Family-Based Treatment for Adolescents with Anorexia Nervosa: 3 Important Considerations

 

Family-Based Treatment (FBT) is an important evidence-based treatment for anorexia nervosa in adolescents. Originally conceived at the Maudsley Hospital in London, and often referred to as the Maudsley Model, it was further developed by James Lock, MD, PhD and Daniel le Grange, PhD in the United States. FBT is an intensive outpatient treatment involving the entire family whereby parents play a primary and critical role in all of the following tasks:

  • managing the restoration of the child’s weight to a healthy place and supporting the blockade of eating disordered behaviors
  • helping the child to re-establish age-appropriate control and management over their own eating
  • re-focusing the family on healthy adolescent development and relationships separate from the eating disorder

FBT is a highly focused treatment that is presented in three stages. It emphasizes behavioral change and supports a gradual increase in autonomy for the adolescent.  As a psychologist who supports and guides families through this treatment, I thought that it might be helpful for those who are considering FBT to have a primer for the treatment. In thinking about what may be helpful to be aware of when considering FBT, I reflected on the first session I have with each family and thought about all of the crucial messages I try to convey during that time. Below, I’ve decided to share the three messages that, in my perspective, stand as the most important tenets of understanding and implementing FBT.

  1. For adolescents struggling with anorexia nervosa, family support can be the most effective tool for making change. At its core, FBT recognizes that parents are capable of helping their child recover and the therapist’s role is to support them in this goal. When a child is confronted with any serious crisis or illness, investment and nurturing from the family is considered a critical asset and anorexia nervosa is no exception to this. Despite lingering misconceptions about a parental role in the development of eating disorders, FBT is built on the knowledge that parents do not cause eating disorders and that they are, in fact, integral to the recovery process. It is our job as therapists to recognize the strengths and qualities of each family and consider how FBT can be applied within each unique family system. Simply put, the aim of FBT is to empower parents to help their child overcome the eating disorder.  In other words, the therapist serves as a consultant who joins with families as they apply skills they already possess. 
  2. Eating disorders have genetic and biological underpinnings.  As such, adolescents with anorexia nervosa have little control over their illness. Furthermore, periods of malnutrition and starvation can trigger a self-perpetuating cycle of anorexic symptoms that can cause considerable disruption and suffering for the whole family. But to be clear, it is the eating disorder, not the child, which has caused such an interruption in life.  Anorexia nervosa is a devastating illness, the biological, physiological and psychological consequences of which can cause individuals to think and behave in self-destructive ways. It is important that the family works together as a team to help fight the illness and to keep it from embedding further in their child’s life. FBT therapists assist parents in distinguishing between their child and their child’s illness. This distinction helps the family to avoid blaming the child for disruption and stress that is actually a result of the illness, and also makes it easier for parents to take action when they realize they can nurture their child while simultaneously battling against the illness. As a result, energy can be better spent fighting the anorexia, not fighting with their child who is likely already suffering a great deal.
  3. Because of #1 and #2, FBT requires serious hard work and commitment. I am very upfront with families involved in FBT that they will be their child’s primary support AND that eating disorders are insidious and overwhelming illnesses. FBT is not easy. Fighting a devastating illness that has convinced your loved one they are not sick and that they don’t need help, is going to be a lot of hard work. And while it can be grueling, it is also worth it. When we hosted author Harriet Brown as a guest speaker in 2010, we asked her to share her family’s experience in doing FBT with her daughter, and she spoke to this difficulty and to the benefits of this tenet:When we took on FBT, we took on both the responsibility and the power to intervene. That was a tremendously liberating step. The worst part of my daughter’s illness for me was standing by helplessly, watching her suffer and starve. The notion that my husband and I could help her required a huge mental paradigm shift—but once we made it, we were much more effective.” 

In the beginning, FBT will require a lot of energy- energy to monitor your child’s behaviors, energy to learn different behavioral responses, energy to deal with the emotional and interpersonal changes that may come about through this work. I warn my families about the commitment that it takes and I’m honest about the dedication needed. But I also talk to families about the benefits of short-term work to outweigh the devastating long-term effects of an eating disorder and I share with them the facts.  I talk to them about the serious and significant risks of anorexia- physically, emotionally, cognitively- and I have found that families most often agree that avoiding these risks is worth putting in the work. I tell them that FBT has been shown in research (and in my office) to be the most efficacious treatment for adolescents with anorexia that we know about today.

After committing to and sticking with the treatment, I see families eventually begin to talk about “having [their] child back.” I hear families talk about their child’s increased energy, sense of humor returning, interest in friendships again, and reestablishment in the family. I hear the satisfaction when parents talk about receiving feedback from others who approach them just to say that they have recognized a positive change in their child. Over time, I hear families talk about feeling confident that they helped their child recover. They share that they can once again trust their child to make healthy food choices, and they feel a sense of relief that they no longer have to live with the constant presence of the illness. I hear families tell me that the “fight” with the eating disorder gets easier and less demanding, and eventually they don’t need to engage in the battle at all. 

If you think your family member, or someone you know may benefit from family-based treatment, I would recommend starting by talking to a professional about this option, either your current treatment provider or, if you are not currently in treatment, finding a family therapist who is trained specifically in FBT. The Center for Eating Disorders has several FBT therapists in our outpatient department, and we are happy to answer any questions you may have about this treatment modality. You can email us at EatingDisorderInfo@sheppardpratt.org or call (410) 938-5252. Additionally, we encourage all of the families we work with to utilize the book, Help Your Teenager Beat an Eating Disorder (Lock & Le Grange, 2005) as an educational and supportive resource throughout the FBT process. You can also access an extensive selection of journal articles regarding clinical research on FBT courtesy of Maudsley Parents organization.

