plans and discharge is the final phase of treat- ment. The therapist in Phase 4 may encounter parental anxiety which is out of step with their child’s progress and therefore sessions in this phase include discussions about relapse prevention, tolerance of uncertainty, reviewing the course of recovery, and some reflection on the expertise of parents and child to manage future difficulties.

Multifamily Therapy for Anorexia Nervosa (MFT-AN)

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MFT-AN draws on the four-phase treatment model in a group therapy for 5–7 seven families at one time. MFT-AN commences with an introductory afternoon comprising a lecture highlighting the psychological and physical consequences of starvation. Par- ents and young people then meet a ‘graduate family’—a family who have previously been through the MFT-AN process—who share their experiences of the group. This meeting is followed by four intensive days of therapy with up to five follow-up days over the following 6 to 9 months. The intensive nature of the treatment has been described as creating a ‘hothouse effect’ (Asen & Scholz, 2010), which makes it a pow- erful context for mutual learning, reducing the sense of isolation and stigma and increasing a sense of hope and the likelihood of change. In addition to the program of therapeutic sessions (see Simic & Eisler, 2015, for details), families also have their meals and snacks together in communal areas, providing multiple opportunities for in vivo learning and support.

Family Therapy for Bulimia Nervosa (FT-BN)

FT-BN differs somewhat from the FT-AN model. FT-BN sessions are far more likely to feature separated sessions, with the therapist meeting the young person and par- ent/s on their own at least early on in treatment. Greater attention is focused on

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building a therapeutic engagement between the therapist and the young person in order to ensure that issues of motivation to change and building trust within the fam- ily can be addressed early on. Early sessions with parents provide psychoeducation, practical parenting skills, and coaching with an emphasis on reducing criticism, blame, and guilt. Validation skills are promoted as a way of supporting future change. Early separated interventions in FT-BN provide a foundation for later conjoint ses- sions, when issues of communication and collaboration can be enhanced to support behavioral change.

Multifamily Therapy for Bulimia Nervosa (MFT-BN)

MFT-BN shares some similarities with MFT-AN, with similar benefits arising from the group process as described above. It provides a group learning opportunity but with ses- sions spaced weekly over 4 months, allowing for a slower process of change, and providing space for reflection and practice of the skills learned. Similarly to FT-BN, initial group meetings have more separate parallel sessions with young people and the parents. The shared context of the MFT group allows parents to feel that they are not alone in dealing with the frustrations and difficult behaviors of their child. Alongside systemic tasks and exercises, elements of both Dialectical and Cognitive-Behavioral approaches are combined to address the unique needs of this patient group (Stewart, Voulgari, Eisler, Hunt, & Simic, 2015).

EFFICACY RESEARCH

The eating disorders field provides a challenging context in which to conduct research. The relative rarity of AN means that multiple sites are often needed to recruit sufficient numbers into an RCT (Watson & Bulik, 2013). In the case of BN, recruitment to studies can also be problematic, as help-seeking is typically delayed by 4–5 years (Turnbull, Ward, Treasure, Jick, & Derby, 1996), meaning that many adolescents with BN are not present- ing to services until adulthood. A further challenge for research is that the urgent medical risks presented by eating disorders, particularly AN, mean that providing a wait-list con- dition in any efficacy trial raises important ethical issues (Watson & Bulik, 2013). This means that treatments under investigation have to go up against other credible, bona fide treatments. This provides a sterner test of efficacy, but provides a methodological chal- lenge in a field with few established treatments.

Relative Efficacy of FT-AN

Three RCTs have investigated the efficacy of family therapy as compared with individ- ual therapy for AN. The first of these, by Russell, Szmukler, Dare, and Eisler (1987), was conducted at the Maudsley Hospital in London, and involved a sample of 57 participants with AN and 23 participants with BN. Participants included both adolescents and adults, and they were divided into four subgroups: one group with BN, and three groups with AN grouped by duration of illness and age at onset of illness. These subgroups were then ran- domized to family or individual therapy. After 1 year of treatment, in the subgroup of AN participants aged under 19 at illness onset and an illness duration of less than three years (n = 21), 90% of those receiving family therapy achieved better categorical outcomes (based on weight, menstruation status, and presence of bulimic behaviors) compared to 18% of those receiving individual therapy. These differences persisted at 5-year follow-up (Eisler et al., 1997). The findings of this influential study are compromised by a number of limitations. Firstly, the lack of manualization of the treatments delivered means that the study would no longer meet criteria for inclusion as evidence for an empirically supported

