Processes of change in family therapies for anorexia nervosa: a systematic review and meta-synthesis of qualitative data

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Method: A systematic search of the literature was conducted to identify qualitative studies focussing on experiences of therapeutic change within family therapies for AN from the perspectives of young people and their families. Fourteen studies met inclusion criteria and underwent quality appraisal following which they were synthesised using a meta-synthesis approach. Results: Six overarching themes were generated: “The psychological underpinnings of AN”; “The therapeutic relationship”; Confinement to a “script”; “A disempowering therapeutic context”; “Externalisation”; and “Family involvement”. Positive change was helped by understanding and support given to the young person’s overall psychological and emotional development and wellbeing, as well as positive therapeutic relationships, relational containment within the family system and externalising conversations in which young people felt seen and heard as individuals beyond an eating disorder. Positive change was hindered by inflexibility in the treatment approach, counter-effects of externalisation, negative experiences of the therapist, a narrow focus on food-intake and weight, as well as the neglect of family difficulties, emotional experiences, and psychological factors. Conclusions: Positive change regarding the young person’s eating-related difficulties ensued in the context of positive relational changes between the young person, their family members and the therapist, highlighting the significance of secure and trusting relationships. The findings of this review can be utilised by Eating Disorder services to consider how they may adapt to the needs of young people and their families in order to improve treatment satisfaction, treatment outcomes, and in turn reduce risk for chronicity in AN. anorexia nervosa family therapy qualitative research meta-synthesis families’ perspectives systematic review Plain English summary This review synthesises the views of young people and their family members regarding their perspectives of therapeutic change within family therapies for Anorexia Nervosa (AN), including both manualised family-based treatment (FBT/ FT-AN) and systemic family therapy (SyFT), to understand which aspects of these treatment approaches are helpful versus hindering to recovery from an eating disorder. Parental involvement was crucial in facilitating the restoration of physical health through the process parents taking temporary responsibility for the young person's eating behaviours until they can feed themselves again. However, treatment often failed to acknowledge and address the psychological and emotional difficulties that made the young person vulnerable to developing AN, as well as the psychological distress caused by increasing food-intake and weight. A positive therapeutic relationship in which families felt well supported by their therapist was important in providing containment during a time of familial strain and instability, yet there was a need for greater flexibility and individualisation within manualised FBT. The findings highlight the importance of eliciting the young person’s voice to enhance their personal agency in treatment, as well as the value of therapeutic space to improve family functioning and enhance family unity. Background Characterised by excessive preoccupation with control over body weight and eating resulting in life-threatening physical effects, Anorexia Nervosa (AN) has significant emotional, social and relational implications for the individual and their family [1, 2, 3]. Whilst the onset is typically in adolescence, AN can continue into adulthood [4]. The aetiology of AN is complex and multifactorial [5]; research suggests an interaction of genetic risk with other factors including emotion dysregulation, anxiety, perfectionism, cognitive rigidity, and early feeding difficulties [6, 7, 8, 9]. Family therapy for anorexia nervosa Family-based treatment (FBT/FT-AN) is the first line NICE recommended treatment for AN in children and adolescents [10, 11]. Its development built on earlier approaches that were informed by Family Systems Theory which describes how family dynamics and processes can contribute to the development and, or maintenance of problems within the family system [12]. Since then, models of family therapy for AN have evolved and emphasise that families are a resource, rather than a treatment target [13]. The family-based treatment model for anorexia nervosa FBT is a manualised outpatient three phase therapy with a behavioural and educative focus. Phase one focuses on refeeding to increase weight orchestrated by parents who are temporarily given responsibility for the individual’s eating and exercise patterns. Phase two focuses on gradually developing the young person’s independence by progressively returning responsibility for eating to the individual. When safe to do so, the focus is taken away from food to problem-solve family and psychosocial issues which interfere with weight restoration. Finally, phase three addresses remaining concerns related to adolescent development, including the re-establishment of healthy boundaries within the family system, and navigating approaching developmental challenges without reverting to ED behaviours. FBT has five key tenets [14]: (1) The therapist takes an agnostic stance, engaging the family in facilitating early behavioural change to improve the management of eating-related behaviours, rather than exploring or resolving aetiology. (2) The therapist uses externalising language encouraging the family to conceptualise AN as an “illness” which has "taken over" the young person. (3) The therapist takes a non-authoritarian therapeutic stance, viewing parents as experts in their family and assuming that giving parents responsibility for weight restoration enables reorganisation of the family to enhance parental effectiveness. (4) Therapists empower parents to orchestrate recovery. By not providing explicit instructions, parental confidence is built through allowing for struggle and self-reliance. (5) FBT utilises a pragmatic approach, adopting a firm initial focus on restoring physical health. Comorbid difficulties are not directly addressed in phase one to ensure that weight restoration is the primary focus and because many are assumed to resolve with eating and weight restoration. Systemic family therapy for anorexia nervosa Systemic Family Therapy (SyFT) is also used in some settings [15]. SyFT is a less defined family therapy characterised by similar principles to FBT, although it is not delivered with adherence to a phased manual. Similar to FBT, the SyFT therapist takes a non-blaming, collaborative stance and encourages parental agency and alliance, however they place greater focus on the family system [16]. Difficulties are conceptualised as arising from the interpersonal relationships, dynamics and narratives about a problem within a family system. Adopting a neutral stance, the therapist explores family patterns of beliefs and behaviours, seeking ways to enable the family to draw on their strengths and generate solutions. Although there is not a specific emphasis on normalisation of eating or weight, the therapist helps the family address these issues when raised. Research on family therapies for anorexia nervosa A meta-synthesis of views about treatment from the perspectives of young people, parents and professionals underlined the central importance of the therapeutic relationship yet the difficulty in forming alliance due to disagreement about treatment targets and mutual distrust [1]. For therapists, the treatment target was normalisation of the young person's eating and weight. However, young people wanted treatment to target their psychological and social functioning, as well as their family environment; and parents wanted treatment to explore the origins and causes of AN. Another meta-synthesis focussed on FBT/SyFT found that whilst young people experienced extreme challenge relinquishing control of their eating, they also considered their caregivers’ involvement in this regard as one of the most important aspects of treatment [17]. However, they also appreciated the gradual restoration of autonomy and assistance with difficulties in family relationships. Moreover, whilst externalisation helped to reduce family criticism and increase praise, young people who engaged in FBT would have liked the causes of AN and other difficulties to have been addressed. Lastly, some young people would have liked individual sessions to address issues they did not feel comfortable discussing with family present. Service-users emphasise that treatments are most helpful when they recognise the emotional impact of weight gain and address psychological as well as physical aspects of AN [1, 17, 18, 19, 20]. They highlight the perceived unhelpfulness of professionals' conceptualisation of recovery as a pre-set target weight, rather than considering the individual's psychological and emotional experiences, as well as their family relationships. A review on the role of family relationships in adolescent EDs highlighted the need to refer to the adolescent’s family context to improve understanding of AN [21]. Findings from a study exploring the effects of FBT illuminated a possible mechanism of change, termed "relational containment" suggesting the importance of relational processes in recovery from AN [22]. Another study highlighted the process of evolving through treatment, for both the individual and their familial system [23]; this involved the repairing of damage through enabling others to improve their understanding of AN. The importance of attending to attachment-related issues has also been emphasised [24, 25, 26, 27, 28, 29], including the intergenerational transmission of attachment styles, emotional communication and coping styles, as well as attitudes towards eating and weight. Whilst there is good evidence for FBT's effectiveness, it does not work for everyone [30, 31, 32]. Many young people continue to experience ED-related distress following treatment, or families terminate treatment due to difficulties experienced with the approach. Accordingly, studies have attempted to identify factors that help and hinder change. Parental expressed emotion, hostility and criticism are associated with poor outcomes [33, 34], while parental warmth, increases in parental self-efficacy, and decreases in maternal critical communication and emotional over-involvement predict good outcomes [35, 36, 37, 38]. These findings suggest that decreasing unhelpful interactions in families is important in treatment for AN. The importance of the therapeutic relationship has also been underscored, with a meta-analysis indicating that younger patients benefit from an initial focus on the alliance to build engagement [39]. In summary, expressed emotion, the therapeutic alliance, family relationships, support with understanding AN, and managing the emotional and psychological experience of disordered eating appear to play a significant role in family therapies for AN. Review aims and rationale The specific processes of change underpinning family therapies for AN remains unclear [40]. Consequently, there is a need to identify their active ingredients, and to learn who this approach works for and why [41]. This study aims to understand what helps and hinders recovery in family therapies for AN to provide insights into their processes of change. Many qualitative studies which have focussed on patient and family member perspectives of family therapies for AN have been undertaken with both adolescents and young adults [15]. The World Health Organisation’s definition of ‘young people’ covers the age range of 10 to 24 years [43]. Therefore, this review will synthesise research including adolescents and young adults aged 10 to 24 at the time of treatment, referred to henceforth as ‘young people’. Methods Study design A meta-synthesis was considered to be the most suitable approach to answer the study’s research question as it allows for the re-interpretation of meaning across a number of qualitative studies [42]. This was important given that a number of existing qualitative studies have explored the experience of treatment for AN from the perspectives of young people and families, however no qualitative studies or meta-syntheses have specifically explored their processes of change from these perspectives. This meta-synthesis aimed to address this gap by synthesising existing qualitative studies which have gathered data on the experience of family therapies from the perspectives of young people and families to form a new interpretation of the research, allowing for the generation of novel explanatory theory of why and how the intervention works or not. Search strategy This systematic review was conducted in accordance with the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [44]. The following databases were systematically searched in August 2022: PsycINFO, Medline, and Web of Science. A hand search was also conducted. The search strategy is described in Table 1 and the search results are detailed within Figure 1. On PsycINFO and Medline, keyword searches for each concept were combined with subject heading searches using the Boolean operator ‘OR’. Web of Science does not have a search by subject heading function, therefore only a keyword search was conducted. This search was conducted again in November 2023 to account new research (see Figure 2). Table 1 Search terms and Boolean operators used to identify studies for this meta-synthesis Key concept Search terms Block 1- Disorder “Anorexi*” OR “restrictive eating disorder” Block 2 – Therapeutic approach “Family therap*” OR “family based treatment*” OR “family intervention” or “systemic psychotherap*” OR “systemic therap*” OR “systemic intervention*” Block 3 – Processes of therapeutic change (phenomenon of interest) “Family function*” OR “family relation*” OR “systemic change*” OR “family structure” OR “family dynamic*” OR “family dysfunction” OR “family role*” OR “systemic change” OR “psychotherapeutic process*” OR “therapeutic change” OR “psychotherapeutic change*” OR “behavio?r change” OR “therapeutic process” OR “strateg*” OR “interaction*” OR “pattern*” OR “support*” OR “manage*” or “attachment*” or “process* of change” OR “process*” OR “recovery process*” OR “change mechanism*” OR “change strategies” OR “change process*” OR “mechanism* of change” OR “therapeutic effect*” OR “recovery” OR “family function*” OR “help*” OR “facilitat*” OR “improve*” OR “outcome*” OR “influenc*” Block 4 – Type of research “Qualitative research” OR “views” OR “perspectives” OR “experience*” OR “interview*” OR “accounts” Block 5 - Population “Youth” OR “adolescen*” OR “teen*” OR “young people” OR “child” Study selection Studies were screened at the title and abstract screening phase, and subsequently at the full text screening phase. The inclusion criteria were: (a) peer-reviewed studies published 2002 onwards following publication of the FBT manual; (b) studies employing a qualitative or mixed-method design (provided the qualitative results were derived from open-ended questions); (c) studies whose participants included young people and/ or family members who had engaged in FBT or SyFT for AN within outpatient or inpatient ED services. The exclusion criteria were: (a) studies in languages other than English; (b) and studies with mainly quantitative data, or survey data with closed questions. Quality appraisal The Critical Appraisal Skills Programme tool for qualitative research was used to assess the methodological quality of papers identified [45]. The checklist has 10 criteria; each paper was given a total score out of 10. This review followed the scoring protocol used by existing ED meta-syntheses [18]. The protocol classified studies from A to C, with A denoting studies scoring 8.5 or above and carrying a low likelihood of methodological flaws; B denoting studies scoring 5 to 8, with a moderate likelihood of methodological flaws, and C indicating a score of less than five and a high likelihood of methodological flaws. Five studies scored within category A, nine studies scored within category B, and none of the studies scored within category C. The mean total score was 7.9. Scores were most commonly lost for criteria 6 and 7 (see Table 2). Table 2 Quality ratings using the Critical Appraisal Skills Programme CASP tool for qualitative research Study number CASP Criteria [49] [30] [31] [50] [51] [52] [53] [54] [55] [56] [57] [22] [58] [32] 1. Was there a clear statement of the aims of the research? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2. Is a qualitative methodology appropriate? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3. Was the research design appropriate to the aims of the research? 1 0.5 1 1 1 1 1 1 1 1 1 1 0.5 1 4. Was recruitment startegy appropriate to the aims? 0 0.5 1 1 1 1 1 1 1 1 0.5 1 1 1 5. Was data collected in a way that addressed the research issue? 1 0.5 1 0.5 0.5 1 0.5 1 1 0.5 1 1 0.5 1 6. Has the researcher-participant relationship been adequately considered? 0 0 0.5 0 0 0 0 0 0.5 0 0 0 0 0.5 7. Have ethical issues been taken into consideration? 0.5 0.5 1 0 0.5 0.5 0.5 0.5 1 0.5 0.5 0.5 0.5 0.5 8. Was the data analysis sufficiently rigorous? 0.5 0.5 1 0 1 0.5 1 0.5 1 1 1 1 0.5 0.5 9. Is there a clear statement of findings? 1 1 1 1 1 0.5 1 1 1 1 1 1 1 1 10. How valuable is the research? 1 1 1 1 1 0.5 1 1 1 1 1 1 1 1 Total Score 7 6.5 9.5 6.5 8.5 7 8 8 9.5 8 8 8.5 7 8.5 Total Score Category B B A B A B B B A B B A B A Note : Response options: 1 = Yes; 0.5 = Insufficient information to answer all criteria within item; 0 = No. Data extraction and synthesis This review utilised the seven-phase guidance provided by Noblit and Hare [46] for conducting a meta-synthesis which was further refined by Walsh and Downe [47]. Studies which met inclusion criteria were read in full and their results and discussion sections were extracted for analysis. Studies were then compared and translated into one another through identifying overlapping concepts (reciprocal translations) and contrasting concepts (refutational translations) across studies. The concepts were subsequently synthesised to create overarching themes and subthemes (third-order concepts). Finally, the synthesis was expressed through written form revealing more refined meanings, novel and exploratory theories. Reflexivity Researcher subjectivity is inevitable within qualitative research and can be used as a valuable research tool [48]. The first author (SC) had both personal and professional experience in treatments for adolescent AN. These experiences helped them to understand the data at an experience-near level, which strengthened the interpretative lens through which the data was read, allowing for a deeper level of analysis. However, they also paid attention to ensuring that the analysis and interpretation stayed close to the data within the primary studies by generating themes which honoured participant quotes. In terms of researcher positionality in relation to the topic, SC reflected on their pre-conceived ideas prior to conducting this review. They acknowledged the importance of an initial focus on the restoration of eating and weight for physical health through eliciting parental management of eating behaviourals, however they also appreciated the intregral role of emotional attunement and containment throughout this process. In addition, they recognised the importance of addressing the emotional and psychological experiences underlying eating behaviours, as well as considering the young person's family relationship context. Maintaining a reflexive journal and engaging in reflexive supervision enabled them to use their own experiences to extrapolate meanings further, whilst also broadening their perspective on the emerging themes. Results Overview of studies Table 3 presents details of the included studies. Sample sizes ranged from n = 1 to n = 98. Five studies focussed on the experience of FBT/SyFT for AN from the perspectives of young people; four focussed on the perspectives of young people and parents; two focussed on the perspectives of young people, parents and siblings; and four focussed on parents’ perspectives alone. Data was collected from 137 young people (129 females and eight males), 189 parents and 12 siblings. The patient age range was 11 to 23 at time of treatment, and 12 to 27 at time of data collection. The majority of patients were female ( n = 187), eleven were male. Parent gender was discernible in twelve out of thirteen studies: 92 were mothers and 69 were fathers. Ethnicity was rarely reported. The studies were conducted in Hong Kong, China, Australia, New Zealand, Norway, United Kingdom, United States of America, Sweden and Scotland. Nine studies collected data from participants who engaged in outpatient FBT. Two collected data from participants who engaged in inpatient FBT. Two collected data from participants who engaged in outpatient SyFT. One collected data from participants who engaged in either outpatient FBT or SyFT. Table 3 Characteristics of studies included in the meta-synthesis Reference Title Aim Therapeutic Approach Sampling Participants Country Data Collection Analysis Description Ethnicity Chan and Joyce [49] A Feminist Family Therapy Research Study: Giving a Voice to a Girl Suffering from AN Explore a patient's experience of treatment by inviting her to review her family sessions. SyFT; outpatient Convenience; the participant was recruited within an ED service where the author worked as the family's family therapist. One female YP, their two siblings, mother and father. The patient was aged 21 at treatment and data collection. Chinese Hong Kong Video playback and interviews Case study analysis Conti et al. [30] ‘Somebody Else's Roadmap’: Lived Experience of Maudsley and FBT for Adolescent AN Explore an experience of FBT by one family; how they negotiated their identities, roles, and alliances in a protracted phase 1. Manualised FBT; outpatient Purposive; the family responded to an advertisement distributed through HCP networks. One female YP, their mother, father and male sibling who engaged in FBT for three years. The patient was aged 14 at time of data collection. NS Australia Interviews Critical discursive analysis Conti et al. [31] “I’m still here, but no one hears you”: a qualitative study of young women’s experiences of persistent distress post FBT for adolescent AN Explore the experiences and identity struggles of adolescents who (1) drop out of FBT and/or (2) continue with substantive psychological distress post-treatment. Manualised FBT; outpatient Purposive; participants responded to advertisements on facebook or via clinicians after completing treatment. 14 female YP who engaged in FBT on average four years prior to participation for three to 24 months. Patients were aged 11 - 18 at treatment and 14 - 27 at data collection. NS Australia, New Zealand and UK Interviews Inductive thematic analysis Krautter and Lock [50] Is manualized family-based treatment for adolescent AN acceptable to patients? Patient satisfaction at the end of treatment Assess the perspectives of families who completed treatment using manual-driven FBT for AN. Manualised FBT; outpatient Convenience; participants were invited to complete a treatment effectiveness survey at the end of treatment in an ED clinic. 34 families including 35 mothers, 31 fathers and 34 YP (32 female, two male). Treatment completion was defined as attending 80% of an average of 14 sessions over six to 12 months. Patients were aged 12 - 18 at data collection. European American ( n = 27), Asian ( n = 3) Hispanic ( n = 2), American Indian ( n = 1), ‘Other’ ( n = 1). Northern California Open ended survey Phenomenological type content analysis and structural synthesis van Langenberg, Duncan and Allen [51] "They don't really get heard": A qualitative study of sibling involvement across two forms of FBT for adolescent AN. Explore families’ experience of sibling involvement in FBT from the perspective of siblings, patients and parents. Manualised FBT; outpatient. Convenience; families attending a program within a specialist ED service were eligible to participate if the adolescent had at least one sibling and had completed FBT two to nine months prior. 12 siblings (10 female, one male) aged 10 to 18, 14 parents (one father, 12 mothers) and seven female patients aged 13 - 17 at data collection. NS Australia Interviews Thematic analysis Lindstedt, Neander, Kjellin and Gustafsson [52] Being me and being us - adolescents’ experiences of treatment for EDs Investigate how YP with AN experience outpatient treatment for EDs, involving family and individual based interventions. Manualised FBT; inpatient Convenience; participants were recruited in collaboration with four ED units. 15 YP (14 female, one male) were treated for AN or EDNOS restrictive over one to two years. Three received FBT, 12 engaged in a blend of FBT and individual sessions. Patients were aged 13 – 19 at treatment. NS Sweden Interviews Hermeneutic phenomenological approach Joyce [53] Patients’ perspective on family therapy for AN: A qualitative onquiry in a chinese context Assess the perceived treatment effectiveness of family therapy from the perspective of families who have completed treatment. SyFT; outpatient Convenience; participants were recruited within an ED service within which the author worked as the families’ family therapist. 24 female YP and their parents treated over two and a half years. Patients were aged 14 - 23 at treatment. Chinese Hong Kong Interviews Content analysis McMahon, Stoddart and Harris [54] Rescripting—A grounded theory study of the contribution that fathers make to FBT when a young person has AN Present a grounded theory of the contribution that fathers make to FBT when a young person has AN. Manualised FBT; outpatient Convenience; participants were recruited from eight CAMH services through HCPs delivering FBT. 15 fathers to a YP with AN (two male, 13 female) who had engaged in FBT. Patients were aged 11 - 17 at treatment. NS Scotland Interviews Classic grounded theory Medway et al. [55] Adolescent development in FBT for AN: Patients’ and parents’ narratives Explore the perspectives of young people and their parents regarding the developmental impact of AN, and the role of FBT in addressing developmental challenges. Manualised FBT; outpatient Convenience; participants were identified from records of families who had received outpatient FBT at an ED service and had completed an adequate number of sessions of phases two and three and were weight restored. 