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Baudinet J, Eisler I, Roddy M, Turner J, Simic M, Schmidt U. Clinician perspectives on how change occurs in multi-family therapy for adolescent anorexia nervosa: a qualitative study. J Eat Disord 2024; 12:103. [PMID: 39049063 PMCID: PMC11267764 DOI: 10.1186/s40337-024-01064-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 07/15/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Multi-family Therapy (MFT) is being increasingly used in specialist eating disorder services internationally. Despite evidence of its efficacy, little is understood about the treatment mechanisms and what specifically promotes change. This study aimed to understand clinician perspectives on how change occurs during MFT. METHODS Clinicians with (a) 5 or more years' experience facilitating MFT and (b) who had facilitated a minimum of two MFT groups were eligible for this study. Two individual interviews and four semi-structured focus groups were conducted online. Recordings were transcribed verbatim and analysed using reflexive thematic analysis. RESULTS Twelve clinicians (five systemic/family psychotherapists, five clinical psychologists, and two consultant child and adolescent psychiatrists) from six different specialist services in the UK participated. Four main inter-connected themes describing how change is perceived to occur were generated; (1) Intensity and immediacy, (2) Flexibility, (3) New ideas and channels of learning and (4) Containment. CONCLUSIONS Current data matches closely with young person and parent experiences of MFT and intensive day treatment and how they perceive change to occur. Quantitative data are now needed to evaluate the impact of these factors on outcome. Plain English Summary Multi-family Therapy (MFT) is being increasingly used in specialist eating disorder services internationally. While there is evidence that it is helpful, little is understood about how the treatment works and what specifically promotes change. This study aimed to understand how clinician believe change to occur during MFT for young people and their family members. Clinicians with (a) five or more years' experience facilitating MFT and (b) who had facilitated a minimum of two MFT groups were eligible for this study. Two individual interviews and four semi-structured focus groups were conducted online. Recordings were written out word-for-word and analysed using reflexive thematic analysis, a commonly used method for analysing this type of data. Twelve clinicians (five systemic/family psychotherapists, five clinical psychologists, and two consultant child and adolescent psychiatrists) from six different specialist services in the UK participated. Four related themes describing how change is perceived to occur were generated; (1) Intensity and immediacy, (2) Flexibility, (3) New ideas and channels of learning and (4) Containment. Current data matches closely with young person and parent experiences of MFT and intensive day treatment and how they perceive change to occur. These factors now need to be tested in future research.
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Affiliation(s)
- Julian Baudinet
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AZ, UK.
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, De Crespigny Park, Denmark Hill, London, SE5 8AZ, UK.
| | - Ivan Eisler
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AZ, UK
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, De Crespigny Park, Denmark Hill, London, SE5 8AZ, UK
| | - Michelle Roddy
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, De Crespigny Park, Denmark Hill, London, SE5 8AZ, UK
| | - Jasmin Turner
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, De Crespigny Park, Denmark Hill, London, SE5 8AZ, UK
| | - Mima Simic
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, De Crespigny Park, Denmark Hill, London, SE5 8AZ, UK
| | - Ulrike Schmidt
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AZ, UK
- Adult Eating Disorders Service, South London and Maudsley NHS Foundation Trust, De Crespigny Park, Denmark Hill, London, SE5 8AZ, UK
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Marchetti D, Sawrikar V. Parents' illness representations of their child with anorexia nervosa: A systematic review of qualitative studies using the common-sense model. Int J Eat Disord 2024; 57:1049-1068. [PMID: 37916901 DOI: 10.1002/eat.24081] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE Research indicates that parents experience distress while caring for a child with anorexia nervosa. Applying the Common Sense Model of Self-Regulation (CSM), a framework to describe responses to illness may help to understand the antecedents of parental distress, which could inform how to support parents in treatment. The aim of this systematic review was to synthesize outcomes from qualitative research in relation to parents' experiences of caring for a child with anorexia nervosa using the CSM. METHOD Systematic search of four electronic databases (psychINFO, MEDLINE, EMBASE, ProQuest Dissertation, and Theses Database) alongside a two-way screening process was used to identify eligible studies. Qualitative themes were synthesized using a "best fit" framework analysis and reported according to CSM dimensions of cognitive and emotional illness representations. RESULTS A total of 32 studies published between 1970 and 2023 were eligible for inclusion for review. Parents perceived their child's anorexia nervosa as a major health threat observable by illness representations that anorexia nervosa was uncontrollable, incomprehensible, chronic, and associated with negative consequences. The themes also suggested parents take responsibility for causing anorexia nervosa. These illness representations were linked with emotional representations of fear, anxiety, shame, guilt, loneliness, and depression. CONCLUSIONS The findings provide evidence of the utility of using the CSM to understand the antecedents of parents' distress and negative impacts of caring for a child with anorexia nervosa. Recommendations for future research and clinical practice are discussed emphasizing the need to understand parents' perceptions of their child's illness to putatively maximize treatment benefits for families. PUBLIC SIGNIFICANCE This review emphasizes the salience of understanding parents distress while caring for a child with anorexia nervosa. The findings present opportunities to best support parents in treatment, with a focus on addressing their cognitive and emotional representations of their child's illness. A multicomponent treatment regimen may be required to support parents if they present with illness representations that negatively affect their well-being and ability to cope with distress.
