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THERAPY FOR ANOREXIA NERVOSA
LETTERS TO THE EDITOR
THERAPY FOR ANOREXIA NERVOSA To the Editor: We are writing in response to the report by Robin et al. (1999), “A Controlled Comparison of Family Versus Individual Therapy for Adolescents With Anorexia Nervosa.” The authors successfully compare the efficacy of behavioral family systems therapy (BFST) with that of ego-oriented individual therapy (EOIT) as interventions for anorexia nervosa. They provide cogent findings that BFST brought about physical health more quickly and EOIT brought about a return to better psychological functioning. The behavioral model used in a family systems model probably has more saliency than in individual settings because the family collaborates in the identified patient’s therapeutic process. Likewise, EOIT did improve psychological functioning, especially in the areas of ego strength, self-esteem, and identity development. In addition, the BFST model likely gave a sense of control to parents, which individual therapy could not provide. These two findings led us to believe that the two methods should be combined to address a larger spectrum of symptoms. Nevertheless, comparative psychotherapy research will always have limitations. However, if this study and its authors hope to receive support from funding sources such as managed care, they should have addressed several factors which could have affected their findings. It is entirely possible that interpersonal factors, which could not be controlled, may have skewed the results one way or another. Finally, we noticed that the design of the study gave almost double the amount of therapeutic contact hours to subjects in the BFST. Also, the investigators used a relatively small (37 subjects) and homogeneous sample. Though we realize that—epidemiologically—white, female, and middle-class populations are more likely to be afflicted with this disorder, the article does not address the implications the results may have had on other populations. The inclusion of a more heterogeneous population can only serve to broaden the understanding of effective treatment for this disorder. In addition, we would like to have seen data on the history of mental disorders within the subjects’ families. For example, it would have been helpful to know of any history of eating disorders within the families. In future replications of this study it would be helpful to know what effects, if any, a history of mental illness within a family has on the results. In conclusion, we wish to express our gratitude to the investigators for taking on this important and difficult research. We
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 2 , F E B RU A RY 2 0 0 1
firmly believe that this type of ongoing research adds greater credibility to psychotherapeutic interventions, by which the field as a whole gains greater esteem in the eyes of the public and, most importantly, patients. Shane Gelbaugh, B.A. Mayra Ramos, B.A. Emil Soucar, Ed.D. Roosevelt Urena, B.A. Temple University, Philadelphia Robin AL, Siegel PT, Moye AW, Gilroy M, Dennis AB, Sikand A (1999), A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. J Am Acad Child Adolesc Psychiatry 38:1482–1489
Dr. Robin replies: Psychotherapy outcome research is always a compromise between the ideals of research methodology and the pragmatics of the clinical settings, budgets, personnel, and other practical constraints. Investigators usually do not discuss how they make such decisions in concisely worded journal articles. As a result, it may appear that they failed to consider such methodological issues. There was such a delicate balance between ideals and pragmatics in planning and conducting my study. The letter from Gelbaugh et al. raises several of the issues which my colleagues and I deliberated. I appreciate the opportunity prompted by this letter to further elucidate my thinking on these issues. Gelbaugh et al. note that we used a relatively small, homogeneous sample of white, female, middle-class patients with anorexia nervosa, restricting our ability to generalize to a more heterogeneous population. In a first controlled test of two psychotherapies, methodology would dictate that we should minimize error variance due to heterogeneity of the subjects in order to obtain the largest treatment effects. This was generally our guiding principle. Nonetheless, we would have preferred a more ethnically diverse sample. We aggressively marketed and advertised our project to an ethnically diverse population in the Detroit metropolitan area through newspapers, radio, community and religious organizations, physician and mental health clinic contacts, word of mouth, talks at schools, and many other mechanisms. In fact, our study was centered in a major urban children’s hospital, where we provide mental health services to a large minority population. Despite our massive marketing campaign conducted over 6 years offering free treatment, very few minority families with adolescents suffering from anorexia nervosa ever requested our help. When we conduct 129
LETTERS TO THE EDITOR
