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Family therapy in the treatment of child and adolescent eating disorders

Author/s
Aisling McGrath, Tom Jewell
Citation
Focus Issue 6: Eating disorders
CEPiP.2024.1.194-200
Abstract

Family therapy is recommended as the first-line treatment for anorexia nervosa and bulimia nervosa in adolescents. There is also emerging evidence for family therapy as a treatment for avoidant/restrictive food intake disorder. The aim of this article is to provide an up-to-date overview of the family therapy approach to treating adolescent eating disorders. Family therapy emerged in the 1980s as an evidence-based approach to treating adolescent eating disorders. A core aspect of the treatment is an early emphasis on parents supporting their child to achieve behavioural change, whilst later helping the child to take responsibility for their eating. The treatment is supported by evidence from randomised controlled trials, but there have been relatively few trials comparing family therapy with individual treatments. To improve the evidence base for family therapy, we recommend greater involvement of people with lived experience of eating disorders in research; the development of "modular" treatment manuals; a focus on improving the validity and reliability of measures; and greater use of alternatives to randomised controlled trials, including experimental studies and use of real-world data.

Cite as: Cutting Edge Psychiatry in Practice 2025, 6(1):194-200; https://doi.org/10.65031/ykld2895

References

  1. National Institute for Health and Care Excellence (NICE). Eating disorders: recognition and treatment. NICE guideline [NG69] 2017. Updated 16 December 2020. Accessed 6 October 2023. Available from: https://www.nice.org.uk/guidance/ng69/chapter/Recommendations#identification-and-assessment. https://doi.org/10.24292/01.mf.0120.14
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders Fifth Edition Text Revision (DSM-5-TR). 5 ed. Washington, DC. APA Publishing (2022). https://doi.org/10.1176/appi.books.9780890423349
  3. Couturier J, Isserlin L, Norris M, Spettigue W, Brouwers M, Kimber M, et al. Canadian practice guidelines for the treatment of children and adolescents with eating disorders. Journal of Eating Disorders. 2020;8(1):1-80. https://doi.org/10.1186/s40337-020-00307-2
  4. Jewell T, Blessitt E, Stewart C, Simic M, Eisler I. Family therapy for child and adolescent eating disorders: a critical review. Family Process. 2016;55(3):577-94. https://doi.org/10.1111/famp.12242
  5. Willmott E, Dickinson R, Hall C, Sadikovic K, Wadhera E, Micali N, et al. A scoping review of psychological interventions and outcomes for avoidant and restrictive food intake disorder (ARFID). International Journal of Eating Disorders. 2024;57(1):27-61. https://doi.org/10.1002/eat.24073
  6. Minuchin S, Baker L, Rosman BL, Liebman R, Milman L, Todd TC. A conceptual model of psychosomatic illness in children: family organization and family therapy. Archives of General Psychiatry. 1975;32(8):1031-8. https://doi.org/10.1001/archpsyc.1975.01760260095008
  7. Minuchin S. Families and Family Therapy. Boston, MA. Harvard University Press (1974).   
  8. Haley J. Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, MD. New York, NY. W W Norton (1973).     
  9. Selvini Palazzoli M, Boscolo L, Cecchin G, Prata G. Paradox and Counterparadox: General Models of Psychotic Processes in the Family. New York, NY. Jason Aronson (1978). https://doi.org/10.1177/000306518403200317
  10. Boscolo L, Cecchin G, Hoffman L, Penn P. Milan Systemic Family Therapy: Conversations in Theory and Practice. New York, NY. Basic Books (1987).