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treatment (Lock, 2015). Secondly, the sample size for the group which showed superior efficacy of FT-AN is very small. Thirdly, the supportive individual therapy arm was not a bona fide therapy, as it lacked a theoretical model of change or clear focus for treatment.

Robin et al. (1999) conducted a small RCT (n = 37) comparing family therapy and indi- vidual therapy in the treatment of adolescents (aged 11–20) with AN. The behavioral fam- ily systems therapy (BFST) used by Robin and colleagues had many similarities with the approach developed at the Maudsley (Eisler, Wallis, and Dodge, 2015; Robin et al., 1999). The comparison treatment consisted of Ego-Oriented Individual Therapy (EOIT), a treat- ment derived from psychodynamic principles. The therapist saw adolescents on a weekly basis, and met with parents fortnightly, although unlike in the family intervention, the parents were encouraged not to get directly involved in the management of mealtimes. BFST resulted in significantly greater increases in body mass index (BMI) at end of treat- ment (BFST mean change 4.7; EOIT mean change 2.3) and at 1-year follow-up (BFST 5.5; EOIT 3.2). Approximately two-thirds of the adolescents reached the target weights (set individually by their pediatrician) at end of treatment with no differences between the treatment arms. Significantly more girls in the BFST group (94%) than in EOIT (64.4%) had resumed menstruation by the end of treatment.

The largest efficacy trial comparing FT-AN and individual work was conducted by Lock et al. (2010). About 121 adolescents with AN were randomized either to a manu- alized family therapy based on the Maudsley approach, referred to as Family-Based Treatment (FBT), or to an individual therapy referred to as Adolescent-Focused Ther- apy (AFT), a modification of EOIT used in Robin et al.’s (1999) study. At the end of treatment, there was no statistical difference between the two treatments in terms of rates of full remission, although FBT was statistically superior in terms of partial remission, participants’ BMI percentile, and hospitalization rates. FBT was signifi- cantly superior in terms of rates of full remission at 6-month (FBT = 40% vs. AFT = 18%) and 12-month follow-up (FBT = 49%; AFT = 23%). Full remission was defined as a participant achieving a minimum of 95% expected body weight adjusted for sex, age, and height, and scores within one standard deviation of community norms for self-reported eating pathology.

Relative Efficacy of FT-BN

There have been three RCTs of FT-BN. Le Grange et al. (2007) compared family therapy (using a modification of their FBT manual) with supportive psychotherapy in a sample of 80 adolescents. FBT-BN emerged as significantly superior at end of treat- ment (39% binge-and-purge abstinence vs. 18% in the supportive therapy arm). At 6- month follow-up, abstinence rates had reduced in both groups (29% for FBT-BN vs. 10% for supportive therapy), but FBT-BN retained its superiority over supportive ther- apy. However, the assessment of treatment response was not blind to treatment condi- tion, thus posing a risk of bias. A further test of the efficacy of FT-BN was provided by Schmidt et al. (2007), in a comparison with guided self-care CBT (n = 85). In this study, there were no significant differences between groups on the primary outcome, abstinence from bingeing and purging, either at 6 months (end of treatment) (FT-BN 13%; CBT 19%), or at follow-up at 12 months when abstinence rates stood at 41% for the FT-BN group, and 36% for the CBT group. However, the CBT group had an ear- lier reduction in binge frequency. Schmidt et al. (2007) highlight a low rate of recruit- ment because of some of the older adolescents’ unwillingness to involve their parents in the treatment, but adolescents who received FT-BN continued to make more improvements after the end of treatment than those seen on their own. Treatment costs were significantly lower for the CBT arm.

