VOL: 98, ISSUE: 06, PAGE NO: 38
Ann Elliott, BA, RN (mental health), is clinical nurse specialist, Eating Disorders Service, Dorset Health Care NHS TrustEating disorders can put a huge strain on family life. However, families need not be seen as part of the problem and, indeed, can help the recovery process. This was the philosophy behind a new group set up by the eating disorders service at Dorset Health Care NHS Trust. The multiple family psychoeducational group (MFPG) - set up by two nurses (including myself), a psychiatrist and a social worker - is intended to help people overcome any obstacles to the healthy functioning of the family. It is aimed at clients over the age of 18, or 16 if they are no longer in full-time education.
Eating disorders can put a huge strain on family life. However, families need not be seen as part of the problem and, indeed, can help the recovery process. This was the philosophy behind a new group set up by the eating disorders service at Dorset Health Care NHS Trust. The multiple family psychoeducational group (MFPG) - set up by two nurses (including myself), a psychiatrist and a social worker - is intended to help people overcome any obstacles to the healthy functioning of the family. It is aimed at clients over the age of 18, or 16 if they are no longer in full-time education.
We were keen to find a way to reach families with whom it was difficult to build a relationship. Clients and their families often wanted more input than the service's relatives' support group could provide but, at the same time, were reluctant to participate in systemic family therapy sessions. We hoped that the new group would be the sort of non-threatening stepping stone that these families needed.
Planning the group
A literature search failed to reveal any research-based evidence for the use of MFPGs with clients with an eating disorder. We accepted that although evidence-based practice is desirable, sometimes it is necessary to take a risk and try something new.
Also, we found that MFPGs had been used effectively with other mental health client groups. McFarlane et al (1995) report relapse-rate reduction in schizophrenia and Bender (1992) shows multiple family therapy to be a valuable component of care for adolescents. Conner et al (1998) describe how MFPGs promote retention in alcohol and cocaine dependency treatment and Brennan (1995) received positive responses from families using a MFPG for bipolar patients. Similar approaches were employed in psychiatric rehabilitation by Van Hammond and Deans (1995).
Our objective was to set up and audit an MFPG for clients with an eating disorder and their families. This consisted of a series of 10 sessions that provided information through the discussion of eating disorders and related topics. We planned to leave time for socialising at the end of each session to enhance the supportive aspects of the group.
Meetings were held regularly to clarify the aims and objectives of the group, to decide how to audit it and to discuss the topics for inclusion. Members of the eating disorders service were asked to look through their caseloads for clients they thought might be interested and invitation letters were sent to potential participants.
This led to the formation of a MFPG consisting of six clients and their families. Two of the clients were inpatients and four were outpatients. Two attended with their husbands, two with their parents, one with her mother and one came with both parents and her partner.
Running the MFPG
We had various qualifications to run the group. The two nurses were studying systemic family therapy, the senior trainee psychiatrist had been involved with similar groups in an addictions service and the social worker had a special interest in eating disorders. There were also two outside observers and a superviser.
Fortnightly supervision sessions were provided by a nurse therapist with a family therapy qualification and we used notes made by the observers to reflect on the sessions.
There were a total of 10 sessions plus a three-month reunion. Each session had 16 participants, one observer and two facilitators, with all four facilitators attending the first and last sessions. Each facilitator led two of the sessions and acted as co-facilitator in two others. The co-facilitator from one week became the lead facilitator the following week. This maintained continuity and having two facilitators on standby enabled us to give the same level of commitment to attendance that was expected from the families.
The first 15 minutes of each session were reserved for thoughts, questions or feedback from the previous session and included a review of homework tasks. The content of the sessions is outlined in Box 1.
The MFPG was evaluated before the first session, after the last session and at follow-up three months later.
We used three standardised tools. The Family Assessment Device (FAD), the General Health Questionnaire (GHQ 12) and the Eating Attitudes Test (EAT 26).
The FAD is designed to measure family functioning and is made up of seven scales (Miller et al, 1985). The facilitators used the general functioning scale that measures overall family functioning. The GHQ 12 looks at general health and the EAT 26 has been validated as an assessment tool for use with anorexia nervosa. The facilitators also produced a brief satisfaction questionnaire and listened to verbal feedback from the group.
FAD scores improved during the group and at follow-up. GHQ and EAT scores improved during the group but had deteriorated slightly at follow-up. It was encouraging that when the clients' scores were separated out, a continued improvement was seen on all three measures (See tables 1, 2 and 3).
Although the number of participants was too small for these results to have any statistical significance, we were pleased that the results were positive enough to suggest that it might be useful to repeat the MFPG with other clients with an eating disorder.
All six families who began the MFPG finished their sessions and some went on to participate in couples or family work. The verbal feedback we received and the responses to the satisfaction questionnaire were mainly very positive. One mother said: 'Listening to other families made me think that maybe we should just smile a bit more, relax and not worry so much.'
One of the fathers who took part in the group sessions said, 'The greatest benefit has been sharing problems with others who have similar problems,' and one of the clients said that even though she had not spoken, she had 'gained a lot by being here - it's reassuring to know my feelings are not unique to me'.
An additional benefit was that the supportive nature of the group encouraged the development of informal self-help support networks and some of the mothers were observed exchanging addresses and telephone numbers at the three-month reunion meeting.
Implications for practice
We had heard multiple family therapy described as a cross between a three-ring circus and an exercise in crowd control. The psychoeducational focus worked by containing the 'crowd', although it may have inhibited some of the group processes. We attempted to control the conversations by preventing interruptions or break-away discussions.
However, we felt that it might have been better to make the group feel more like the experts by eliciting as much knowledge as possible from them, rather than simply offering them information.
Another implication for future practice is the need to collaborate. We were employed by managers who wanted to see empirical evidence for everything. This usually requires randomised-controlled trials, which in this case would have meant increasing the numbers considerably and creating a control group. It is possible that quantitative evidence could have been obtained if we had been able to find a way to share the data with other services.
You do not have to be working in a London teaching hospital with a large research budget to embark upon this kind of innovative work. Even though the MFPG required a significant time commitment, we found that it was not only possible, but also clinically effective, to carry out this piece of work in the context of a small local eating disorders service.
If you have a hunch that a particular intervention would be worth introducing to your own practice but are unable to find any research-based evidence for it, do not be frightened to follow your intuition. If you audit your work and disseminate the results, you will be carrying out good nursing practice.
Addressing the gap we discovered in the literature on eating disorders improved the quality of care our clients received and was fascinating, stimulating and rewarding.