  11. Flaskas C. Frameworks for practice in the systemic field: Part 1 - Continuities and transitions in family therapy knowledge. Australian and New Zealand Journal of Family Therapy. 2010;31(3):232-47. https://doi.org/10.1375/anft.31.3.232
  12. Dare C, Eisler I. Family Therapy for Anorexia Nervosa. In: Garner D, Garfinkel P, editors. Handbook of treatment for eating disorders. 2nd ed. New York, NY. Guilford Press (1997). p. 307-24. https://doi.org/10.1080/10640266.2013.779194
  13. Russell GF, Szmukler GI, Dare C, Eisler I. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry. 1987;44(12):1047-56. https://doi.org/10.1001/archpsyc.1987.01800240021004
  14. Lock J, Le Grange D, Agras WS, Dare C. Treatment Manual for Anorexia Nervosa: A Family-Based Approach. First ed. New York, NY. Guilford Press (2001). https://doi.org/10.1007/bf03062113
  15. Gorrell S, Simic M, Le Grange D. Toward the integration of family therapy and family-based treatment for eating disorders. Eating Disorders: An International Comprehensive View. Springer (2023). p. 1-17. https://doi.org/10.1007/978-3-030-97416-9_59-1
  16. Austin A, Anderson A, Lee J, Vander Steen H, Savard C, Bergmann C, et al. Efficacy of eating disorder focused family therapy for adolescents with anorexia nervosa: a systematic review and meta‐analysis. International Journal of Eating Disorders. 2025;58(1):3-36. https://doi.org/10.1002/eat.24252
  17. Glashouwer KA, Brockmeyer T, Cardi V, Jansen A, Murray SB, Blechert J, et al. Time to make a change: a call for more experimental research on key mechanisms in anorexia nervosa. European Eating Disorders Review. 2020;28(4):361-7. https://doi.org/10.1002/erv.2754
  18. Murray SB, Quintana DS, Loeb KL, Griffiths S, Le Grange D. Treatment outcomes for anorexia nervosa: a systematic review and meta-analysis of randomized controlled trials. Psychological Medicine. 2019;49(4):535-44. https://doi.org/10.1017/s0033291718002088
  19. Murray SB, Pila E, Griffiths S, Le Grange D. When illness severity and research dollars do not align: are we overlooking eating disorders? World Psychiatry. 2017;16(3):321. https://doi.org/10.1002/wps.20465
  20. Phillips M, İnce B, Webb H, Dalton B, McCombie C, Irish M, et al. Autopsy of a failed trial part 1: a qualitative investigation of clinician's views on and experiences of the implementation of the DAISIES trial in UK‐based intensive eating disorder services. European Eating Disorders Review. 2023;31(4):489-504. https://doi.org/10.1002/erv.2975
  21. Le Grange D, Hughes EK, Court A, Yeo M, Crosby RD, Sawyer SM. Randomized clinical trial of parent-focused treatment and family-based treatment for adolescent anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry. 2016;55(8):683-92. https://doi.org/10.1016/j.jaac.2016.05.007
  22. Lock JD, Le Grange D, Bohon C, Matheson B, Jo B. Who responds to an adaptive intervention for adolescents with anorexia nervosa being treated with family-based treatment? Outcomes from a randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2024;63(6):605-14. https://doi.org/10.1016/j.jaac.2023.10.012
  23. Eisler I, Simic M, Hodsoll J, Asen E, Berelowitz M, Connan F, et al. A pragmatic randomised multi-centre trial of multifamily and single family therapy for adolescent anorexia nervosa. BMC Psychiatry. 2016;16(1):1-14. https://doi.org/10.1186/s12888-016-1129-6
  24. Baudinet J, Eisler I, Dawson L, Simic M, Schmidt U. Multi‐family therapy for eating disorders: a systematic scoping review of the quantitative and qualitative findings. International Journal of Eating Disorders. 2021;54(12):2095-120. https://doi.org/10.1002/eat.23616
  25. Lock J, Robinson A, Sadeh‐Sharvit S, Rosania K, Osipov L, Kirz N, et al. Applying family‐based treatment (FBT) to three clinical presentations of avoidant/restrictive food intake disorder: similarities and differences from FBT for anorexia nervosa. International Journal of Eating Disorders. 2019;52(4):439-46. https://doi.org/10.1002/eat.22994
