Introduction and Purpose of This Book
In his book, Persuasion and Healing, Jerome Frank (1991) noted that all psychotherapies are characterized by a âconceptual scheme or mythâ that provides a credible explanation for patient symptoms and a prescribed approach believed to resolve these symptoms and restore health (pp. 42â43). Identifying a credible framework for understanding the symptoms and experiences of young adults with anorexia nervosa (AN) and their families is critical because making sense of events transpiring in recovery and life are as essential as âthe need for food and waterâ (Frank & Frank, 1991, p. 24). This need is amplified in AN because the disorder obstructs young adultsâ abilities to accurately make sense of their own internal and interpersonal experiences, while also preventing them from taking in the needed energy required for recovery and continued growth and development. AN also challenges caregiver sensibilities, because their young adult loved ones either do not recognize they are ill or are unable to articulate what is transpiring within. A credible explanation or âconceptual frameâ for the symptoms and experiences of young adults with AN and their families must be heavily informed by patient and family lived experience, along with clinical observations, theory, and research for it to be meaningful and acceptable. It must be compelling enough to keep the therapist, young adult with AN, and family members connected and actively participating in the prescribed treatment throughout the hardships of treatment and joys of recovery.
This treatment manual describes a new and innovative multifamily therapy group (MFTG) approach (Reconnecting for Recovery, R4R) for young adults with AN that is based on a relational reframing of eating disorders as Diseases of Disconnection. This new conceptual frame was developed in concert with young adults and their families over the last decade (Tantillo, 2006; Tantillo, McGraw, Hauenstein, & Groth, 2015; Tantillo & Sanftner, 2010a) and is also informed by clinical observations, theory, and research (Tantillo, 2010; Tantillo, McGraw, Lavigne, Brasch, & Le Grange, 2019; Tantillo & Sanftner, 2010b; Tantillo, Sanftner, & Hauenstein, 2013). Although the R4R approach integrates Motivational Interviewing (MI) principles (Miller & Rollnick, 2013) and Stages of Change Theory (Prochaska, Norcross, & DiClemente, 1994), it is heavily informed by Relational-Cultural Theory (R-CT) ( Jordan, 2018; Miller & Stiver, 1997; Tantillo & Sanftner, 2010a). The latter asserts that intrapersonal (biological and psychological) and interpersonal (affective and behavioral) processes of disconnection occurring in concert with other biopsychosocial risk factors can increase risk for development and maintenance of eating disorders and other mental and physical health problems. Examples of intrapersonal processes of disconnections include alexithymia and poor interoceptive awareness, which obstruct a patientâs ability to name and express internal emotional and bodily states. Examples of interpersonal processes of disconnection include self-silencing and avoidance, which prevent communication of feelings and needs and increase isolation and conflict with family members. It is the interplay of intra- and interpersonal processes of disconnection that contributes to the interpersonal disconnections experienced by young adults with AN and their families. Interpersonal disconnections are marked by a lack of communication or high expressed emotion (e.g., emotional over-involvement, hostility, and criticism [Butzlaff & Hooley, 1998; Leff & Vaughn, 1985; Le Grange, Eisler, Dare, & Hodes, 1992; Le Grange, Hoste, Lock, & Bryson, 2010; van Furth, van Strien, Martina, van Son, Hendrickx, & van Engeland, 1996]) due to a neural and relational misalignment (Stephens, Silbert, & Hasson, 2010) between patient and family. Thus, the young adult with AN and family members are not accurately reading each otherâs emotions and needs, and caregivers have difficulty developing accurate empathy and responding effectively. These experiences can perpetuate illness, because young adults with AN are often psychosocially challenged, do not cope well with intense emotion, and frequently end up using AN symptoms to manage intense affect and interpersonal stress.