studies or offer services for other presenting problems (attentiondeficit/hyperactivity disorder, depression, etc.), large numbers of minority patients seek our help, so we know that we are a credible mental health provider to minority populations. We can only conclude that in our metropolitan area very few minority adolescents with anorexia nervosa have been identified. The letter notes that we did not address how each therapist could have affected the findings. Ideally, it would have been desirable to include therapist as a factor in the analysis of the results of such a comparative psychotherapy outcome study. To have the statistical power to legitimately address therapist factors with therapists nested within treatment conditions, we would have needed a larger sample size, which was not feasible because of budgetary constraints and the difficulties recruiting subjects. Instead, we built in a number of features designed to reduce therapist variability: (1) written manuals which all of the therapists were trained to follow, (2) coding of audiotapes of therapist behavior to demonstrate fidelity to the manuals, and (3) regular meetings of the therapists to review progress and maintain standardized adherence to the manuals. As far as we can determine, these procedures did reduce therapist variability. We also considered crossing therapists with treatment conditions, e.g., the same therapists conduct both treatments, permitting analysis of therapist factors with a smaller sample size. We rejected this option because the treatments were so different from each other that we could not find any experienced therapist equally trained and/or committed to both treatments. Gelbaugh and colleagues’ letter erroneously asserts that we gave almost double the amount of therapeutic contact hours to subjects in the BFST compared with the EOIT condition. We gave careful consideration to the need to make the total therapeutic contact time comparable across the two conditions, but when comparing family to individual therapy, the definition of “comparable” is not at all clear. Does this mean that the adolescent in either BFST or EOIT meets with a therapist for the same amount of time? Or does this mean that the total therapy contact time for all family members is comparable across conditions? We decided that in a study involving family therapy, the latter definition made more conceptual sense. Therefore, as described in our Method section, the total monthly family therapeutic contact was set at 288 minutes, and equalized across conditions as follows: (1) BFST families met for 72 minutes per week with the therapist; and (2) adolescents in EOIT met for 45 minutes per week with the therapist, and their parents met for 54 minutes with the therapist every other week. I hope that these comments will illuminate our thinking as we planned our study. Arthur L. Robin, Ph.D. Psychiatry and Behavioral Neurosciences Wayne State University School of Medicine Detroit 130
MORE ON THE DICA-IV To the Editor: This letter reports on the use of the Diagnostic Interview for Children and Adolescents-IV (DICA-IV) (Reich et al., 1997) in a British sample of burned children and adolescents who were participants in a longitudinal study. The DICA-IV was used for various reasons. Briefly, it can be used for research purposes with no prior training, it is computer-based, and it was used in the only previous similar research design (Stoddard et al., 1989). A number of problems limited the research findings and were implicated in the poor follow-up rate. The DICA-IV has more than 1,600 questions. This makes for an extremely structured interview, covering all the categories of childhood disorder, but it also makes for an interview that can last for 2 hours, depending on the child or adult. Many children and their parents found this problematic, and many children found the interview boring, despite all the efforts of the interviewer. If the interview lasted more than approximately 45 minutes, all children, regardless of age, tended to have problems with attention. On a practical level, if both a parent and child were being interviewed, home visits could last as long as 5 hours, which was obviously inconvenient for the family. The DICA-IV was not designed to be culture-specific, and it has been used successfully in Spanish samples (e.g., Ezpeleta et al., 1997). In the present sample, however, there were cultural and language problems with some of the questions. Although these could usually be corrected by the interviewer as the interview was being used as an “interview driver,” some questions were problematic. Children often giggled at questions, and parents voiced concern. An example was the questions pertaining to “gangs.” The question “Are there any gangs in your neighborhood?” could be changed to “Are there any gangs where you live?” but the meaning of the term “gang” obviously varies between American inner cities and Scottish housing estates. Another example was questions pertaining to alcohol. A child’s affirmative answer to the question “Have you ever had a drink of alcohol?” could be followed by up to 10 minutes of questions about alcohol consumption. Moderate drinking in European teenagers, not generally regarded as a problem behavior, is probably viewed as a “rite of passage.” Children and teenagers could become quite exasperated about questions concerned with alcohol addiction when they had honestly answered yes, but were referring to drinking with their parents on special occasions! Leaving out such questions would have compromised the internal reliability and validity of the study. The DICA-IV is certainly useful, but if it is to be used successfully in British samples, it may need to be more culturally attuned. I am not aware of any other British studies which have used the DICA-IV, and this may be why.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 2 , F E B RUA RY 2 0 0 1