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Affiliation(s)
- Doriana Marchetti
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK
- Department of Clinical Psychology, NHS Grampian, UK
| | - Vilas Sawrikar
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK
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Baudinet J, Eisler I, Konstantellou A, Hunt T, Kassamali F, McLaughlin N, Simic M, Schmidt U. 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; 31:822-836. [PMID: 37415392 DOI: 10.1002/erv.3006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 01/20/2023] [Accepted: 06/24/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Multi-family therapy (MFT-AN) is a promising group-based treatment for adolescent anorexia nervosa. This study aimed to explore how young people and parents perceived change to occur during MFT treatment. METHODS Young people (10-18 years) diagnosed with anorexia nervosa or atypical anorexia nervosa and their parents who completed MFT-AN alongside family therapy for anorexia nervosa within the preceding 2 years were eligible for this study. Semi-structured qualitative interviews were conducted. Recordings were transcribed verbatim and analysed using reflexive thematic analysis. RESULTS Twenty-three participants (8 young people, 10 mothers and 5 fathers) completed interviews. Five main themes were identified; (1) Powerful connection, (2) Intensity, (3) New learning and perspective shifts, (4) Comparisons, and (5) Discharge is not recovery. There was a strong sense that being with others in a similar position in an intense environment were key factors in promoting change. Comparisons were inevitable and could promote insight and foster motivation, but could also be unhelpful at times. Participants spoke about how recovery continues beyond service use and requires ongoing attention and support. CONCLUSIONS Through the mechanisms of connection, intensity, new learning and comparisons change is perceived to occur in MFT-AN. Some of these are considered unique to this treatment format.
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Affiliation(s)
- Julian Baudinet
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Ivan Eisler
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Anna Konstantellou
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Tammy Hunt
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Fatema Kassamali
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Natalie McLaughlin
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Mima Simic
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Ulrike Schmidt
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Adult Eating Disorders Service, South London and Maudsley NHS Foundation Trust, London, UK
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Oketah NO, Hur JO, Talebloo J, Cheng CM, Nagata JM. Parents' perspectives of anorexia nervosa treatment in adolescents: a systematic review and metasynthesis of qualitative data. J Eat Disord 2023; 11:193. [PMID: 37904246 PMCID: PMC10617236 DOI: 10.1186/s40337-023-00910-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/12/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Studies have established the central role of the family in the recognition, treatment, and recovery of anorexia nervosa. The objective of this study was to review, synthesize, and critically appraise the literature on parents' views on the treatment and recovery process of anorexia nervosa in their adolescent child. METHOD A systematic search of Medline, PsychINFO, CINHAL, EMBASE, Cochrane library, and SSCI was conducted for qualitative studies published regarding parents' views about the treatment of anorexia nervosa. The quality of articles was assessed using the critical appraisal skills program (CASP) and findings were analysed using thematic synthesis. RESULTS A total of 25 studies from nine countries reporting the views of 357 parents met the inclusion criteria. Four major themes were developed from the analysis: understanding the child and the disease, experience of services and treatment modalities, the role of professionals, and the experience of recovery. CONCLUSION Parents report struggles with delays in finding help, judgmental attitudes of professionals, and uncertainty about the future. Recognition of the challenges faced by parents and families empowers clinicians to build stronger therapeutic relationships essential for long-term recovery from anorexia nervosa.
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Affiliation(s)
- Ngozi O Oketah
- Department of Paediatrics, Children's Health Ireland (CHI) at Crumlin & Connolly Hospitals, Cooley Road, Dublin, D12 N512, Ireland
| | - Jacqueline O Hur
- Division of Adolescent and Young Adult Medicine, Department of Paediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0503, San Francisco, CA, 94143, USA
| | - Jonanne Talebloo
- Division of Adolescent and Young Adult Medicine, Department of Paediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0503, San Francisco, CA, 94143, USA
| | - Chloe M Cheng
- Division of Adolescent and Young Adult Medicine, Department of Paediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0503, San Francisco, CA, 94143, USA
| | - Jason M Nagata
- Division of Adolescent and Young Adult Medicine, Department of Paediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0503, San Francisco, CA, 94143, USA.