12 young people (11 female, one male) who ceased FBT a minimum one year prior, and one of their parents ( n = 12; 10 mothers, two fathers). Patients were aged 12 - 16 at onset and 16 - 24 at data collection. NS Australia Interviews Narrative inquiry method Nilsen, Hage, Rø, Halvorsen and Oddli [56] External support and personal agency - young persons' reports on recovery after family-based inpatient treatment for AN: a qualitative descriptive study Investigate the reflections of young persons with a lived experience of AN, and what factors they consider important for the recovery process. Inpatient FBT; “The treatment offered did not strictly adhere to manualised outpatient FBT” Convenience; former inpatients were invited to participate following completion of family based inpatient treatment at an ED unit. 33 females and four males who were offered two FBT sessions per week during their admission. The average time from discharge to data collection was four and a half years. Patients were aged 12 - 19.5 at admission and 15.8 - 25.3 at data collection. NS Norway Interviews Thematic analysis Socholotiuk and Young [57] Weight restoration in adolescent anorexia: parents’ goal-directed processes Describe how parents participated in the weight restoration of their adolescent while engaged in FBT for AN. FBT; outpatient Purposive; participants responded to advertisements at local child/youth mental health centres or online. Adolescents could be in the early, middle, or late stages of weight restoration. Three mothers and one mother-father dyad who were actively engaged in FBT. Patients were aged 13 - 16 at treatment. Caucasian ( n = 4), indigenous ( n = 1) Parents were born in Canada ( n = 3) and Western European countries ( n = 2). Canada Video playback and systematic analysis of video recorded conversations. Qualitative action project Wallis et al. [22] Relational containment: Exploring the effect of FBT for AN on familial relationships. Investigate the process of familial relationship change for adolescents with AN and their parents who participated in FBT. Manualised FBT; outpatient Purposive; families who completed a 20-session protocol within an ED service at least six months before an interview with weight greater than 85% expected body weight were invited to participate. 16 female adolescents, 28 parents (15 mothers, 12 fathers) who completed a mean of 33 FBT sessions on average 12.11 months prior to data collection. Patients were 12 - 18 at treatment and 14 - 20 at data collection. NS Australia Interviews Constructionist grounded theory Williams, Wood and Plath [58] Parents’ experiences of family therapy for adolescent AN Examine parents’ experiences of family therapy for adolescents with AN. Manualised FBT (n=6) or SyFT (n=3); outpatient Purposive; parents were eligible to participate if they had received or were undergoing FBT or SyFT in CAMHS, their YP was aged 12 – 18 years at diagnosis, their BMI was in the healthy weight range at data collection, and illness duration was less than three years prior to treatment. Six mothers and three fathers of seven YP (six females, one male). Treatment duration ranged from 0 - 6 to > 36 months. Patients were 13 - 18 at treatment. NS Australia Interviews Interpretative phenomenological analysis Wufong, Rhodes & Conti [32] "We don't really know what else we can do": Parent experiences when adolescent distress persists after the MFT/FBT for AN. Exploration of parents’ experiences of FBT in cases where treatment was discontinued and/or their child continued to experience psychological distress post-treatment. Manualised FBT; outpatient Purposive; participants responded to advertisements distributed through HCP networks. Nine mothers and four fathers of 11 female YP who completed FBT at least one year prior. Patients were aged 12 - 17 at treatment. NS Australia Interviews Critical discursive analysis † NS: Not Specified, YP: Young People, AN: Anorexia Nervosa, ED: Eating Disorder, FBT: Family Based Treatment; HCP: Healthcare Professional; CAMH: Child and Adolescent Mental Health Meta-synthesis findings Six themes relating to factors that helped and hindered positive change in family therapies for AN were identified (Table 4). Table 4 Overview of themes and subthemes Theme Subtheme The psychological underpinnings of Anorexia Nervosa A coping tool for difficulties Attending to young people’s development The therapeutic relationship Young peoples' experience of the therapist Parents' experience of the therapist Confinement to a “script” Neglect of young people's emotional distress Neglect of family distress A disempowering therapeutic context Parents “on trial” Rigid inflexibility versus individualised tailoring Externalisation Loss of the individual to Anorexia Nervosa Separation of Anorexia Nervosa from the individual Family involvement Recruitment of the family to help the young person The parent-young person relationship Changes to family functioning Complex family difficulties and relationships The psychological underpinnings of anorexia nervosa Families considered it important to maintain a holistic focus in treatment in order to attend to the young person's overall wellbeing including their psychological, emotional and social development. A coping tool for difficulties. Young people and their parents described pre-existing psychological, emotional and interpersonal difficulties which made individuation and separation from caregivers difficult [49, 55, 57]. Young people conceptualised their eating behaviours as a "coping strategy"; they used restriction as a tool for regulating emotions associated with low self-esteem, difficult life experiences, relationships, separations and transitions [56]. Some parents conveyed concern that externalising AN as “an illness” overlooked a psychological explanation for eating difficulties: "Something causes it [...] and not being able to treat what causes it, as well as the anorexia itself, trying to separate the two is a problem. And I come back to the need for a more holistic approach [...] something that recognises all the complementary parts and doesn't try and treat one in isolation of the other" [ 58 ]. Families reported how AN further impacted on young people’s development as it withdrew them from normal adolescent activities [55, 56]. Young people described feeling "stuck" and unable to relate to their peers who "continued to develop” [49, 55, 56]. Attending to young peoples’ development. Parents perceived the goals of weight restoration and young peoples’ development as competing and in tension [30, 50, 57, 58]; they considered it crucial to be attentive to balancing these two priorities. The requirement for parents to take responsibility for feeding the young person within phase one led to further developmental regression. Therefore, it was important that later phases of treatment focussed on supporting the development of young people's autonomy [55, 56]. Parents were required to “trust” the process and their young person in order to tolerate anxiety associated with moving away from the structured routines of treatment [56, 57]: “[…] there’s still a part of me that still really worries about it. […], but […] I need to, you know, trust that she is getting better and that she’ll start doing some of the stuff on her own” [ 57 ]. Young people who experienced more significant difficulties with anxiety and separation experienced later phases of treatment as anxiety-provoking and overwhelming; this was a time of increased risk for returning to disordered eating [55]. However, others were motivated to engage in changes to their eating by the prospect of engaging in valued activities [55, 56]: "As I had more control, I felt like I was more free and more able to enjoy my social life or my schooling life or I was able to work... I was like, well this is great...How could I throw it away and go back to something like that?" [ 55] . These young people emphasised the significance of engaging in meaningful aspects of life and redirecting their focus away from food and weight. This included reconnecting within relationships, as well as obtaining a sense of mastery and achievement in important areas of life [55, 56]: "It's been crucial to accomplish high school, to get a driver's license...It feels really great to accomplish those, it's this sense of mastering, which is very important. To feel you can live a pretty normal life, where the focus is on everything else but body and food” [ 56 ]. The therapeutic relationship Families conveyed how the experience of containment in the therapeutic relationship helped to facilitate positive change. Young peoples’ experiences of the therapist. On starting treatment, young people described relief coinciding with significant anxiety associated with the prospect of "letting go of control” [52, 56]: "There were two different sides within me, one saying 'Oh God, this is great, I'm going to get help now’…At the same time, […] 'No, now they're going to destroy what you have achieved, and you who have come this far’" [52] . Young people emphasised the time it took for the development of trust in the therapist before they could hand over control or share their feelings [52]. Feeling able to share their internal experiences was perceived as a catalyst for change [52, 53]: “An important part of the turnaround was when I invited her into my feelings. [...] I started to trust her [therapist]" [52] . Young people desired human connection, understanding, collaboration, compassion, and non-judgement; a therapist who showed genuine interest in them, rather than solely increasing their food-intake and weight [49, 52, 53, 56]. When the therapeutic relationship had these qualities, young people developed confidence and trust in their therapist: "The key to her significant improvement lies in the fact she trusted her [therapist] completely. It's so difficult for her to trust anybody" [Parent, 53 ]. Young people described disengagement in the absence of a positive therapeutic relationship. Some conveyed how their disengagement was influenced by a lack of perceived understanding by their therapist, a lack of positive family relationships, or their disagreement with how weight restoration was achieved [52, 55]. Parents’ experiences of the therapist. A positive therapeutic relationship was important in providing parents with emotional containment [22, 53, 58]. Parents desired a clinician who took an active role in aiding parental understanding and support of the young person, as well as family communication [22, 53, 54, 58]: “She [therapist] knew how to teach us to deal with my daughter’s problem and that’s most memorable” [ 53 ]. The therapist was experienced positively when they had a neutral quality and were compassionate, collaborative, helpful, flexible and placed emphasis on building trust [22, 30, 32, 53, 54, 58]. Parents wanted to feel connected with their therapist, have their concerns contextualised and validated, and their circumstances and values respected [22, 30, 32, 53, 54, 58]: “We have built up mutual trust. There’s genuine concern between her [therapist] and us. She didn’t treat us as if it were her job or profession” [ 53 ]. Moreover, parents wanted to improve their knowledge of AN in order to feel confident in their capacities to help [54, 57]. A lack of adequate information and guidance given by the therapist contributed to a lack of containment experienced within the therapeutic relationship [54]: "[…] It seemed to be pushing all the onus on correction and enforcement on to my wife and I, and nothing coming from the clinicians, no support for us in our battle". [ 54 ]. Some parents perceived the therapist as cold, harsh, scrutinising, condescending and detached [22, 30, 32, 53, 54, 58]. One parent made a distinction between a positive experience of SyFT versus a negative experience of FBT, describing the SyFT therapist as coming "alongside" the family, as opposed to the FBT therapist acting as a "removed expert" [58]. Confinement to a "script" Families conveyed how positive change was hindered by a confined focus on food intake and weight. Neglect of young people's emotional distress . Young people frequently described FBT as an isolating process that ignored "what was going on inside" wherein their parents and therapist did not understand how distressing increasing their eating and weight was [30, 31, 50, 55]: "[…] they just solely focused on my physical health, they didn't really take on much consideration as to my mental health and how much of a toll everything was taking on me" [ 30 ]. Young people desired support with managing the psychological experience of AN and its associated difficulties rather than solely focussing on increasing their food-intake and weight [53]. Areas of importance included motivation, emotions, thoughts, relationship difficulties, self-esteem, body image and identity issues [30, 31, 50, 54, 55, 56]: "Because they never really addressed the underlying problems, it was all so much harder than it probably should have been, because I was still battling with the thoughts and the guilt" [ 52 ]. Some young people felt that important conversations (i.e., the impact of their parent's attitudes to eating and weight) were not sufficiently acknowledged [31]: "We opened old wounds and then they never really got closed I never got to just express how I was really feeling, which is probably why I was so angry, because it was all, like building up inside” [ 31 ]. Some parents emphasised how FBT assumes that weight restoration leads to cognitive change [30, 32]; they expressed concerns that the psychological underpinnings of AN and its associated difficulties were unaddressed by the “FBT script” [30, 31, 32, 50, 51, 55, 56, 57]: "The focus seems to be all on the food aspects […] the food is the end product of the whole problem, what's going on underneath?" [ 32 ]. When young people were not restoring weight in FBT, parents were concerned by the continued confined focus on food intake and weight as the young person became increasingly distressed and conflicts worsened [32]. They questioned whether FBT was doing more harm than good; for some, this led to treatment termination [30, 31, 52]. Neglect of family distress . Parents often described how being redirected to the “FBT script” caused distancing in the therapeutic relationship and reduced confidence about therapy [22, 30, 54, 58]. Many families conveyed a lack of space for the exploration of familial distress and conflict, which for some contributed to family estrangement and exacerbation of distress [30, 58]: "FBT ruined a previously strong relationship and caused my parents and siblings their own psychological unease and detriment. This contributed to a loss of myself and my identity and resulted in further destructive behaviours" [Young person, 31 ]. Parents conveyed how the task of "refeeding" as the solution obscured how demanding, distressing and dilemmatic their experience was. They considered it important to feel resourced emotionally, practically and personally to create capacity for the task of weight restoration; parental management of emotion was significant in this respect [57]. They felt overwhelmed, exhausted, isolated and let down by the therapist when their challenges were not recognised or supported [22, 30, 32, 54]: "[…] it sounds easy in principle, […] when you actually do it at home it's not that easy when a teenager's screaming at the top of her lungs […] you feel a little thrown to the wolves [...] once you close the door of your family home that's it; you're on your own" [ 58 ]. Parents engaged in an internal search for answers regarding the cause for their young person’s eating difficulties to provide them with a sense of coherence and to guide day-to-day decision making [32, 54, 57]. Parents acknowledged the therapists’ attempts to relieve them of guilt and blame with FBT's agnostic aetiological stance, however described the experience of persistent guilt, self-blame and inadequacy [22, 50, 54, 58]: "[…] it felt like, well as a parent, what have we done wrong?” [ 32 ]. Parental co-regulation was a strategy for the management of difficult emotions [30, 57], as were internal processes such as practicing acceptance, managing expectations and finding meaning in adversity [57]. However, practical challenges to parents’ capacity such as the lack of time and financial resources posed significant dilemmas for single parents [57, 58]: “I can’t take any time off work, I don’t have any money, I don’t know how I’m going to help her!” [ 57 ]. A disempowering therapeutic context Families conveyed how the experience of disempowerment in treatment was hindering to positive change. Parents “on trial”. It was important to parents that treatment monitored progress in the overall health and wellbeing of their young person [57]. Attending to markers of progress was a powerful motivator that instilled hope, or revealed what was not working [57]. However, some parents described FBT as a "ruthless", "dogmatic" approach in which they felt "put on trial" [30, 32]. These parents reported to receive blaming, punitive responses from the therapist when there was insufficient weight restoration. Such interactions exacerbated parental guilt and self-blame, causing parents to feel exposed and vulnerable [30, 32]. “I have never been so challenged in my life as a mother. I felt wretched. It's such a fundamental thing to feed and protect your child and anorexia has already challenged that […] then to, on a weekly basis, be in a context (emotional tone to voice) where your failings are on show and also on show to your children" [ 32 ]. Parents reported that these interactions implicitly conveyed how they were failing in their role as parents and at FBT [30, 32], particularly when the therapist endorsed the assumption that "the Maudsley works": " I felt like she was on trial […]. Hayley's failure to put on weight was Margaret's failure to feed her enough ultimately" [ 32 ]. Rigid inflexibility versus individualised tailoring. Some families reported to feel that FBT was “rigid”, “prescribed” and “inflexible” [30, 32]. Many families would have liked more separated sessions in addition to conjoint sessions in order that parents' and young peoples' individual emotional needs could be met [30, 50, 57]. These families reported a lack of tailoring to preferences regarding session format and content, treatment duration, ending, and opportunity to have a follow up [30, 50, 54]: "The rigidity and inflexibility [,,,] was such a shame […] because [...] the heavy lifting was done, which was the trust [...]. The lack of progress or our frustration or anything to just flex the approach and to lean on the trust that had been built. Well, I think we'd have gone to the edge of the earth with her you know until it became so rigid, dogmatic […]" [Parent, 30 ]. Some families reported that time-limited FBT was not sufficient to support a full recovery [32, 50, 52]. Young people wanted the therapist to be attuned to their needs and to make a collaborative decision rather than ending treatment on reaching a “target weight” [52]. The therapists’ perceived assumption that they were psychologically recovered on reaching a healthy weight evoked feelings of anger and abandonment: "OK, now you have reached normal weight - so now you are well again. The simple fact that I had put on weight meant that everything was fine, and that was all there was to it. I felt like…I'm not prepared to walk out weighing like this, if you leave me, I will start losing weight again” [ 52 ]. Externalisation Externalisation could help and hinder positive change depending on how it was used and its effects on the individual and their relationships. Loss of the individual to Anorexia Nervosa. Some parents described how young people were spoken about rather than with as a result of externalisation, which contributed to a perceived loss of the young person’s voice and identity [30, 32]: "[…] I accept that when she was very sick, […] we talk in these beautiful terms of ‘It was the eating disorder and not Hayley in the room' […] but effectively Hayley was still in the room but she was treated as though she wasn't” [ 30 ]. Some young people did not find it helpful for others to perceive of them as being under the influence of an external entity because they felt unseen and unheard [30, 31]. Moreover, externalising conversations that highlighted family member burden due to AN were particularly difficult for some young people as they evoked guilt and shame. Instead, young people wanted their voice to be actively sought and to be given ownership over session content, rather than feel “talked about” and instructed what to do in an impersonalised manner [30, 52]: "[...] the fact that you had an eating disorder meant they were dismissive of anything you say, they believed anything you say was completely motivated by the eating disorder [...]. I was very distressed by that because I thought I'm still me, I'm still here, I can recognise that I have anxiety and unhelpful thoughts but I can still communicate as a person” [ 31 ]. In contrast, a collaborative involvement in treatment fostered greater security and safety in the young person’s relationships with their therapist and family [30, 49, 52, 56]. Feeling seen as a person beyond AN helped to build young people’s sense of self, rather than reinforce an illness identity through the exclusion of their voice. Separation of Anorexia Nervosa from the individual. At the start of treatment, conceptualising AN as an ‘unwanted temporary illness’ enabled parents to channel difficult emotions into “fighting” AN [22, 30, 31, 32, 50]: "There was Sally and there was the eating disorder and once you separate them you realise that she is still there and we're fighting the eating disorder and she is too. [...] it wasn't just her doing this to herself" [ 32 ]. However, it was important that externalising conversations validated the young person’s lived experience. For instance, Venn diagrams acknowledging overlaps between the identity of the young person and that of AN, as well as engaging in chair work to speak to AN were described as meeting young peoples' emotional and psychological needs [31]: "[…] they’d be like, what would your eating disorder say to this? Now sit in this chair and it'd be like, what would you say to this? [...] that was helpful, but they just didn't do it enough. Like, it was just so much about food but they needed to care about my feelings" [ 31 ]. Young people emphasised the significance of transitioning from “denial” to “realisation” through externalising conversations which elicited the young person's voice and facilitated reflection on their personal values and life aspirations [30, 56]. "Ask yourself, why, why do you do this? What do you want to get out of your life? What are your true dreams? What is your greatest wish?" [ 56 ]. Young people acknowledged the importance, yet difficulty, of becoming aware of AN’s negative effects and its function in their lives: "It's important to realize and see more clearly the negative influences the ED has, because it is, after all, a way of handling difficulties or mastering life. […] It's not easy to be attentive to the negative consequences the ED will have" [ 56 ]. Young people stressed their anxieties and resistance to making changes to their eating. However, they tolerated difficult feelings in the service of their commitment to a preferred identity underpinned by their personal values [56]: "I haven't thought much about having kids. Still, I think it is important to stay in treatment, because I want to be able to take good care of my kids, which is a huge motivation for me” [ 56 ]. Family involvement Interventions aimed at improving parental understanding and management of AN, as well as family functioning were supportive of positive change. Improving parental understanding and management of AN: Parents entered treatment feeling powerless, not knowing how to help their young person [58]. For some, the structure and guidance on commencing FBT provided direction which instilled hope [22, 30, 31, 32, 52, 57, 58]: "I felt totally out of control. […] So, having a plan just made me feel like I had something secure to-to work on, to work with, to trust in" [ 32 ]. One mother conveyed how FBT gave her permission and resources to challenge their young person's eating behaviour: "Treatment gave me tools and framework and a structure and permission I suppose" [ 22 ]. Some young people experienced relief, safety and security when control over their eating was taken away [22, 30, 31]. Most young people acknowledged that they would not have restored weight without parental support [22, 30, 31, 56]: "[…] I don't think I would have been able to gain that weight and get to the medically stable point if it had sort of been all up to me. […] I still definitely needed my family support because […] even if it was unintentionally, I would've just slipped back […]” [ 30 ]. Parents reflected on the potential of AN to undermine the marital relationship and the importance of parental unification and partnership which involved co-parent coordination and negotiation [32, 54, 56, 57, 58]. It was helpful when treatment scaffolded the sharing of roles and responsibilities between co-parents to ease parental burden as well as to ensure that both parents were engaged in changes conducive to young peoples’ recovery [57, 58]: "We were a joint force. I think if you can work together really quickly it helps because an eating disorder can get around one of you, but if it knows that dad's there backing up everything that mum says and vice-versa […]" [ 32 ]. Parents who were not supported in treatment by their co-parent would have liked to have shared parental responsibility and were concerned about their co-parent’s lack of understanding for their young person's difficulties [57, 58]. In the context of parental separation, it was important that both parents pulled together to preserve the young person’s sense of unified family support [58]. This necessitated parental acceptance of disparate parenting philosophies and weight-restoration strategies [58]: “At first it was like, […] “Hello? Uh, that’s not happening”. And then, you know, it’s like, “Actually, we need to do this for [our daughter]. Darn. Okay”. So suck it up, bury those emotions” [ 58 ]. Strengthening of the parent-young person relationship. Whilst some parents felt that treatment disrupted the parent-young person relationship [30, 31], others felt it helped them to maintain a connection with their young person. Some parents described personal changes which served to strengthen the parent-young person relationship, for instance becoming firmer with boundaries, more resilient and emotionally attuned [22, 32, 54, 57, 58]: "I was one of these people who didn't show my emotions much, very tough orientated, very much the job at hand...once I understood what anorexia was like for my son, it helped me change. Now I've let my guard down and let people in. […] It’s [AN] made me a better person and a better parent...” [ 58 ]. Young people acknowledged how difficult it was for their parents to understand AN, however their efforts to do so made them feel worthy of care [31, 52, 55, 56]. In the context of relationships in which young people felt seen, heard and cared for, they were more accepting of the structures put in place to support them with eating [22, 30, 31, 52, 56]. Thus, young people found it helpful when the therapist mobilised supportive, understanding relationships [31, 52, 55]: "[...] it definitely did teach my family […] and […] educated them on what would be helpful for me and what wouldn't be helpful. And I think it was nice not to feel alone; it was nice to have my family there" [ 31 ]. Parental capacity to take non-coercive control over the young person’s eating appeared to be influenced by parents’ capacity to tolerate the young person’s