A Comparison of Short- and Long-Term Family Therapy

for Adolescent Anorexia Nervosa

JAMES LOCK, M.D., PH.D., W. STEWART AGRAS, M.D., SUSAN BRYSON, M.A.,
AND HELENA C. KRAEMER, PH.D.

ABSTRACT
Objective: Research suggests that family treatment for adolescents with anorexia nervosa may be effective. This study
was designed to determine the optimal length of such family therapy. Method: Eighty-six adolescents (12–18 years of age)
diagnosed with anorexia nervosa were allocated at random to either a short-term (10 sessions over 6 months) or long-term
treatment (20 sessions over 12 months) and evaluated at the end of 1 year using the Eating Disorder Examination (EDE)
between 1999 and 2002. Results: Although adequately powered to detect differences between treatment groups, an in-
tent-to-treat analysis found no significant differences between the short-term and long-term treatment groups. Although
a nonsignificant finding does not prove the null hypothesis, in no instance does the confidence interval on the effect size on
the difference between the groups approach a moderate .5 level. However, post hoc analyses suggest that subjects with
severe eating-related obsessive-compulsive features or who come from nonintact families respond better to long-term
treatment. Conclusions: A short-term course of family therapy appears to be as effective as a long-term course for ado-
lescents with short-duration anorexia nervosa. However, there is a suggestion that those with more severe eating-related
obsessive-compulsive thinking and nonintact families benefit from longer treatment. J. Am. Acad. Child Adolesc. Psychi-
atry, 2005;44(7):632–639. Key Words: anorexia nervosa, family therapy.

Anorexia nervosa usually first presents in adolescence.
Despite the severity of this condition both medically
and psychologically, it is still unclear how to treat this
disorder (American Academy of Pediatrics, 2003).
However, the few existing controlled studies suggest
that family therapy that initially promotes parental con-
trol over refeeding may be effective for this age group
(Dare and Eisler, 1997). Results of two of these trials
provide preliminary evidence that this form of family
treatment is superior to individual therapy for adoles-
cents with anorexia nervosa (Robin et al., 1999; Russell
et al., 1987) Further, on follow-up in one of these stud-
Accepted December 21, 2004.
From the Department of Psychiatry and Behavioral Sciences, Stanford
University School of Medicine, Stanford, CA.
Dr. Lock’s work on this project was supported by NIH Career Development
Award MH01457.
Correspondence to Dr. James Lock, Department of Psychiatry and Behavioral
Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford,
CA 94305; e-mail: Jimlock@stanford.edu.
0890-8567/05/4407–0632Ó2005 by the American Academy of Child
and Adolescent Psychiatry.
DOI: 10.1097/01.chi.0000161647.82775.0a
ies, this superiority was maintained 5 years after treat-
ment was completed (Eisler et al., 1997).
Among the treatment trials employing family therapy
for adolescents, treatment intensity averaged 20 sessions
(range 9–36), whereas treatment duration averaged ap-
proximately 12 months (range 6–36) (Lock and Le
Grange, 2001). Comparison of patient outcomes among
these studies suggests that there was little difference in
outcome as a result of having more treatment sessions or
longer treatment. However, no study has evaluated the
relationship between the dose of therapy and outcome
(Le Grange et al., 1992; Robin et al., 1999; Russell
et al., 1987). To advance our understanding of the ef-
fectiveness of family therapy for adolescents with an-
orexia nervosa, we undertook a study to determine the
optimal length of treatment. Specifically we wished to
determine whether patients treated for only 6 months
(short-term) would do as well at the end of 1 year as
those who were treated for the entire period (long-
term). We hypothesized that there would be no differ-
ence in outcome between the short- and long-term
groups.

