A NEW FAMILY-BASED TREATMENT FOR ANOREXIA AND BULIMIA IN ADOLESCENTS Cris Haltom, Ph.D. Eating Disorder Recovery Center

1. A NEW FAMILY-BASED TREATMENT FORANOREXIA AND BULIMIA IN ADOLESCENTSCris Haltom, Ph.D.Eating Disorder Recovery Center of Western NYOct. 5, 2007

2. The trouble with parentectomies: old thinking revised • Minuchin and colleagues (1975) found family involvement helped patients with anorexia • Dare and Eisler at the Maudsley Hospital in London built on Minuchin et al’s work: families recruited as necessary for recovery • Radical change and new paradigm: parents supervise eating

3. Research support for FBT • Randomized controlled trials indicate 70-80% of adolescents with anorexia do well, when treated early, with weight restoration, normalization of eating-related thoughts and behaviors, and psychosocial functioning (LeGrange et al, 1992; Eisler et al, 2000; Lock et al, 2005) • Two large controlled trials of FBT for adolescents with bulimia support using FBT (LeGrange and Lock, 2007, LeGrange and Schmidt, 2005)

4. Overview • Who, why, where, what and when of the Maudsley approach or FBT • Review three phases of Family-Based Treatment (FBT) • Comparison with traditional family treatment model • Harnessing parents’ anxiety • Facilitating positive parent characteristics • When not to use FBT • Important differences between AN and BN • Description of Phases I and II • Transitioning to adolescent autonomy • What patients and parents have to say

5. Parents are necessary • Included: family is the best resource • Empowered: parents challenge/disrupt disordered eating behaviors • Informed: parents given information about ED’s as part of therapy, e.g., medical/psych. problems • Prepared: join with the therapist to persistently deal with the illness and figure out how to take it away • Equipped: therapist guides, doesn’t give specific solutions – parents figure out their own mutually agreeable solutions

6. Parents united against ED Parent Parent ED

7. Who is Family-Based Treatment intended for? 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

8. Why Family-Based Treatment? • Avoid separation of parents from children during a hospitalization • Outpatient: child stays in usual surroundings • Less need for hospitalization and specialty care • Better use of easily available resources • Less costly • Not worried about “Why?” • Helps parents not blame themselves: no one to blame • Helps parents overcome helplessness

9. Where does the work take place? • Mostly at home: Newer research by LeGrange, Lock and others looking at applications in IP, IOP, PHP settings including multi-family groups • Whole family attends therapist-led family meetings in initial phases in outpatient setting • Other consultations in other outpatient or clinic settings will likely take place • Other safe, therapeutic settings like partial hospitalization or inpatient may be needed

10. Multi-family group applications -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

11. WHAT is FBT? FIVE BASIC PRINCIPLES 1. Agnostic 2. Parent-empowered 3. Focus on restoring healthy eating 4. Separate illness from child 5. Therapist as consultant

12. 1. Agnostic -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

13. 2. Parent-empowerment • Adolescent is out-of-control of eating disorder • Parents take charge of nutrition restoration: manage meals, disrupt extreme dieting, exercise, and purging • In the case of bulimia, parents seek collaboration with their child to promote healthy eating and disrupt pathological eating and purging behaviors • Parents respect need for adolescent control and autonomy in areas other than weight/food

14. 2. Parent-empowerment • Parents in authority: Siblings play patient-supportive (not parent-supportive) role • Parents’ supervision and involvement in adolescent’s eating and weight-related behaviors is temporary: once ED hold is released control is returned to adolescent • Parents return control of eating and weight-related behaviors to adolescent after eating patterns normalized and purging discontinued

15. FBT can be demanding …it takes time and focused effort.

16. 3.Focus on restoring healthyeating habits • Initial task is focus on healthy eating habits and normalizing eating at home: parents manage the eating disorder • Family encouraged to work out for themselves how to best manage eating disorder symptoms: restore healthy eating and curtail purging

17. 4. Separate illness from child • Adolescent is ill rather than obstinate: prevent criticism of patient • Illness is externalized: symptoms don’t belong to child, illness overtakes child • Parents sympathize with the plight the illness has created for their offspring • Therapist models sympathy and understanding

18. 5. Therapist as consultant • Outpatient family therapist acts as consultant and coach • Therapist asks, “What will it take to restore your child’s health?” • Therapist guides, assists, encourages parents to take an active role • Reminds parents of their skills • Reinvigorates when parents discouraged

19. Other professionals on the team: biopsychosocial approach • The family therapist leads the treatment philosophy – make regular team contacts • Co-therapist in family therapy, if available • Nutritionists, physicians, psychopharmacologists act as consultants • Close medical management is important: weights usually taken by therapist, objective weights occur in physician’s office • Everybody on the same page: team members need to be familiar with the treatment philosophy and allow it to guide their contact with the patient and family

20. Three phases of treatment with Maudsley approach or FBT • Phase I: Establish healthy eating and curtail purge behavior (1-10 sessions or as needed) • Phase II: Return control of eating and weight management to the adolescent (Sessions 11-16 or as needed) • PhaseIII: Address family and normal adolescent developmental issues (Sessions 17-20 or as needed)

21. Phase I: The eating disorder rules

22. Phase III: Adolescent has mastered the symptoms

23. Phase III • Attention to other family and developmental problems deferred until later in therapy when illness no longer basis for interaction unless there is obvious interference with therapy • Phase III already familiar to experienced therapists

