"I'm still here, but no one hears you": a qualitative study of young women's experiences of persistent distress post family-based treatment for adolescent anorexia nervosa

"I don't know how, if, it's ever going to end": narratives of caring for someone with an enduring eating disorder

BACKGROUND

Families and carers are pivotal in supporting loved ones experiencing eating disorders. This role can bring immense distress and burden, yet the experience of caring for someone with an enduring eating disorder has had minimal research focus. Thus, the purpose of this study is to give voice to carers empowering their stories to increase awareness and understanding, which could inform support to carers and consequently people with a lived and/or living experience of eating disorders.

METHODS

Semi-structured interviews were conducted with 9 carers supporting individuals who had been experiencing an eating disorder for 7 or more years. Data were collected and analysed using narrative inquiry approach.

RESULTS

Carers' narratives revealed feelings of guilt and personal failure; a profound sense of disillusion with current treatment approaches; and immense grief and anguish. As they negotiated a tenuous relationship with hope and the uncertainty of their loved one's future, carers spoke to a complex myriad of feelings of acceptance, letting go, and forging on.

CONCLUSION

Carers deserve to have their voices heard where they are too often silenced. Their narratives provide an urgent call for transformation in our treatments for eating disorders and further involvement of carers within the treatment journey, and their lived experience perspectives have great potential to guide this endeavour.

LEVEL OF EVIDENCE

Level V, qualitative interviews.

Processes of change in family therapies for anorexia nervosa: a systematic review and meta-synthesis of qualitative data

OBJECTIVE

To synthesise young person and family member perspectives on processes of change in family therapy for anorexia nervosa (AN), including systemic family therapy and manualised family-based treatments, to obtain an understanding of what helps and hinders positive change.

METHOD

A systematic search of the literature was conducted to identify qualitative studies focussing on experiences of therapeutic change within family therapies for AN from the perspectives of young people and their families. Fifteen studies met inclusion criteria and underwent quality appraisal following which they were synthesised using a meta-synthesis approach.

RESULTS

Six overarching themes were generated: "A holistic focus on the young person's overall development"; "The therapeutic relationship as a vehicle for change"; "The therapist's confinement to a script and its impact on emotional attunement"; "A disempowering therapeutic context"; "Externalisation of the eating disorder (ED)"; and "The importance of family involvement". Positive change was helped by understanding and support given to the young person's overall development including their psychological, emotional, social and physical wellbeing, positive therapeutic relationships, relational containment within the family system and externalising conversations in which young people felt seen and heard. Positive change was hindered by inflexibility in the treatment approach, counter-effects of externalisation, negative experiences of the therapist, a narrow focus on food-intake and weight, as well as the neglect of family difficulties, emotional experiences, and psychological factors.

CONCLUSIONS

Positive change regarding the young person's eating-related difficulties ensued in the context of positive relational changes between the young person, their family members, the therapist and treatment team, highlighting the significance of secure and trusting relationships. The findings of this review can be utilised by ED services to consider how they may adapt to the needs of young people and their families in order to improve treatment satisfaction, treatment outcomes, and in turn reduce risk for chronicity in AN.

Key-in-session identity negotiations in a first line treatment for adult anorexia nervosa

BACKGROUND

Exploration of client identity negotiations during treatment for Anorexia Nervosa (AN) is a relatively new area of research. Research suggests that difficulties with identity negotiations may present as a barrier to treatment. This study sought to explore individuals' identity negotiations during therapy sessions using Compulsive Exercise Activity Therapy (LEAP) combined with Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN). Analysis focused on moments in therapy where individuals' identities were dominated or defined by AN and where alternative identities could be generated.

METHOD

40 in-session transcripts from sessions at early, mid and end points of the CBT-AN (with LEAP) treatment were qualitatively analysed for nine of the 78 participants in the original randomised control trial. Through a constructivist framework, thematic analysis was used to identify surface and latent meanings and discursive material participants used to negotiate their identities in the context of therapy sessions.

RESULTS

Analysis of in-therapy transcripts generated two themes pertaining to identity negotiations: (1) troubled identities and (2) rebuilding identities and lives outside of AN. Early therapy sessions explored fragmented and AN dominated identities, including how AN was troubling to participants' sense of self, contributed to conflicted identities, positioned them outside of normality, and was associated with isolated and othering identities. Within therapy sessions, participants engaged in a recursive process of shifting relationships with AN and themselves and building identities and lives outside of the AN identity. This included generating hopes for recovery and the future more frequently in mid- to late- therapy sessions.