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Funderud I, Halvorsen I, Kvakland AL, Nilsen JV, Skjønhaug J, Stedal K, Rø Ø. Multifamily therapy for adolescent eating disorders: a study of the change in eating disorder symptoms from start of treatment to follow-up. J Eat Disord 2023; 11:92. [PMID: 37287009 DOI: 10.1186/s40337-023-00814-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND This study aimed to evaluate multifamily therapy (MFT) for adolescents with eating disorders (EDs) in a clinical setting, by presenting the outcome of families participating in this treatment at a specialist ED service. MFT was an adjunct to treatment at local mental health services. In particular, the study aimed to present the change in eating disorder symptoms and psychological distress from before to after treatment and at a 6 months follow-up. METHODS Participants were 207 adolescents receiving outpatient MFT (10 or 5 months) at Oslo University Hospital in Norway between 2009 and 2022. Adolescents had heterogeneous ED presentations, with a preponderance of anorexia nervosa (AN) and atypical AN. All participants completed pre- and post-treatment questionnaires [The eating disorder examination questionnaire (EDE-Q) and the strengths and difficulties questionnaire (SDQ)]. 142 adolescents additionally completed the same questionnaires at 6 months follow-up. Weight and height were measured at all time points. RESULTS Linear mixed model analyses showed that from start of treatment to follow-up, there was a significant increase in BMI percentile (p < 0.001) and a significant decrease in EDE-Q global score (p < 0.001) and SDQ total score (p < 0.001). CONCLUSIONS The study shows that adolescents with an eating disorder who received adjunct outpatient MFT in a real world clinical setting, experienced reductions in ED symptoms comparable to that found in a randomized controlled trial. TRIAL REGISTRATION The data used in this study was collected as part of routine clinical procedures for quality assurance and trial registration is therefore not required.
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Affiliation(s)
- Ingrid Funderud
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.
| | - Inger Halvorsen
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Anne-Lise Kvakland
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Jan-Vegard Nilsen
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Jeanette Skjønhaug
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Kristin Stedal
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Øyvind Rø
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Terache J, Wollast R, Simon Y, Marot M, Van der Linden N, Franzen A, Klein O. Promising effect of multi-family therapy on BMI, eating disorders and perceived family functioning in adolescent anorexia nervosa: an uncontrolled longitudinal study. Eat Disord 2023; 31:64-84. [PMID: 35649125 DOI: 10.1080/10640266.2022.2069315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This contribution reports on the results of an uncontrolled longitudinal study investigating the effects of a Multi-Family Therapy (MFT) as treatment for adolescent Anorexia Nervosa (AN) and the role played by perceived family functioning in these effects. 150 patients (144 females) and their families took part in an MFT and were assessed at the beginning, middle, end of the therapy, as well as 6 and 12 months after the end of therapy. BMI, eating disorders symptomatology (EDI-II) and perceived family functioning (FAD) all improved over the time of MFT, and these benefits remained at both times of follow-up. Ultimately, we found that the improvement of some dimensions of family functioning (i.e., roles, communication, and general family functioning) mediated the improvement of several dimensions of symptomatology (i.e., ineffectiveness, impulsivity, social insecurity, interpersonal distrust). These observations provide further support for MFT as useful for improving mental health, weight restoration, and perceived family functioning of adolescents with AN.