distress [22]. When treatment contained parental anxiety and increased parental confidence, parents had greater capacity to provide emotional containment to the young person [22, 57]. Consequently, over time young people experienced greater security, safety and trust in the parent-young person relationship and were able to replace control with trust in others [22, 30, 52, 55, 57]: "I felt the need to be in control but […] I sort of had to put my trust in to them that they were going to take care of me" [ 22 ]. Increased relational security in the parent-young person relationship was depicted by young people as learning to understand each other, reduced parental criticism, and increased parental provision of emotional support and reassurance [22]. “They tried to be as understanding as they could be [parents] […] it helped because for the first time I didn't actually shun them, I went to them...it's so weird cause for the first time in my life I let myself depend on someone else" [ 22 ]. Parents perceived the quality of connection between themselves and their young person as a tangible marker of positive progress in treatment [22, 57]. These relational changes had a positive impact on young peoples’ attachment system and sense of selves. Young people described reduced self-criticism, improved confidence, greater self-acceptance, increased capacity to trust others and in turn, in their selves [22, 57]. Parents described reduced secretiveness, increased resilience and emotional expressiveness in their young person [22, 57]. Changes to family functioning. Many families entered treatment with strained family relationships. Some young people felt they were a “burden” and "a stranger" within their family [22]: "We weren't being like a family, a bit separated, like I was separated from everyone else in the family" [ 22 ]. In the context of family sessions which permitted space for therapeutic focus on relationships, positive changes to family functioning were reported, including improved communication, cohesion and problem-solving skills; increased honesty, openness and closeness; mutual understanding and trust; emotional awareness and tolerance; reduced conflict, criticism and blame; and increased capability and compatibility [22, 32, 49, 50, 51, 52, 53, 54, 57, 58]. Having a safe, contained space for difficult conversations helped to reduce emotional disconnection: "They […] guided us through […] very hard conversations. Hard as in about feelings, about guilt, about perceptions, and about the effects it had on us [...] I think as a family we've grown a lot closer [...]" [Parent, 32 ]. Families often described more space to focus on the family system within SyFT [49, 53, 58]. They valued the therapist's directiveness on what needed to change, and their appreciation for each person's feelings and views [53]. These processes helped young people to share their feelings: "What helped most is to talk about my feelings without any reservation. She helped everyone to speak out, including those who didn't talk much" [Young person, 53 ]. Some fathers became more involved in their young person's life practically and emotionally through their involvement in treatment [22, 49, 54]. One young person described how her father’s involvement helped to reduce the disconnection between them: "[…] I can see that my father also tries to show concern for me. That feeling has been lost for years. He loves me and really wants to help me" [ 49 ]. Siblings struggled to understand AN and wanted to be included in treatment [51, 52]. When siblings were not included, sibling-relationship ruptures were often left unrepaired causing young people to experience loss, sadness and guilt. Families reported positive aspects of sibling involvement, including increased understanding and unified support, increased closeness in the sibling relationship, reduced sibling worry, greater transparency in the family system and opportunity to clarify appropriate family roles [51]: "I think it made it so [sibling] understood […] what was going on. So it wasn't like she was kept in the dark and we were trying to avoid talking about it to her. So she was a bit more aware of what was going on and she didn't feel left out of it. She knew what not to say […]" [ 51 ]. Complex family difficulties and relationships. It was important that treatment addressed parental belief systems which served to maintain young peoples’ disordered relationships with eating and weight [31, 57]. One mother viewed slimness to confer protective factors for their young person and thus experienced challenge and unease during the process of refeeding. In order for treatment to facilitate weight restoration, the mother’s own beliefs in relation to eating and weight needed to be explored and addressed as an ongoing process: “The thinner you are, the more beautiful you are, the easier the world is for you. I truly...believe that. […] You want your kid to be....to fit in, […] and obviously that’s easier if you look a certain way […]. What if they’re wrong? What if they make her gain too much weight, and then…and then she feels like she’s...too heavy”[ 57 ]. Young people did not perceive parental involvement to be helpful when they did not have trusting relationships with their parents, or when they had family difficulties which were not openly discussed in treatment [22, 52, 55]. They expressed uncertainty about what they were able to share due to concerns about disclosing their parents' own difficulties, or revealing family conflict: "My parents have alcohol problems […] I preferred going on my own. [...] the fact is I never told anyone at the eating disorder unit. [...] I was so ashamed […] I was so dead scared of what might happen if they learnt about it" [ 52 ]. These young people explained how there were difficulties which felt out of their control that they needed help with before letting go of control over their eating [55]; they described poorer relationships with parents, family conflict and high expressed emotions at home. Unresolved family difficulties and conflicts led to unrepaired ruptures and disconnection in their family relationships following treatment. Some families for whom relational change did not eventuate were experiencing grief, loss and trauma [22]. For example, one young person explained that previous abuse in the family impacted on her ability to trust her parents [22]: "[…] I didn't trust my parents [...] it would just have been so strange to have my mum sitting there. Then I would not have dared to be honest in the same way" [ 52 ]. Discussion This meta-synthesis explored the processes of change in family therapies for AN, elucidating factors that help and hinder recovery from the perspectives of young people and their families. The narratives depict several therapeutic processes which are integral to facilitating positive change including psychological formulation, the therapeutic relationship, emotional attunement, family involvement and family empowerment. These findings are discussed in relation to existing research, theory and their clinical implications. Psychological formulation Restriction provided young people with a sense of control over psychological and emotional difficulties, however it also resulted in the loss of agency and stalled development. Whilst treatment often failed to explore and address the psychological underpinnings of AN, parental re-feeding was often successful at supporting physical recovery and enabling young people to return to developmentally appropriate activities. Some young people experienced their return to valued activities reinforcing of their sense of personal agency which had a positive impact on their recovery. Research demonstrates how shifts in motivation for change occur in parallel with shifts in values and self-definitions through a process of identity renegotiation [59]. The findings alongside existing research underscore the significance of relinquishing control, self-discovery, and the development of a new identity in recovery from an ED which provides a false sense of security [60, 61, 62]. Accordingly, empowering young people to identify and return to developmentally appropriate activities that bring personal meaning and identity may support them in working towards and maintaining recovery in FBT/SyFT. The finding that FBT’s agnostic aetiological stance does not alleviate parental guilt and blame is consistent with existing research. Carers are often perplexed by ANs cause, place blame on themselves and question their parenting [63, 64]. Hence, they place value on the opportunity to improve their understanding [65]. Caregiver cognitive appraisals relating to their understanding of AN are important because they have a direct impact on caregiver self-efficacy, the caregiving experience and their responses to the individual with AN [63]. This meta-synthesis suggests that some parents feel frustrated by FBT’s agnostic aetiological stance and continue to seek a causal explanation for their young person’s eating difficulties. The findings suggest that the illness metaphor may have contributed to a neglect of psychological formulation for the young person’s eating difficulties. In turn, families experienced concern regarding FBT’s efficacy in meeting young peoples’ psychological and emotional needs. Some FBT clinicians experience the illness metaphor dilemmatic as it does not fit with their psycho-social understanding of EDs, however they continue to use it as recommended in the manual [66]. Baudinet, Simic and Eisler [67] underscore the importance psychological formulation in ED-focussed family therapy; proposing that it is through the formulation that treatment can be adjusted to target maintenance factors specific to individual families and that barriers to progress can be identified and overcome. Moreover, formulating collaboratively with a family can create a shared narrative about the problem and support the development of therapeutic alliance [68]. It has been proposed that AN arises from emotional processing difficulties resulting in a ‘lost sense of emotional self’ which ‘self-perpetuates’ and ‘relentlessly deepens’ [69]. Psychological factors including obsessive-compulsive personality traits, perfectionism, extreme need for self-control, cognitive rigidity, experiential avoidance, positive beliefs about the value/function of AN, and responses from close others play a significant role in its maintenance [70, 71, 72]. Developing a psychological formulation would help therapists to develop a holistic understanding of the young person within their family context, prioritise which issues to focus on, and select interventions to address not only the physical symptoms of AN, but also its psychological underpinnings. The therapeutic relationship The therapist's knowledge, flexibility and willingness to come alongside the family were significant in supporting positive change. The findings support reviews which point to the significance of building trusting therapeutic relationships with young people and families [1, 20]. They also support studies which demonstrate significant associations between therapeutic alliance, treatment retention and outcome for individuals with AN [73, 74, 75, 76] Entering a therapeutic relationship required young people to relinquish control and place trust in others which necessitated the tolerance of heightened distress. A common theme raised by families is a concern about the lack of therapeutic alliance in treatment for AN [1, 77]. The findings in combination with existing research suggest that individuals want to feel seen and treated as a ‘whole person’, within a ‘real’ relationship with a therapist who is attuned to their emotional and psychological experiences rather than neglectful of their distress in the pursuit of weight restoration [1, 17, 18, 19, 20, 78, 79]. Attention to building and maintaining a strong therapeutic alliance with young people and their families by attending to and repairing ruptures, seeking to accurately understand their experiences, clarifying expectations and mutually agreeing treatment goals appear crucial to facilitating positive change. Negative experiences of the therapeutic relationship were more common within FBT than SyFT. Manual-based treatments have been criticised for contributing to ‘bland’, ‘rule governed’, and ‘emotionally detached’ therapy [80]. Clinical situations can differ from the tightly controlled conditions of a clinical research study in which evidence for a manual-based treatment is developed as clinicians are often required to adapt their practice to meet individual needs [81]. Therefore, it has been argued that while fidelity is a crucial component of successful evidence-based psychotherapy, flexible implementation allowing for deviation from the manual to individualise treatment is necessary [81]. The findings alongside existing research stress a need for greater flexibility in the delivery of FBT. Emotional attunement Many young people reported to feel that what they were experiencing internally “did not matter” within FBT. Some healthcare professionals (HCPs) treating AN feel that the biomedical model supports them to define target symptoms and goals for recovery, however families perceive the model to place too much focus on the physical, ignoring psychological distress [20]. This meta-synthesis alongside existing research illustrates how families seek a holistic individually-adapted treatment that is flexible, and considers the psychology of the young person’s eating behaviour, as well as their family environment [1, 17, 18, 20]. Some FBT clinicians assume that weight restoration is the primary agent of cognitive symptom relief through the alleviation of cognitive rigidity resulting from starvation [82]. However, this meta-synthesis alongside existing research suggests that the psychological experience of AN can persist beyond weight restoration [83]. Thus, therapists should be cognisant of the messages conveyed to families through holding this assumption as they may risk invalidating families and hindering the alliance. The findings suggests that whilst FBT can support weight restoration, many young people experience ongoing difficulties in their relationship to eating and weight which they would like support for within individual therapy, alongside and/or following completion of FBT/SyFT. Some HCPs working within ED services express a lack of knowledge about EDs, and perceive limitations in their capacity to help [20, 84, 85, 86, 87]. ED groups are considered difficult to treat because they present with physical and psychological risks, as well as ambivalence [87]. For clinicians, the FBT “script” can be experienced as a relief in terms of managing their own anxiety [84]. Yet, the manual can also be experienced as constraining, morally dilemmatic and burdensome when there is no positive change; nonetheless, clinicians fear scrutiny if they do not practice with strict adherence [84]. The narratives within this meta-synthesis reveal the impact of this dilemma on therapeutic change. Whilst therapists’ drift from evidence-based practice is suggested to reduce treatment effectiveness [88], adherence to the FBT manual is not associated with outcome as determined by weight [89]. This meta-synthesis suggests that strict adherence to the FBT manual may reduce therapist attunement, which in turn may hinder positive change by negatively impacting on the alliance. Research has shown that family therapy focussing on intra-familial dynamics rather than ED symptoms improves treatment effectiveness in severe adolescent AN, indicating the broader impact of family therapy beyond the effects of parental management of eating behaviours [90]. Research comparing manualised ED-focussed family therapy (FT-AN) with a generic systemic manual (SyFT) found that those who engaged in FT-AN restored weight more promptly in treatment and spent less time in hospital than those who engaged in SyFT, whereas individuals with greater obsessive-compulsive comorbidity restored more weight over the course of treatment in SyFT than in FT-AN [91]. Therefore, there is likely to be overlap between SyFT and FBT/FT-AN in terms of guidance on managing eating behaviours, however therapists delivering SyFT may have greater capacity to be attuned and responsive to individual needs as a result of feeling less constrained by the FBT manual. Evidence-based family therapy models of AN require more flexible, normative, less guilt-inducing, diversified, elective and integrative practices [92]. If FBT and SyFT achieve equivalent outcomes, and SyFT may be more effective at addressing comorbidity and creating a family environment conducive to positive change, there may be scope to expand focus beyond food-intake and weight within FBT. With greater flexibility and integration of models, therapists could attend to the psychological and emotional e xperience of AN, as well as the individual’s relational context which may provide families with a greater sense of containment. It has been suggested that FBT can be enhanced by integrating Emotion-Focussed Family Therapy (EFFT) with the aims of working with parents’ own emotions and supporting parents to equip the young person with emotion regulation skills [93]. Families highlighted dissatisfaction with FBT for neglecting their emotional experiences. Hence, the findings support the integration of EFFT to aid therapeutic change in FBT/SyFT. Empowering families Some parents perceived a harsh response from the therapist in the absence of sufficient weight restoration during FBT. In the context of non-successful outcomes, FBT clinicians often attribute causality to parents or family systems factors [82]; this assumption aligns with parents’ narratives within this meta-synthesis. Parental self-blame has been captured within this study, as well as in existing research [64]. Concerningly, interactions which inadvertently disempower parents may hinder positive change by negatively impacting on the therapeutic relationship and reducing parental self-efficacy. Furthermore, the findings suggest that positive change can be hindered by the experience of rigidity and inflexibility within FBT. Lock and Nicholls [94] maintain that whilst FBT initially targets weight restoration, it also addresses temperament/personality traits, emotional processing, cognitive content and process, social communication and relationships, comorbidity and family factors. However, some families did not feel that they were given sufficient opportunity to address such factors. Lavender [77] asserts that it is possible to achieve a full recovery using FBT and suggests that allowing the young person more individual time can support with alliance building, with phase three being extended to focus on areas of difficulty that made the young person vulnerable to AN. This meta-synthesis suggests that therapeutic change may be helped through the provision of greater flexibility in terms of treatment duration, content and format. Externalisation The finding that the conceptualisation of AN as an ‘unwanted temporary illness’ was mobilising of parental compassion and support is consistent with the FBT manual which suggests that viewing AN as an external force gives new meaning to AN’s physical, psychological and behavioural effects [10, 11]. FBT clinicians report that externalisation can improve family functioning, communication, and reduce family conflict; however, they also highlight the importance of listening skills and attunement to identify how and when to time externalisation, including recognition of when a family may not benefit [66]. This meta-synthesis provides further insight by demonstrating how externalising language can cause relational disconnection when young people feel unseen and unheard because all of their views and behaviours are ascribed to AN. The findings are consistent with existing research in that they underscore a prevalent negative experience of ED service-users which is feeling treated as an ‘illness’ [1, 18, 95]. It has been suggested that implicit value judgement carried by ‘illness’ may lead to negative interactions between service-users and healthcare professionals resulting in epistemic injustice [96]. This meta-synthesis alongside existing research demonstrates that individuals value a non-judgemental, respectful and supportive therapist [31]. Therefore,therapists should be careful that their use of externalisation enables individuals to feel recognised and respected as a person beyond AN. Conversations in which the therapist actively involved the young person to reflect on their values and aspirations alongside exploration of the function and effects of their eating behaviours helped to separate AN from the young person’s identity. Motivation, insight and subjective meaning of AN are valuable tools to manage resistance [97]. Successful treatment facilitates the development of an identity that is separate to and broader than that defined AN [98]. Hence, an important part of motivating young people to engage in changes to their eating behaviour may be to engage them in externalising conversations which place emphasis on identity development. Accordingly, practicing externalisation with adherence to the principles of narrative therapy may positively impact on therapeutic change in FBT/SyFT. Family involvement The finding that parental involvement was important for physical recovery aligns with the reports of FBT clinicians that parental input is crucial for weight-based symptom remission [82]. Parents experience fear related to their involvement in the recovery process [99]; maternal fear predicts lower self-efficacy, as well as more accommodating and enabling behaviours. This meta-synthesis highlights the importance of supporting parents to feel equipped in helping their young person to manage AN. Parents experienced containment within treatment when they felt supported by their therapist. In turn, they were able to provide their young person with containment through becoming emotionally attuned, understanding and validating of their experiences. Containment denotes the relational ability to ‘hold’ the emotion that the other person needs held and to create a felt sense of safety in the relational space [100, 101] Attunement refers to the parent’s awareness of and responsiveness to the young person’s emotions and needs, and ability to stay present with them even when that feels difficult [102]. The effect is that the young person feels understood, seen and felt with by the parent; this attuning process grows the capacity for felt safety in relationships [102]. The findings are consistent with research which has shown that increases in parental self-efficacy throughout treatment predict reduced ED, depression and anxiety symptoms [103]. It is possible that when parents feel ‘held’ by the therapist, they feel more confident in their ability to support their young person, which in turn enables the young person to feel more ‘held’ within their family system. The narratives depict how positive relational changes within the parent-young person relationship were internalised by young people, and in turn positively impacted on young peoples' emotional and psychological wellbeing. Hence, this meta-synthesis supports quantitative research which demonstrates that FBT/SyFT can support positive changes to the parent-young person relationship, which in turn has a positive impact on outcome [37]. Positive affective family relationships are crucial with respect to adolescent eating behaviour and emotional adaptive psychological functioning [21]. The findings alongside existing research underscore the importance of nurturing secure parent-adolescent attachment relationships to support positive change. This meta-synthesis uncovered narratives of intergenerational patterns in emotional expression and interpersonal relating that impacted the parent-young person relationship [58], as well as the intergenerational transmission of attitudes towards eating and weight [31]. Exploring transgenerational family relationship patterns and their influence in the development of coping strategies and identity within individuals experiencing AN can determine areas for development in the family, as well as treatment strategies [104]. This meta-synthesis underscores the importance of family involvement and the value of therapeutic space to focus on family relationships. However, there was greater opportunity to enhance family unity within SyFT than in FBT. Thus, the findings suggest that families may benefit from greater systemic family focus within FBT. Relatedly, the findings underscore the importance of scaffolding parental unification in the treatment of AN. Research suggests that the presence of co-parental conflict is associated with lower adolescent BMI and to more dysfunctional family functioning [105]. Hence, attending to the co-parent relationship within FBT/SyFT may help to support positive change. Assessing and modifying family functioning early in treatment may be of benefit to young people who have more complex family difficulties. Adolescents experiencing AN present with more severe psychological profiles within families that display more severe dysfunctional profiles [106]. Research indicates a bio-directional relationship between family dysfunction and AN, with difficult dynamics and unhelpful cycles becoming entrenched [107]. Families of adolescents with AN often report interpersonal boundary problems, low conflict tolerance, and low general satisfaction within the family system [108]. Adolescents who report more positive views of their family at the start of treatment have better outcomes in FBT [109]; hence, it is important to assess family functioning in order that adolescent reported impairment can promote the delivery of FBT with greater relational focus. This modification may foster relational containment within the young person’s family system, creating a conducive environment for reducing disordered eating. Attachment-Based FBT can serve as a beneficial augmentation through its focus on repairing factors that impact relational security and maintain AN (i.e., parental criticism and low warmth, family conflict and adolescent affect intolerance) [29]. Research on attachment and narrative theory in SyFT indicates the common presence of extreme separation anxiety, unresolved trauma and loss, as well as conflict avoidance and difficulties discussing relationships and feelings consistent with transgenerational experiences of insecure/avoidant attachments in young people with EDs and their families [27, 110]. These authors suggest that helping families to explore their experiences from a secure base can foster ability to reflect on their relationships, externalise the past, and relate to one another in emotionally different ways. Hence, an attachment-informed relational focus in FBT/SyFT may support positive change for families experiencing more complex relational difficulties. Lastly, this meta-synthesis illustrates how weight restoration takes place within relational systems that are shaped by sociocultural and other contextual variables. Recognising factors which under-resource parents such as the influence of financial strain and time constraints is important, particularly for those who are unsupported by a co-parent. Research suggests that socioeconomic factors do not predict