Bringing in Family to Combat Anorexia
By RONI CARYN RABIN
Published: October 18, 2010
At their first family therapy session, Rina Ranalli and her husband tried to coax their anorexic 13-year-old daughter to eat a bagel with cream cheese. What followed was a protracted negotiation.
The girl said she would eat it only if she could have it plain, with nothing on it. The parents countered that they really wanted her to eat it with the cream cheese. Her last offer: she would eat half.
“Does this happen at every meal?” the therapist, Daniel Le Grange, asked them, Ms. Ranalli recalled. He added gently, “It has to stop.”
“It’s anorexic debate, and it’s really not helpful,” Dr. Le Grange said later in an interview. “I will usually turn to the parents and say: ‘Mom and Dad — it’s your decision what she has to eat. You have to make the choices for her, because the anorexia doesn’t allow her to think clearly.’ ”
Unlike traditional treatments for anorexia nervosa in adolescents, in which the patient sees the therapist one on one, this kind of family-based treatment encourages parents to play a pivotal role in restoring their child’s weight while trying to avoid hospitalizations.
It is a demanding program: for the first two weeks of treatment, at least one parent must be available around the clock to supervise meals and snacks, and monitor children between meals to make sure they do not burn off the calories with excessive exercise.
Now a new study by Dr. Le Grange, of the University of Chicago, reports that the family approach, called the Maudsley method after the London hospital where it was developed, not only is more effective than individual therapy but also keeps working even after the treatment ends. The study, published this month in Archives of General Psychiatry, is one of just a handful of clinical trials that have evaluated treatments for anorexia nervosa in adolescents. Researchers randomly assigned 121 patients ages 12 to 18, mostly girls, to a year of either family or individual therapy at the University of Chicago and at Stanford — 24 hours in all.
Twelve months after the treatment had ended, 49 percent of those who had been in family therapy were in full remission, more than double the 23 percent of those who had been in individual therapy. And among patients who were in remission at the end of the treatment itself, only 10 percent of the family-therapy group had relapsed a year later, compared with 40 percent of those who had individual therapy.
Ms. Ranalli said that until she started family-based treatment with her daughter, “I was never given the tools to say, ‘You are going to sit down and eat this, and I will be here for you and help you through this.’ ”
The family method gave her the skills and confidence to approach her daughter’s anorexia the same way she would approach any other disease, whether flu or cancer.
“If you had medicine for your child, you wouldn’t let your child take half a dose,” Ms. Ranalli said. “I would say to her: ‘This is your food — this is your medicine. You’re not leaving the table before you eat it. We will get through this together. I will hold your hand and support you through this.’ ”
Ultimately, she went on, her daughter “realized she was not going to leave the table without eating.”
She and her husband took turns making sure the girl ate three meals a day and plenty of high-calorie snacks; Ms. Ranalli even went to her daughter’s school, where the two were given a private room so she could make sure the child ate lunch. At the beginning, it could take 30 minutes to get through breakfast, and dinner could last hours.
At one of the first sessions of the Maudsley method, the therapist sits in on a family meal to observe the dynamics, Dr. Le Grange said. Everyone in the family has a role: siblings are instructed to clear out once they are finished eating, “not jump up and yell at their sister for not eating or yell at the parent.”
Unlike traditional approaches, the Maudsley method “says we don’t think the parents are to blame for the problem,” Dr. Le Grange said. “We think they’re part of the solution, and should be center stage.” Their job is to be calm, supportive and consistent.
“It’s a daunting task, no doubt, and it would not be right to create the impression that it’s an easy treatment,” Dr. Le Grange said, adding that parents are not to use physical contact to get their child to eat.
Caregivers need to speak with one voice, he said; one parent cannot be telling the child to eat while the other says, “Just give her a break tonight.”
“The parents need to be on the same page — not just the same page, but the same line and the same word and the same letter,” Dr. Le Grange said.
The trial was limited to adolescents who had been ill for a year or less and were at least 75 percent of their ideal body weight, and Michael Strober, director of the eating disorders program at the University of California, Los Angeles, said it was not clear whether the family-based approach would benefit more severely ill patients.
“When patients are losing weight rapidly, it’s rare to be able to turn it around, and they often must move to a higher level of care,” like residential treatment or hospitalization, said Dr. Strober, who was not involved in the study. And some families are so mired in conflict that they cannot work together as required by the family-based treatment.
But many families can “rise to the occasion,” said Harriet Brown, the author of “Brave Girl Eating: A Family’s Struggle With Anorexia,” a book about her own family’s struggle with her daughter’s anorexia. (Ms. Brown has written about eating and weight problems for The New York Times.) While her daughter was in adolescent-focused therapy, she said the therapist told her that parents should not be the “food police,” and that therapy had to get to the root causes of the problem before her daughter would resume eating.
“It doesn’t work that way,” Ms. Brown said in an interview. “You need the physical recovery first, and then the cognitive recovery. The patient is racked with guilt, anxiety, feeling she’s fat and loathsome if she eats — it was our job to be louder and drown out those voices in her head.”