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Affiliation(s)
- Julie Terache
- Department of Psychology, Center for Social and Cultural Psychology, Université libre de Bruxelles, Brussels, Belgium
| | - Robin Wollast
- Department of Psychology, Stanford University, Stanford, California, United States
| | - Yves Simon
- Laboratory of Medical Psychology, Department of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Medhi Marot
- Department of Psychology, Laboratoire de Psychologie Sociale et Cognitive, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Nicolas Van der Linden
- Department of Psychology, Center for Social and Cultural Psychology, Université libre de Bruxelles, Brussels, Belgium
| | - Aurélie Franzen
- Department of Psychology, Center for Social and Cultural Psychology, Université libre de Bruxelles, Brussels, Belgium
| | - Olivier Klein
- Department of Psychology, Center for Social and Cultural Psychology, Université libre de Bruxelles, Brussels, Belgium
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Escoffié A, Pretorius N, Baudinet J. Multi-family therapy for bulimia nervosa: a qualitative pilot study of adolescent and family members' experiences. J Eat Disord 2022; 10:91. [PMID: 35786421 PMCID: PMC9250718 DOI: 10.1186/s40337-022-00606-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multi-family therapy (MFT-BN) is a new treatment for adolescent bulimia nervosa with emerging empirical support. It extends the bulimia nervosa focussed family therapy model, by offering treatment in a group setting. Up to nine families work together with a team of clinicians over the course of 20 weeks. No qualitative study to date has investigated the experience of MFT-BN. This study aimed to explore this from the adolescent and parent/caregiver perspective. METHODS Participants from two consecutive MFT-BN groups facilitated at the Maudsley Hospital in London, UK, were invited to participate in either a focus group or individual qualitative interview about the experience of MFT-BN. Of the 19 eligible participants (from 9 families), 15 (8 parents, 1 older sibling, 6 adolescents) consented and participated. Audio-recordings of interviews and focus groups were transcribed verbatim and analysed using reflexive thematic analysis. RESULTS Three main themes were identified; (1) seeing and being seen, (2) holistic shift, (3) the unspoken. Participants reported overall shifts in cognitions, emotions, behaviours, and relationships both individually and within the family as a result of attending MFT-BN. Meeting other families with similar struggles and sharing experiences, skills and learning helped reduce isolation and promote change. There was also a sense from participants that some things did not, or could not, be spoken about in the group context and that more direct and challenging conversations might have been helpful at times. DISCUSSION The current study identifies some of the perceived benefits and challenges of MFT-BN. The three themes demonstrate the holistic nature of change that can occur across the treatment, as well as the power and limits of the group therapy setting and process. Further research is needed to explore the experience of MFT-BN and its outcomes across a more diverse range of participants and treatment settings.
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Affiliation(s)
- Anabel Escoffié
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AZ, UK
| | - Natalie Pretorius
- Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED), Maudsley Hospital, De Crespigny Park, Denmark Hill, London, SE5 8AZ, UK
| | - Julian Baudinet
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AZ, UK. .,Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED), Maudsley Hospital, De Crespigny Park, Denmark Hill, London, SE5 8AZ, UK.
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Gil M, Simões MDM, Oliveira-Cardoso ÉAD, Pessa RP, Leonidas C, Santos MAD. Percepção de familiares de pessoas com transtornos alimentares acerca do tratamento: uma metassíntese da literatura. PSICOLOGIA: TEORIA E PESQUISA 2022. [DOI: 10.1590/0102.3772e38417.pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Resumo Relações familiares parecem ter uma contribuição relevante na etiopatogenia dos transtornos alimentares (TAs), o que faz com que as diretrizes internacionais de tratamento recomendem a participação da família. Esta metassíntese teve como objetivo sintetizar e reinterpretar os resultados de estudos qualitativos primários sobre a percepção de familiares de pessoas com TAs acerca do tratamento. A estratégia de busca foi organizada utilizando-se a ferramenta SPIDER e as análises foram realizadas por dois revisores independentes. A partir de 1.115 estudos originariamente recuperados de 6 bases de dados (CINAHL, LILACS, PsycINFO, PubMed, Scopus e Web of Science), foram selecionados 19 artigos. Os resultados convergem para o reconhecimento de que a família é parte do processo saúde-doença e precisa ser considerada como destinatária de cuidados, não apenas como coadjuvante/acompanhante no cuidado à pessoa acometida. Como a dinâmica familiar tem contribuição relevante no desenvolvimento e na manutenção dos TAs, é necessário investir na transformação das relações familiares para que se possam obter ganhos mais efetivos e duradouros no tratamento.
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Gil M, Simões MDM, Oliveira-Cardoso ÉAD, Pessa RP, Leonidas C, Santos MAD. Perception of family members of people with eating disorders about treatment: a metasynthesis of the literature,. PSICOLOGIA: TEORIA E PESQUISA 2022. [DOI: 10.1590/0102.3772e38417.en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract Family relationships seem to have a relevant contribution to the etiopathogenesis of eating disorders (EDs), which makes the international treatment guidelines recommend family participation. This study aimed to synthesize and reinterpret the findings of primary qualitative studies about the perception of family of people with EDs about treatment. The search strategy was organized using the SPIDER tool, and the analyzes were carried out by two independent reviewers. From 1115 studies originally retrieved from six databases (CINAHL, LILACS, PsycINFO, PubMed, Scopus and Web of Science), 19 articles were selected. The results converge to the recognition that the family is part of the process and also needs to be considered as a care recipient, not just as a coadjuvant/companion for the patient. Since family dynamics have a relevant contribution in the development and maintenance of EDs, it is necessary to invest in the transformation of family relationships so that more effective and lasting gains in treatment can be obtained.