outcome in FBT [111], however this meta-synthesis reveals how some families are faced with significant challenge when they are required to reduce their income to fulfil the role required of them within FBT. This may become more problematic in the global cost-of-living crisis [112]. To support positive change, future research and ED services could give consideration to adaptations that may support families who struggle to meet the demands of FBT in the face of socio-economic pressures. Strengths, limitations and future research A limitation of this review is that the systematic search strategy did not include the term ‘young adults’. This is because FBT is the first line recommended treatment for adolescent AN [113], whereas young adults may be offered individual CBT-ED or MANTRA as first line treatments for AN [114]. Therefore, the review initially set out to include studies gathering the perspectives of adolescents and their family members. However, following having completed the searches, it was evident that many studies included both adolescents and young adults, using the term ‘young people’ to describe their sample. Consequently, given the lack of existing research on change processes within family therapies for AN, the decision was made to be inclusive by including studies that collected data from both adolescents, young adults and their family members. Nonetheless, the United Nations define ‘youth’ as persons between the ages of 14 and 24 years [115] the NHS uses the term ‘young people’ to classify individuals aged 16 to 24 years [116] and the World Health Organisation defines ‘young persons’ as those aged 10 to 24 years [117]. Therefore, it is possible that this limitation was somewhat mitigated through inclusion of the search terms ‘youth’ and ‘young people’. A further limitation is that a large proportion of patients were female and ethnic background was rarely reported. This information may have provided insight into differences in perceptions of therapeutic change across ethnicities and genders. Both gender and ethnicity influence the experience of AN [118, 119]. Therefore, whilst it is difficult to make conclusions about the ethnicity of participants represented within this review, the experience of those who identify as male or non-binary are under-represented. Reporting ethnicity in future studies and increasing the diversity of samples may enhance our understanding of under-researched groups. Moreover, attempts to narrow the search strategy to ensure the study’s feasibility within a restricted timeframe resulted in the exclusion of unpublished studies which may have contributed to the loss of information [120]. However, unpublished studies may be of lower methodological quality [121]. Alongside the consideration of conceptual quality which is an important component of qualitative research [122], the methodological quality of included studies was critically appraised using the CASP tool. Nevertheless, studies often lacked sufficient detail to answer all items on this tool, in which case the item was scored zero. Studies rarely engaged in reflexivity in relation to their position as a researcher which is an important considerstion in qualitative research [123]. Future research should aim to report how the researcher has examined their own influence on all parts of the research process. Lastly, the findings illuminate the need to explore the role of the therapist in establishing and maintaining a strong therapeutic alliance in FBT/SyFT as this was a key driver of therapeutic change. This review’s suggested changes to FBT could be evaluated using measures of therapeutic alliance, family functioning, ED symptoms and common comorbidities. Conclusion This review highlights the importance of facilitating positive relational changes within the family system, exploring, understanding and addressing the psychological and emotional experiences of AN, supporting young people to return to valued activities, and creating an empowering and supportive therapeutic context in which young people and their families experience containment within the therapeutic relationship. Young people and families perceived positive change to be hindered by inflexibility in the treatment approach, a lack of positive therapeutic alliance and attunement to their emotional experiences, counter-effects of externalisation such as the exclusion of the individual’s voice, and a narrow focus on food-intake and weight. The findings can be utilised by ED services to consider how they may adapt to the needs of young people and their families. For example, by broadening the focus of treatment beyond restoring food intake and weight to attending to the young person's emotional needs and facilitating relational containment within their family system. Abbreviations UK: United Kingdom AN: Anorexia nervosa ED: Eating disorder FBT: Family based treatment for Anorexia nervosa FT-AN: Family therapy for Anorexia nervosa Declarations Acknowledgements I (the first author; SC) express my appreciation to the researchers and participants who have contributed to research within the eating disorders field. All of this existing work made for a rich and enlightening experience conducting this review. Author contributions SC conducted this research as part of their thesis on the Doctorate in Clinical Psychology at UCL. SC and MP conceptualised the review. SC led on the systematic search, quality appraisal, data analysis, and write up of this manuscript. MP and LS supervised the study, and edited the final manuscript. All authors reviewed the final manuscript. Funding This research was funded by the University College of London. Availability of data and materials The data supporting the results in this paper are accessible through the published primary studies from which the data (results and discussion sections) were extracted for analysis. Human ethics and consent to participate Not applicable. Consent for publication Not applicable. Competing interests The authors declare they have no competing interests. Author details Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, United Kingdom, WC1E 6BT References Sibeoni J, Orri M, Valentin M, Podlipski MA, Colin S, Pradere J, Revah-Levy A. Metasynthesis of the views about treatment of anorexia nervosa in adolescents: perspectives of adolescents, parents, and professionals. PloS one. 2017;12(1):e0169493. https://doi.org/10.1371/journal.pone.0169493 van Hoeken D, Hoek HW. Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. 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Inclusive content – Age - How to talk about different age groups and stages of life. 2021. https://service-manual.nhs.uk/content/inclusive-content/age#:~:text=child%3A%204%20to%2012%20years,18%20but%20this%20may%20vary. World Health Organisation. Pan American Health Organisation: Adolescent Health. n.d https://www.paho.org/en/topics/adolescent-health#:~:text=Adolescents%20represent%20the%20well%2Dbeing,10%20and%2024%20years%20old. Acle A, Cook BJ, Siegfried N, Beasley T. Cultural Considerations in the Treatment of Eating Disorders among Racial/Ethnic Minorities: A Systematic Review. Journal of Cross-Cultural Psychology. 2021;52(5):468–88. https://doi.org/10.1177/00220221211017664 Thapliyal, P., Hay, P., & Conti, J. (2018). Role of gender in the treatment experiences of people with an eating disorder: a metasynthesis. Journal of Eating Disorders , 6 (1). https://doi.org/10.1186/s40337-018-0207-1 Petticrew M, Egan M, Thomson H, Hamilton V, Kunkler R, Roberts H. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4059211","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":288696668,"identity":"52553f3e-8176-4c3b-9aaf-f3c61c8fc732","order_by":0,"name":"Sophie Cripps","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABOElEQVRIie2Rv0rDQBjAvxDodG3WL1aTV7gSqIJ5mBxCu9i9Q5ADIV2UrhHFlygUx4RAssTOEZdm9wGyVL1rWmxj6+xwv+Xuvrsf358DUCj+Jy3w5KKvDy4xQOdigzLE1zH8WxlYJte2inZc2SFxaLR5eUyxJ/fpcjkG+3zSTssKdDbL4uDk7eUCaBZzqHxgD3xPofliSL0cek9JZ+gQaLF5zoLuKEdxxbh2lwJ73M9C8bqPLAAPddLvAhA2j6QSCKUQhbU5sOdGYaFUPmvFrADZbFr+KNrqtwKFVHitIAHqUNzJossszcLyxQC9FHuhLnuhnoVFeXspFGKKXpLTFJ1G+3JiZuW7NhqvYmLjL2JMr+L3UXBjdbIkLj989yyMGpWR7eiJ+CDaiEeHPrK+go2iUCgUigN8A9rdarBnqKh7AAAAAElFTkSuQmCC","orcid":"","institution":"University College London","correspondingAuthor":true,"prefix":"","firstName":"Sophie","middleName":"","lastName":"Cripps","suffix":""},{"id":288696670,"identity":"d09d7e2f-9acb-4aca-af3c-d115dd44b2b6","order_by":1,"name":"Lucy Serpell","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Lucy","middleName":"","lastName":"Serpell","suffix":""},{"id":288696671,"identity":"4ed0d870-c44f-4f56-9ab0-1e565d8f05a1","order_by":2,"name":"Matthew Pugh","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"","lastName":"Pugh","suffix":""}],"badges":[],"createdAt":"2024-03-09 19:06:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4059211/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4059211/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40337-024-01037-5","type":"published","date":"2024-07-25T16:16:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61596388,"identity":"edd44604-e52f-4d2f-8a64-c0e535eba7b9","added_by":"auto","created_at":"2024-08-01 17:27:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1173090,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4059211/v1/299db38b-88ce-4d2e-9a3b-d374d210fa40.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Processes of change in family therapies for anorexia nervosa: a systematic review and meta-synthesis of qualitative data","fulltext":[{"header":"Plain English summary","content":"\u003cp\u003eThis review synthesises the views of young people and their family members regarding their perspectives of therapeutic change within family therapies for Anorexia Nervosa (AN), including both manualised family-based treatment (FBT/ FT-AN) and systemic family therapy (SyFT), to understand which aspects of these treatment approaches are helpful versus hindering to recovery from an eating disorder. Parental involvement was crucial in facilitating the restoration of physical health through the process parents taking temporary responsibility for the young person\u0026apos;s eating behaviours until they can feed themselves again. However, treatment often failed to acknowledge and address the psychological and emotional difficulties that made the young person vulnerable to developing AN, as well as the psychological distress caused by increasing food-intake and weight. A positive therapeutic relationship in which families felt well supported by their therapist was important in providing containment during a time of familial strain and instability, yet there was a need for greater flexibility and individualisation within manualised FBT. The findings highlight the importance of eliciting the young person\u0026rsquo;s voice to enhance their personal agency in treatment, as well as the value of therapeutic space to improve family functioning and enhance family unity.\u0026nbsp;\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eCharacterised by excessive preoccupation with control over body weight and eating resulting in life-threatening physical effects, Anorexia Nervosa (AN) has significant emotional, social and relational implications for the individual and their family [1, 2, 3]. Whilst the onset is typically in adolescence, AN can continue into adulthood [4]. The aetiology of AN is complex and multifactorial [5]; research suggests an interaction of genetic risk with other factors including emotion dysregulation, anxiety, perfectionism, cognitive rigidity, and early feeding difficulties [6, 7, 8, 9]. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFamily therapy for anorexia nervosa\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFamily-based treatment (FBT/FT-AN) is the first line NICE recommended treatment for AN in children and adolescents [10, 11]. Its development built on earlier approaches that were informed by Family Systems Theory which describes how family dynamics and processes can contribute to the development and, or maintenance of problems within the family system [12]. Since then, models of family therapy for AN have evolved and emphasise that families are a resource, rather than a treatment target [13]. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe family-based treatment model for anorexia nervosa\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFBT is a manualised outpatient three phase therapy with a behavioural and educative focus. Phase one focuses on refeeding to increase weight orchestrated by parents who are temporarily given responsibility for the individual\u0026rsquo;s eating and exercise patterns. Phase two focuses on gradually developing the young person\u0026rsquo;s independence by progressively returning responsibility for eating to the individual. When safe to do so, the focus is taken away from food to problem-solve family and psychosocial issues which interfere with weight restoration. Finally, phase three addresses remaining concerns related to adolescent development, including the re-establishment of healthy boundaries within the family system, and navigating approaching developmental challenges without reverting to ED behaviours. FBT has five key tenets [14]:\u003c/p\u003e\n\u003cp\u003e(1) The therapist takes an agnostic stance, engaging the family in facilitating early behavioural change to improve the management of eating-related behaviours, rather than exploring or resolving aetiology. \u003c/p\u003e\n\u003cp\u003e(2) The therapist uses externalising language encouraging the family to conceptualise AN as an \u0026ldquo;illness\u0026rdquo; which has \u0026quot;taken over\u0026quot; the young person. \u003c/p\u003e\n\u003cp\u003e(3) The therapist takes a non-authoritarian therapeutic stance, viewing parents as experts in their family and assuming that giving parents responsibility for weight restoration enables reorganisation of the family to enhance parental effectiveness. \u003c/p\u003e\n\u003cp\u003e(4) Therapists empower parents to orchestrate recovery. By not providing explicit instructions, parental confidence is built through allowing for struggle and self-reliance.\u003c/p\u003e\n\u003cp\u003e(5) FBT utilises a pragmatic approach, adopting a firm initial focus on restoring physical health. Comorbid difficulties are not directly addressed in phase one to ensure that weight restoration is the primary focus and because many are assumed to resolve with eating and weight restoration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSystemic family therapy for anorexia nervosa\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSystemic Family Therapy (SyFT) is also used in some settings [15]. SyFT is a less defined family therapy characterised by similar principles to FBT, although it is not delivered with adherence to a phased manual. Similar to FBT, the SyFT therapist takes a non-blaming, collaborative stance and encourages parental agency and alliance, however they place greater focus on the family system [16]. Difficulties are conceptualised as arising from the interpersonal relationships, dynamics and narratives about a problem within a family system. Adopting a neutral stance, the therapist explores family patterns of beliefs and behaviours, seeking ways to enable the family to draw on their strengths and generate solutions. Although there is not a specific emphasis on normalisation of eating or weight, the therapist helps the family address these issues when raised.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch on family therapies for anorexia nervosa\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA meta-synthesis of views about treatment from the perspectives of young people, parents and professionals underlined the central importance of the therapeutic relationship yet the difficulty in forming alliance due to disagreement about treatment targets and mutual distrust [1]. For therapists, the treatment target was normalisation of the young person\u0026apos;s eating and weight. However, young people wanted treatment to target their psychological and social functioning, as well as their family environment; and parents wanted treatment to explore the origins and causes of AN. \u003c/p\u003e\n\u003cp\u003eAnother meta-synthesis focussed on FBT/SyFT found that whilst young people experienced extreme challenge relinquishing control of their eating, they also considered their caregivers\u0026rsquo; involvement in this regard as one of the most important aspects of treatment [17]. However, they also appreciated the gradual restoration of autonomy and assistance with difficulties in family relationships. Moreover, whilst externalisation helped to reduce family criticism and increase praise, young people who engaged in FBT would have liked the causes of AN and other difficulties to have been addressed. Lastly, some young people would have liked individual sessions to address issues they did not feel comfortable discussing with family present. \u003c/p\u003e\n\u003cp\u003eService-users emphasise that treatments are most helpful when they recognise the emotional impact of weight gain and address psychological as well as physical aspects of AN [1, 17, 18, 19, 20]. They highlight the perceived unhelpfulness of professionals\u0026apos; conceptualisation of recovery as a pre-set target weight, rather than considering the individual\u0026apos;s psychological and emotional experiences, as well as their family relationships.\u003c/p\u003e\n\u003cp\u003eA review on the role of family relationships in adolescent EDs highlighted the need to refer to the adolescent\u0026rsquo;s family context to improve understanding of AN [21]. Findings from a study exploring the effects of FBT illuminated a possible mechanism of change, termed \u0026quot;relational containment\u0026quot; suggesting the importance of relational processes in recovery from AN [22]. Another study highlighted the process of evolving through treatment, for both the individual and their familial system [23]; this involved the repairing of damage through enabling others to improve their understanding of AN. The importance of attending to attachment-related issues has also been emphasised [24, 25, 26, 27, 28, 29], including the intergenerational transmission of attachment styles, emotional communication and coping styles, as well as attitudes towards eating and weight. \u003c/p\u003e\n\u003cp\u003eWhilst there is good evidence for FBT\u0026apos;s effectiveness, it does not work for everyone [30, 31, 32]. Many young people continue to experience ED-related distress following treatment, or families terminate treatment due to difficulties experienced with the approach. Accordingly, studies have attempted to identify factors that help and hinder change. Parental expressed emotion, hostility and criticism are associated with poor outcomes [33, 34], while parental warmth, increases in parental self-efficacy, and decreases in maternal critical communication and emotional over-involvement predict good outcomes [35, 36, 37, 38]. These findings suggest that decreasing unhelpful interactions in families is important in treatment for AN. The importance of the therapeutic relationship has also been underscored, with a meta-analysis indicating that younger patients benefit from an initial focus on the alliance to build engagement [39]. \u003c/p\u003e\n\u003cp\u003eIn summary, expressed emotion, the therapeutic alliance, family relationships, support with understanding AN, and managing the emotional and psychological experience of disordered eating appear to play a significant role in family therapies for AN.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReview aims and rationale\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003eThe specific processes of change underpinning family therapies for AN remains unclear [40]. Consequently, there is a need to identify their active ingredients, and to learn who this approach works for and why [41]. This study aims to understand what helps and hinders recovery in family therapies for AN to provide insights into their processes of change. Many qualitative studies which have focussed on patient and family member perspectives of family therapies for AN have been undertaken with both adolescents and young adults [15]. The World Health Organisation\u0026rsquo;s definition of \u0026lsquo;young people\u0026rsquo; covers the age range of 10 to 24 years [43]. Therefore, this review will synthesise research including adolescents and young adults aged 10 to 24 at the time of treatment, referred to henceforth as \u0026lsquo;young people\u0026rsquo;. \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA meta-synthesis was considered to be the most suitable approach to answer the study\u0026rsquo;s research question as it allows for the re-interpretation of meaning across a number of qualitative studies [42]. This was important given that a number of existing qualitative studies have explored the experience of treatment for AN from the perspectives of young people and families, however no qualitative studies or meta-syntheses have specifically explored their processes of change from these perspectives. This meta-synthesis aimed to address this gap by synthesising existing qualitative studies which have gathered data on the experience of family therapies from the perspectives of young people and families to form a new interpretation of the research, allowing for the generation of novel explanatory theory of why and how the intervention works or not.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSearch strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis systematic review was conducted in accordance with the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [44]. The following databases were systematically searched in August 2022: PsycINFO, Medline, and Web of Science. A hand search was also conducted. The search strategy is described in Table 1 and the search results are detailed within Figure 1. On PsycINFO and Medline, keyword searches for each concept were combined with subject heading searches using the Boolean operator \u0026lsquo;OR\u0026rsquo;. Web of Science does not have a search by subject heading function, therefore only a keyword search was conducted. This search was conducted again in November 2023 to account new research (see Figure 2).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"606\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eSearch terms and Boolean operators used to identify studies for this meta-synthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey concept Search terms\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.00330033003301%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003eBlock 1- Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"66.996699669967%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026ldquo;Anorexi*\u0026rdquo; OR \u0026ldquo;restrictive eating disorder\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.00330033003301%\" valign=\"top\"\u003e\n \u003cp\u003eBlock 2 \u0026ndash; Therapeutic approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"66.996699669967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;Family therap*\u0026rdquo; OR \u0026ldquo;family based treatment*\u0026rdquo; OR \u0026ldquo;family intervention\u0026rdquo; or \u0026ldquo;systemic psychotherap*\u0026rdquo; OR \u0026ldquo;systemic therap*\u0026rdquo; OR \u0026ldquo;systemic intervention*\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.00330033003301%\" valign=\"top\"\u003e\n \u003cp\u003eBlock 3 \u0026ndash; Processes of therapeutic change (phenomenon of interest)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"66.996699669967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;Family function*\u0026rdquo; OR \u0026ldquo;family relation*\u0026rdquo; OR \u0026ldquo;systemic change*\u0026rdquo; OR \u0026ldquo;family structure\u0026rdquo; OR \u0026ldquo;family dynamic*\u0026rdquo; OR \u0026ldquo;family dysfunction\u0026rdquo; OR \u0026ldquo;family role*\u0026rdquo; OR \u0026ldquo;systemic change\u0026rdquo; OR \u0026ldquo;psychotherapeutic process*\u0026rdquo; OR \u0026ldquo;therapeutic change\u0026rdquo; OR \u0026ldquo;psychotherapeutic change*\u0026rdquo; OR \u0026ldquo;behavio?r change\u0026rdquo; OR \u0026ldquo;therapeutic process\u0026rdquo; OR \u0026ldquo;strateg*\u0026rdquo; OR \u0026ldquo;interaction*\u0026rdquo; OR \u0026ldquo;pattern*\u0026rdquo; OR \u0026ldquo;support*\u0026rdquo; OR \u0026ldquo;manage*\u0026rdquo; or \u0026ldquo;attachment*\u0026rdquo; or \u0026ldquo;process* of change\u0026rdquo; OR \u0026ldquo;process*\u0026rdquo; OR \u0026ldquo;recovery process*\u0026rdquo; OR \u0026ldquo;change mechanism*\u0026rdquo; OR \u0026ldquo;change strategies\u0026rdquo; OR \u0026ldquo;change process*\u0026rdquo; OR \u0026ldquo;mechanism* of change\u0026rdquo; OR \u0026ldquo;therapeutic effect*\u0026rdquo; OR \u0026ldquo;recovery\u0026rdquo; OR \u0026ldquo;family function*\u0026rdquo; OR \u0026ldquo;help*\u0026rdquo; OR \u0026ldquo;facilitat*\u0026rdquo; OR \u0026ldquo;improve*\u0026rdquo; OR \u0026ldquo;outcome*\u0026rdquo; OR \u0026ldquo;influenc*\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.00330033003301%\" valign=\"top\"\u003e\n \u003cp\u003eBlock 4 \u0026ndash; Type of research\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"66.996699669967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;Qualitative research\u0026rdquo; OR \u0026ldquo;views\u0026rdquo; OR \u0026ldquo;perspectives\u0026rdquo; OR \u0026ldquo;experience*\u0026rdquo; OR \u0026ldquo;interview*\u0026rdquo; OR \u0026ldquo;accounts\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.00330033003301%\" valign=\"top\"\u003e\n \u003cp\u003eBlock 5 - Population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"66.996699669967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;Youth\u0026rdquo; OR \u0026ldquo;adolescen*\u0026rdquo; OR \u0026ldquo;teen*\u0026rdquo; OR \u0026ldquo;young people\u0026rdquo; OR \u0026ldquo;child\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eStudy selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudies were screened at the title and abstract screening phase, and subsequently at the full text screening phase. The inclusion criteria were: (a) peer-reviewed studies published 2002 onwards following publication of the FBT manual; (b) studies employing a qualitative or mixed-method design (provided the qualitative results were derived from open-ended questions); (c) studies whose participants included young people and/ or family members who had engaged in FBT or SyFT for AN within outpatient or inpatient ED services. The exclusion criteria were: (a) studies in languages other than English; (b) and studies with mainly quantitative data, or survey data with closed questions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality appraisal\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Critical Appraisal Skills Programme tool for qualitative research was used to assess the methodological quality of papers identified [45]. The checklist has 10 criteria; each paper was given a total score out of 10. This review followed the scoring protocol used by existing ED meta-syntheses [18]. The protocol classified studies from A to C, with A denoting studies scoring 8.5 or above and carrying a low likelihood of methodological flaws; B denoting studies scoring 5 to 8, with a moderate likelihood of methodological flaws, and C indicating a score of less than five and a high likelihood of methodological flaws. Five studies scored within category A, nine studies scored within category B, and none of the studies scored within category C. The mean total score was 7.9. Scores were most commonly lost for criteria 6 and 7 (see Table 2).