  26. Eisler I, Simic M, Blessitt E, Dodge E. Maudsley Service Manual for Child and Adolescent Eating Disorders (Revised). 2016. Available from: https://mccaed.slam.nhs.uk/wp-content/uploads/2019/11/Maudsley-Service-Manual-for-Child-and-Adolescent-Eating-Disorders-July-2016.pdf https://doi.org/10.1007/978-3-319-49425-8_168
  27. Lonergan K, Whyte A, Ryan C. Externalisation in family‐based treatment of anorexia nervosa: the therapist's experience. Journal of Family Therapy. 2022;44(3):351-69. https://doi.org/10.1111/1467-6427.12380
  28. Eisler I, Wallis A, Dodge E. What's New is Old and What's Old is New: The Origins and Evolution of Eating Disorders Family Therapy. Family Therapy for Adolescent Eating and Weight Disorders. New York, NY. Routledge (2015). p. 26-62. https://doi.org/10.1080/21662630.2016.1172914
  29. Keys A, Brožek J, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation. Minneapolis, MN. University of Minnesota Press (1950). https://doi.org/10.5749/j.ctv9b2tqv
  30. Eisler I. The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa. Journal of Family therapy. 2005;27(2):104-31. https://doi.org/10.1111/j.1467-6427.2005.00303.x
  31. Simic M, Baudinet J, Blessitt E, Wallis A, Eisler I. Multi-family Therapy for Anorexia Nervosa: A Treatment Manual. Hove. Routledge (2021). https://doi.org/10.4324/9781003038764
  32. Asen E, Scholz M. Multi-family Therapy: Concepts and Techniques. London/New York, NY. Routledge; (2010).    
  33. Simic M, Eisler I. Multi-family Therapy. In: Loeb K, Le Grange D, Lock J, editors. Family Therapy for Adolescent Eating and Weight Disorders. New York. Routledge (2015). p. 110-38. https://doi.org/10.4324/9781315882444
  34. Le Grange D, Lock J. Treating Bulimia in Adolescents: A Family-based Approach. New York, NY. Guilford Press (2007). https://doi.org/10.1080/10640260701667946
  35. Lock JD. Family-based Treatment for Avoidant Restrictive Food Intake Disorder. New York, NY. Routledge (2022). https://doi.org/10.4324/9781003042020-3
  36. Sanchez-Cerezo J, Neale J, Julius N, Croudace T, Lynn RM, Hudson LD, et al. Subtypes of avoidant/restrictive food intake disorder in children and adolescents: a latent class analysis. eClinicalMedicine. 2024;68:102440. https://doi.org/10.1016/j.eclinm.2024.102440
  37. Byrne SM, Fursland A. New understandings meet old treatments: putting a contemporary face on established protocols. Journal of Eating Disorders. 2024;12(1):26. https://doi.org/10.1186/s40337-024-00983-4
  38. Hamadi L, Holliday J. Moderators and mediators of outcome in treatments for anorexia nervosa and bulimia nervosa in adolescents: a systematic review of randomized controlled trials. International Journal of Eating Disorders. 2020;53(1):3-19. https://doi.org/10.1002/eat.23159
  39. Pennesi J-L, Wade TD. A systematic review of the existing models of disordered eating: do they inform the development of effective interventions? Clinical Psychology Review. 2016;43:175-92. https://doi.org/10.1016/j.cpr.2015.12.004
  40. Rienecke RD, Le Grange D. The five tenets of family-based treatment for adolescent eating disorders. Journal of Eating Disorders. 2022;10(1):60. https://doi.org/10.1186/s40337-022-00585-y
  41. Baudinet J, Eisler I, Konstantellou A, Hunt T, Kassamali F, McLaughlin N, et al. Perceived change mechanisms in multi-family therapy for anorexia nervosa: a qualitative follow-up study of adolescent and parent experiences. European Eating Disorders Review. 2023;31(6):822- 36. https://doi.org/10.1002/erv.3006
  42. Baudinet J, Eisler I, Konstantellou A, Simic M, Schmidt U. How young people perceive change to occur in family therapy for anorexia nervosa: a qualitative study. Journal of Eating Disorders. 2024;12(1):11. https://doi.org/10.1186/s40337-024-00971-8