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In the most recent RCT, Le Grange et al. (2015) compared FBT-BN, CBT, and support- ive psychotherapy in a sample of 130 adolescents. Recruitment rates were structured in such a way that more adolescents were randomized to FBT-BN (n = 51) and CBT (n = 58) than the supportive psychotherapy arm (n = 20). Compared to CBT, abstinence rates were higher for FBT-BN at end of treatment (39% for FBT-BN vs. 20% for CBT) and at 6-month follow-up (44% for FBT-BN vs. 25% for CBT). At 1-year follow-up, there were no differ- ences between groups. Rates of hospitalization were significantly lower for FBT-BN. The risk of bias is reduced in this study as compared with the earlier Le Grange et al. (2007) study, due to the use of independent assessors.

Efficacy Trials Comparing Different Forms of FT-AN

Four studies have compared the efficacy of different forms of FT-AN. Le Grange, Eisler, Dare, and Hodes (1992) conducted a pilot RCT comparing conjoint FT-AN, in which family members were seen together for therapy, with separated FT-AN, in which adolescents and parents were seen separately by the same therapist. This small study (n = 18) found no significant differences between the two forms of treatment. Eisler et al. (2000) conducted a larger RCT (n = 40) comparing separated and conjoint FT-AN, replicating the finding that overall neither was superior, either at end of treatment or at five-year follow-up. The lack of difference between the two treatment arms was important because it challenged the prevailing theoretical assumptions of the model, as the findings further undermined the idea that family members needed to be seen together, in order to intervene in family patterns that might be illness-maintaining. Moreover, while at aggregate level there was no difference between treatment arms, families rated as high in maternal criticism—an aspect of the measure expressed emotion (EE) (Leff & Vaughn, 1985) —achieved signifi- cantly better outcomes when offered separated FT-AN, a finding that was sustained at 5- year follow-up (Eisler, Simic, Russell, and Dare, 2007).

A recent RCT by Le Grange et al. (2016) (n = 107) compared conjoint FBT with a manu- alized form of separated FBT, which they name Parent-Focused Treatment (PFT). In PFT, a nurse weighs the adolescent, assesses medical stability, and provides brief supportive counseling, with the total individual contact time limited to 15 minutes. The adolescent’s weight and any other pertinent information is then communicated to the therapist, who then sees the parents for 50 minutes with a similar treatment focus to that used with the whole family in FBT. Remission, defined as in the Lock et al. (2010) study, was higher in PFT than in conjoint FBT at end of treatment (6 months) (43% vs. 22%), but did not differ statistically at 6- or 12-month follow-up. Lower parental EE predicted higher rates of remission in both study arms, but in contrast to the Eisler et al. (2000, 2007) studies, treatment response in families with high EE did not differ according to treatment. While the study further undermines the idea that conjoint sessions are a necessary ingredient of successful treatment, the findings also demonstrate the benefits of conjoint treatment for certain patient groups. For instance, patients with higher eating disorder-related obses- sionality benefited more from FBT than PFT, in keeping with previous findings suggest- ing that conjoint treatment is more beneficial to this group of patients as compared to separated treatment (Eisler et al., 2000) or individual work (Lock et al., 2010). Finally, Lock, Agras, Bryson, and Kraemer (2005) have investigated dose of treatment, comparing outcomes of short (10 sessions over 6 months) versus long forms (20 sessions over 12 months) of FBT. In this study of outpatient treatment (n = 86), there were no signifi- cant differences in outcomes between the two treatment arms. The study suggests that there are a number of treatment ‘responders’ for whom FBT works well within a short duration of time. For this group, increased contact hours appear to confer no additional benefit. However, nonintact families, and families where the young person had high levels

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of eating disorder-related obsessionality, benefited significantly more from the longer form of treatment.