THERAPY FOR ANOREXIA NERVOSA To the Editor: We are writing in response to the report by Robin et al. (1999), “A Controlled Comparison of Family Versus Individual Therapy for Adolescents With Anorexia Nervosa.” The authors successfully compare the efficacy of behavioral family systems therapy (BFST) with that of ego-oriented individual therapy (EOIT) as interventions for anorexia nervosa. They provide cogent findings that BFST brought about physical health more quickly and EOIT brought about a return to better psychological functioning. The behavioral model used in a family systems model probably has more saliency than in individual settings because the family collaborates in the identified patient’s therapeutic process. Likewise, EOIT did improve psychological functioning, especially in the areas of ego strength, self-esteem, and identity development. In addition, the BFST model likely gave a sense of control to parents, which individual therapy could not provide. These two findings led us to believe that the two methods should be combined to address a larger spectrum of symptoms. Nevertheless, comparative psychotherapy research will always have limitations. However, if this study and its authors hope to receive support from funding sources such as managed care, they should have addressed several factors which could have affected their findings. It is entirely possible that interpersonal factors, which could not be controlled, may have skewed the results one way or another. Finally, we noticed that the design of the study gave almost double the amount of therapeutic contact hours to subjects in the BFST. Also, the investigators used a relatively small (37 subjects) and homogeneous sample. Though we realize that—epidemiologically—white, female, and middle-class populations are more likely to be afflicted with this disorder, the article does not address the implications the results may have had on other populations. The inclusion of a more heterogeneous population can only serve to broaden the understanding of effective treatment for this disorder. In addition, we would like to have seen data on the history of mental disorders within the subjects’ families. For example, it would have been helpful to know of any history of eating disorders within the families. In future replications of this study it would be helpful to know what effects, if any, a history of mental illness within a family has on the results. In conclusion, we wish to express our gratitude to the investigators for taking on this important and difficult research. We
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 2 , F E B RU A RY 2 0 0 1
firmly believe that this type of ongoing research adds greater credibility to psychotherapeutic interventions, by which the field as a whole gains greater esteem in the eyes of the public and, most importantly, patients. Shane Gelbaugh, B.A. Mayra Ramos, B.A. Emil Soucar, Ed.D. Roosevelt Urena, B.A. Temple University, Philadelphia Robin AL, Siegel PT, Moye AW, Gilroy M, Dennis AB, Sikand A (1999), A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. J Am Acad Child Adolesc Psychiatry 38:1482–1489
Dr. Robin replies: Psychotherapy outcome research is always a compromise between the ideals of research methodology and the pragmatics of the clinical settings, budgets, personnel, and other practical constraints. Investigators usually do not discuss how they make such decisions in concisely worded journal articles. As a result, it may appear that they failed to consider such methodological issues. There was such a delicate balance between ideals and pragmatics in planning and conducting my study. The letter from Gelbaugh et al. raises several of the issues which my colleagues and I deliberated. I appreciate the opportunity prompted by this letter to further elucidate my thinking on these issues. Gelbaugh et al. note that we used a relatively small, homogeneous sample of white, female, middle-class patients with anorexia nervosa, restricting our ability to generalize to a more heterogeneous population. In a first controlled test of two psychotherapies, methodology would dictate that we should minimize error variance due to heterogeneity of the subjects in order to obtain the largest treatment effects. This was generally our guiding principle. Nonetheless, we would have preferred a more ethnically diverse sample. We aggressively marketed and advertised our project to an ethnically diverse population in the Detroit metropolitan area through newspapers, radio, community and religious organizations, physician and mental health clinic contacts, word of mouth, talks at schools, and many other mechanisms. In fact, our study was centered in a major urban children’s hospital, where we provide mental health services to a large minority population. Despite our massive marketing campaign conducted over 6 years offering free treatment, very few minority families with adolescents suffering from anorexia nervosa ever requested our help. When we conduct 129
LETTERS TO THE EDITOR