632 J. AM . ACAD. CH ILD ADOLE SC. PSY CH IAT RY, 44:7, JULY 20 05
 SHORT- AND LONG-TERM FAMI LY THERAPY FOR ANOREX IA
METHOD
Participants
Eighty-six adolescents (between the ages of 12 and 18 years; 77
females and 9 males) were entered into the study. All subjects com-
pleted human subjects informed consent processes as approved by
the institutional review board at the study site. These adolescents
met DSM-IV criteria for anorexia nervosa except that some partially
weight restored participants were entered and for postmenarchal fe-
males, those who had missed a minimum of one menstrual period
instead of the usual three required by DSM-IV criteria. This sample
represents the typical range of adolescents presenting for outpatient
treatment for anorexia nervosa.
Participants were recruited by referral from pediatricians and
therapists to a specialty evaluation clinic for child and adolescent
eating disorders (Fig. 1). Screening of all referrals to this clinic (n
= 241) from September 1999 to April 2002 yielded 141 eligible par-
ticipants over a 32-month period, of whom 86 (61%) agreed to ran-
domization. Subjects screened for the study included many patients
with other eating disorders (e.g., bulimia nervosa), which accounts
for the high proportion of potential subjects screened out initially.
Reasons for nonparticipation were (1) distance to treatment site
(27%), (2) preferred individual treatment (22%), (3) did not want to
participate in research (6%), and (4) no reason given for refusal (45%).
Our plan called for exclusion of participants with severe physical
health problems likely to affect weight (e.g., diabetes mellitus) or psy-
chiatric illnesses that would interfere with treatment (e.g., psychosis)
and those who had failed family treatment using the model em-
ployed in the study, but no potential participants were excluded
based on these criteria. Psychotherapy in addition to that offered
in the study protocol was not permitted. However, psychotropic
medications used to treat common comorbid psychiatric illnesses
(e.g., depression, obsessive-compulsive disorder, generalized anxiety
disorder) were allowed.
The sample size for this study was developed using data from
the previously published controlled trials of family treatment for
Fig. 1 Flow diagram of subject progress during the randomized clinical trial.
J. AM. ACAD. CH ILD ADO LESC. PSY CH IATRY, 44:7, JULY 200 5
anorexia nervosa available at the time to estimate effect size (Le Grange
et al., 1992; Robin et al., 1999; Russell et al., 1987). For change
in body mass index (BMI), the primary outcome, a sample of 86
subjects yields 80% power (assuming a conservative moderate
effect size, a standardized mean difference of 0.5, and a 5% two-
tailed test of significance) to detect group differences (Kraemer and
Thienemann, 1987).
Baseline characteristics of participants in the study are summa-
rized on Table 1. The mean BMI at the initial point of identification
of the subjects for the study was 16.0 ± 1.6 kg/m2. The mean BMI at
the point of randomization to treatments was 17.1 ± 1.4 kg/m2. This
mean increase in BMI before randomization was a result of weight
gain in those adolescents (30% [26 patients]) briefly hospitalized
(average length of stay was 12.3 days) for acute medical instability
before starting treatment. In addition, 31 (36%) had comorbid psy-
chiatric illness at baseline. Twenty-one (24%) had major depression
or dysthymia, 12 (14%) had an anxiety disorder including obsessive-
compulsive disorder, and four (5%) had other psychiatric disorders.
Of these subjects, 12 (14%) received medications during the trial
(selective serotonin reuptake inhibitors and atypical antipsychotics),
five in long-term treatment and seven in short-term treatment.
There were no significant differences at the pretreatment evaluation
between treatment groups on any baseline measures.
Measures
Participants were assessed pretreatment and at 6 and 12 months
using the Eating Disorder Examination (EDE), an interview that
measures height, weight, and the severity of the characteristic psy-
chopathology of eating disorders (Cooper et al., 1989). The adult
version of this interview was used because we found that adolescent
participants were able to understand and respond to questions as
formulated in this iteration (Passi et al., 2003).
General psychopathology was assessed with structured interviews
using the Schedule for Affective Disorders and Schizophrenia for
School-Age Children (6–18 years) (Kaufman et al., 1997). The
Yale-Brown-Cornell Eating Disorder Scale (YBC-ED) was employed
633
LOCK ET AL.