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"964\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"96.57676348547717%\" colspan=\"16\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eQuality ratings using the Critical Appraisal Skills Programme CASP tool for qualitative research\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.4232365145228214%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.087136929460584%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.912863070539416%\" colspan=\"16\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy number\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCASP Criteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[49]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[31]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[51]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[53]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[54]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[55]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[56]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[57]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e[58]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.865424430641822%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e[32]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e1. Was there a clear statement of the aims of the research?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e2. Is a qualitative methodology appropriate?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e3. Was the research design appropriate to the aims of the research?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e4. Was recruitment startegy appropriate to the aims?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e5. Was data collected in a way that addressed the research issue?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e6. Has the researcher-participant relationship been adequately considered?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e7. Have ethical issues been taken into consideration?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e8. Was the data analysis sufficiently rigorous?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e9. Is there a clear statement of findings?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003e10. How valuable is the research?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003eTotal Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.99585921325052%\" valign=\"top\"\u003e\n \u003cp\u003eTotal Score Category\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.9337474120082816%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.3478260869565215%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.451345755693581%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: Response options: 1 = Yes; 0.5 = Insufficient information to answer all criteria within item; 0 = No.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData extraction and synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review utilised the seven-phase guidance provided by Noblit and Hare [46] for conducting a meta-synthesis which was further refined by Walsh and Downe [47]. Studies which met inclusion criteria were read in full and their results and discussion sections were extracted for analysis. Studies were then compared and translated into one another through identifying overlapping concepts (reciprocal translations) and contrasting concepts (refutational translations) across studies. The concepts were subsequently synthesised to create overarching themes and subthemes (third-order concepts). Finally, the synthesis was expressed through written form revealing more refined meanings, novel and exploratory theories.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReflexivity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearcher subjectivity is inevitable within qualitative research and can be used as a valuable research tool [48]. The first author (SC) had both personal and professional experience in treatments for adolescent AN. These experiences helped them to understand the data at an experience-near level, which strengthened the interpretative lens through which the data was read, allowing for a deeper level of analysis. However, they also paid attention to ensuring that the analysis and interpretation stayed close to the data within the primary studies by generating themes which honoured participant quotes. In terms of researcher positionality in relation to the topic, SC reflected on their pre-conceived ideas prior to conducting this review. They acknowledged the importance of an initial focus on the restoration of eating and weight for physical health through eliciting parental management of eating behaviourals, however they also appreciated the intregral role of emotional attunement and containment throughout this process. In addition, they recognised the importance of addressing the emotional and psychological experiences underlying eating behaviours, as well as considering the young person\u0026apos;s family relationship context. Maintaining a reflexive journal and engaging in reflexive supervision enabled them to use their own experiences to extrapolate meanings further, whilst also broadening their perspective on the emerging themes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eOverview of studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 presents details of the included studies. Sample sizes ranged from \u003cem\u003en\u003c/em\u003e = 1 to \u003cem\u003en\u003c/em\u003e = 98. Five studies focussed on the experience of FBT/SyFT for AN from the perspectives of young people; four focussed on the perspectives of young people and parents; two focussed on the perspectives of young people, parents and siblings; and four focussed on parents\u0026rsquo; perspectives alone. Data was collected from 137 young people (129 females and eight males), 189 parents and 12 siblings.\u003c/p\u003e\n\u003cp\u003eThe patient age range was 11 to 23 at time of treatment, and 12 to 27 at time of data collection. The majority of patients were female (\u003cem\u003en\u003c/em\u003e = 187), eleven were male. Parent gender was discernible in twelve out of thirteen studies: 92 were mothers and 69 were fathers. Ethnicity was rarely reported. The studies were conducted in Hong Kong, China, Australia, New Zealand, Norway, United Kingdom, United States of America, Sweden and Scotland. Nine studies collected data from participants who engaged in outpatient FBT. Two collected data from participants who engaged in inpatient FBT. Two collected data from participants who engaged in outpatient SyFT. One collected data from participants who engaged in either outpatient FBT or SyFT.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"1030\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"11\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eCharacteristics of studies included in the meta-synthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.232264334305151%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.84645286686103%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.82798833819242%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTitle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.9533527696793%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.35762876579203%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTherapeutic Approach\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.85617103984451%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSampling\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.24198250728863%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.41399416909621%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.26044703595724%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.00971817298348%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.02542372881356%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.059322033898304%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.10169491525424%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.983050847457626%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.008474576271187%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.822033898305083%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eChan and Joyce [49]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003eA Feminist Family Therapy Research Study: Giving a Voice to a Girl Suffering from AN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eExplore a patient\u0026apos;s experience of treatment by inviting her to review her family sessions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eSyFT; outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003eConvenience; the participant was recruited within an ED service where the author worked as the family\u0026apos;s family therapist.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eOne female YP, their two siblings, mother and father. The patient was aged 21 at treatment and data collection.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eHong Kong\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eVideo playback and interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eCase study analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eConti et al. [30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lsquo;Somebody Else\u0026apos;s Roadmap\u0026rsquo;: Lived Experience of Maudsley and FBT for Adolescent AN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eExplore an experience of FBT by one family; how they negotiated their identities, roles, and alliances in a protracted phase 1.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eManualised FBT; outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003ePurposive; the family responded to an advertisement distributed through HCP networks.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eOne female YP, their mother, father and male sibling who engaged in FBT for three years. The patient was aged 14 at time of data collection.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eCritical discursive analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eConti et al. [31]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ldquo;I\u0026rsquo;m still here, but no one hears you\u0026rdquo;: a qualitative study of young women\u0026rsquo;s experiences of persistent distress post FBT for adolescent AN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eExplore the experiences and identity struggles of adolescents who (1) drop out of FBT and/or (2) continue with substantive psychological distress post-treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eManualised FBT; outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003ePurposive; participants responded to advertisements on facebook or via clinicians after completing treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003e14 female YP who engaged in FBT on average four years prior to participation for three to 24 months. Patients were aged 11 - 18 at treatment and 14 - 27 at data collection.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eAustralia, New Zealand and UK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eInductive thematic analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eKrautter and Lock [50]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003eIs manualized family-based treatment for adolescent AN acceptable to patients? Patient satisfaction at the end of treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eAssess the perspectives of families who completed treatment using manual-driven FBT for AN.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eManualised FBT; outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003eConvenience; participants were invited to complete a treatment effectiveness survey at the end of treatment in an ED clinic.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003e34 families including 35 mothers, 31 fathers and 34 YP (32 female, two male). Treatment completion was defined as attending 80% of an average of 14 sessions over six to 12 months. Patients were aged 12 - 18 at data collection.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eEuropean American (\u003cem\u003en\u003c/em\u003e = 27), Asian (\u003cem\u003en\u003c/em\u003e = 3) Hispanic (\u003cem\u003en\u003c/em\u003e = 2), American Indian (\u003cem\u003en\u003c/em\u003e = 1), \u0026lsquo;Other\u0026rsquo; (\u003cem\u003en\u003c/em\u003e = 1).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eNorthern California\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eOpen ended survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003ePhenomenological type content analysis and structural synthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003evan Langenberg, Duncan and Allen [51]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026quot;They don\u0026apos;t really get heard\u0026quot;: A qualitative study of sibling involvement across two forms of FBT for adolescent AN.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eExplore families\u0026rsquo; experience of sibling involvement in FBT from the perspective of siblings, patients and parents.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eManualised FBT; outpatient.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003eConvenience; families attending a program within a specialist ED service were eligible to participate if the adolescent had at least one sibling and had completed FBT two to nine months prior.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003e12 siblings (10 female, one male) aged 10 to 18, 14 parents (one father, 12 mothers) and seven female patients aged 13 - 17 at data collection.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eThematic analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eLindstedt, Neander, Kjellin and Gustafsson [52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003eBeing me and being us - adolescents\u0026rsquo; experiences of treatment for EDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eInvestigate how YP with AN experience outpatient treatment for EDs, involving family and individual based interventions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eManualised FBT; inpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003eConvenience; participants were recruited in collaboration with four ED units.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003e15 YP (14 female, one male) were treated for AN or EDNOS restrictive over one to two years. Three received FBT, 12 engaged in a blend of FBT and individual sessions. Patients were aged 13 \u0026ndash; 19 at treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eSweden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eHermeneutic phenomenological approach\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eJoyce [53]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003ePatients\u0026rsquo; perspective on family therapy for AN: A qualitative onquiry in a chinese context\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eAssess the perceived treatment effectiveness of family therapy from the perspective of families who have completed treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eSyFT; outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003eConvenience; participants were recruited within an ED service within which the author worked as the families\u0026rsquo; family therapist.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003e24 female YP and their parents treated over two and a half years. Patients were aged 14 - 23 at treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eHong Kong\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eContent analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eMcMahon, Stoddart and Harris [54]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003eRescripting\u0026mdash;A grounded theory study of the contribution that fathers make to FBT when a young person has AN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003ePresent a grounded theory of the contribution that fathers make to FBT when a young person has AN.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eManualised FBT; outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003eConvenience; participants were recruited from eight CAMH services through HCPs delivering FBT.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003e15 fathers to a YP with AN (two male, 13 female) who had engaged in FBT. Patients were aged 11 - 17 at treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eScotland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eClassic grounded theory\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eMedway et al. [55]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003eAdolescent development in FBT for AN: Patients\u0026rsquo; and parents\u0026rsquo; narratives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eExplore the perspectives of young people and their parents regarding the developmental impact of AN, and the role of FBT in addressing developmental challenges.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eManualised FBT; outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003eConvenience; participants were identified from records of families who had received outpatient FBT at an ED service and had completed an adequate number of sessions of phases two and three and were weight restored.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003e12 young people (11 female, one male) who ceased FBT a minimum one year prior, and one of their parents (\u003cem\u003en\u003c/em\u003e = 12; 10 mothers, two fathers). Patients were aged 12 - 16 at onset and 16 - 24 at data collection.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eNarrative inquiry method\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eNilsen, Hage, R\u0026oslash;, Halvorsen and Oddli [56]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003eExternal support and personal agency - young persons\u0026apos; reports on recovery after family-based inpatient treatment for AN: a qualitative descriptive study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eInvestigate the reflections of young persons with a lived experience of AN, and what factors they consider important for the recovery process.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eInpatient FBT; \u0026ldquo;The treatment offered did not strictly adhere to manualised outpatient FBT\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003eConvenience; former inpatients were invited to participate following completion of family based inpatient treatment at an ED unit.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003e33 females and four males who were offered two FBT sessions per week during their admission. The average time from discharge to data collection was four and a half years. Patients were aged 12 - 19.5 at admission and 15.8 - 25.3 at data collection.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eNorway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eThematic analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eSocholotiuk and Young [57]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003eWeight restoration in adolescent anorexia: parents\u0026rsquo; goal-directed processes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eDescribe how parents participated in the weight restoration of their adolescent while engaged in FBT for AN.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eFBT; outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003ePurposive; participants responded to advertisements at local child/youth mental health centres or online. Adolescents could be in the early, middle, or late stages of weight restoration.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eThree mothers and one mother-father dyad who were actively engaged in FBT. Patients were aged 13 - 16 at treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eCaucasian (\u003cem\u003en\u003c/em\u003e = 4), indigenous (\u003cem\u003en\u003c/em\u003e = 1) Parents were born in Canada (\u003cem\u003en\u003c/em\u003e = 3) and Western European countries (\u003cem\u003en\u003c/em\u003e = 2).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eCanada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eVideo playback and systematic analysis of video recorded conversations.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eQualitative action project\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eWallis et al. [22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003eRelational containment: Exploring the effect of FBT for AN on familial relationships.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eInvestigate the process of familial relationship change for adolescents with AN and their parents who participated in FBT.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eManualised FBT; outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003ePurposive; families who completed a 20-session protocol within an ED service at least six months before an interview with weight greater than 85% expected body weight were invited to participate.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003e16 female adolescents, 28 parents (15 mothers, 12 fathers) who completed a mean of 33 FBT sessions on average 12.11 months prior to data collection. Patients were 12 - 18 at treatment and 14 - 20 at data collection.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eConstructionist grounded theory\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003cp\u003eWilliams, Wood and Plath [58]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003eParents\u0026rsquo; experiences of family therapy for adolescent AN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eExamine parents\u0026rsquo; experiences of family therapy for adolescents with AN.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eManualised FBT (n=6) or SyFT (n=3); outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003ePurposive; parents were eligible to participate if they had received or were undergoing FBT or SyFT in CAMHS, their YP was aged 12 \u0026ndash; 18 years at diagnosis, their BMI was in the healthy weight range at data collection, and illness duration was less than three years prior to treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eSix mothers and three fathers of seven YP (six females, one male). Treatment duration ranged from 0 - 6 to \u0026gt; 36 months. Patients were 13 - 18 at treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eInterpretative phenomenological analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.223300970873787%\" valign=\"top\"\u003e\n \u003col\u003e\n \u003cli\u003eWufong, Rhodes \u0026amp; Conti [32]\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.8446601941747574%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815533980582524%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026quot;We don\u0026apos;t really know what else we can do\u0026quot;: Parent experiences when adolescent distress persists after the MFT/FBT for AN.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eExploration of parents\u0026rsquo; experiences of FBT in cases where treatment was discontinued and/or their child continued to experience psychological distress post-treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.349514563106796%\" valign=\"top\"\u003e\n \u003cp\u003eManualised FBT; outpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.844660194174757%\" valign=\"top\"\u003e\n \u003cp\u003ePurposive; participants responded to advertisements distributed through HCP networks.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.941747572815533%\" valign=\"top\"\u003e\n \u003cp\u003eNine mothers and four fathers of 11 female YP who completed FBT at least one year prior. Patients were aged 12 - 17 at treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.378640776699029%\" valign=\"top\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.407766990291262%\" valign=\"top\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.25242718446602%\" valign=\"top\"\u003e\n \u003cp\u003eInterviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eCritical discursive analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"11\" valign=\"top\"\u003e\n \u003cp\u003e\u0026dagger; NS: Not Specified, YP: Young People, AN: Anorexia Nervosa, ED: Eating Disorder, FBT: Family Based Treatment; HCP: Healthcare Professional; CAMH: Child and Adolescent Mental Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eMeta-synthesis findings\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSix themes relating to factors that helped and hindered positive change in family therapies for AN were identified (Table 4).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003eOverview of themes and subthemes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.41098169717138%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.58901830282862%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.41098169717138%\" valign=\"top\"\u003e\n \u003cp\u003eThe psychological underpinnings of Anorexia Nervosa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.58901830282862%\" valign=\"top\"\u003e\n \u003cp\u003eA coping tool for difficulties\u003c/p\u003e\n \u003cp\u003eAttending to young people\u0026rsquo;s development\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.41098169717138%\" valign=\"top\"\u003e\n \u003cp\u003eThe therapeutic relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.58901830282862%\" valign=\"top\"\u003e\n \u003cp\u003eYoung peoples\u0026apos; experience of the therapist\u003c/p\u003e\n \u003cp\u003eParents\u0026apos; experience of the therapist\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.41098169717138%\" valign=\"top\"\u003e\n \u003cp\u003eConfinement to a \u0026ldquo;script\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.58901830282862%\" valign=\"top\"\u003e\n \u003cp\u003eNeglect of young people\u0026apos;s emotional distress\u003c/p\u003e\n \u003cp\u003eNeglect of family distress\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.41098169717138%\" valign=\"top\"\u003e\n \u003cp\u003eA disempowering therapeutic context\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.58901830282862%\" valign=\"top\"\u003e\n \u003cp\u003eParents \u0026ldquo;on trial\u0026rdquo;\u003c/p\u003e\n \u003cp\u003eRigid inflexibility versus individualised tailoring\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.41098169717138%\" valign=\"top\"\u003e\n \u003cp\u003eExternalisation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.58901830282862%\" valign=\"top\"\u003e\n \u003cp\u003eLoss of the individual to Anorexia Nervosa\u003c/p\u003e\n \u003cp\u003eSeparation of Anorexia Nervosa from the individual\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.41098169717138%\" valign=\"top\"\u003e\n \u003cp\u003eFamily involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.58901830282862%\" valign=\"top\"\u003e\n \u003cp\u003eRecruitment of the family to help the young person\u003c/p\u003e\n \u003cp\u003eThe parent-young person relationship\u003c/p\u003e\n \u003cp\u003eChanges to family functioning\u003c/p\u003e\n \u003cp\u003eComplex family difficulties and relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe psychological underpinnings of anorexia nervosa\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFamilies considered it important to maintain a holistic focus in treatment in order to attend to the young person\u0026apos;s overall wellbeing including their psychological, emotional and social development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA coping tool for difficulties.