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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. Int J Eat Disord 2021; 54:2095-2120. [PMID: 34672007 PMCID: PMC9298280 DOI: 10.1002/eat.23616] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE This study reviewed the quantitative and qualitative evidence-base for multi-family therapy (MFT) for eating disorders regarding change in physical and psychological symptoms, broader individual and family factors, and the experience of treatment. METHOD A systematic scoping review was conducted. Four databases (PsycInfo, Medline, Embase, CENTRAL) and five grey literature databases were searched on 24th June 2021 for relevant peer-reviewed journal articles, book chapters, and dissertations. No beginning time-point was specified. Only papers that presented quantitative or qualitative data were included. No restrictions on age or diagnosis were imposed. Studies were first mapped by study design, participant age, and treatment setting, then narratively synthesized. RESULTS Outcomes for 714 people who received MFT across 27 studies (one mixed-method, 17 quantitative and nine qualitative) were synthesized. MFT is associated with improvements in eating disorder symptomatology and weight gain for those who are underweight. It is also associated with improvements in other individual and family factors including comorbidities, self-esteem, quality of life, and some aspects of the experience of caregiving, although these findings are more mixed. MFT is generally experienced as both helpful and challenging due to the content addressed and intensive group process. DISCUSSION MFT is associated with significant improvements in eating disorder symptoms across the lifespan and improvement in broader individual and family factors. The evidence base is small and studies are generally underpowered. Larger, higher-quality studies are needed, as is research investigating the unique contribution of MFT on outcomes, given it is typically an adjunctive treatment.
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Affiliation(s)
- Julian Baudinet
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN)King's College LondonLondonUK,Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED)South London and Maudsley NHS Foundation TrustLondonUK
| | - Ivan Eisler
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN)King's College LondonLondonUK,Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED)South London and Maudsley NHS Foundation TrustLondonUK
| | - Lisa Dawson
- Eating Disorder ServiceWestmead Children's Hospital, Sydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Mima Simic
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN)King's College LondonLondonUK
| | - Ulrike Schmidt
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN)King's College LondonLondonUK,Adult Eating Disorders ServiceSouth London and Maudsley NHS Foundation Trust, De Crespigny ParkDenmark Hill, LondonUK
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Ruiz-Íñiguez R, Carralero-Montero A, Martínez-González A, Méndez-Parra E, Valdés-Díaz Y, Sempere J. Interfamily Therapy, a multifamily therapy model settled in infant-juvenile mental health services of Havana (Cuba): A qualitative study from participants' perspectives. JOURNAL OF MARITAL AND FAMILY THERAPY 2021; 47:843-863. [PMID: 34291840 DOI: 10.1111/jmft.12542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 06/13/2023]
Abstract
Interfamily therapy (IFT) is a specific model for multifamily therapy (MFT) of recent expansion in Latin American and European countries. In IFT a multifamily group becomes a community of learning where professionals and family members establish collaborative relationships and participate in dialogues. This study used a qualitative phenomenological approach to explore the participants' perspective of 14 members and ex-members of two IFT groups conducted in Infant-Juvenile Mental Health Centers in Havana (Cuba). In this study IFT was well accepted and effective, and it was perceived as beneficial due to its positive influence for participants, with benefits on a personal, family and social level. In addition, participants articulated a series of therapeutic elements of IFT that were essential to promote these benefits. In conclusion, IFT seems to be a useful therapeutic model in the treatment of children, adolescents and their families in a Cuban psychiatric setting.
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Brinchmann BS, Krvavac S. "Breaking down the wall" patients` and families` experience of multifamily therapy for young adult women with severe eating disorders. J Eat Disord 2021; 9:56. [PMID: 33902688 PMCID: PMC8077824 DOI: 10.1186/s40337-021-00412-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/14/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This paper addresses patients` and families` experience of multifamily therapy (MFT) for young adults (18-22) with an eating disorder (ED). EDs are serious illnesses leading to lowered quality of life for the patient and their family. The Regional Centre for Eating Disorders (RESSP) at Nordland Hospital in Bodø, Norway has developed an adjunct psychotherapeutic approach for the treatment of young adult patients with severe EDs. The patient's family members take part in the multifamily therapy (MFT) group programme. METHODS The aim of the study was to explore patients` and families` experience of MFT for young adult women with severe EDs. A Grounded Theory (GT) approach was used. Data were collected by field observations in two MFT groups, qualitative group interviews and qualitative individual interviews with patients and their family members. Data were analysed using the constant comparative method. The data analysis consisted of open and selective coding and memo writing. RESULTS Two main categories were identified: 'Connectedness and recognition' and 'Opening up and sharing`. MFT was described as a space for recognition within which it was possible to speak of things happening in the family with others with similar difficulties. It felt good and freeing, but also painful, to meet others with similar experiences. The participants had in common a considerable loneliness because it is difficult for outsiders to grasp what it is like in a home dominated by an ED. The meeting with other families created an underlying safety. The participants received help to distinguish between realistic and unrealistic concerns and learned about openness and communication in relation to their daughter. Some women with EDs said that MFT was most important for the parents but also had been good for them as things had become better at home. CONCLUSION The participants reported that their family had become better at talking to each other after having been in MFT. As a result, they were able to speak more openly about difficult things and share feelings. This gave rise to increased understanding. The study shows that MFT was found to be valuable and important. Never before had these families had such an opportunity, something so directly tailored to them. MFT for adults can be developed further and used in other groups, such as those concerning other chronic illnesses.