TABLE 1 procedures by a research assistant not involved in assessments to ei-

Baseline Sample Demographics ther a short-term (6 months and 10 sessions) or a long-term (12
months and 20 sessions) treatment (Efron, 1971). The latter con-
Long- Short-
dition was designed to replicate a standard family treatment package
Term Term similar to the usual duration and intensity of sessions provided in
(N = 42) (N = 44) most studies (Dare et al., 2001; Eisler et al., 2000; Russell et al.,
1987). Randomization resulted in 42 subjects in intensive treatment
Age (yr) 15.2 (1.7) 15.2 (1.6)
and 44 subjects in less intensive treatment.
Duration of illness (mo) 12.0 (9.9) 11.3 (10.4) Assessments were conducted by trained assessors who were not
Ethnicity involved with the treatment of patients in the study and who were
Asian 2 (5%) 6 (14%) not told which group that the patient was randomized to for treat-
White 32 (76%) 32 (73%) ment. The assessments were undertaken before randomization and
Hispanic 6 (14%) 4 (9%) at 6 and 12 months. Questionnaires were completed by the partic-
Native American 0 (0%) 1 (2%) ipants at home. All therapists (including the principal investigator)
Other 2 (5%) 1 (2%) as well as patients and their family members were blinded to the
Gender randomization status of patients until after the seventh session
Male 4 (9%) 5 (11%) (the point of delineation between the two arms in terms of treatment
session frequency). There were no instances in which either the
Female 38 (91%) 39 (89%)
therapists or patients were ‘‘unblinded’’ before the seventh treatment
Family incomea session. This prevented therapists and families from responding to
<50K 4 (10%) 4 (9%) the knowledge that they had either a short- or long-term treatment
50–100K 18 (43%) 14 (33%) by either intensifying or relaxing treatment procedures during these
>100K 20 (48%) 24 (57%) early sessions.
Maximum parental education Four therapists treated participants in both treatment condi-
High school or less 3 (7%) 6 (14%) tions. The therapists were all trained in the manual-based version
College 21 (50%) 20 (46%) of family-based treatment for anorexia nervosa using a written text,
Graduate school 18 (43%) 18 (41%) videotaped sessions, and role-playing (Lock and Le Grange, 2001;
Hospitalization before treatment 14 (34%) 12 (27%) Lock et al., 2001). During the treatment phase of the study, there
Average no. of hospital days for those was weekly supervision of cases. Three of the therapists were master’s
degree level psychologists and one was a child and adolescent
hospitalized before treatment 12.4 (7.0) 12.2 (6.7)
psychiatrist (J.L.).
Psychotropic use for comorbid 5 (12%) 7 (16%) The manual-based treatments were conducted on an outpatient
conditions basis. In the shorter treatment, sessions were initially held weekly for
Previous treatment (excluding 7 weeks, then monthly for 2 months, and a final session 2 months
hospitalization immediately later at the 6-month mark. In the longer treatment, sessions were
before treatment) 36 (90%) 39 (89%) initially held weekly for 7 weeks, then biweekly through session
Purgers 9 (21%) 7 (16%) 13 (at 5 months), and the remaining seven sessions were monthly
Restrictors 33 (79%) 37 (84%) until the end of the treatment year. None of the participants received
Intact families 31 (74%) 36 (82%) any other psychotherapy during the treatment phase of the study.
All participants were required to be medically stable before and
a
Missing two subjects. during treatment, employing criteria similar to those of published
recommendations (Lock, 1999). To be medically stable, participants
were required to meet the following criteria: heart rate more than 45
as a measure of severity of obsessionality and compulsiveness about beats per minute, orthostatic blood pressures changes of fewer than
eating behaviors, weight, and exercise (Mazure, et al., 1994, 1995). 35 points, body temperature higher than 36.4°C, no evidence of
It was administered immediately after each EDE assessment. electrolyte abnormalities or prolonged QTc on electrocardiogram,
The Child Behavior Checklist (CBCL) and Youth Self-Report and weight greater than 75% of that expected for height.
were used to assess global problems of interpersonal functioning Brief hospitalization for medical instability was occasionally needed
(Achenbach, 1991). The CBCL was completed by one of the parents for participants in both conditions. Treatment in hospital consisted
pretreatment and 6 and 12 months. The Youth Self-Report was com- of medical monitoring, nutritional supplementation, and nonspecific
pleted by the adolescent participant at the same intervals as the CBCL. supportive therapies.
Family functioning was assessed using the Family Environment On discharge, participants re-entered the treatment condition to
Scale (Moos, 1974; Moos and Moos, 1994). The same parent com- which they were randomized and completed the allotted treatment
pleted the FES pretreatment and at 6 and 12 months. duration (not including the days of hospitalization) with no change
in the allocated number of treatment sessions.
Medical treatment during the study consisted of brief (10–
Design and Procedures
20 minute) medical checks by pediatricians, most of whom had sig-
Because duration of illness has been shown to predict a negative nificant expertise in the medical presentations of adolescents with
outcome using this treatment (Russell et al., 1987), randomized sub- eating disorders. These physicians were blinded to the randomiza-
jects were stratified on this variable with balance being sought for tion status of the participants. Medical visits were scheduled at in-
those with more than 1 year of illness before treatment. Participants tervals determined by these physicians and ranged from twice-
were randomized within each stratum using the Efron biased coin weekly visits to monthly visits, depending on their assessment of

