Attachment and mentalization as predictors of outcome in family therapy for adolescent anorexia nervosa

Anorexia nervosa-focussed family therapy (FT-AN) is the first-line treatment for adolescent anorexia nervosa (AN), but the predictors of poor treatment response are not well understood. The main aim of this study was to investigate the role of attachment and mentalization in predicting treatment outcome. The secondary aims of the study were to investigate therapeutic alliance at 1 month as a predictor of outcome, and to test the associations between alliance and baseline attachment and mentalization. 192 adolescents with AN and their parents were recruited as they began family therapy in out-patient specialist eating disorder services. Self-report measures of attachment, mentalization, and emotion regulation were completed at the start of treatment by adolescent patients and one of their parents. Self-reported alliance scores were collected at one month. Higher scores on the Certainty Scale of the Reflective Functioning Questionnaire, completed by parents, which indicate over-certainty about mental states, were the strongest predictor of poor outcome (Odds Ratio: 0.42, CI: 0.20–0.87). Similarly, for adolescents, higher Lack of Clarity scores on the Difficulties in Emotion Regulation Scale, representing being unclear about one’s feelings, were predictive of positive treatment outcome (OR: 1.10, CI: 1.00–1.21). Higher alliance scores at 1 month predicted positive outcome, and were associated with attachment security and mentalization. These novel findings suggest that, particularly in parents, a tendency towards excessive certainty about mental states in others may predict poor outcome in FT-AN. Further research is warranted to replicate the finding and characterise families at risk of poor outcome.

Attachment and mentalization as predictors of outcome in family therapy for adolescent anorexia nervosa (Thesis)

Family therapy for adolescent anorexia nervosa (FT-AN) is the first line treatment for the disorder, but little is known about who the treatment works for, or how it works. This thesis investigates the potential value of the constructs of attachment and mentalization as predictors of outcome in family therapy for adolescent AN. The thesis presents a systematic review of attachment and mentalization and their association with child and adolescent eating pathology in which 22 relevant studies were found. In keeping with the evidence base for adults with eating disorders, both attachment and mentalization were found to be correlates of eating pathology in childhood and adolescence. However, evidence for these constructs in the process of treatment in child and adolescent eating disorders is scarce. In a second systematic review, the psychometric properties of attachment measures in middle childhood and adolescence were investigated across 53 studies. The overall conclusion of the study is that there is a lack of evidence of adequate psychometric properties for attachment measures in this age group.In the main study, attachment and mentalization were investigated as predictors of outcome in a sample of adolescents and their parents (n = 192) receiving FT-AN across three specialist outpatient eating disorder services. Mentalization, but not attachment, was found to predict poor clinical outcome at nine months after starting of treatment, with the strongest predictive effect being excessive certainty about mental states as assessed in parents. Therapeutic alliance scores at one month were predictive of outcome but did not play a mediating role in relation to baseline attachment or mentalization. In a further empirical study, definitions of eating disorder recovery were investigated through a qualitative analysis of comments on recovery-focused social media forums. Two super-ordinate themes emerged: firstly, recovery was defined as encompassing broad psychosocial domains of wellbeing; secondly, recovery was understood to be an ongoing process. Social connectedness to others was regarded as important both to the process and definition of eating disorder recovery. The final chapter of the thesis integrates findings from across the studies with emerging theoretical developments in the fields of attachment and mentalization. It is argued that attachment and mentalization represent worthwhile constructs for further FT-AN research, with a particular emphasis on the need to better understand the mechanisms by which excessive mental state certainty might lead to poor clinical outcomes.

Exploring alternatives for adolescent anorexia nervosa: adolescent and parent treatment (APT) as a novel intervention prospect

Recovery and remission rates of adolescent anorexia nervosa (AN) following Family Based Treatment (FBT) have seen a relative decline over recent years. While reasonably successful in achieving physical recovery (i.e. weight restoration), both empirical and anecdotal accounts highlight a lack of attention to the psychological recovery of the adolescent within manualised FBT. As such, there is a need for innovation to explore treatment variations and alternatives for the proportion of adolescents with AN who do not respond favourably to this first-line treatment. This paper introduces a new treatment framework to the field for clinical consideration and empirical assessment. Adolescent and Parent Treatment (APT) for adolescent AN draws from both family-based and individual treatment models, applying a developmental lens. APT attends to physical and psychological recovery simultaneously and from the start of treatment, with capacity to tailor individual psychological modules to the adolescent formulation. While clearly in its infancy, APT provides an exciting new avenue for exploration within the field, as we seek new avenues to support young people and their families to effectively combat this deadly illness.

Intensive Treatments in Adolescent Anorexia Nervosa

Approximately one-fifth to one-third of patients with adolescent anorexia nervosa (AN) need intensive care in the course of their illness. This article provides an update and discussion on different levels of intensive care (inpatient treatment (IP), day patient treatment (DP) and home treatment (HoT)) in different health care systems based on recently published literature. Important issues discussed in this article are new recommendations for the refeeding process and the definition of target weight as well as principles of medical stabilization and psychotherapeutic approaches. The pros and cons of longer or shorter hospitalization times are discussed, and the advantages of stepped care and day patient treatment are described. A new promising intensive treatment method involving the patient, their caregivers and the direct home environment is introduced. Parents and caregivers should be included in treatment research to foster collaborative work with the attending clinicians. There is an urgent need to evaluate the mid- to long-term outcomes of various intensive treatment programs to compare their effectiveness and costs across different health care systems. This could help policy makers and other stakeholders, such as public and private insurances, to enhance the quality of eating disorder care.

Family members’ reflections upon a family-based inpatient treatment program for adolescent anorexia nervosa: a thematic analysis

Background Family-based outpatient treatment is usually recommended as the treatment of choice when a child develops anorexia nervosa. However, some young persons will inevitably require higher levels of care. Qualitative research on family perspectives may help inform strategies to adapt family-based practices into intensified treatment settings. Our overarching aim was to investigate family members’ perspectives following a family-based inpatient treatment program for adolescent anorexia nervosa and to discuss clinical implications for treatment providers. Methods A subsample of eight families taking part in a naturalistic outcome study at a specialized eating disorder unit participated in the study (8 patients, 14 parents, and 10 siblings). The thematic analyses were inductive, predominantly descriptive, and guided by a multi-perspective framework. Results Five main themes were identified: 1: Expectations and evaluation of needs. Entering treatment from different vantage points, 2: Interactions with peers during the admission as highly beneficial or problematic, 3: Perspectives on staff expertise and the eating disorder unit’s structure, 4: Influencing within family relationships in different ways, and 5: Being admitted is at best only half the job: reflections on leaving the eating disorder unit. Conclusions Our study offers insight into how former inpatients and their family members experienced an inpatient treatment program designed to align treatment with the central elements of an outpatient family-based treatment approach for adolescent anorexia nervosa. Overall, the findings support emerging research underlining the necessity of strengthening the family-based treatment approach within intensified treatment settings. Moreover, the results emphasized the need for more knowledge on how to optimize inpatient treatment as well as the importance of providing smooth transitions between care settings.