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Affiliation(s)
- Berit Støre Brinchmann
- Regional Centre for Eating Disorders, Nordland Hospital, 8076 Bodø, Norway
- The Faculty of Nursing and Health Sciences, Nord University, 8026 Bodø, Norway
| | - Sanja Krvavac
- The Faculty of Nursing and Health Sciences, Nord University, 8026 Bodø, Norway
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Nilsen JV, Rø Ø, Halvorsen I, Oddli HW, Hage TW. Family members' reflections upon a family-based inpatient treatment program for adolescent anorexia nervosa: a thematic analysis. J Eat Disord 2021; 9:7. [PMID: 33407914 PMCID: PMC7788959 DOI: 10.1186/s40337-020-00360-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Jan-Vegard Nilsen
- Department of Psychology, University of Oslo, Oslo, Norway. .,Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.
| | - Øyvind Rø
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Inger Halvorsen
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | | | - Trine Wiig Hage
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
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Imgart H, Plassmann R. [Effective factors in multifamily therapy in patients with eating disorders : Critical appraisal and implications for practice]. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT ÖSTERREICHISCHER NERVENÄRZTE UND PSYCHIATER 2020; 34:48-60. [PMID: 31997267 DOI: 10.1007/s40211-020-00330-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 01/08/2020] [Indexed: 10/25/2022]
Abstract
Multifamily therapy (MFT), the treatment of several families simultaneously, is an established method of psychotherapy used in a wide range of diagnoses. However, there is limited knowledge about the exact factors of action of this treatment method. The development of MFT as a separate form of therapy is presented, as are its previous applications in the treatment of patients with eating disorders. Known factors of change are critically evaluated, new factors of change are discussed and the practical application in MFT in the context of inpatient treatment of adolescents with eating disorders is demonstrated.Processes in the large group that have not yet been considered, such as emotional contagion, exaltation of emotion and subgroup formation and work with the meta-family, are described for the first time in the context of MFT and possibly represent mediators in the therapeutic process.The model of affect and process resonance in Plassmann's individual therapy can be applied well to the processes in the MFT and possibly represents its own effect factor through the production of episodes of secure attachment. Further research on the factors of change in the MFT is of practical relevance.
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Affiliation(s)
- Hartmut Imgart
- Kompetenzzentrum für Essstörungen und Adipositas, Parkland-Klinik, Im Kreuzfeld 6, 34537, Bad Wildungen, Deutschland.
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Sepúlveda AR, Anastasiadou D, Parks M, Gutiérrez E. A controlled study of the Collaborative Care Skills Workshops versus Psycho‐educational Workshops among Spanish caregivers of relatives with an eating disorder. EUROPEAN EATING DISORDERS REVIEW 2018; 27:247-262. [DOI: 10.1002/erv.2658] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 10/16/2018] [Accepted: 11/04/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Ana R. Sepúlveda
- Department of Biological and Health Psychology, Faculty of PsychologyAutonomous University of Madrid Madrid Spain
| | - Dimitra Anastasiadou
- Department of Biological and Health Psychology, Faculty of PsychologyAutonomous University of Madrid Madrid Spain
| | - Melissa Parks
- Department of Biological and Health Psychology, Faculty of PsychologyAutonomous University of Madrid Madrid Spain
| | - Elena Gutiérrez
- Usera Mental Health Center12 de Octubre University Hospital Madrid Spain
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Richards IL, Subar A, Touyz S, Rhodes P. Augmentative Approaches in Family-Based Treatment for Adolescents with Restrictive Eating Disorders: A Systematic Review. EUROPEAN EATING DISORDERS REVIEW 2017; 26:92-111. [PMID: 29282801 DOI: 10.1002/erv.2577] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 11/29/2017] [Accepted: 12/04/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To systematically review the literature reporting outcomes of augmentative family-based treatment (FBT) interventions for adolescents with restrictive eating disorders (EDs). METHOD Articles were identified through a systematic search of five electronic databases (PsycINFO, MEDLINE, EMBASE, CINAHL, Cochrane Database). RESULTS Thirty articles were included, reporting on FBT augmentations featuring adjunctive treatment components, modified treatment structure and/or content with adherence to FBT principles, and adaptations allowing FBT delivery in different settings. All reported significant improvements in weight and/or ED symptoms at end-of-treatment, although few compared augmentative and standard FBT interventions and good quality follow-up data was generally lacking. CONCLUSIONS There is early evidence for the effectiveness of augmentative FBT-based approaches in facilitating weight and/or ED symptom improvements for adolescents with restrictive EDs. There remains a lack of robust evidence demonstrating superior effects of such approaches over standard FBT, and further controlled studies are required to expand on the current evidence. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