\u0026nbsp;\u003c/strong\u003eYoung people and their parents described pre-existing psychological, emotional and interpersonal difficulties which made individuation and separation from caregivers difficult [49, 55, 57]. Young people conceptualised their eating behaviours as a \u0026quot;coping strategy\u0026quot;; they used restriction as a tool for regulating emotions associated with low self-esteem, difficult life experiences, relationships, separations and transitions [56]. Some parents conveyed concern that externalising AN as \u0026ldquo;an illness\u0026rdquo; overlooked a psychological explanation for eating difficulties:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Something causes it [...] and not being able to treat what causes it, as well as the anorexia itself, trying to separate the two is a problem. And I come back to the need for a more holistic approach [...] something that recognises all the complementary parts and doesn\u0026apos;t try and treat one in isolation of the other\u0026quot; [\u003c/em\u003e\u003cem\u003e58\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFamilies reported how AN further impacted on young people\u0026rsquo;s development as it withdrew them from normal adolescent activities [55, 56]. Young people described feeling \u0026quot;stuck\u0026quot; and unable to relate to their peers who \u0026quot;continued to develop\u0026rdquo; [49, 55, 56].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttending to young peoples\u0026rsquo; development.\u003c/strong\u003e Parents perceived the goals of weight restoration and young peoples\u0026rsquo; development as competing and in tension [30, 50, 57, 58]; they considered it crucial to be attentive to balancing these two priorities. The requirement for parents to take responsibility for feeding the young person within phase one led to further developmental regression. Therefore, it was important that later phases of treatment focussed on supporting the development of young people\u0026apos;s autonomy [55, 56]. Parents were required to \u0026ldquo;trust\u0026rdquo; the process and their young person in order to tolerate anxiety associated with moving away from the structured routines of treatment [56, 57]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] there\u0026rsquo;s still a part of me that still really worries about it. [\u0026hellip;], but [\u0026hellip;] I need to, you know, trust that she is getting better and that she\u0026rsquo;ll start doing some of the stuff on her own\u0026rdquo; [\u003c/em\u003e\u003cem\u003e57\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people who experienced more significant difficulties with anxiety and separation experienced later phases of treatment as anxiety-provoking and overwhelming; this was a time of increased risk for returning to disordered eating [55]. However, others were motivated to engage in changes to their eating by the prospect of engaging in valued activities [55, 56]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;As I had more control, I felt like I was more free and more able to enjoy my social life or my schooling life or I was able to work... I was like, well this is great...How could I throw it away and go back to something like that?\u0026quot; [\u003c/em\u003e\u003cem\u003e55]\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese young people emphasised the significance of engaging in meaningful aspects of life and redirecting their focus away from food and weight. This included reconnecting within relationships, as well as obtaining a sense of mastery and achievement in important areas of life [55, 56]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It\u0026apos;s been crucial to accomplish high school, to get a driver\u0026apos;s license...It feels really great to accomplish those, it\u0026apos;s this sense of mastering, which is very important. To feel you can live a pretty normal life, where the focus is on everything else but body and food\u0026rdquo; [\u003c/em\u003e\u003cem\u003e56\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe therapeutic relationship\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFamilies conveyed how the experience of containment in the therapeutic relationship helped to facilitate positive change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYoung peoples\u0026rsquo; experiences of the therapist.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eOn starting treatment, young people described relief coinciding with significant anxiety associated with the prospect of \u0026quot;letting go of control\u0026rdquo; [52, 56]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;There were two different sides within me, one saying \u0026apos;Oh God, this is great, I\u0026apos;m going to get help now\u0026rsquo;\u0026hellip;At the same time, [\u0026hellip;] \u0026apos;No, now they\u0026apos;re going to destroy what you have achieved, and you who have come this far\u0026rsquo;\u0026quot;\u0026nbsp;\u003c/em\u003e\u003cem\u003e[52]\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people emphasised the time it took for the development of trust in the therapist before they could hand over control or share their feelings [52]. Feeling able to share their internal experiences was perceived as a catalyst for change [52, 53]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;An important part of the turnaround was when I invited her into my feelings. [...] I started to trust her [therapist]\u0026quot;\u0026nbsp;\u003c/em\u003e\u003cem\u003e[52]\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people desired human connection, understanding, collaboration, compassion, and non-judgement; a therapist who showed genuine interest in them, rather than solely increasing their food-intake and weight [49, 52, 53, 56]. When the therapeutic relationship had these qualities, young people developed confidence and trust in their therapist:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The key to her significant improvement lies in the fact she trusted her [therapist] completely. It\u0026apos;s so difficult for her to trust anybody\u0026quot; [Parent,\u0026nbsp;\u003c/em\u003e\u003cem\u003e53\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people described disengagement in the absence of a positive therapeutic relationship. Some conveyed how their disengagement was influenced by a lack of perceived understanding by their therapist, a lack of positive family relationships, or their disagreement with how weight restoration was achieved [52, 55].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParents\u0026rsquo; experiences of the therapist.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eA positive therapeutic relationship was important in providing parents with emotional containment [22, 53, 58]. Parents desired a clinician who took an active role in aiding parental understanding and support of the young person, as well as family communication [22, 53, 54, 58]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;She [therapist] knew how to teach us to deal with my daughter\u0026rsquo;s problem and that\u0026rsquo;s most memorable\u0026rdquo; [\u003c/em\u003e\u003cem\u003e53\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe therapist was experienced positively when they had a neutral quality and were compassionate, collaborative, helpful, flexible and placed emphasis on building trust [22, 30, 32, 53, 54, 58]. Parents wanted to feel connected with their therapist, have their concerns contextualised and validated, and their circumstances and values respected [22, 30, 32, 53, 54, 58]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We have built up mutual trust. There\u0026rsquo;s genuine concern between her [therapist] and us. She didn\u0026rsquo;t treat us as if it were her job or profession\u0026rdquo; [\u003c/em\u003e\u003cem\u003e53\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMoreover, parents wanted to improve their knowledge of AN in order to feel confident in their capacities to help [54, 57]. A lack of adequate information and guidance given by the therapist contributed to a lack of containment experienced within the therapeutic relationship [54]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[\u0026hellip;] It seemed to be pushing all the onus on correction and enforcement on to my wife and I, and nothing coming from the clinicians, no support for us in our battle\u0026quot;. [\u003c/em\u003e\u003cem\u003e54\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome parents perceived the therapist as cold, harsh, scrutinising, condescending and detached [22, 30, 32, 53, 54, 58]. One parent made a distinction between a positive experience of SyFT versus a negative experience of FBT, describing the SyFT therapist as coming \u0026quot;alongside\u0026quot; the family, as opposed to the FBT therapist acting as a \u0026quot;removed expert\u0026quot; [58].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConfinement to a \u0026quot;script\u0026quot;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFamilies conveyed how positive change was hindered by a confined focus on food intake and weight.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeglect of young people\u0026apos;s emotional distress\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eYoung people frequently described FBT as an isolating process that ignored \u0026quot;what was going on inside\u0026quot; wherein their parents and therapist did not understand how distressing increasing their eating and weight was [30, 31, 50, 55]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[\u0026hellip;] they just solely focused on my physical health, they didn\u0026apos;t really take on much consideration as to my mental health and how much of a toll everything was taking on me\u0026quot; [\u003c/em\u003e\u003cem\u003e30\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people desired support with managing the psychological experience of AN and its associated difficulties rather than solely focussing on increasing their food-intake and weight [53]. Areas of importance included motivation, emotions, thoughts, relationship difficulties, self-esteem, body image and identity issues [30, 31, 50, 54, 55, 56]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Because they never really addressed the underlying problems, it was all so much harder than it probably should have been, because I was still battling with the thoughts and the guilt\u0026quot; [\u003c/em\u003e\u003cem\u003e52\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome young people felt that important conversations (i.e., the impact of their parent\u0026apos;s attitudes to eating and weight) were not sufficiently acknowledged [31]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We opened old wounds and then they never really got closed I never got to just express how I was really feeling, which is probably why I was so angry, because it was all, like building up inside\u0026rdquo;\u003c/em\u003e \u003cem\u003e[\u003c/em\u003e\u003cem\u003e31\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome parents emphasised how FBT assumes that weight restoration leads to cognitive change [30, 32]; they expressed concerns that the psychological underpinnings of AN and its associated difficulties were unaddressed by the \u0026ldquo;FBT script\u0026rdquo; [30, 31, 32, 50, 51, 55, 56, 57]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The focus seems to be all on the food aspects [\u0026hellip;] the food is the end product of the whole problem, what\u0026apos;s going on underneath?\u0026quot; [\u003c/em\u003e\u003cem\u003e32\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhen young people were not restoring weight in FBT, parents were concerned by the continued confined focus on food intake and weight as the young person became increasingly distressed and conflicts worsened [32]. They questioned whether FBT was doing more harm than good; for some, this led to treatment termination [30, 31, 52].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeglect of family distress\u003c/strong\u003e. Parents often described how being redirected to the \u0026ldquo;FBT script\u0026rdquo; caused distancing in the therapeutic relationship and reduced confidence about therapy [22, 30, 54, 58]. Many families conveyed a lack of space for the exploration of familial distress and conflict, which for some contributed to family estrangement and exacerbation of distress [30, 58]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;FBT ruined a previously strong relationship and caused my parents and siblings their own psychological unease and detriment. This contributed to a loss of myself and my identity and resulted in further destructive behaviours\u0026quot; [Young person,\u0026nbsp;\u003c/em\u003e\u003cem\u003e31\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParents conveyed how the task of \u0026quot;refeeding\u0026quot; as the solution obscured how demanding, distressing and dilemmatic their experience was. They considered it important to feel resourced emotionally, practically and personally to create capacity for the task of weight restoration; parental management of emotion was significant in this respect [57]. They felt overwhelmed, exhausted, isolated and let down by the therapist when their challenges were not recognised or supported [22, 30, 32, 54]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[\u0026hellip;] it sounds easy in principle, [\u0026hellip;] when you actually do it at home it\u0026apos;s not that easy when a teenager\u0026apos;s screaming at the top of her lungs [\u0026hellip;] you feel a little thrown to the wolves [...] once you close the door of your family home that\u0026apos;s it; you\u0026apos;re on your own\u0026quot;\u003c/em\u003e \u003cem\u003e[\u003c/em\u003e\u003cem\u003e58\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParents engaged in an internal search for answers regarding the cause for their young person\u0026rsquo;s eating difficulties to provide them with a sense of coherence and to guide day-to-day decision making [32, 54, 57]. Parents acknowledged the therapists\u0026rsquo; attempts to relieve them of guilt and blame with FBT\u0026apos;s agnostic aetiological stance, however described the experience of persistent guilt, self-blame and inadequacy [22, 50, 54, 58]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[\u0026hellip;] it felt like, well as a parent, what have we done wrong?\u0026rdquo; [\u003c/em\u003e\u003cem\u003e32\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParental co-regulation was a strategy for the management of difficult emotions [30, 57], as were internal processes such as practicing acceptance, managing expectations and finding meaning in adversity [57]. However, practical challenges to parents\u0026rsquo; capacity such as the lack of time and financial resources posed significant dilemmas for single parents [57, 58]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I can\u0026rsquo;t take any time off work, I don\u0026rsquo;t have any money, I don\u0026rsquo;t know how I\u0026rsquo;m going to help her!\u0026rdquo; [\u003c/em\u003e\u003cem\u003e57\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eA disempowering therapeutic context\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFamilies conveyed how the experience of disempowerment in treatment was hindering to positive change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParents \u0026ldquo;on trial\u0026rdquo;.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIt was important to parents that treatment monitored progress in the overall health and wellbeing of their young person [57]. Attending to markers of progress was a powerful motivator that instilled hope, or revealed what was not working [57]. However, some parents described FBT as a \u0026quot;ruthless\u0026quot;, \u0026quot;dogmatic\u0026quot; approach in which they felt \u0026quot;put on trial\u0026quot; [30, 32]. These parents reported to receive blaming, punitive responses from the therapist when there was insufficient weight restoration. Such interactions exacerbated parental guilt and self-blame, causing parents to feel exposed and vulnerable [30, 32].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have never been so challenged in my life as a mother. I felt wretched. It\u0026apos;s such a fundamental thing to feed and protect your child and anorexia has already challenged that [\u0026hellip;] then to, on a weekly basis, be in a context (emotional tone to voice) where your failings are on show and also on show to your children\u0026quot; [\u003c/em\u003e\u003cem\u003e32\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParents reported that these interactions implicitly conveyed how they were failing in their role as parents and at FBT [30, 32], particularly when the therapist endorsed the assumption that \u0026quot;the Maudsley works\u0026quot;:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot; I felt like she was on trial [\u0026hellip;]. Hayley\u0026apos;s failure to put on weight was Margaret\u0026apos;s failure to feed her enough ultimately\u0026quot; [\u003c/em\u003e\u003cem\u003e32\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRigid inflexibility versus individualised tailoring.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eSome families reported to feel that FBT was \u0026ldquo;rigid\u0026rdquo;, \u0026ldquo;prescribed\u0026rdquo; and \u0026ldquo;inflexible\u0026rdquo; [30, 32]. Many families would have liked more separated sessions in addition to conjoint sessions in order that parents\u0026apos; and young peoples\u0026apos; individual emotional needs could be met [30, 50, 57]. These families reported a lack of tailoring to preferences regarding session format and content, treatment duration, ending, and opportunity to have a follow up [30, 50, 54]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The rigidity and inflexibility [,,,] was such a shame [\u0026hellip;] because [...] the heavy lifting was done, which was the trust [...]. The lack of progress or our frustration or anything to just flex the approach and to lean on the trust that had been built. Well, I think we\u0026apos;d have gone to the edge of the earth with her you know until it became so rigid, dogmatic [\u0026hellip;]\u0026quot; [Parent,\u0026nbsp;\u003c/em\u003e\u003cem\u003e30\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome families reported that time-limited FBT was not sufficient to support a full recovery [32, 50, 52]. Young people wanted the therapist to be attuned to their needs and to make a collaborative decision rather than ending treatment on reaching a \u0026ldquo;target weight\u0026rdquo; [52]. The therapists\u0026rsquo; perceived assumption that they were psychologically recovered on reaching a healthy weight evoked feelings of anger and abandonment:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;OK, now you have reached normal weight - so now you are well again. The simple fact that I had put on weight meant that everything was fine, and that was all there was to it. I felt like\u0026hellip;I\u0026apos;m not prepared to walk out weighing like this, if you leave me, I will start losing weight again\u0026rdquo; [\u003c/em\u003e\u003cem\u003e52\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExternalisation\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExternalisation could help and hinder positive change depending on how it was used and its effects on the individual and their relationships.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLoss of the individual to Anorexia Nervosa.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eSome parents described how young people were spoken about rather than with as a result of externalisation, which contributed to a perceived loss of the young person\u0026rsquo;s voice and identity [30, 32]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[\u0026hellip;] I accept that when she was very sick, [\u0026hellip;] we talk in these beautiful terms of \u0026lsquo;It was the eating disorder and not Hayley in the room\u0026apos; [\u0026hellip;] but effectively Hayley was still in the room but she was treated as though she wasn\u0026apos;t\u0026rdquo; [\u003c/em\u003e\u003cem\u003e30\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome young people did not find it helpful for others to perceive of them as being under the influence of an external entity because they felt unseen and unheard [30, 31]. Moreover, externalising conversations that highlighted family member burden due to AN were particularly difficult for some young people as they evoked guilt and shame. Instead, young people wanted their voice to be actively sought and to be given ownership over session content, rather than feel \u0026ldquo;talked about\u0026rdquo; and instructed what to do in an impersonalised manner [30, 52]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[...] the fact that you had an eating disorder meant they were dismissive of anything you say, they believed anything you say was completely motivated by the eating disorder [...]. I was very distressed by that because I thought I\u0026apos;m still me, I\u0026apos;m still here, I can recognise that I have anxiety and unhelpful thoughts but I can still communicate as a person\u0026rdquo; [\u003c/em\u003e\u003cem\u003e31\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast, a collaborative involvement in treatment fostered greater security and safety in the young person\u0026rsquo;s relationships with their therapist and family [30, 49, 52, 56]. Feeling seen as a person beyond AN helped to build young people\u0026rsquo;s sense of self, rather than reinforce an illness identity through the exclusion of their voice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSeparation of Anorexia Nervosa from the individual.\u0026nbsp;\u003c/strong\u003eAt the start of treatment, conceptualising AN as an \u0026lsquo;unwanted temporary illness\u0026rsquo; enabled parents to channel difficult emotions into \u0026ldquo;fighting\u0026rdquo; AN [22, 30, 31, 32, 50]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;There was Sally and there was the eating disorder and once you separate them you realise that she is still there and we\u0026apos;re fighting the eating disorder and she is too. [...] it wasn\u0026apos;t just her doing this to herself\u0026quot; [\u003c/em\u003e\u003cem\u003e32\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, it was important that externalising conversations validated the young person\u0026rsquo;s lived experience. For instance, Venn diagrams acknowledging overlaps between the identity of the young person and that of AN, as well as engaging in chair work to speak to AN were described as meeting young peoples\u0026apos; emotional and psychological needs [31]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[\u0026hellip;] they\u0026rsquo;d be like, what would your eating disorder say to this? Now sit in this chair and it\u0026apos;d be like, what would you say to this? [...] that was helpful, but they just didn\u0026apos;t do it enough. Like, it was just so much about food but they needed to care about my\u0026nbsp;\u003c/em\u003efeelings\u0026quot; \u003cem\u003e[\u003c/em\u003e\u003cem\u003e31\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people emphasised the significance of transitioning from \u0026ldquo;denial\u0026rdquo; to \u0026ldquo;realisation\u0026rdquo; through externalising conversations which elicited the young person\u0026apos;s voice and facilitated reflection on their personal values and life aspirations [30, 56].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Ask yourself, why, why do you do this? What do you want to get out of your life? What are your true dreams? What is your greatest wish?\u0026quot; [\u003c/em\u003e\u003cem\u003e56\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people acknowledged the importance, yet difficulty, of becoming aware of AN\u0026rsquo;s negative effects and its function in their lives:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It\u0026apos;s important to realize and see more clearly the negative influences the ED has, because it is, after all, a way of handling difficulties or mastering life. [\u0026hellip;] It\u0026apos;s not easy to be attentive to the negative consequences the ED will have\u0026quot; [\u003c/em\u003e\u003cem\u003e56\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people stressed their anxieties and resistance to making changes to their eating. However, they tolerated difficult feelings in the service of their commitment to a preferred identity underpinned by their personal values [56]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I haven\u0026apos;t thought much about having kids. Still, I think it is important to stay in treatment, because I want to be able to take good care of my kids, which is a huge motivation for me\u0026rdquo; [\u003c/em\u003e\u003cem\u003e56\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFamily involvement\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterventions aimed at improving parental understanding and management of AN, as well as family functioning were supportive of positive change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImproving parental understanding and management of AN:\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eParents entered treatment feeling powerless, not knowing how to help their young person [58]. For some, the structure and guidance on commencing FBT provided direction which instilled hope [22, 30, 31, 32, 52, 57, 58]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I felt totally out of control. [\u0026hellip;] So, having a plan just made me feel like I had something secure to-to work on, to work with, to trust in\u0026quot; [\u003c/em\u003e\u003cem\u003e32\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne mother conveyed how FBT gave her permission and resources to challenge their young person\u0026apos;s eating behaviour:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Treatment gave me tools and framework and a structure and permission I suppose\u0026quot; [\u003c/em\u003e\u003cem\u003e22\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome young people experienced relief, safety and security when control over their eating was taken away [22, 30, 31]. Most young people acknowledged that they would not have restored weight without parental support [22, 30, 31, 56]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[\u0026hellip;] I don\u0026apos;t think I would have been able to gain that weight and get to the medically stable point if it had sort of been all up to me. [\u0026hellip;] I still definitely needed my family support because [\u0026hellip;] even if it was unintentionally, I would\u0026apos;ve just slipped back [\u0026hellip;]\u0026rdquo; [\u003c/em\u003e\u003cem\u003e30\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParents reflected on the potential of AN to undermine the marital relationship and the importance of parental unification and partnership which involved co-parent coordination and negotiation [32, 54, 56, 57, 58]. It was helpful when treatment scaffolded the sharing of roles and responsibilities between co-parents to ease parental burden as well as to ensure that both parents were engaged in changes conducive to young peoples\u0026rsquo; recovery [57, 58]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We were a joint force. I think if you can work together really quickly it helps because an eating disorder can get around one of you, but if it knows that dad\u0026apos;s there backing up everything that mum says and vice-versa [\u0026hellip;]\u0026quot; [\u003c/em\u003e\u003cem\u003e32\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParents who were not supported in treatment by their co-parent would have liked to have shared parental responsibility and were concerned about their co-parent\u0026rsquo;s lack of understanding for their young person\u0026apos;s difficulties [57, 58]. In the context of parental separation, it was important that both parents pulled together to preserve the young person\u0026rsquo;s sense of unified family support [58]. This necessitated parental acceptance of disparate parenting philosophies and weight-restoration strategies [58]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;At first it was like, [\u0026hellip;] \u0026ldquo;Hello? Uh, that\u0026rsquo;s not happening\u0026rdquo;. And then, you know, it\u0026rsquo;s like, \u0026ldquo;Actually, we need to do this for [our daughter]. Darn. Okay\u0026rdquo;. So suck it up, bury those emotions\u0026rdquo; [\u003c/em\u003e\u003cem\u003e58\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrengthening of the parent-young person relationship.