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 Written by Laura Sproch, PhD
Individual and Family Therapist
The Center for Eating Disorders at Sheppard Pratt

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New Collaborative Care Programs for parents, caregivers and loved ones

The Center for Eating Disorders at Sheppard Pratt has long urged the participation and inclusion of family members in the treatment process for both adolescent and adult patients with eating disorders.  In addition to all of our family treatment components, parents and family members have been able to access our community support group as well as a weekly family psychoeducation group.  We are excited to announce that, beginning in July 2012, family members and caregivers of our patients will be provided with an additional level of support and engagement in the recovery process.

The Collaborative Care Workshops are designed to help provide education and support for the friends and family members who are most central to the patient’s recovery process.

Building from the strengths of the family based model, Janet Treasure and her colleagues have developed a series of workshops for caregivers of loved ones who have been diagnosed with eating disorders as a way of meeting the needs of the carers.  The workshops are designed to educate carers on the key skills that clinicians have in treating eating disorders so that there is more continuity in care between the treatment setting and at home. The workshops are designed to address the most universal needs of the carers: connection with other carers; support; and skills training. Sessions reflect an adult learning modality in which skills are taught and then there is ample time for participants to practice these skills experientially. Key skills taught include motivational interviewing, communication, the trans-theoretical model of change, self-care and behavior analysis. Research suggests that participation in these workshops, leads to benefits for both the carers and the patient. (Treasure, Sepulveda, Whitaker, Todd and Lopez).

 ~ Outpatient Collaborative Care Workshops at CED ~

The 6-week Collaborative Care workshop series will be offered to parents, significant others and primary caregivers of individuals who are stepping down from our higher levels of care (inpatient or partial hospital programs). Typically, participation in the workshop series will begin the week following a loved one’s discharge from the eating disorder unit.  [UPDATE: As of July 2013, CC Workshops are open to all family members and support people during any stage of a loved one’s treatment and recovery.] Participation in the program will provide caregivers with the following resources, skills and opportunities:

  1. Provide basic eating disorder education, including current research findings about treatment recommendations, course of illness and treatment, prognosis, and basic understanding of how eating disorders are maintained.
  2. Define and recognize symptom substitution behaviors and strategies for managing these should they arise.
  3. Analyze carer needs and learning to implement self-care strategies, including mindfulness techniques.
  4. Learn effective communication skills to improve communication with their loved one who has an eating disorder.
  5. Recognize caregiver styles and learning to maximize strengths while working towards the most effective caregiver style.
  6. Define the different stages of change in the trans-theoretical model of change and understand how these stages can impact a loved one’s motivation throughout the treatment process.
  7. Learn how to help increase their loved one’s motivation towards recovery.
  8. Improve emotional intelligence by learning basic emotion regulation skills.
  9. Learn the basic theoretical model of cognitive behavioral therapy, as well as basic CBT techniques.
  10. Learn how to analyze how caregiver behaviors may inadvertently contribute to the maintenance of eating disorder behaviors in the family context.

Additionally, caregivers will learn about the interventions most commonly used by the Center for Eating Disorders.  Providing carers with education on the basic theoretical underpinnings of cognitive behavioral therapy and dialectical behavioral therapy will ensure that carers understand the skills that their loved ones have been taught in treatment. This will allow carers to be more fully able to support their loved one in attempts to challenge and/or block eating disorder cognitions and behaviors when they are at home. For more information about this program please email the Collaborative Care group facilitator, jmoran@sheppardpratt.org.

The Center for Eating Disorders has also added a 4-weekend Collaborative Care workshop series exclusively for family members  of current CED inpatients and partial hospital patients.  Please call us at (410) 938-5252 for more information.

Visit our website: www.eatingdisorder.org

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 References & Additional Resources:

Lock, J; Couturier, J; and Agras, W.S. (2006)Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy. Journal of American Academy of Child and Adolescent Psychiatry, 45(6), 66-72.

Lock, J.; Le Grange, D.; Agras, W.S. and Dare, C. (2001) Treatment Manual for Anorexia Nervosa: A Family Based Approach. New York: Guilford.

Silverman, J. Anorexia Nervosa: Historical Perspective on Treament (1997). In D.M. Garner & P.E. Garfinkel (Eds), Handbook of treatment for eating disorders, 2nd edition(pp 3-10) New York: Guilford Press.

Treasure, J., Schmidt, U. & Macdonald, P. (Eds). (2010) The Clinician’s Guide to Collaborative Caring in Eating Disorders: The New Maudsley Method. New York: Routledge.

Treasure, J., Sepulveda, A., Whitaker, W., Todd, G. & Lopez, C. (2010) Family and Carer workshops. In Treasure, J., Schmidt, U. & Macdonald, P. (Eds). (2010) The Clinician’s Guide to Collaborative Caring in Eating Disorders: The New Maudsley Method.(pp167-173) New York: Routledge.

Treasure, J.; Smith, G.; and Crane. A. (2007) Skills-based learning for caring for a loved one with an eating disorder: The new Maudsley method. New York: Routledge.