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Affiliation(s)
- Imogen Lim Richards
- Clinical Psychology Unit, School of Psychology, The University of Sydney, NSW, Australia
| | - Anni Subar
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA
| | - Stephen Touyz
- Clinical Psychology Unit, School of Psychology, The University of Sydney, NSW, Australia
| | - Paul Rhodes
- Clinical Psychology Unit, School of Psychology, The University of Sydney, NSW, Australia
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Depestele L, Claes L, Dierckx E, Colman R, Schoevaerts K, Lemmens GMD. An Adjunctive Multi-family Group Intervention with or without Patient Participation during an Inpatient Treatment for Adolescents with an Eating Disorder: A Pilot Study. EUROPEAN EATING DISORDERS REVIEW 2017; 25:570-578. [PMID: 28960604 DOI: 10.1002/erv.2556] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 08/18/2017] [Accepted: 08/25/2017] [Indexed: 11/07/2022]
Abstract
This study reports on a pilot study of a family group intervention with or without patient participation adjunctive to a specialized inpatient treatment for eating disorders (EDs). Participants were 112 female adolescent ED inpatients and one or both of their parents. The parents were invited to participate in an adjunctive multi-family group with patient (MFT) or in a similar multi-parent group without patient participation (MPT). Questionnaires assessing ED symptoms, family functioning and caregiving experiences were administered before and after intervention. Post-intervention results obtained from both patient and parent(s) indicated that improvement in ED symptoms and parental burden occurred after both types of interventions. Family functioning improved differently according to the informant: fathers reported an improvement of general family functioning, patients reported an improvement of problem solving and mothers reported a decrease in problem solving across both formats. This study emphasized the importance of including a multi-informant approach in family interventions. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
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Affiliation(s)
- Lies Depestele
- Eating Disorders Unit, Psychiatric Hospital Alexianen Tienen, Belgium.,Faculty of Psychology and Educational Sciences, University of Leuven, Belgium.,Department of Psychiatry and Medical Psychology, Ghent University, Belgium
| | - Laurence Claes
- Faculty of Psychology and Educational Sciences, University of Leuven, Belgium.,Faculty of Medicine and Health Sciences (CAPRI), University of Antwerp, Belgium
| | - Eva Dierckx
- Eating Disorders Unit, Psychiatric Hospital Alexianen Tienen, Belgium.,Department of Clinical and Life Span Psychology, Vrije Universiteit Brussel, Belgium
| | - Roos Colman
- Biostatistics Unit, Department of Public Health, Ghent University, Belgium
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18
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Sibeoni J, Orri M, Valentin M, Podlipski MA, Colin S, Pradere J, Revah-Levy A. Metasynthesis of the Views about Treatment of Anorexia Nervosa in Adolescents: Perspectives of Adolescents, Parents, and Professionals. PLoS One 2017; 12:e0169493. [PMID: 28056106 PMCID: PMC5215824 DOI: 10.1371/journal.pone.0169493] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/16/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Anorexia nervosa in adolescents can be a difficult-to-treat disease. Because qualitative research is a well-established method for deepening our understanding of subjective experiences, such as eating disorders and their treatment, we sought to perform a systematic review of qualitative studies to synthesize the views of adolescents with this disease, their parents, and their healthcare providers about its treatment. METHODS We performed a thematic synthesis to develop the central themes that summarize all of the topics raised in the articles included in our review. The quality of the articles was assessed by the Critical Appraisal Skills Program. RESULTS We included 32 articles from seven different countries. Two central themes were inductively developed from the analysis: (1) the treatment targets (i.e., symptoms and patients in context), and (2) a therapeutic tool-a relationship, specifically the core concept of the therapeutic relationship. CONCLUSION Our results underline the difficulty in establishing a therapeutic alliance, the barriers to it, especially the risk that professionals, adolescents, and parents will not converse about treatment; although such a dialogue appears to be an essential component in the construction of a therapeutic alliance.