634 J. AM . ACAD. CH ILD ADOLE SC. PSY CH IAT RY, 44:7, JULY 20 05
 SHORT- AND LONG-TERM FAMI LY THERAPY FOR ANOREX IA
medical acuity, with an overall average of approximately 35 brief
contacts per patient during the year. Patients were followed by the
physician group throughout the 1-year study period regardless of
the treatment group assigned. A nutritionist was also available for brief
consultations with participants and their parents during these visits as
a part of the overall medical service; however, no structured program
of nutritional counseling was provided for subjects in the study.
Treatments
The family treatment used is based on treatment developed by
Dare and colleagues at the Maudsley Hospital in London (Dare
and Eisler, 1997). The treatment was manual based and piloted be-
fore initiating the controlled trial (Lock and Le Grange, 2001; Lock
et al., 2001). This form of family treatment is highly focused on the
behaviors and thoughts associated with anorexia nervosa and sees the
adolescent as incapacitated mostly in terms of his or her eating dis-
order specifically in the inability to maintain an optimal weight for
age and height. In the first phase, the therapist strives to unite the
parents in developing a consistent approach to refeeding. The ther-
apist explicitly disclaims the notion that the parents have caused the
eating problem and instead expresses sympathy for the parents’
plight in trying to find a way to help their child. In addition, the
therapist attempts to recruit the sibling subsystem to support their
affected sibling. Parents work out for themselves how best to refeed
their child with anorexia nervosa with the therapist’s ongoing sup-
port and consultation.
Once steady weight gain is evident and the family experiences re-
lief that they are being effective in taking charge of the eating dis-
order, the second phase of treatment begins. During this phase,
symptoms of anorexia nervosa remain central in the discussions,
but other issues that are perceived to interfere with the parents in
their task of ensuring steady weight gain can be brought forward
(e.g., eating at school or at parties, level of activity, sports partici-
pation).
When the patient achieves a stable weight and there are no strug-
gles with eating, the third phase of treatment is initiated. The goal of
this phase is to identify and briefly address other adolescent concerns
that have been ignored because of the development of anorexia nerv-
osa. Depending on the age of development, this entails, among other
things, working toward increased personal autonomy for the adoles-
cent, more appropriate family boundaries, and the need for the pa-
rents to reorganize their life together as their children mature.
Regardless of the treatment phase, each session begins with a 10–
15 minute check-in with the adolescent and is followed by a 45- to
50-minute meeting with the entire family. Occasional brief tele-
phone calls (less than 10 minutes in duration) are allowed when
problems arise that require consultation with the therapist.
In the current study, the short-term treatment focused on the first
and second phases of treatment, although at least one session, usually
the last, examined more general adolescent issues. On the other
hand, the long-term treatment group allowed for more time in each
treatment phase and in particular more time to focus on general ad-
olescent concerns during the third phase.
Data Analysis
The primary analysis was by intention-to-treat. A random regres-
sion model was used to compare the response trajectories (based on
the EDE outcome data) of the two groups. This assumes a linear
model for each subject’s trajectory, such that the intercept represents
J. AM. ACAD. CH ILD ADO LESC. PSY CH IATRY, 44:7, JULY 200 5
the baseline response (which, given randomization, should not dif-
ferentiate the two groups), and the slope represents the rate of re-
sponse for each individual subject. This approach uses the repeated
measures for each subject to reduce the unreliability of the response
measure and is helpful in dealing with missing data and dropout.
Effect sizes (ES) are reported using the mean difference between
groups divided by the pooled within-group SD. In a post hoc ex-
ploratory analysis of possible moderators of treatment outcome, we
employed a linear regression model using the measures at 1 year as
the dependent measure and controlling for baseline values. Indepen-
dent variables were centered (Kraemer et al., 2002). For the analysis
of the use of hospitalization during treatment, we used a Mann-
Whitney U (a nonparametric test) to account for nonnormally dis-
tributed values associated with this variable.
RESULTS
Of the 86 participants, nine (10%) did not complete
treatment (defined before the start of study as attending
80% of assigned treatment sessions, i.e., eight of 10 ses-
sions in the short-term treatment group and 16 of 20 in
the long-term treatment group). Two (4%) dropped
out of the short-term allocation and seven (16%) drop-
ped out of the long-term allocation. The reasons for
dropping out included a perception by the parents that
the treatment offered was not effective (n = 1), a wish for
a different form of treatment (n = 1), living too far away
(n = 1), need for other psychiatric treatment (n = 1), and
participant refusal (n = 1). In the remaining cases (n =
4), the reason for dropout was unknown because the
participant could not be contacted. In addition, eight
treatment completers (three from the long-term treat-
ment group and five from the short-term group) did
not complete the final assessment (Fig. 1).
Treatment Outcome
Comparison of intent-to-treat outcomes between the
two groups can be found in Table 2 and Figs. 2 and 3.
Despite the fact that multiple testing increases the prob-
ability of a false positive, no statistically significant dif-
ference between the treatment groups was detected on
the primary outcomes (BMI, EDE) or on any of the
secondary outcomes. Indeed there were only two out-
comes, EDE eating and CBCL Internalizing subscale,
for which the long-term treatment has results better
than those of the short-term treatment (indicated by
positive signs on the ES of the slope, the standardized
mean difference between the slopes in the long-term
versus short-term treatments).
Clearly, a nonsignificant difference does not prove
the null hypothesis, even when the study is adequately
635
LOCK ET AL.

