Attachment and mentalization as predictors of outcome in family therapy for adolescent anorexia nervosa

Tom Jewell,Peter Fonagy,Alison Eivors,Moritz Herle,Mima Simic,Ivan Eisler,Lucy Serpell

doi:10.1007/s00787-021-01930-3

Abstract

Anorexia nervosa-focussed family therapy (FT-AN) is the first-line treatment for adolescent anorexia nervosa (AN), but the predictors of poor treatment response are not well understood. The main aim of this study was to investigate the role of attachment and mentalization in predicting treatment outcome. The secondary aims of the study were to investigate therapeutic alliance at 1 month as a predictor of outcome, and to test the associations between alliance and baseline attachment and mentalization. 192 adolescents with AN and their parents were recruited as they began family therapy in out-patient specialist eating disorder services. Self-report measures of attachment, mentalization, and emotion regulation were completed at the start of treatment by adolescent patients and one of their parents. Self-reported alliance scores were collected at one month. Higher scores on the Certainty Scale of the Reflective Functioning Questionnaire, completed by parents, which indicate over-certainty about mental states, were the strongest predictor of poor outcome (Odds Ratio: 0.42, CI: 0.20–0.87). Similarly, for adolescents, higher Lack of Clarity scores on the Difficulties in Emotion Regulation Scale, representing being unclear about one’s feelings, were predictive of positive treatment outcome (OR: 1.10, CI: 1.00–1.21). Higher alliance scores at 1 month predicted positive outcome, and were associated with attachment security and mentalization. These novel findings suggest that, particularly in parents, a tendency towards excessive certainty about mental states in others may predict poor outcome in FT-AN. Further research is warranted to replicate the finding and characterise families at risk of poor outcome.

Highlights

Anorexia nervosa (AN) is a serious condition which typically emerges during adolescence
Our results suggest that excessive certainty about mental states, a variable uncorrelated with alliance, was the strongest predictor of poor outcome, with each unit increase on the RFQ8 Certainty scale reducing the odds of a good outcome by more than half
Whilst this finding was in the opposite direction to our hypotheses, it is consistent with our findings for parents, since extreme clarity about one’s feelings is conceptually similar to certainty about mental states, and we found that parental RFQ8 Certainty and adolescent Difficulties in Emotion Regulation Strategies Scale (DERS) Lack of Emotional Clarity scores are negatively correlated in our data (r = − 0.28, p < 0.01)

Summary

Introduction

Anorexia nervosa (AN) is a serious condition which typically emerges during adolescence. AN is associated with high rates of psychiatric co-morbidity [1] and significantly raised mortality rates [2], with an estimated incidence of 14 per 100,000 [3]. Specialist anorexia nervosa-focussed family therapy for children and young people (FT-AN) has the strongest efficacy evidence in the treatment of adolescent AN and was recommended by NICE [4] as the first-line treatment. A significant proportion of patients fail to respond and a lack of evidence on predictors of treatment response and understanding of mechanisms of change limits efforts to personalise treatment recommendations. There is an urgent need for well-designed and sufficiently powered research that can investigate predictors of response and change processes in FT-AN [5].

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Discussion

Conclusion