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Affiliation(s)
- Jordan Sibeoni
- Service Universitaire de Psychiatrie de l’Adolescent, Argenteuil Hospital Centre, Argenteuil, France
- ECSTRA Team, UMR-1153, Inserm, Paris Diderot University, Sorbonne Paris Cite, Paris, France
| | - Massimiliano Orri
- ECSTRA Team, UMR-1153, Inserm, Paris Diderot University, Sorbonne Paris Cite, Paris, France
| | - Marie Valentin
- Service Universitaire de Psychiatrie de l’Adolescent, Argenteuil Hospital Centre, Argenteuil, France
| | - Marc-Antoine Podlipski
- Centre Hospitalier du Rouvray, Fédération Hospitalo-Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, CHU de Rouen - CH du Rouvray, Rouen, France
| | - Stephanie Colin
- Service Universitaire de Psychiatrie de l’Adolescent, Argenteuil Hospital Centre, Argenteuil, France
| | - Jerome Pradere
- Service Universitaire de Psychiatrie de l’Adolescent, Argenteuil Hospital Centre, Argenteuil, France
| | - Anne Revah-Levy
- Service Universitaire de Psychiatrie de l’Adolescent, Argenteuil Hospital Centre, Argenteuil, France
- ECSTRA Team, UMR-1153, Inserm, Paris Diderot University, Sorbonne Paris Cite, Paris, France
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Cook-Darzens S. The role of family meals in the treatment of eating disorders: a scoping review of the literature and implications. Eat Weight Disord 2016; 21:383-393. [PMID: 26932829 DOI: 10.1007/s40519-016-0263-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/11/2016] [Indexed: 11/30/2022] Open
Abstract
Family meal research is a fast growing field that has significant implications for the prevention and treatment of eating disorders (ED). Using a scoping review procedure, this article overviewed major historical and clinical trends that have guided the use of family meals or lunch sessions in adolescent ED family therapy over the past 40 years, and synthesized essential findings from current therapeutic family meal research. The relevant body of literature is reported within the framework of three models of family therapy (Maudsley model, family-based treatment, multi-family therapy), with a focus on their specific use of family lunch sessions and related empirical evidence. Although promising, current evidence remains contradictory, tentative and colored by therapists' convictions, resistance and fears. Future research priorities are discussed, including the need for a more direct examination of the impact of the family meal practice on therapeutic change, as well as a better understanding of its active ingredients and of the characteristics of patients/families that may benefit most from it. This review of the literature may help clinicians and family therapists (1) adhere more reliably and confidently to ED-focused treatment protocols that include a strong family meal component, and (2) make more informed decisions regarding the inclusion or exclusion of family meals in their practice. When feasibility or acceptability issues preclude their use, alternatives to family meals are also discussed, including family meal role-plays and drawings, coaching of home-based family meals and manual/DVD-based guidance.
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Affiliation(s)
- Solange Cook-Darzens
- Department of Child and Adolescent Psychiatry, Hôpital Robert Debré, 48 Boulevard Sérurier, 75019, Paris, France. .,, 10 Grande Rue, 60460, Blaincourt, France.
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Jewell T, Blessitt E, Stewart C, Simic M, Eisler I. Family Therapy for Child and Adolescent Eating Disorders: A Critical Review. FAMILY PROCESS 2016; 55:577-594. [PMID: 27543373 DOI: 10.1111/famp.12242] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Eating disorder-focused family therapy has emerged as the strongest evidence-based treatment for adolescent anorexia nervosa, supported by evidence from nine RCTs, and there is increasing evidence of its efficacy in treating adolescent bulimia nervosa (three RCTs). There is also emerging evidence for the efficacy of multifamily therapy formats of this treatment, with a recent RCT demonstrating the benefits of this approach in the treatment of adolescent anorexia nervosa. In this article, we critically review the evidence for eating disorder-focused family therapy through the lens of a moderate common factors paradigm. From this perspective, this treatment is likely to be effective as it provides a supportive and nonblaming context that: one, creates a safe, predictable environment that helps to contain anxiety generated by the eating disorder; two, promotes specific change early on in treatment in eating disorder-related behaviors; and three, provides a vehicle for the mobilization of common factors such as hope and expectancy reinforced by the eating disorder expertise of the multidisciplinary team. In order to improve outcomes for young people, there is a need to develop an improved understanding of the moderators and mediators involved in this treatment approach. Such an understanding could lead to the refining of the therapy, and inform adaptations for those families who do not currently benefit from treatment.
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Affiliation(s)
- Tom Jewell
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | | | - Catherine Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Mima Simic
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Ivan Eisler
- South London and Maudsley NHS Foundation Trust, London, UK
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