TABLE 2
Comparison of Long-Term and Short-Term Treatments
Long-Term Treatment Short-Term Treatment
(N = 42) Mean (SD) (N = 44) Mean (SD) Effect Size of
12 mo 6 mo Slope (95%
(End of (End of Confidence
Baseline 6 mo Treatment) Baseline Treatment) 12 mo Interval) AUC

Eating Disorder
Examination: Eating
Concerns Subscale 1.04 (1.33) 0.75 (1.00) 0.52 (0.83) 1.35 (1.13) 0.86 (1.01) 0.71 (0.92) +0.09 (–0.33 to +0.51) 53%
Eating Disorder
Examination:
Restraint Subscale 2.64 (1.96) 1.64 (1.70) 1.42 (1.63) 2.76 (1.97) 1.84 (1.77) 1.62 (1.80) –0.08 (–0.51 to +0.34) 48%
Eating Disorder
Examinations:
Shape Concerns
Subscale 2.41 (1.67) 1.96 (1.55) 1.76 (1.69) 2.61 (1.73) 2.25 (1.63) 2.08 (1.70) –0.12 (–0.54 to +0.31) 47%
Eating Disorder
Examinations: Weight
Concerns Subscale 1.96 (1.52) 1.62 (1.48) 1.39 (1.44) 2.32 (1.51) 2.01 (1.50) 1.97 (1.60) –0.11 (–0.53 to +0.31) 47%
Body mass index 17.3 (1.5) 19.0 (1.8) 19.5 (2.1) 17.0 (1.3) 19.0 (2.3) 19.5 (2.2) –0.26 (–0.68 to +0.17) 43%
Weight (kg) 46.7 (7.2) 51.4 (7.5) 53.2 (8.0) 44.6 (5.5) 50.6 (8.1) 52.0 (7.6) –0.21 (–0.63 to +0.22) 44%
Youth Self-Report
Externalizing Scale 9.2 (6.5) 8.6 (6.7) 8.5 (6.0) 9.4 (6.6) 9.5 (6.8) 9.6 (6.6) –0.19 (–0.62 to +0.25) 45%
Internalizing Scale 16.6 (11.7) 14.6 (10.7) 14.0 (10.8) 19.2 (12.3) 19.6 (12.6) 18.2 (12.2) –0.15 (–0.58 to +0.29) 46%
Total score 40.6 (25.6) 36.1 (23.7) 35.7 (23.1) 45.0 (27.7) 46.1 (28.3) 44.9 (27.6) –0.24 (–0.67 to +0.20) 43%
Child Behavior
Checklist
Externalizing Scale 7.71 (6.6) 6.05 (5.8) 6.0 (5.2) 8.5 (6.3) 7.3 (5.5) 7.3 (5.9) –0.04 (–0.47 to +0.39) 49%
Internalizing Scale 15.6 (10.5) 12.6 (9.0) 11.2 (9.0) 18.7 (10.5) 15.7 (9.5) 13.8 (9.8) +0.04 (–0.40 to +0.47) 51%
Total Score 36.4 (25.4) 28.3 (17.7) 26.1 (19.1) 41.2 (21.3) 35.5 (20.7) 32.3 (22.6) –0.06 (–0.49 to +0.37) 48%
Yale-Brown Cornell
Eating Disorder Scale:
total score 12.2 (8.4) 8.8 (6.6) 6.4 (6.4) 13.4 (7.9) 10.9 (9.7) 9.2 (9.6) –0.28 (–0.70 to +0.15) 42%