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eWhilst some parents felt that treatment disrupted the parent-young person relationship [30, 31], others felt it helped them to maintain a connection with their young person. Some parents described personal changes which served to strengthen the parent-young person relationship, for instance becoming firmer with boundaries, more resilient and emotionally attuned [22, 32, 54, 57, 58]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I was one of these people who didn\u0026apos;t show my emotions much, very tough orientated, very much the job at hand...once I understood what anorexia was like for my son, it helped me change. Now I\u0026apos;ve let my guard down and let people in. [\u0026hellip;] It\u0026rsquo;s [AN] made me a better person and a better parent...\u0026rdquo; [\u003c/em\u003e\u003cem\u003e58\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people acknowledged how difficult it was for their parents to understand AN, however their efforts to do so made them feel worthy of care [31, 52, 55, 56]. In the context of relationships in which young people felt seen, heard and cared for, they were more accepting of the structures put in place to support them with eating [22, 30, 31, 52, 56]. Thus, young people found it helpful when the therapist mobilised supportive, understanding relationships [31, 52, 55]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[...] it definitely did teach my family [\u0026hellip;] and [\u0026hellip;] educated them on what would be helpful for me and what wouldn\u0026apos;t be helpful. And I think it was nice not to feel alone; it was nice to have my family there\u0026quot; [\u003c/em\u003e\u003cem\u003e31\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParental capacity to take non-coercive control over the young person\u0026rsquo;s eating appeared to be influenced by parents\u0026rsquo; capacity to tolerate the young person\u0026rsquo;s distress [22]. When treatment contained parental anxiety and increased parental confidence, parents had greater capacity to provide emotional containment to the young person [22, 57]. Consequently, over time young people experienced greater security, safety and trust in the parent-young person relationship and were able to replace control with trust in others [22, 30, 52, 55, 57]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I felt the need to be in control but [\u0026hellip;] I sort of had to put my trust in to them that they were going to take care of me\u0026quot; [\u003c/em\u003e\u003cem\u003e22\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIncreased relational security in the parent-young person relationship was depicted by young people as learning to understand each other, reduced parental criticism, and increased parental provision of emotional support and reassurance [22].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They tried to be as understanding as they could be [parents] [\u0026hellip;] it helped because for the first time I didn\u0026apos;t actually shun them, I went to them...it\u0026apos;s so weird cause for the first time in my life I let myself depend on someone else\u0026quot; [\u003c/em\u003e\u003cem\u003e22\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParents perceived the quality of connection between themselves and their young person as a tangible marker of positive progress in treatment [22, 57]. These relational changes had a positive impact on young peoples\u0026rsquo; attachment system and sense of selves. Young people described reduced self-criticism, improved confidence, greater self-acceptance, increased capacity to trust others and in turn, in their selves [22, 57]. Parents described reduced secretiveness, increased resilience and emotional expressiveness in their young person [22, 57].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eChanges to family functioning.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eMany families entered treatment with strained family relationships. Some young people felt they were a \u0026ldquo;burden\u0026rdquo; and \u0026quot;a stranger\u0026quot; within their family [22]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We weren\u0026apos;t being like a family, a bit separated, like I was separated from everyone else in the family\u0026quot; [\u003c/em\u003e\u003cem\u003e22\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the context of family sessions which permitted space for therapeutic focus on relationships, positive changes to family functioning were reported, including improved communication, cohesion and problem-solving skills; increased honesty, openness and closeness; mutual understanding and trust; emotional awareness and tolerance; reduced conflict, criticism and blame; and increased capability and compatibility [22, 32, 49, 50, 51, 52, 53, 54, 57, 58]. Having a safe, contained space for difficult conversations helped to reduce emotional disconnection:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;They [\u0026hellip;] guided us through [\u0026hellip;] very hard conversations. Hard as in about feelings, about guilt, about perceptions, and about the effects it had on us [...] I think as a family we\u0026apos;ve grown a lot closer [...]\u0026quot; [Parent,\u0026nbsp;\u003c/em\u003e\u003cem\u003e32\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFamilies often described more space to focus on the family system within SyFT [49, 53, 58]. They valued the therapist\u0026apos;s directiveness on what needed to change, and their appreciation for each person\u0026apos;s feelings and views [53]. These processes helped young people to share their feelings:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;What helped most is to talk about my feelings without any reservation. She helped everyone to speak out, including those who didn\u0026apos;t talk much\u0026quot; [Young person,\u0026nbsp;\u003c/em\u003e\u003cem\u003e53\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome fathers became more involved in their young person\u0026apos;s life practically and emotionally through their involvement in treatment [22, 49, 54]. One young person described how her father\u0026rsquo;s involvement helped to reduce the disconnection between them:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[\u0026hellip;] I can see that my father also tries to show concern for me. That feeling has been lost for years. He loves me and really wants to help me\u0026quot; [\u003c/em\u003e\u003cem\u003e49\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSiblings struggled to understand AN and wanted to be included in treatment [51, 52]. When siblings were not included, sibling-relationship ruptures were often left unrepaired causing young people to experience loss, sadness and guilt. Families reported positive aspects of sibling involvement, including increased understanding and unified support, increased closeness in the sibling relationship, reduced sibling worry, greater transparency in the family system and opportunity to clarify appropriate family roles [51]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I think it made it so [sibling] understood [\u0026hellip;] what was going on. So it wasn\u0026apos;t like she was kept in the dark and we were trying to avoid talking about it to her. So she was a bit more aware of what was going on and she didn\u0026apos;t feel left out of it. She knew what not to say [\u0026hellip;]\u0026quot; [\u003c/em\u003e\u003cem\u003e51\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplex family difficulties and relationships.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIt was important that treatment addressed parental belief systems which served to maintain young peoples\u0026rsquo; disordered relationships with eating and weight [31, 57]. One mother viewed slimness to confer protective factors for their young person and thus experienced challenge and unease during the process of refeeding. In order for treatment to facilitate weight restoration, the mother\u0026rsquo;s own beliefs in relation to eating and weight needed to be explored and addressed as an ongoing process:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The thinner you are, the more beautiful you are, the easier the world is for you. I truly...believe that. [\u0026hellip;] You want your kid to be....to fit in, [\u0026hellip;] and obviously that\u0026rsquo;s easier if you look a certain way [\u0026hellip;]. What if they\u0026rsquo;re wrong? What if they make her gain too much weight, and then\u0026hellip;and then she feels like she\u0026rsquo;s...too heavy\u0026rdquo;[\u003c/em\u003e 57\u003cem\u003e].\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people did not perceive parental involvement to be helpful when they did not have trusting relationships with their parents, or when they had family difficulties which were not openly discussed in treatment [22, 52, 55]. They expressed uncertainty about what they were able to share due to concerns about disclosing their parents\u0026apos; own difficulties, or revealing family conflict:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;My parents have alcohol problems [\u0026hellip;] I preferred going on my own. [...] the fact is I never told anyone at the eating disorder unit. [...] I was so ashamed [\u0026hellip;] I was so dead scared of what might happen if they learnt about it\u0026quot; [\u003c/em\u003e\u003cem\u003e52\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese young people explained how there were difficulties which felt out of their control that they needed help with before letting go of control over their eating [55]; they described poorer relationships with parents, family conflict and high expressed emotions at home. Unresolved family difficulties and conflicts led to unrepaired ruptures and disconnection in their family relationships following treatment. Some families for whom relational change did not eventuate were experiencing grief, loss and trauma [22]. For example, one young person explained that previous abuse in the family impacted on her ability to trust her parents [22]:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;[\u0026hellip;] I didn\u0026apos;t trust my parents [...] it would just have been so strange to have my mum sitting there. Then I would not have dared to be honest in the same way\u0026quot; [\u003c/em\u003e\u003cem\u003e52\u003c/em\u003e\u003cem\u003e].\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis meta-synthesis explored the processes of change in family therapies for AN, elucidating factors that help and hinder recovery from the perspectives of young people and their families. The narratives depict several therapeutic processes which are integral to facilitating positive change including psychological formulation, the therapeutic relationship, emotional attunement, family involvement and family empowerment. These findings are discussed in relation to existing research, theory and their clinical implications. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePsychological formulation \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRestriction provided young people with a sense of control over psychological and emotional difficulties, however it also resulted in the loss of agency and stalled development. Whilst treatment often failed to explore and address the psychological underpinnings of AN, parental re-feeding was often successful at supporting physical recovery and enabling young people to return to developmentally appropriate activities. Some young people experienced their return to valued activities reinforcing of their sense of personal agency which had a positive impact on their recovery. Research demonstrates how shifts in motivation for change occur in parallel with shifts in values and self-definitions through a process of identity renegotiation [59]. The findings alongside existing research underscore the significance of relinquishing control, self-discovery, and the development of a new identity in recovery from an ED which provides a false sense of security [60, 61, 62]. Accordingly, empowering young people to identify and return to developmentally appropriate activities that bring personal meaning and identity may support them in working towards and maintaining recovery in FBT/SyFT.\u003c/p\u003e\n\u003cp\u003eThe finding that FBT\u0026rsquo;s agnostic aetiological stance does not alleviate parental guilt and blame is consistent with existing research. Carers are often perplexed by ANs cause, place blame on themselves and question their parenting [63, 64]. Hence, they place value on the opportunity to improve their understanding [65]. Caregiver cognitive appraisals relating to their understanding of AN are important because they have a direct impact on caregiver self-efficacy, the caregiving experience and their responses to the individual with AN [63]. This meta-synthesis suggests that some parents feel frustrated by FBT\u0026rsquo;s agnostic aetiological stance and continue to seek a causal explanation for their young person\u0026rsquo;s eating difficulties. \u003c/p\u003e\n\u003cp\u003eThe findings suggest that the illness metaphor may have contributed to a neglect of psychological formulation for the young person\u0026rsquo;s eating difficulties. In turn, families experienced concern regarding FBT\u0026rsquo;s efficacy in meeting young peoples\u0026rsquo; psychological and emotional needs. Some FBT clinicians experience the illness metaphor dilemmatic as it does not fit with their psycho-social understanding of EDs, however they continue to use it as recommended in the manual [66]. Baudinet, Simic and Eisler [67] underscore the importance psychological formulation in ED-focussed family therapy; proposing that it is through the formulation that treatment can be adjusted to target maintenance factors specific to individual families and that barriers to progress can be identified and overcome. Moreover, formulating collaboratively with a family can create a shared narrative about the problem and support the development of therapeutic alliance [68].\u003c/p\u003e\n\u003cp\u003eIt has been proposed that AN arises from emotional processing difficulties resulting in a \u0026lsquo;lost sense of emotional self\u0026rsquo; which \u0026lsquo;self-perpetuates\u0026rsquo; and \u0026lsquo;relentlessly deepens\u0026rsquo; [69]. Psychological factors including obsessive-compulsive personality traits, perfectionism, extreme need for self-control, cognitive rigidity, experiential avoidance, positive beliefs about the value/function of AN, and responses from close others play a significant role in its maintenance [70, 71, 72]. Developing a psychological formulation would help therapists to develop a holistic understanding of the young person within their family context, prioritise which issues to focus on, and select interventions to address not only the physical symptoms of AN, but also its psychological underpinnings. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe therapeutic relationship\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe therapist\u0026apos;s knowledge, flexibility and willingness to come alongside the family were significant in supporting positive change. The findings support reviews which point to the significance of building trusting therapeutic relationships with young people and families [1, 20]. They also support studies which demonstrate significant associations between therapeutic alliance, treatment retention and outcome for individuals with AN [73, 74, 75, 76]\u003c/p\u003e\n\u003cp\u003eEntering a therapeutic relationship required young people to relinquish control and place trust in others which necessitated the tolerance of heightened distress. A common theme raised by families is a concern about the lack of therapeutic alliance in treatment for AN [1, 77]. The findings in combination with existing research suggest that individuals want to feel seen and treated as a \u0026lsquo;whole person\u0026rsquo;, within a \u0026lsquo;real\u0026rsquo; relationship with a therapist who is attuned to their emotional and psychological experiences rather than neglectful of their distress in the pursuit of weight restoration [1, 17, 18, 19, 20, 78, 79]. Attention to building and maintaining a strong therapeutic alliance with young people and their families by attending to and repairing ruptures, seeking to accurately understand their experiences, clarifying expectations and mutually agreeing treatment goals appear crucial to facilitating positive change.\u003c/p\u003e\n\u003cp\u003eNegative experiences of the therapeutic relationship were more common within FBT than SyFT. Manual-based treatments have been criticised for contributing to \u0026lsquo;bland\u0026rsquo;, \u0026lsquo;rule governed\u0026rsquo;, and \u0026lsquo;emotionally detached\u0026rsquo; therapy [80]. Clinical situations can differ from the tightly controlled conditions of a clinical research study in which evidence for a manual-based treatment is developed as clinicians are often required to adapt their practice to meet individual needs [81]. Therefore, it has been argued that while fidelity is a crucial component of successful evidence-based psychotherapy, flexible implementation allowing for deviation from the manual to individualise treatment is necessary [81]. The findings alongside existing research stress a need for greater flexibility in the delivery of FBT. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEmotional attunement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany young people reported to feel that what they were experiencing internally \u0026ldquo;did not matter\u0026rdquo; within FBT. Some healthcare professionals (HCPs) treating AN feel that the biomedical model supports them to define target symptoms and goals for recovery, however families perceive the model to place too much focus on the physical, ignoring psychological distress [20]. This meta-synthesis alongside existing research illustrates how families seek a holistic individually-adapted treatment that is flexible, and considers the psychology of the young person\u0026rsquo;s eating behaviour, as well as their family environment [1, 17, 18, 20].\u003c/p\u003e\n\u003cp\u003eSome FBT clinicians assume that weight restoration is the primary agent of cognitive symptom relief through the alleviation of cognitive rigidity resulting from starvation [82]. However, this meta-synthesis alongside existing research suggests that the psychological experience of AN can persist beyond weight restoration [83]. Thus, therapists should be cognisant of the messages conveyed to families through holding this assumption as they may risk invalidating families and hindering the alliance. The findings suggests that whilst FBT can support weight restoration, many young people experience ongoing difficulties in their relationship to eating and weight which they would like support for within individual therapy, alongside and/or following completion of FBT/SyFT.\u003c/p\u003e\n\u003cp\u003eSome HCPs working within ED services express a lack of knowledge about EDs, and perceive limitations in their capacity to help [20, 84, 85, 86, 87]. ED groups are considered difficult to treat because they present with physical and psychological risks, as well as ambivalence [87]. For clinicians, the FBT \u0026ldquo;script\u0026rdquo; can be experienced as a relief in terms of managing their own anxiety [84]. Yet, the manual can also be experienced as constraining, morally dilemmatic and burdensome when there is no positive change; nonetheless, clinicians fear scrutiny if they do not practice with strict adherence [84]. The narratives within this meta-synthesis reveal the impact of this dilemma on therapeutic change. Whilst therapists\u0026rsquo; drift from evidence-based practice is suggested to reduce treatment effectiveness [88], adherence to the FBT manual is not associated with outcome as determined by weight [89]. This meta-synthesis suggests that strict adherence to the FBT manual may reduce therapist attunement, which in turn may hinder positive change by negatively impacting on the alliance. \u003c/p\u003e\n\u003cp\u003eResearch has shown that family therapy focussing on intra-familial dynamics rather than ED symptoms improves treatment effectiveness in severe adolescent AN, indicating the broader impact of family therapy beyond the effects of parental management of eating behaviours [90]. Research comparing manualised ED-focussed family therapy (FT-AN) with a generic systemic manual (SyFT) found that those who engaged in FT-AN restored weight more promptly in treatment and spent less time in hospital than those who engaged in SyFT, whereas individuals with greater obsessive-compulsive comorbidity restored more weight over the course of treatment in SyFT than in FT-AN [91]. Therefore, there is likely to be overlap between SyFT and FBT/FT-AN in terms of guidance on managing eating behaviours, however therapists delivering SyFT may have greater capacity to be attuned and responsive to individual needs as a result of feeling less constrained by the FBT manual. \u003c/p\u003e\n\u003cp\u003eEvidence-based family therapy models of AN require more flexible, normative, less guilt-inducing, diversified, elective and integrative practices [92]. If FBT and SyFT achieve equivalent outcomes, and SyFT may be more effective at addressing comorbidity and creating a family environment conducive to positive change, there may be scope to expand focus beyond food-intake and weight within FBT. With greater flexibility and integration of models, therapists could attend to the psychological and emotional \u003cstrong\u003ee\u003c/strong\u003experience of AN, as well as the individual\u0026rsquo;s relational context which may provide families with a greater sense of containment. It has been suggested that FBT can be enhanced by integrating Emotion-Focussed Family Therapy (EFFT) with the aims of working with parents\u0026rsquo; own emotions and supporting parents to equip the young person with emotion regulation skills [93]. Families highlighted dissatisfaction with FBT for neglecting their emotional experiences. Hence, the findings support the integration of EFFT to aid therapeutic change in FBT/SyFT. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEmpowering families\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome parents perceived a harsh response from the therapist in the absence of sufficient weight restoration during FBT. In the context of non-successful outcomes, FBT clinicians often attribute causality to parents or family systems factors [82]; this assumption aligns with parents\u0026rsquo; narratives within this meta-synthesis. Parental self-blame has been captured within this study, as well as in existing research [64]. Concerningly, interactions which inadvertently disempower parents may hinder positive change by negatively impacting on the therapeutic relationship and reducing parental self-efficacy.\u003c/p\u003e\n\u003cp\u003eFurthermore, the findings suggest that positive change can be hindered by the experience of rigidity and inflexibility within FBT. Lock and Nicholls [94] maintain that whilst FBT initially targets weight restoration, it also addresses temperament/personality traits, emotional processing, cognitive content and process, social communication and relationships, comorbidity and family factors. However, some families did not feel that they were given sufficient opportunity to address such factors. Lavender [77] asserts that it is possible to achieve a full recovery using FBT and suggests that allowing the young person more individual time can support with alliance building, with phase three being extended to focus on areas of difficulty that made the young person vulnerable to AN. This meta-synthesis suggests that therapeutic change may be helped through the provision of greater flexibility in terms of treatment duration, content and format. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExternalisation \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe finding that the conceptualisation of AN as an \u0026lsquo;unwanted temporary illness\u0026rsquo; was mobilising of parental compassion and support is consistent with the FBT manual which suggests that viewing AN as an external force gives new meaning to AN\u0026rsquo;s physical, psychological and behavioural effects [10, 11]. FBT clinicians report that externalisation can improve family functioning, communication, and reduce family conflict; however, they also highlight the importance of listening skills and attunement to identify how and when to time externalisation, including recognition of when a family may not benefit [66]. This meta-synthesis provides further insight by demonstrating how externalising language can cause relational disconnection when young people feel unseen and unheard because all of their views and behaviours are ascribed to AN.