It’s now well-established that interpersonal relationships play a key role in maintaining – and recovering from – anorexia nervosa. Families usually constitute a young person’s closest and most important relationships. This means that how family members interact and relate to a young person is crucial to their recovery journey.
For years, family-based treatment (FBT) has been the go-to treatment approach for adolescents with anorexia. FBT centres the family in the recovery process, giving parents or carers the responsibility to manage a young person’s recovery. During the earlier stages of treatment, parents have complete control over an adolescent’s eating and exercise habits before gradually handing back their independence as their mental and physical health improves.
The cognitive-interpersonal maintenance model (CIMM) is a newer approach to understanding and treating anorexia. It focuses on the personality traits, ways of thinking, and interpersonal difficulties that sustain disordered eating symptoms. Therapists work with young people and their families to identify the way that certain attitudes and interpersonal relationships affect their eating disorders and develop skills to facilitate positive change.
While family-based treatment and the cognitive-interpersonal maintenance model centre interpersonal relationships in the recovery process, they offer very different treatment approaches. FBT prioritises improving eating behaviours, expecting cognitive and emotional changes to follow as a young person regains physical health. On the other hand, the CIMM begins by addressing the cognitive, emotional, and social factors that underpin disordered eating behaviours. With these changes, they develop healthier eating habits and restore their physical health.
What Is Anorexia Nervosa?
Anorexia nervosa is a serious mental health disorder that usually develops during adolescence. Young people with anorexia restrict their energy intake even though it harms their physical and mental health. They may restrict their diets, excessively exercise, or use other methods to limit the amount of energy their bodies receive.
Anorexia is often associated with a very low body weight, but young people at a normal or higher weight can also have anorexia. This is usually diagnosed as atypical anorexia.
Anorexia causes serious harm to someone’s mental and physical health. As well as leading to malnutrition, it may cause fatigue, irritation, social withdrawal, low mood, difficulty sleeping, and anxiety. Treatment is most effective in the early stages of anorexia, so seeking immediate help is really important.
How Does Family-Based Treatment Work?
Family-based treatment supports young people to recover from anorexia at home rather than in a residential setting. It’s based on the idea that pre-teens and adolescents living with anorexia are unable to make good decisions about the way they eat and exercise.
FBT assumes that malnutrition severely impacts cognitive decision-making processes, increasing rigid thinking and difficulties seeing the bigger picture. This causes young people to maintain disordered eating attitudes and behaviours despite its harmful impact.
During FBT, therapists work with parents to change the way they approach their young person’s illness. This includes taking responsibility for the amount and what they eat and mealtime practices. But it also involves managing their own emotional and behavioural responses to a young person’s eating behaviours, minimising frustration and anger and showing care, understanding and compassion.
FBT acknowledges parents as the most important resource in a young person’s recovery, empowering parents to take on this role. It maintains that parents are not the cause of a young person’s eating disorder but the key to overcoming it.
How Does the Cognitive-Interpersonal Maintenance Model Treat Anorexia Nervosa?
The cognitive-interpersonal maintenance model understands anorexia as a consequence of personality traits, ways of thinking, and difficulties forming relationships with others.
It describes how personality traits like social anxiety, sensitivity to criticism, and a tendency to compare oneself with others make a young person more vulnerable to experiencing body dissatisfaction and becoming preoccupied with the ‘thin ideal’. These traits can also lead to social withdrawal and isolation, encouraging thoughts about body shape and weight to dominate an adolescent’s life.
At the same time, the responses of family members and close friends to eating disorders often make symptoms worse. It’s common for family members to unintentionally fall into patterns of enabling disordered eating behaviours or reacting with criticism, hostility, and over-involvement.
However, just as interpersonal relationships are key to the development and maintenance of anorexia, they’re equally fundamental to recovery. MANTRa (the Maudsley Model of Anorexia Nervosa Treatment for Adolescents or Young Adults) is a specialised treatment approach based on CIMM. MANTRa addresses the different factors that maintain anorexia, including:
- detail-focused and rigid thinking
- fear of making mistakes
- avoiding emotions and lack of emotional expression
- false beliefs about perceived ‘benefits’ of anorexia
- responses from family members and friends that enable the illness
MANTRa works primarily with the young person experiencing anorexia while also including families in the treatment process. Parents are invited to join therapy sessions to address family difficulties and develop supporting strategies.
What Are the Differences Between FBT and CIMM (MANTRa)?
While sharing some core principles (such as recognising the role of the family in recovery), FBT and CIMM offer very different approaches to anorexia treatment. Some of the key differences include:
- CIMM focuses on the thoughts, emotions, and interpersonal challenges that cause and maintain disordered eating behaviours. FBT, on the other hand, emphasises changing disordered eating behaviours directly, assuming that emotional and cognitive changes will follow.
- FBT primarily works with the parents of adolescents with eating disorders, while CIMM focuses foremost on the adolescents themselves (while still closely involving families in treatment).
- FBT is an outpatient treatment approach, while CIMM can be used in both residential and outpatient settings.
- FBT gives parents total responsibility over a young person’s eating habits at the start of the treatment program. CIMM, on the other hand, empowers adolescents to lead their own recovery, while supporting parents to avoid enabling behaviours.
What Are the Limitations of FBT?
FBT focuses on weight restoration as a measure of eating disorder recovery. But while almost all young people receiving FBT gain weight during treatment, many still experience psychological symptoms at the end of their treatment program. One study found that 40% of adolescents experienced psychological distress at follow-up, affecting both their quality of life and chances of relapse.
FBT may be especially unsuitable for families with high levels of parental criticism and hostility. While FBT works with parents to develop caring and compassionate attitudes towards a young person, these changes usually take time. This means that the FBT model of empowering parents to direct a young person’s recovery may be counter-productive, instead intensifying harmful family dynamics that can maintain disordered eating behaviours. Research shows that parental criticism is linked to poorer outcomes in FBT.
In these situations, CIMM may offer a more effective treatment alternative that avoids giving parents too much responsibility until problematic dynamics are resolved. CIMM can be combined with more specific family interventions, such as parent skills training and family therapy, to address hostility, criticism, and other issues within the family system.
By addressing the thoughts, emotions, and personality traits that underpin anorexia, CIMM may also lead to more meaningful, positive changes to a young person’s well-being, especially for those with co-occurring mental health disorders. A 2023 study found that CIMM (MANTRa) successfully improved both eating disorder symptoms and co-occurring disorders 18 months after the end of treatment.
The Wave Clinic: Specialist Recovery Programs for Young People
The Wave Clinic offers specialist recovery programs for young people, supporting them to plan and build better futures. We provide expert clinical care to children, teenagers, and young adults living with eating disorders and other mental health conditions.
Our programs focus on education, personal development, and growing self-confidence, building life advantages for young people. If you’re interested in our programs, visit our website and contact us today.