24. Duration of FBT • Studies (Lock et al, 2005) and others studying FBT show treatment of AN lasts from 6 to 18 months with anywhere from 9 to 47 sessions. • Study by Lock, Agras, Bryson, and Kraemer (2005) shows short-term course of family therapy for AN as effective as long term, regardless of intensity and duration, except in case of non-intact family and more severe eating-related obsessive-compulsive features • Length of each phase can vary, especially with BN: be flexible, maintain integrity of protocol (example: comorbidities with BN)

26. Traditional family treatment model: similarities • Family support recruited • Family-based guidelines commonly given to parents during nutrition restoration • Like Maudsley or FBT, unity/coordination of treatment professionals across disciplines required

27. Key differences between traditional family and FBT approaches Traditional approaches: • A combination of individual and family sessions are included from the beginning. • Strong emphasis placed on developing assertiveness, autonomy, and self-control in adolescents from early stage. • May involve child meal planning

28. Traditional approaches: • Buy and keep around the house a wide variety of nutritionally balanced foods for child to chose from • Family meals: encourage parents not to comment on child’s eating behavior at meals: neutral discussion topics • If patient does not want meal prepared by parent, child prepares an alternative meal to be eaten at family meal

29. Traditional approaches: • Parents avoid responding to requests from child for reassurance about food choices • Binge/purging patients need to clean up any messes and replace binge foods • Parents do not disrupt dieting, exercise, or purging: child typically reports symptoms to team

31. Harnessing parents’ anxiety with FBT • Families are highly anxious when they present for treatment • Families are often preoccupied with food, weight, and purging and eating behavior • Families are often feeling helpless and despairing

32. Families are often frozen with fear because of the life-threatening nature of the illness: rigid about change • Families may be avoiding any stress or conflict that they think will aggravate their child’s symptoms • If conflict does ensue or there is failure at pre-treatment attempts to restore healthy eating, guilt and blame result

33. Therapist harnesses the anxiety • Therapist validates, joins, and enhances anxiety in early phase of treatment: use anxiety asmotivational tool • Families are relieved from theirhelplessness: therapist gives direction, control and clear responsibility to parents under watchful eye of therapist. • Get family organized, consistent, persistent

34. Families are relieved to have therapist join their primary focus on managing and eliminating eatingdisorder • Enhance therapeutic alliance by searching for and identifying family strengths that may surface in the midst of family helplessness and anxiety, e.g., find positives in enmeshment, “This is close knit family with lots of caring and support.”

35. What family characteristics need to be facilitated with FBT? • Parental unity: parental agreement needs to be present • Willingness to take control or supervise: starvation, pathological eating, purging not an option, parents may be reluctant • Patience and empathy: parents try to understand the patient’s internal landscape • Organized, persistent and consistent: available daily, routinely • Willingness to see the therapist as collaborator: de-mystify therapy as having all the answers

36. Non-blaming of child for eating disorder: parental criticism found to be associated with poor outcomes (LeGrange et al, 1992): Separated family therapy may be necessary • Willingness to let go of parental self-blame • Tolerance of child’s anger and resistance to change • Knowledgeable of ED’s and Tx goals • Flexible, e.g., let go of “why?”, put recovery first, be experimental

37. Whennotto use FBT • Excessive marital discord, parental disunity • Parent(s) too disabled • Lack of understanding child’s eating disorder • Excessive, chronic parental self-blame: often results in excessive parental frustration, anger, defensiveness, lack of therapeutic alliance • Child too ill with other mental health or medical problems • Too few resources or opportunities • Unable to attend initial sessions at least 3x per month

39. Important differences in AN and BN(LeGrange and Lock, 2007) • More adolescents with BN – 2-5% of adolescent girls with BN (Walsh and Wilson, 1997). Some have progressed from AN. • Broader specturm of co-morbid illnesseswith BN, e.g., self-harm behaviors common: can derail the therapy • AN often arouses more fear making it easier to stay focused on ED symptoms • BN more secretive, less obvious: patient may appear well, detracting from parental motivation

40. Important differences in AN andBN • BN usually ego-dystonic: more shame, embarrassment, & motivation to get rid of binge/purge symptoms – child unable to stop or interrupt symptoms • BN adolescents often appear more independent: have more active life experiences - parents de-motivated to interfere with adolescent freedoms and emerging independence by supervising eating and purging behaviors • BN often more connected to peer group, reactive to others: higher peer exposure and motivation to yield and conform to ideal to be thin or perfect (AN more self-willed)

41. FBT in phase I 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

42. Weight chart Weight In Lbs. or kg. 115 110 105 100 Date of session 1 2 3 4 5 6 7 8 9 10 11 12

43. Phase I: Family picnic 5. Family picnic: forbidden foods + healthy amounts of food Role play

44. Phase I 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

45. Phase I 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

46. Differences between AN & BN treatment interventions in Phase I 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

47. Patient binge/purge log (LeGrange and Lock, 2007, p. 29)

48. Therapist binge/purge charts(LeGrange and Lock, 2007, p. 30-31) # O F P U R G E S Or B I N G E S Date of session or session number

49. 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.”

50. With BN parents negotiate with adolescent to help disrupt binge eating and purge episodes: examples: (1) negotiate planned distractions (2) adolescent fills out B/P chart with parent reminders (3) parents and child agree to work on one problem at a time