\u003c/p\u003e\n\u003cp\u003eThe findings are consistent with existing research in that they underscore a prevalent negative experience of ED service-users which is feeling treated as an \u0026lsquo;illness\u0026rsquo; [1, 18, 95]. It has been suggested that implicit value judgement carried by \u0026lsquo;illness\u0026rsquo; may lead to negative interactions between service-users and healthcare professionals resulting in epistemic injustice [96]. This meta-synthesis alongside existing research demonstrates that individuals value a non-judgemental, respectful and supportive therapist [31]. Therefore,therapists should be careful that their use of externalisation enables individuals to feel recognised and respected as a person beyond AN.\u003c/p\u003e\n\u003cp\u003eConversations in which the therapist actively involved the young person to reflect on their values and aspirations alongside exploration of the function and effects of their eating behaviours helped to separate AN from the young person\u0026rsquo;s identity. Motivation, insight and subjective meaning of AN are valuable tools to manage resistance [97]. Successful treatment facilitates the development of an identity that is separate to and broader than that defined AN [98]. Hence, an important part of motivating young people to engage in changes to their eating behaviour may be to engage them in externalising conversations which place emphasis on identity development. Accordingly, practicing externalisation with adherence to the principles of narrative therapy may positively impact on therapeutic change in FBT/SyFT. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFamily involvement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe finding that parental involvement was important for physical recovery aligns with the reports of FBT clinicians that parental input is crucial for weight-based symptom remission [82]. Parents experience fear related to their involvement in the recovery process [99]; maternal fear predicts lower self-efficacy, as well as more accommodating and enabling behaviours. This meta-synthesis highlights the importance of supporting parents to feel equipped in helping their young person to manage AN. \u003c/p\u003e\n\u003cp\u003eParents experienced containment within treatment when they felt supported by their therapist. In turn, they were able to provide their young person with containment through becoming emotionally attuned, understanding and validating of their experiences. Containment denotes the relational ability to \u0026lsquo;hold\u0026rsquo; the emotion that the other person needs held and to create a felt sense of safety in the relational space [100, 101] Attunement refers to the parent\u0026rsquo;s awareness of and responsiveness to the young person\u0026rsquo;s emotions and needs, and ability to stay present with them even when that feels difficult [102]. The effect is that the young person feels understood, seen and felt with by the parent; this attuning process grows the capacity for felt safety in relationships [102]. The findings are consistent with research which has shown that increases in parental self-efficacy throughout treatment predict reduced ED, depression and anxiety symptoms [103]. It is possible that when parents feel \u0026lsquo;held\u0026rsquo; by the therapist, they feel more confident in their ability to support their young person, which in turn enables the young person to feel more \u0026lsquo;held\u0026rsquo; within their family system. \u003c/p\u003e\n\u003cp\u003eThe narratives depict how positive relational changes within the parent-young person relationship were internalised by young people, and in turn positively impacted on young peoples\u0026apos; emotional and psychological wellbeing. Hence, this meta-synthesis supports quantitative research which demonstrates that FBT/SyFT can support positive changes to the parent-young person relationship, which in turn has a positive impact on outcome [37]. Positive affective family relationships are crucial with respect to adolescent eating behaviour and emotional adaptive psychological functioning [21]. The findings alongside existing research underscore the importance of nurturing secure parent-adolescent attachment relationships to support positive change. \u003c/p\u003e\n\u003cp\u003eThis meta-synthesis uncovered narratives of intergenerational patterns in emotional expression and interpersonal relating that impacted the parent-young person relationship [58], as well as the intergenerational transmission of attitudes towards eating and weight [31]. Exploring transgenerational family relationship patterns and their influence in the development of coping strategies and identity within individuals experiencing AN can determine areas for development in the family, as well as treatment strategies [104]. This meta-synthesis underscores the importance of family involvement and the value of therapeutic space to focus on family relationships. However, there was greater opportunity to enhance family unity within SyFT than in FBT. Thus, the findings suggest that families may benefit from greater systemic family focus within FBT.\u003c/p\u003e\n\u003cp\u003eRelatedly, the findings underscore the importance of scaffolding parental unification in the treatment of AN. Research suggests that the presence of co-parental conflict is associated with lower adolescent BMI and to more dysfunctional family functioning [105]. Hence, attending to the co-parent relationship within FBT/SyFT may help to support positive change. Assessing and modifying family functioning early in treatment may be of benefit to young people who have more complex family difficulties. Adolescents experiencing AN present with more severe psychological profiles within families that display more severe dysfunctional profiles [106]. Research indicates a bio-directional relationship between family dysfunction and AN, with difficult dynamics and unhelpful cycles becoming entrenched [107]. Families of adolescents with AN often report interpersonal boundary problems, low conflict tolerance, and low general satisfaction within the family system [108]. Adolescents who report more positive views of their family at the start of treatment have better outcomes in FBT [109]; hence, it is important to assess family functioning in order that adolescent reported impairment can promote the delivery of FBT with greater relational focus. This modification may foster relational containment within the young person\u0026rsquo;s family system, creating a conducive environment for reducing disordered eating.\u003c/p\u003e\n\u003cp\u003eAttachment-Based FBT can serve as a beneficial augmentation through its focus on repairing factors that impact relational security and maintain AN (i.e., parental criticism and low warmth, family conflict and adolescent affect intolerance) [29]. Research on attachment and narrative theory in SyFT indicates the common presence of extreme separation anxiety, unresolved trauma and loss, as well as conflict avoidance and difficulties discussing relationships and feelings consistent with transgenerational experiences of insecure/avoidant attachments in young people with EDs and their families [27, 110]. These authors suggest that helping families to explore their experiences from a secure base can foster ability to reflect on their relationships, externalise the past, and relate to one another in emotionally different ways. Hence, an attachment-informed relational focus in FBT/SyFT may support positive change for families experiencing more complex relational difficulties.\u003c/p\u003e\n\u003cp\u003eLastly, this meta-synthesis illustrates how weight restoration takes place within relational systems that are shaped by sociocultural and other contextual variables. Recognising factors which under-resource parents such as the influence of financial strain and time constraints is important, particularly for those who are unsupported by a co-parent. Research suggests that socioeconomic factors do not predict outcome in FBT [111], however this meta-synthesis reveals how some families are faced with significant challenge when they are required to reduce their income to fulfil the role required of them within FBT. This may become more problematic in the global cost-of-living crisis [112]. To support positive change, future research and ED services could give consideration to adaptations that may support families who struggle to meet the demands of FBT in the face of socio-economic pressures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths, limitations and future research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA limitation of this review is that the systematic search strategy did not include the term \u0026lsquo;young adults\u0026rsquo;. This is because FBT is the first line recommended treatment for adolescent AN [113], whereas young adults may be offered individual CBT-ED or MANTRA as first line treatments for AN [114]. Therefore, the review initially set out to include studies gathering the perspectives of adolescents and their family members. However, following having completed the searches, it was evident that many studies included both adolescents and young adults, using the term \u0026lsquo;young people\u0026rsquo; to describe their sample. Consequently, given the lack of existing research on change processes within family therapies for AN, the decision was made to be inclusive by including studies that collected data from both adolescents, young adults and their family members. Nonetheless, the United Nations define \u0026lsquo;youth\u0026rsquo; as persons between the ages of 14 and 24 years [115] the NHS uses the term \u0026lsquo;young people\u0026rsquo; to classify individuals aged 16 to 24 years [116] and the World Health Organisation defines \u0026lsquo;young persons\u0026rsquo; as those aged 10 to 24 years [117]. Therefore, it is possible that this limitation was somewhat mitigated through inclusion of the search terms \u0026lsquo;youth\u0026rsquo; and \u0026lsquo;young people\u0026rsquo;. \u003c/p\u003e\n\u003cp\u003eA further limitation is that a large proportion of patients were female and ethnic background was rarely reported. This information may have provided insight into differences in perceptions of therapeutic change across ethnicities and genders. Both gender and ethnicity influence the experience of AN [118, 119]. Therefore, whilst it is difficult to make conclusions about the ethnicity of participants represented within this review, the experience of those who identify as male or non-binary are under-represented. Reporting ethnicity in future studies and increasing the diversity of samples may enhance our understanding of under-researched groups. \u003c/p\u003e\n\u003cp\u003eMoreover, attempts to narrow the search strategy to ensure the study\u0026rsquo;s feasibility within a restricted timeframe resulted in the exclusion of unpublished studies which may have contributed to the loss of information [120]. However, unpublished studies may be of lower methodological quality [121]. Alongside the consideration of conceptual quality which is an important component of qualitative research [122], the methodological quality of included studies was critically appraised using the CASP tool. Nevertheless, studies often lacked sufficient detail to answer all items on this tool, in which case the item was scored zero. Studies rarely engaged in reflexivity in relation to their position as a researcher which is an important considerstion in qualitative research [123]. Future research should aim to report how the researcher has examined their own influence on all parts of the research process.\u003c/p\u003e\n\u003cp\u003eLastly, the findings illuminate the need to explore the role of the therapist in establishing and maintaining a strong therapeutic alliance in FBT/SyFT as this was a key driver of therapeutic change. This review\u0026rsquo;s suggested changes to FBT could be evaluated using measures of therapeutic alliance, family functioning, ED symptoms and common comorbidities.\u003c/p\u003e\n"},{"header":"Conclusion","content":"\u003cp\u003eThis review highlights the importance of facilitating positive relational changes within the family system, exploring, understanding and addressing the psychological and emotional experiences of AN, supporting young people to return to valued activities, and creating an empowering and supportive therapeutic context in which young people and their families experience containment within the therapeutic relationship. Young people and families perceived positive change to be hindered by inflexibility in the treatment approach, a lack of positive therapeutic alliance and attunement to their emotional experiences, counter-effects of externalisation such as the exclusion of the individual\u0026rsquo;s voice, and a narrow focus on food-intake and weight. The findings can be utilised by ED services to consider how they may adapt to the needs of young people and their families. For example, by broadening the focus of treatment beyond restoring food intake and weight to attending to the young person\u0026apos;s emotional needs and facilitating relational containment within their family system.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUK: United Kingdom\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;AN: Anorexia nervosa\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;ED: Eating disorder\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;FBT: Family based treatment for Anorexia nervosa\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;FT-AN: Family therapy for Anorexia nervosa\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eI (the first author; SC) express my appreciation to the researchers and participants who have contributed to research within the eating disorders field. All of this existing work made for a rich and enlightening experience conducting this review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eSC conducted this research as part of their thesis on the Doctorate in Clinical Psychology at UCL. SC and MP conceptualised the review. SC led on the systematic search, quality appraisal, data analysis, and write up of this manuscript. MP and LS supervised the study, and edited the final manuscript. All authors reviewed the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThis research was funded by the University College of London.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe data supporting the results in this paper are accessible through the published primary studies from which the data (results and discussion sections) were extracted for analysis.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman ethics and consent to participate\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eNot applicable. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, United Kingdom, WC1E 6BT\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSibeoni J, Orri M, Valentin M, Podlipski MA, Colin S, Pradere J, Revah-Levy A. 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Clinical Psychology Review. 2022;93:102132. https://doi.org/10.1016/j.cpr.2022.102132\u003c/li\u003e\n\u003cli\u003eDimitropoulos G, Lock J, Agras WS, Brandt H, Halmi KA, Jo B, et al. Therapist adherence to family‐based treatment for adolescents with anorexia nervosa: A multi‐site exploratory study. European Eating Disorders Review. 2019;28(1):55\u0026ndash;65. https://doi.org/10.1002/erv.2695\u003c/li\u003e\n\u003cli\u003eGodart N, Berthoz S, Curt F, Perdereau F, Rein Z, Wallier J, et al. A randomized controlled trial of adjunctive family therapy and treatment as usual following inpatient treatment for anorexia nervosa adolescents. PLOS ONE. 2012;7(1):e28249. https://doi.org/10.1371/journal.pone.0028249\u003c/li\u003e\n\u003cli\u003eAgras WS, Lock J, Brandt H, Bryson SW, Dodge E, Halmi KA, et al. Comparison of 2 family therapies for adolescent anorexia nervosa. JAMA Psychiatry. 2014;71(11):1279. https://doi.org/10.1001/jamapsychiatry.2014.1025\u003c/li\u003e\n\u003cli\u003eCook‐Darzens S, Doyen C, Mouren M. Family therapy in the treatment of adolescent anorexia nervosa: Current research evidence and its therapeutic implications. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. 2008;13(4):157\u0026ndash;70. https://doi.org/10.1007/bf03327502\u003c/li\u003e\n\u003cli\u003eRobinson AL, Dolhanty J, Greenberg LS. Emotion-Focused family therapy for eating disorders in children and adolescents. Clinical Psychology \u0026amp; Psychotherapy. 2013;22(1):75\u0026ndash;82. https://doi.org/10.1002/cpp.1861\u003c/li\u003e\n\u003cli\u003eLock J, Nicholls D. Toward a greater understanding of the ways Family-Based Treatment addresses the full range of psychopathology of adolescent anorexia nervosa. Frontiers in Psychiatry. 2020;10. https://doi.org/10.3389/fpsyt.2019.00968\u003c/li\u003e\n\u003cli\u003eTierney S. The individual within a Condition: A qualitative study of young people\u0026rsquo;s reflections on being treated for anorexia nervosa. Journal of the American Psychiatric Nurses Association. 2008;13(6):368\u0026ndash;75. https://doi.org/10.1177/1078390307309215\u003c/li\u003e\n\u003cli\u003eVoswinkel MMH, Rijkers C, Van Delden JJM, Elburg A. Externalizing your eating disorder: a qualitative interview study. Journal of Eating Disorders. 2021;9(1). https://doi.org/10.1186/s40337-021-00486-6\u003c/li\u003e\n\u003cli\u003eAbbate‐Daga G, Amianto F, Delsedime N, De-Bacco C, Fassino S. Resistance to treatment and change in anorexia nervosa: a clinical overview. BMC Psychiatry. 2013;13(1). https://doi.org/10.1186/1471-244x-13-294\u003c/li\u003e\n\u003cli\u003eCruzat־Mandich C, D\u0026iacute;az־Castrill\u0026oacute;n F, Escobar-Koch T, Simpson S. From eating identity to authentic selfhood: Identity transformation in eating disorder sufferers following psychotherapy. Clinical Psychologist. 2017;21(3):227\u0026ndash;35. https://doi.org/10.1111/cp.12067\u003c/li\u003e\n\u003cli\u003eStillar, A., Merali, N., Gusella, J., Scarborough, J., Nash, P., Orr, E., Henderson, K., Mayman, S., Files, N., \u0026amp; Lafrance, A. (2023). Caring for a child with an eating disorder: Understanding differences among mothers and fathers of adolescent and adult children. European Eating Disorders Review: \u003cem\u003eThe Journal of the Eating Disorders Association, 31\u003c/em\u003e(1), 87\u0026ndash;97. https://doi.org/10.1002/erv.2935\u003c/li\u003e\n\u003cli\u003eBion, WR. Container and contained. Group Relations Reader. 1985; 2(8):127-133. https://www.cpor.org/otc/Bion(1985)ContainerAndContained.pdf\u003c/li\u003e\n\u003cli\u003eOgden TH. On holding and containing, being and dreaming. The International Journal of Psychoanalysis. 2004;85(6):1349\u0026ndash;64. https://doi.org/10.1516/t41h-dgux-9jy4-gqc7\u003c/li\u003e\n\u003cli\u003eJohnson SM. Attachment theory in practice: Emotionally focused therapy (EFT) with individuals, couples, and families. New York: Guilford Publications; 2019. https://openlibrary.org/books/OL27341343M/Attachment_Theory_in_Practice\u003c/li\u003e\n\u003cli\u003eRobinson AL, Strahan EJ, Girz L, Wilson AE, Boachie A. \u0026lsquo;I know I can help you\u0026rsquo;: Parental Self‐efficacy predicts adolescent outcomes in family‐based therapy for eating disorders. European Eating Disorders Review. 2012;21(2):108\u0026ndash;14. https://doi.org/10.1002/erv.2180\u003c/li\u003e\n\u003cli\u003eHooper A, Dallos R. Fathers and Daughters: Their relationship and attachment themes in the shadow of an eating disorder. Contemporary Family Therapy. 2012;34(4):452\u0026ndash;67. https://doi.org/10.1007/s10591-012-9204-8\u003c/li\u003e\n\u003cli\u003eCriscuolo M, Marchetto C, Chianello I, Cereser L, Castiglioni MC, Salvo P, et al. 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Family profiles in eating disorders: family functioning and psychopathology. Psychology Research and Behavior Management. 2017;10:305\u0026ndash;12. https://doi.org/10.2147/prbm.s145463\u003c/li\u003e\n\u003cli\u003eWallis A, Miskovic-Wheatley J, Madden S, Rhodes P, Crosby RD, Cao L, Touyz S. How does family functioning effect the outcome of family based treatment for adolescents with severe anorexia nervosa?. Journal of Eating Disorders. 2017;5(1):1-9. https://doi.org/10.1186/s40337-017-0184-9\u003c/li\u003e\n\u003cli\u003eDallos R. Using Narrative and Attachment Theory in Systemic Family Therapy with Eating Disorders. Clinical Child Psychology and Psychiatry. 2003;8(4):521\u0026ndash;35. https://doi.org/10.1177/13591045030084009\u003c/li\u003e\n\u003cli\u003eDatta N, Hagan KE, Bohon C, Stern M, Kim B, Matheson BE, et al. Predictors of family‐based treatment for adolescent eating disorders: Do family or diagnostic factors matter? International Journal of Eating Disorders. 2022;56(2):384\u0026ndash;93. https://doi.org/10.1002/eat.23867\u003c/li\u003e\n\u003cli\u003eOffice for National Statistics. Cost of living latest insights. 2023. https://www.ons.gov.uk/economy/inflationandpriceindices/articles/costofliving/latestinsights\u003c/li\u003e\n\u003cli\u003eNational Institute of Care Excellence. Anorexia nervosa: treatment for children and young people. Information for the public. Eating disorders: recognition and treatment. Guidance. NICE. 2017. https://www.nice.org.uk/guidance/ng69/ifp/chapter/Anorexia-nervosa-treatment-for-children-and-young-people\u003c/li\u003e\n\u003cli\u003eNational Institute of Care Excellence. Anorexia nervosa: treatment for adults. Information for the public. Eating disorders: recognition and treatment. Guidance. NICE. 2017. https://www.nice.org.uk/guidance/ng69/ifp/chapter/Anorexia-nervosa-treatment-for-adults\u003c/li\u003e\n\u003cli\u003eUnited Nations. Definition of Youth - Factsheet\u003cem\u003e. \u003c/em\u003en.d. https://www.un.org/esa/socdev/documents/youth/fact-sheets/youth-definition.pdf\u003c/li\u003e\n\u003cli\u003eNational Health Service Digital Service Manual. Inclusive content \u0026ndash; Age - How to talk about different age groups and stages of life. 2021. https://service-manual.nhs.uk/content/inclusive-content/age#:~:text=child%3A%204%20to%2012%20years,18%20but%20this%20may%20vary.\u003c/li\u003e\n\u003cli\u003eWorld Health Organisation. Pan American Health Organisation: Adolescent Health. n.d https://www.paho.org/en/topics/adolescent-health#:~:text=Adolescents%20represent%20the%20well%2Dbeing,10%20and%2024%20years%20old.\u003c/li\u003e\n\u003cli\u003eAcle A, Cook BJ, Siegfried N, Beasley T. Cultural Considerations in the Treatment of Eating Disorders among Racial/Ethnic Minorities: A Systematic Review. 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Cochrane Database. 2023. www.training.cochrane.org/handbook.\u003c/li\u003e\n\u003cli\u003eToye F, Seers K, Allcock N, Briggs M, Carr E, Andrews J, et al. \u0026lsquo;Trying to pin down jelly\u0026rsquo; - exploring intuitive processes in quality assessment for meta-ethnography. BMC Medical Research Methodology. 2013;13(1). https://doi.org/10.1186/1471-2288-13-46\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Toward good practice in thematic analysis: Avoiding common problems and be(com)ing aknowingresearcher. International Journal of Transgender Health. 2022;24(1):1\u0026ndash;6. https://doi.org/10.1080/26895269.2022.2129597\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"anorexia nervosa, family therapy, qualitative research, meta-synthesis, families’ perspectives, systematic review","lastPublishedDoi":"10.21203/rs.3.rs-4059211/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4059211/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To synthesise young person and family member perspectives on processes of change in family therapy for anorexia nervosa (AN), including systemic family therapy and manualised family-based treatment, to obtain an understanding of what helps and hinders positive change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e A systematic search of the literature was conducted to identify qualitative studies focussing on experiences of therapeutic change within family therapies for AN from the perspectives of young people and their families. Fourteen studies met inclusion criteria and underwent quality appraisal following which they were synthesised using a meta-synthesis approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Six overarching themes were generated: “The psychological underpinnings of AN”; “The therapeutic relationship”; Confinement to a “script”; “A disempowering therapeutic context”; “Externalisation”; and “Family involvement”. Positive change was helped by understanding and support given to the young person’s overall psychological and emotional development and wellbeing, as well as positive therapeutic relationships, relational containment within the family system and externalising conversations in which young people felt seen and heard as individuals beyond an eating disorder. Positive change was hindered by inflexibility in the treatment approach, counter-effects of externalisation, negative experiences of the therapist, a narrow focus on food-intake and weight, as well as the neglect of family difficulties, emotional experiences, and psychological factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003ePositive change regarding the young person’s eating-related difficulties ensued in the context of positive relational changes between the young person, their family members and the therapist, highlighting the significance of secure and trusting relationships. The findings of this review can be utilised by Eating Disorder services to consider how they may adapt to the needs of young people and their families in order to improve treatment satisfaction, treatment outcomes, and in turn reduce risk for chronicity in AN.\u003c/p\u003e","manuscriptTitle":"Processes of change in family therapies for anorexia nervosa: a systematic review and meta-synthesis of qualitative data","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-10 11:06:43","doi":"10.21203/rs.3.rs-4059211/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2024-03-22T20:15:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"dcf0984d-bf0a-4873-a335-0c46a6a81ee6","date":"2024-03-20T08:00:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-19T18:08:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-12T13:26:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-12T13:26:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Eating Disorders","date":"2024-02-26T18:45:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"845618dc-9804-4b5b-b430-518acaf94ef1","owner":[],"postedDate":"April 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-01T17:11:38+00:00","versionOfRecord":{"articleIdentity":"rs-4059211","link":"https://doi.org/10.1186/s40337-024-01037-5","journal":{"identity":"journal-of-eating-disorders","isVorOnly":false,"title":"Journal of Eating Disorders"},"publishedOn":"2024-07-25 16:16:10","publishedOnDateReadable":"July 25th, 2024"},"versionCreatedAt":"2024-04-10 11:06:43","video":"","vorDoi":"10.1186/s40337-024-01037-5","vorDoiUrl":"https://doi.org/10.1186/s40337-024-01037-5","workflowStages":[]},"version":"v1","identity":"rs-4059211","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4059211","identity":"rs-4059211","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}