Efficacy of FT-AN Compared with Generic Family Therapy Approaches

From a moderate common factors perspective, an obvious question to ask is whether the efficacy of FT-AN is due to specific ingredients of the model, or whether an alternative family therapy model might achieve equivalent outcomes. Thus far only one RCT, con- ducted by Agras et al. (2014), has been designed to help answer this question. This study of outpatient treatment (n = 164) compared two forms of manualized family therapy: FBT and Systemic Family Therapy (SyFT—Pote, Stratton, Cottrell, Boston, & Shapiro, 2001). The latter was a ‘generic’ form of family therapy, not specifically designed for treating ado- lescent AN. At end of treatment, there were no significant differences between treatments in terms of the primary outcome measures of percentage of ideal body weight and remis- sion. However, participants receiving FBT gained weight faster early on in treatment, spent fewer days in hospital, and treatment costs were lower, suggesting overall advan- tages of FBT. The study therefore provides support for the view that therapists adhering to a FT-AN treatment manual will achieve superior results overall as compared to those utilizing a more generic approach.

Interpreting the findings of this study is complicated by two potential confounding vari- ables: the eating disorder expertise of clinicians, and the role of specialist service contexts. Participants in both arms of the Agras et al. study were seen in specialist eating disorder services by therapists with an average of 6 years of experience of working with eating dis- orders. SyFT did not preclude a focus on the eating disorder, and given the treatment con- text and the therapists’ expertise, it is understandable that many families brought the discussion of the child’s eating disorder to therapy as a treatment priority. As a result, the two forms of family therapy investigated may have been more similar than it would other- wise seem (Blessitt, Voulgari, & Eisler, 2015).

These issues are illustrated by Godart et al.’s (2012) RCT conducted in France (n = 60), which investigated whether family therapy improved outcomes in adolescents treated in hospital. The family therapy model used in the study was not FT-AN, but a more generic approach in which family dynamics were conceptualized as being involved in the development and maintenance of the eating disorder. Adolescents receiving family therapy achieved significantly better outcomes compared with those receiving treatment as usual. Consequently, we can surmise that family therapy can have a beneficial impact on outcome even if the FT-AN model is not used. However, given that again the study was conducted by therapists with significant eating disor- ders expertise in a specialist service, it does not follow that family therapists without eating disorders expertise, working in nonspecialist services, can achieve equivalent results. The impact of service context is discussed in more detail later in this article.

Efficacy of MFT-AN and MFT-BN

Currently, one RCT has been conducted examining the efficacy of MFT-AN (Eisler et al., 2016) This UK study (n=169) compared outcomes for families receiving single family FT-AN as compared with MFT-AN. At end-of-treatment (12 months), categorical treat- ment outcomes were significantly better for those families who received MFT-AN (76% in the good or intermediate outcome categories) as compared with FT-AN (58%). At 6-month follow-up, families who received MFT-AN fared better than those receiving FT-AN, with a significantly higher weight, although the difference in categorical outcome was no longer significant. A strength of this RCT is that it was a pragmatic study with minimal exclusion criteria conducted across six treatment centers in and around London. Whilst this study

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suggests that the addition of a multi-family intervention improves outcomes, the authors are cautious in the conclusions, noting among other things that families in the MFT-AN arm also received single family therapy sessions, and that total therapist contact time was higher for families in this treatment arm.

The potential benefit of MFT-AN is also indicated by several smaller studies. For instance, Salaminiou, Campbell, Simic, Kuipers, and Eisler (2015) report good or interme- diate outcomes achieved by 6 months in 62% of the 30 families receiving MFT-AN. Gabel, Pinhas, Eisler, Katzman, and Heinmaa (2014), in a case-matched comparison, reported higher weight gain in adolescents receiving MFT-AN as compared to treatment as usual. Finally, Marzola et al. (2015) reported a brief treatment adaptation of MFT-AN, in which treatment was delivered over five full consecutive days. A follow-up of between 2–5 years of 74 patients showed that nearly 90% had achieved full or partial remission.

Research findings on the efficacy of MFT-BN are currently scarce. Stewart et al. (2015) have described the development of a MFT-BN group delivered in an outpatient context over 20 weeks in 1.5-hour-long sessions. Preliminary findings reported in their paper (n = 10) suggest that the group reduces eating pathology and depression, and increases adaptive coping skills. Thus MFT-BN currently shows promise, but further research is needed with larger samples and comparison groups.

FINDINGS ON IMPLEMENTATION AND SERVICE CONTEXT

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