A NEW FAMILY-BASED TREATMENT FOR ANOREXIA AND BULIMIA IN ADOLESCENTS Cris Haltom, Ph.D. Eating Disorder Recovery Center of Western NY Oct. 5, 2007. The trouble with parentectomies: old thinking revised.
A NEW FAMILY-BASED TREATMENT FORANOREXIA AND BULIMIA IN ADOLESCENTSCris Haltom, Ph.D.Eating Disorder Recovery Center of Western NYOct. 5, 2007
Efficacy of the program has been demonstrated with adolescents with anorexia under the age of 18 years old and living at home with their families.
Daniel Le Grange and James Lock have recently published a new treatment manual, Treating Bulimia in Adolescents: A Family-Based Approach (2007): a family-based treatment adapted for adolescents with bulimia 19 years of age or younger, at home.
Can be used with weight-restored patients who need balanced eating: Prevent weight loss/normalize eating/curtail purging
-Dare and Eisler (2000) have adapted FBT to use as part of a multiple family day treatment program
- Meet with 4-6 families over several long weekends or sessions
- aim to help families share, develop skills and become motivated together, united against the eating disorder: especially helpful with unskilled, reluctant, or defeated parents (15-20% poor outcome rates w/ single families)
-therapist does not have the answer as to what any individual family will need
-Dr. Tantillo will introduce a related MFG method
3. Focus on restoring healthy
4. Separate illness from child
5. Therapist as consultant
-Agnostic with regard to causes: for example, “no ‘anorexegenic’ family” and causes are multiple and complex
-Family seen as resource rather than the source of the problem: little evidence that families cause ED’s
FBT can be demanding …it takes time and focused effort.
parents to take an active role
The eating disorder rules
Phase III: Adolescent has mastered the symptoms
(example: comorbidities with BN)
e.g., find positives in enmeshment, “This is close knit family with lots of caring and support.”
1. Take weights with patient individually, then join family in session
2. Harness anxiety to motivate family
3. Take a history from each family member about the impact of ED
4. Give parents permission to involve themselves actively with adolescent’ s eating
Lbs. or kg.
Date of session 1 2 3 4 5 6 7 8 9 10 11 12
5. Family picnic: forbidden foods + healthy amounts of food
6. Re-emphasize goal is to normalize eating and eliminate binge eating and purging.
7. Congratulate any progress, sympathize with lack of progress, reinforce vigilant stance against ED
8. Regularize, organize family meals: parents supervise eating
9. Sibling support defined
10. Therapist helps parents eliminate criticism and judgment as well as avoid arguments with patient: will improve patient’s honesty, reduce shame and guilt common with BN
Take more firm control with AN:
With AN review weight charts each session. Look for progress in the form of an upward trajectory as sessions progress
With BN, keep binge and purge charts, take weights with patient individually, then join family in session. Report B/P progress to family, not weight with BN, unless extreme weight loss
Date of session or session number
Show respect for the adolescent’s point of view and experience: adolescents with AN more regressed than adolescents with BN - help shape eating behavior of adolescent with BN while carefully keeping some distance from adolescent’s other life activities:
Say to parents: “Your role is to help your child get better with your daughter’s (or son’s) help.”
With BN parents negotiate with adolescent to help disrupt binge eating and purge episodes:
(1) negotiate planned distractions
(2) adolescent fills out B/P chart with parent
(3) parents and child agree to work on one
problem at a time
The Effective Meal Support for Family andFriends video: British Columbia Children’s Hospital
“The eating disorder (rather than child) is a very selfish
illness right now – it is trying to stop you from eating.”
1. Adolescent gradually makes more food choices as long as choices are healthy and in adequate volume: e.g., allow some healthy substitutions
2. Reduce supervision of snacks
3. Reduce supervision of one meal at a time
4. Increase food shopping responsibility and
5. Eat alone sometimes versus with family
6. Adolescent able to report urges to purge/restrict/binge to parents and ask for support, when needed
7. Adolescent dishes out own portions under watchful eye of parents
- Adolescents appreciate seeing their parentsrelieved from their anxiety. Many tend to worry about their parents’ distress.
- If given a choice between a more traditional model and FBT, many choose FBT because they felt out-of control of ED
Adolescents generally form a good therapeutic alliance even though therapist supporting their parents’ supervising their eating and weight management behavior:
they know you know and know they need help
“Yelling at my mother about food was the first time I ever yelled at her since I was little.”
“I hate this even though I understand why my parents had to do it.”
“I can tell my father when I feel like purging and he helps me think about it and not vomit.”
“I have learned the best way to eat things I am afraid of is just do it.”