  43. Fonagy P, Target M. The mentalization-focused approach to self pathology. Journal of Personality Disorders. 2006;20(6):544-76. https://doi.org/10.1521/pedi.2006.20.6.544
  44. Jewell T, Herle M, Serpell L, Eivors A, Simic M, Fonagy P, et al. Attachment and mentalization as predictors of outcome in family therapy for adolescent anorexia nervosa. European Child and Adolescent Psychiatry. 2023;32(7):1241-51. https://doi.org/10.31234/osf.io/fgytk
  45. Jewell T, McLaren V, Sharp C. Psychometric properties of the reflective function questionnaire for youth five-item version in adolescents with restrictive eating disorders. Journal of Psychopathology and Behavioral Assessment. 2024;46(3):760-7. https://doi.org/10.31234/osf.io/je4zk
  46. Couturier J, Kimber M, Jack S, Niccols A, Van Blyderveen S, McVey G. Understanding the uptake of family‐based treatment for adolescents with anorexia nervosa: therapist perspectives. International Journal of Eating Disorders. 2013;46(2):177-88. https://doi.org/10.1002/eat.22049
  47. Dimitropoulos G, Lock JD, Agras WS, Brandt H, Halmi KA, Jo B, et al. Therapist adherence to family‐based treatment for adolescents with anorexia nervosa: a multi‐site exploratory study. European Eating Disorders Review. 2020;28(1):55-65. https://doi.org/10.1002/erv.2695
  48. Dimitropoulos G, Singh M, Sauerwein J, Pedram P, Kimber M, Pradel M, et al. Examining clinicians' perceptions and experiences working with diverse families in family-based treatment: common adaptations and considerations for treatment engagement. International Journal of Eating Disorders. 2024;57(3):635-47. https://doi.org/10.1002/eat.24144
  49. Loomes R, Bryant-Waugh R. Widening the reach of family-based interventions for anorexia nervosa: autism-adaptations for children and adolescents. Journal of Eating Disorders. 2021;9(1):157. https://doi.org/10.1186/s40337-021-00511-8
  50. Le Grange D, Eckhardt S, Dalle Grave R, Crosby RD, Peterson CB, Keery H, et al. Enhanced cognitive-behavior therapy and family-based treatment for adolescents with an eating disorder: a non-randomized effectiveness trial. Psychological Medicine. 2022;52(13):2520-30. https://doi.org/10.1017/s0033291720004407
  51. Wergeland GJ, Ghaderi A, Fjermestad K, Enebrink P, Halsaa L, Njardvik U, et al. Family therapy and cognitive behavior therapy for eating disorders in children and adolescents in routine clinical care: a systematic review and meta-analysis. European Child and Adolescent Psychiatry. 2024:1-20. https://doi.org/10.1007/s00787-024-02544-1
  52. Pellizzer ML, Thompson M, Edney LC. Lived experience perspectives on eating disorder research: the use of adaptive trials and research priorities. The International Journal of Eating Disorders. 2024;57(6):1390-8. https://doi.org/10.1002/eat.24167
  53. Papastavrou Brooks C, Kafle E, Butt N, Chawner D, Day A, Elsby-Pearson C, et al. Co-producing principles to guide health research: an illustrative case study from an eating disorder research clinic. Research Involvement and Engagement. 2023;9(1):84. https://doi.org/10.1186/s40900-023-00460-3
  54. Aouad P, Hambleton A, Marks P, Maloney D, Calvert S, Caldwell B, et al. Setting the top 10 eating disorder research and translation priorities for Australia. Australian and New Zealand Journal of Psychiatry. 2023;57(9):1281-91. https://doi.org/10.1177/00048674221128754
  55. Downs J, Baker S, Carnegie A. Eating disorders: meeting the need for a data driven and coproduced response to pandemic disruption. BMJ. 2024;385:q1403. https://doi.org/10.1136/bmj.q1403
  56. King's College London. Eating disorders clinical research network. 2024. Accessed 25 November 2025. Available from: https://www.kcl.ac.uk/research/eating-disorders-clinical-research-network.          
  57. Matthews AA, Danaei G, Islam N, Kurth T. Target trial emulation: applying principles of randomised trials to observational studies. BMJ. 2022;378:e071108. https://doi.org/10.1136/bmj-2022-071108