studies or offer services for other presenting problems (attentiondeficit/hyperactivity disorder, depression, etc.), large numbers of minority patients seek our help, so we know that we are a credible mental health provider to minority populations. We can only conclude that in our metropolitan area very few minority adolescents with anorexia nervosa have been identified. The letter notes that we did not address how each therapist could have affected the findings. Ideally, it would have been desirable to include therapist as a factor in the analysis of the results of such a comparative psychotherapy outcome study. To have the statistical power to legitimately address therapist factors with therapists nested within treatment conditions, we would have needed a larger sample size, which was not feasible because of budgetary constraints and the difficulties recruiting subjects. Instead, we built in a number of features designed to reduce therapist variability: (1) written manuals which all of the therapists were trained to follow, (2) coding of audiotapes of therapist behavior to demonstrate fidelity to the manuals, and (3) regular meetings of the therapists to review progress and maintain standardized adherence to the manuals. As far as we can determine, these procedures did reduce therapist variability. We also considered crossing therapists with treatment conditions, e.g., the same therapists conduct both treatments, permitting analysis of therapist factors with a smaller sample size. We rejected this option because the treatments were so different from each other that we could not find any experienced therapist equally trained and/or committed to both treatments. Gelbaugh and colleagues’ letter erroneously asserts that we gave almost double the amount of therapeutic contact hours to subjects in the BFST compared with the EOIT condition. We gave careful consideration to the need to make the total therapeutic contact time comparable across the two conditions, but when comparing family to individual therapy, the definition of “comparable” is not at all clear. Does this mean that the adolescent in either BFST or EOIT meets with a therapist for the same amount of time? Or does this mean that the total therapy contact time for all family members is comparable across conditions? We decided that in a study involving family therapy, the latter definition made more conceptual sense. Therefore, as described in our Method section, the total monthly family therapeutic contact was set at 288 minutes, and equalized across conditions as follows: (1) BFST families met for 72 minutes per week with the therapist; and (2) adolescents in EOIT met for 45 minutes per week with the therapist, and their parents met for 54 minutes with the therapist every other week. I hope that these comments will illuminate our thinking as we planned our study. Arthur L. Robin, Ph.D. Psychiatry and Behavioral Neurosciences Wayne State University School of Medicine Detroit 130
MORE ON THE DICA-IV To the Editor: This letter reports on the use of the Diagnostic Interview for Children and Adolescents-IV (DICA-IV) (Reich et al., 1997) in a British sample of burned children and adolescents who were participants in a longitudinal study. The DICA-IV was used for various reasons. Briefly, it can be used for research purposes with no prior training, it is computer-based, and it was used in the only previous similar research design (Stoddard et al., 1989). A number of problems limited the research findings and were implicated in the poor follow-up rate. The DICA-IV has more than 1,600 questions. This makes for an extremely structured interview, covering all the categories of childhood disorder, but it also makes for an interview that can last for 2 hours, depending on the child or adult. Many children and their parents found this problematic, and many children found the interview boring, despite all the efforts of the interviewer. If the interview lasted more than approximately 45 minutes, all children, regardless of age, tended to have problems with attention. On a practical level, if both a parent and child were being interviewed, home visits could last as long as 5 hours, which was obviously inconvenient for the family. The DICA-IV was not designed to be culture-specific, and it has been used successfully in Spanish samples (e.g., Ezpeleta et al., 1997). In the present sample, however, there were cultural and language problems with some of the questions. Although these could usually be corrected by the interviewer as the interview was being used as an “interview driver,” some questions were problematic. Children often giggled at questions, and parents voiced concern. An example was the questions pertaining to “gangs.” The question “Are there any gangs in your neighborhood?” could be changed to “Are there any gangs where you live?” but the meaning of the term “gang” obviously varies between American inner cities and Scottish housing estates. Another example was questions pertaining to alcohol. A child’s affirmative answer to the question “Have you ever had a drink of alcohol?” could be followed by up to 10 minutes of questions about alcohol consumption. Moderate drinking in European teenagers, not generally regarded as a problem behavior, is probably viewed as a “rite of passage.” Children and teenagers could become quite exasperated about questions concerned with alcohol addiction when they had honestly answered yes, but were referring to drinking with their parents on special occasions! Leaving out such questions would have compromised the internal reliability and validity of the study. The DICA-IV is certainly useful, but if it is to be used successfully in British samples, it may need to be more culturally attuned. I am not aware of any other British studies which have used the DICA-IV, and this may be why.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 2 , F E B RUA RY 2 0 0 1