“Later on when I went to college I had trouble eating enough consistently but I never lost my ability to eat all kinds of foods I learned to eat with my parents. That did not change.”
“I might as well gain weight because my parents won’t give up.”
“Don’t give up too soon, as the family is the best resource for recovery.”
(Lock et al. 2001. Treatment Manual forAnorexia Nervosa: A Family-based Approach. NY: The Guilford Press. p. 21.)
British Columbia Children’s Hospital (2002) Effective Meal Support for Family and Friends (DVD-R and VHS film)
Collins, Laura (2005) Eating with Your Anorexic. NY:McGraw Hill.
Eisler, I The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia. Journal of Family Therapy, 2005; 27:2, 104-131.
Eisler, I., Dare, C., Hodes, M., Russell, G.F. M., Dodge, E. and LeGrange, D. “Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions.” Journal of Child Psychology and Psychiatry. 2000; 41, 727-736.
Haltom, C. (2004) A Stranger at the Table: Dealing with Your Child’s EatingDisorder. Denton, TX: Ronjon Pub. (in Gurze on-line catalog)
Krautter, T. and Lock, James. Is manualized family-based treatment for adolescent anorexia nervosa acceptable to patients? Patient satisfaction at the end of treatment. Journal of Family Therapy. 2004; 26: 65-81.
Le Grange, D., Eisler, I, Dare, C., and Hodes, M. Family criticism and self-starvation: A study of expressed emotion. Journal of Family Therapy. 1992; 14: 177-192.
Le Grange, D., Eisler, I., Dare, C., Russell, G. Evaluation of family treatments in adolescent anorexia nervosa: A pilot study. International Journal of EatingDisorders. 1992; 12:4: 347-357.
Le Grange, D., Gelman, T. The patient’s perspective of treatment in eating disorders: A preliminary study. South African Journal of Psychology. 1998;
Le Grange, D. and Lock, J. The dearth of psychological treatment studies for anorexia nervosa, International Journal of Eating Disorders 2005; 37,79-81
Le Grange, D. and Lock, J. Treating Bulimia in Adolescents:
A Family-Based Approach (2007) NY: Guilford Press.
Le Grange, D., Lock, J., and Dymek, M. Family-based therapy for adolescents with bulimia nervosa. American Journal of Psychotherapy. 2003; 67, 237.
Le Grange, D., Loeb, K., Van Orman, S., Jellar, C. Bulimia nervosa in adolescents: A disorder of evolution? Archives of Pediatrics & AdolescentMedicine. 2004; 158:5, 478-482.
LeGrange, D. and Schmidt, U. (2005) The treatment of adolescents with bulimia nervosa. Journal of Mental Health. 14:6, 587-597.
Lock, J. (2006) The role of family therapy for adolescents with anorexia nervosa. Psychiatric Times. Sept 1, 2006. CMP Media LLC.
Lock, J., Agras, W.S., Bryson, S., Kraemer, H. A comparison of short-and long-term family therapy for adolescent anorexia nervosa. Journal of theAcademy of Child & Adolescent Psychiatry. 2005; 44:7, 632-639.
Lock, J., Courtier, J., Bryson, S., Agras, S. (2006) Predictors of dropout and remission in family therapy for adolescent anorexia nervosa in a randomized clinical trial. International Journal of Eating Disorders.
Lock, J. and Gowers, S. (2005) Effective interventions for adolescents with anorexia nervosa. Journal of Mental Health. 14:6, 599-610.
Lock, James and Le Grange, Daniel. (2005) Help Your Teenager Beat an EatingDisorder. NY: Guilford Press.
Lock et al. (2001) Treatment Manual for Anorexia Nervosa: A Family-based Approach. NY: Guilford Press.
Lock, J. LeGrange, D., Forsberg, S., and Hewell, K. (2006)
Is family therapy useful for treating children with anorexia nervosa? Results of a case series. Journal of the American Academy of Childand Adolescent Psychiatry. 45:11, 1323-1328.
Minuchin, S. et al (1978) Psyhosomatic Families: Anorexia Nervosa InContext. Cambridge, MA: Harvard University Press.
Siegel, M., Brisman, J. and Weinshel, M. (1997) Surviving an EatingDisorder: Strategies for Families and Friends. New York: Harper Collins Publishers.
Tantillo, M. “Staying afloat in a sea of disconnections: using a multifamily therapy group to engage patients, families and providers in the treatment of eating disorders,” Presentation at Renfrew Center Foundation Conference. Philadelphia, Pa. Nov. 11, 2006.
Treasure, J. Whitaker, W., Whitney, J., and Schmidt, U. Working with families of adults with anorexia. Journal of Family Therapy. 2005;27:2, 158-170.