In the R4R MFTG approach, AN is externalized and viewed as the force that creates and maintains disconnections. Patients and family members are often reminded that AN does this to continue its exclusive ârelationshipâ with the patient. They are taught that AN not only creates disconnections but also offers itself as a solution to these disconnections. Although R4R MFTG affirms the importance of nutritional rehabilitation and mealtime assistance to target the disconnections related to malnutrition and starvation (e.g., numbing of emotions), it predominantly focuses on building group member emotional and relational skills that are required to identify the disconnections characterizing AN and to foster mutual relationships for recovery. Qualitative and quantitative empirical findings, patient and family narratives, and clinical observations support the notion that improved connections with self and others are essential for recovery from AN (Bell, 2011; Berkman, Lohr, & Bulik, 2007; Federici & Kaplan, 2008; Lowe, Zipfel, Buchholz, Dupont, Reas, & Herzog., 2001; Tozzi, Sullivan, Fear, McKenzie, & Bulik, 2003; Wright & Hacking, 2012). Relational-Cultural Theory ( Jordan, 2018; Miller & Stiver, 1997; Tantillo & Sanftner, 2010a), at the heart of R4R, emphasizes that a mutual sense of perceived understanding, empathy, and empowerment (perceived mutuality) in relationships is what moves patients and families toward new and better connections and continues forward momentum in treatment and recovery.
If we adopt the relational reframe that AN is a disease of disconnection, then helping young adults with AN and their family members to develop relational skills that promote perceived mutuality is critical. Clinical observation, patient and family subjective accounts, and empirical work (Frey, 2013; Lenz, 2016; Jordan, 2018; Tantillo, 2006; Tantillo, 2010; Tantillo, Anson, Lavigne, & Wilkosz, 2019; Tantillo, McGraw, Hauenstein, & Groth, 2015; Tantillo, McGraw, Lavigne, Brasch, & Le Grange, 2019; Tantillo, Sanftner, & Hauenstein, 2013) lend support to the notion that promoting perceived mutuality among young adults with AN and their family members is an essential evidence-based practice. Relational skills that foster a sense of perceived mutuality are also especially important for young adults who developmentally are supposed to be refining connections with their families of origin while building additional connections with others outside the family at school, work, and in the broader community. Poor psychosocial functioning predicts outcome in AN (Bell, 2011; Berkman, Lohr, & Bulik, 2007; Federici & Kaplan, 2008; Lowe, Zipfel, Buchholz, Dupont, Reas, & Herzog, 2001; Tozzi, Sullivan, Fear, McKenzie, & Bulik, 2003; Wright & Hacking, 2012). The inability to build and sustain mutual connections can hinder a young adultâs ability to navigate the myriad transitions that characterize this developmental period. Perceived failure and low self-efficacy can lead to increased use of AN symptoms to cope with stress and loss, contributing to illness maintenance (Schmidt & Treasure, 2006).
Although individual therapy, family therapy, and group therapy can all assist in promoting reconnection with self and others (Byrne et al., 2017; Grenon, Schwartze, Hammond, Ivanova, Proulx, & Tasca, 2017; Jewell, Blessit, Stewart, Simic, & Eisler, 2016; Jordan, 2018), R4R MFTG leverages the combined strengths, resources, and coping strategies of a number of patients and families. MFTG becomes a therapeutic village in which group members experience a strong sense of universality and purpose. Patients and families can try out new ways of thinking, explore new values and goals, and experiment with new behaviors.
The R4R MFTG approach puts connection and collaboration at the heart of therapeutic work and teaches patients and family members to view disconnection (in R-CT) and dissonance (in MI) as signals to re-examine what is happening in relationships. Our integrated Relational/Motivational R4R MFTG approach views the experience of dissonance or disconnection as an opportunity to strengthen relationships versus allow AN to take advantage of the disconnection, damage relationships, perpetuate illness, and obstruct recovery.
The R4R treatment manual begins with a concise overview of AN in young adults; the promise of MFTG for treating AN; and the Relational/Motivational theory, principles, and research informing the R4R treatment approach. This information allows readers to understand the rationale behind group goals, structure, content, and processes. The manual outlines 16 weekly outpatient sessions over 26 weeks, beginning with two sessions emphasizing joining, assessment, and orientation, and continuing with the description of eight weekly, four biweekly, and two monthly group treatment sessions. Each session describes group goals, content, exercises, and materials, as well as relevant therapist interventions. The manual includes protocols, case vignettes, and other materials that translate patient lived experience, theory, and research underlying this multifamily therapy group model into practice. Because the R4R approach was developed in partnership with patients and families, this manual clearly conveys the power of family work and the resources families bring to bear upon treatment and recovery. The manual reminds us of the importance of caring communities including families of origin and families of choice (partners, friends, sponsors, and mentors) in the treatment of young adults with AN.