AUC = area under the curve (probability that a long-term subject will have better outcome than a short-term subject).
Means and SD are presented. Significance tests and effect sizes compare the slopes in the two groups.

powered. However, all the confidence intervals for the
ES indicate that the true ES is unlikely to be anywhere
near moderate (d = 0.5) (Cohen, 1988. Another method
for examining ES, the area under the curve (Grissom,
1994; McGraw and Wong, 1992) uses the probability
that a long-term treatment subject has an outcome pref-
erable to that of a short-term treatment subject. In this
case, area under the curve calculations (with a null value
of 50%) is at best 53% for EDE Eating Concerns. The
number needed to treat (NNT) (Cook, 1995), which is
the number of subjects needed to be treated with long-
term treatment to have one more success than if all had
been treated with short-term treatment is 20 subjects for
EDE Eating Concerns and 44 subjects for CBCL Inter-
nalizing Scale, the only two variables in which the ES
favored longer term treatment. In short, there is no ev-
idence supporting that, in general, long-term treatment
will produce more favorable results than the short-term
treatment.
Another outcome of interest relates to the use of hospital-
ization. A total of 19 participants (22%) were medically
hospitalized according to study criteria after beginning
treatment. Of these, nine (21%) of the participants in the
long-term group were hospitalized after the study treat-
ment had begun for an average of 16 days. Ten (23%) of
those in the short-term group were hospitalized after the
study treatment had begun for an average of 20 days.
There was no significant difference between the groups.