CONCLUSION

Identity negotiations evident in the therapeutic conversations aligned with the key components of the CBT-AN intervention, including addressing (1) the characterisation of oneself as 'an anorexic' and (2) the diversification of roles and activities to broaden and enhance self-concepts. Future developments of therapeutic interventions for AN would benefit from greater consideration of ways to assist individuals to more comprehensively address problematic identities, including uncovering identities hidden by the AN identity and generating preferred identities.

TRIAL REGISTRATION

Ethics approval was obtained at the time of the initial study and for this embedded research by the HREC at the Western Sydney University (HR777332).

A case series to test the acceptability, feasibility and preliminary efficacy of AVATAR therapy in anorexia nervosa

BACKGROUND

Patients with anorexia nervosa tend to experience an inner "eating disorder" voice. They struggle to recognise and assert their own identity over the illness's identity and relate to it from a powerless and subordinate position. AVATAR therapy was developed to help patients with psychosis to gain greater power and control over distressing voices. The goal of this study was to test the feasibility, acceptability, safety and preliminary efficacy of an adaptation of AVATAR therapy for anorexia nervosa.

METHODS

Twelve adult patients with anorexia nervosa were recruited. Ten completed an assessment session and between five to seven therapy sessions. The assessment session consisted in the creation of an avatar to represent the "eating disorder". This was accomplished by manipulating auditory and visual characteristics through a specialist computer software. During the therapy sessions, patients interacted with the avatar to assert their own desires and will. Patients completed baseline, end of intervention and follow-up (4-week) online questionnaires. A non-concurrent multiple baselines single case experimental design (SCED) was used (A1BA2). Feasibility, acceptability, safety and preliminary efficacy of the intervention were assessed.

RESULTS

The therapy met pre-specified criteria relating to (1) Feasibility: sample recruited within three months; retention rate at the end of the treatment phase = 81.9%; therapy completion rate = 90.1%. (2) Safety: no serious adverse events associated with the intervention. (3) Acceptability: mean ratings = 7.5 (SD = 2.61) out of ten, on a 0-10 scale of acceptability (10 = complete satisfaction). With regards to efficacy, participants reported significantly lower levels of distress associated with the eating disorder voice and higher levels of self-compassion at the end of treatment. No other significant changes were observed in frequency of the eating disorder voice, voice's characteristics, such as omnipotence and malevolence, eating disorder symptoms and symptoms of anxiety, depression and stress. Patients' feedback indicated that the therapy had helped with their ability to stand up to the illness, make positive changes around eating, and increase their motivation to recover and self-compassion.

CONCLUSION

AVATAR therapy for anorexia nervosa is feasible, acceptable and safe for patients. Larger studies are needed to test clinical efficacy.

TRIAL REGISTRATION

The study was pre-registered on the clinicaltrials.gov registry (https://clinicaltrials.gov/ct2/show/NCT04778423).

Paper 2: a systematic review of narrative therapy treatment outcomes for eating disorders-bridging the divide between practice-based evidence and evidence-based practice

BACKGROUND

Narrative therapy has been proposed to have practice-based evidence however little is known about its research evidence-base in the treatment of eating disorders. The aim of this study was to conduct a systematic review of the outcome literature of narrative therapy for eating disorders.

METHOD

Treatment outcome data were extracted from 33 eligible included studies following systematic search of five data bases. The study is reported according to Preferred Reporting items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Of the identified 33 studies, 3 reported positive outcomes using psychometric instruments, albeit some were outdated. Otherwise, reported outcomes were based on therapy transcript material and therapist reports. The most commonly reported treatment outcome was in relation to shifts in identity narratives and improved personal agency with a trend towards under-reporting shifts in ED symptoms. Some improvements were reported in interpersonal and occupational engagement, reduced ED symptoms, and improved quality of life, however, there was an absence of standardized measures to support these reports.

CONCLUSIONS

This systematic review found limited support for narrative therapy in the treatment of eating disorders through practice-based evidence in clinician reports and transcripts of therapy sessions. Less is known about systematic treatment outcomes of narrative therapy. There is a need to fill this gap to understand the effectiveness of narrative therapy in the treatment of EDs through systematic (1) Deliveries of this intervention; and (2) Reporting of outcomes. In doing so, the research arm of narrative therapy evidence base will become more comprehensively known.