636 J. AM . ACAD. CH ILD ADOLE SC. PSY CH IAT RY, 44:7, JULY 20 05
 SHORT- AND LONG-TERM FAMI LY THERAPY FOR ANOREX IA
Fig. 2 Change in weight (kg) by treatment group.
Moderators of Outcome
Because there may be some subjects for whom one or
the other length of treatment might be more effective,
we examined possible moderators of outcome for both
BMI and global EDE. The variables explored were age,
session attendance, baseline BMI (including low qual-
ifying BMI), comorbidity, duration of illness, EDE re-
straint subscale scores, gender, intact family, principal
investigator being the therapist, purging status, medica-
tion use, hospitalization, YBC-ED total score, internal-
izing score on the Youth Self-Report and the CBCL,
and family income.
Two moderators of treatment outcome were found.
For BMI, the total score on the YBC-ED moderated
outcome (Fig. 4) in favor of longer treatment for those
with the most severe symptoms (t 81 = 2.7, p = .008). For
global EDE, those with nonintact families (Fig. 5) did
better in longer treatment (t 81 = 2.9, p = .004).
Fig. 3 Change in global eating disorder examination by treatment group.
J. AM. ACAD. CH ILD ADO LESC. PSY CH IATRY, 44:7, JULY 200 5
Fig. 4 Change in body mass index by treatment and Yale-Brown-Cornell
Eating Disorder Scales.
DISCUSSION
The present study was designed to determine the op-
timal length of family-based treatment for anorexia
nervosa in adolescents, a treatment that has been sug-
gested to be effective in controlled trials (Eisler et al.,
2000; Le Grange et al., 1992; Russell et al., 1987).
The results of this study can be regarded as reliable
for the following reasons. First, the study was designed
to have adequate power to detect a moderate difference
between the two treatments (Kraemer and Thienemann,
1987). Second, treatment manuals were used for the
two levels of therapy (Lock and Le Grange, 2001).
Third, the quality of the therapy was closely monitored
to ensure fidelity to the treatment type and to the in-
tensity and duration of its application. Fourth, the main
Fig. 5 Change in global eating disorder examination by family status.
637
LOCK ET AL.
outcome measures (BMI and EDE) were independently
assessed by interviewers trained and experienced in its
use. Therefore, it seems likely that both the therapy
and the assessment of eating-disordered psychopatho-
logical processes were carried out with high fidelity,
lending credibility to the results obtained.
The results of the study suggest that many adolescents
with anorexia nervosa can be as effectively treated with
a relatively short-term family therapy as with long-term
family therapy. It appears, however, that participants
with more severe and persistent eating-related obses-
sive-compulsive thinking or those who come from non-
intact families did significantly better in long-term
treatment. Both of these potential moderators make
clinical sense. Those with the highest degree of obses-
sional concern and most intractable compulsive behav-
iors are more challenging for parents to redirect and
thereby might take longer to change. Intact families
have an advantage in taking on the tasks of changing
behaviors related to anorexia nervosa because both pa-
rents are more likely to be available and invested sim-
ilarly in their child’s recovery. Because family-based
treatment for anorexia nervosa depends heavily on this
parental resource, any compromise in it would likely
lead to the need for additional assistance. Thus, longer
term treatment might be expected. These findings pro-
vide preliminary evidence to guide therapists when se-
lecting patients for long- or short-term treatment.
Limitations
There are important qualifications relevant to the
current study that may limit its generalizability. The
study sample consisted of participants who agreed to
family treatment from referrals to a tertiary treatment
center for eating disorders. The conclusions therefore
may pertain to help-seeking families willing and able
to participate in family-based therapy. The socioeco-
nomic status of the sample and education of the parents
were on average higher than expected in the general
community, although similar to many samples of par-
ticipants with anorexia nervosa. Additional variables
that might have played a role in the overall outcome
include the availability of medical hospitalization for
acutely ill patients both before and during the study,
use of medications, and expectation effects of participa-
tion in a treatment study. It should also be emphasized
that treatments provided in this study were supported
638
by an excellent medical staff with expertise in the treat-
ment of adolescent anorexia nervosa.
Clinical Implications
Overall, the results of this study suggest that for ado-
lescents with anorexia nervosa, a short-term treatment
with family therapy is as effective as long-term family
therapy for the majority of such patients when their out-
comes are assessed at the end of 1 year. A follow-up
study to determine whether the effects of treatment were
maintained would be a useful future study. However,
although there is no clear definition of remission or re-
covery in anorexia nervosa, using BMI of greater than
17.5 alone (the DSM-IV diagnostic threshold for an-
orexia nervosa), 96% of the sample are remitted at
the end of treatment, whereas using a stricter criterion
of a BMI of 20 and a global EDE score within 2 SDs of
normal, 67% would be considered remitted.
Clinicians interested in using family-based therapy
for anorexia nervosa should consider the possibility that
a short-term course will benefit the patients; however, if
there are exceptionally high levels of eating-related ob-
sessionality and compulsiveness or the patient comes
from a single-parent or divorced family, it is probably
more likely that a longer course will be required. The
increase in the EDE scores for this subgroup (Fig. 5)
may portent future relapse. This might suggest that the-
rapists consider alternative treatments (e.g., individual
treatment) in addition to more family therapy. Longer
term follow-up and additional treatment studies may
help to shed light on this important subject. Clinicians
using this approach may not generally have the avail-
ability of medical experts to support their treatment
as such a resource is not always or commonly available.
At the same time, in the United Kingdom, where this
treatment originated, adolescents treated with this ap-
proach generally are not provided with this level of med-
ical support and appear to have similar outcomes (Eisler
et al., 2000). It is also important to remember that in
both arms of the study, treatments were titrated upward
from a base of weekly sessions for approximately 2 months
at the start. Getting patients started in the right way ap-
pears to be key in the success of this approach. The de-
creased frequency of sessions later in therapy may serve
to boost and continue the impact of the earlier sessions.
While these findings provide encouragement for the
use of this form of treatment for the majority of such
J. AM . ACAD. CH ILD ADOLE SC. PSY CH IAT RY, 44:7, JULY 20 05
 SHORT- AND LONG-TERM FAMI LY THERAPY FOR ANOREX IA
patients, albeit combined with hospitalization and psy-
chotropic medications when needed, further research is
needed to determine definitively whether this type of
family therapy is superior to other forms of treatment
for adolescent anorexia nervosa.
Disclosure: The authors have no financial relationships to disclose.
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