Expanding the Therapist Tool Belt: Novel Approaches to Working with Families: A Three-Part Series

BY: Cristin Runfola

Date: July 30, 2015

In a Special Issue, the Eating Disorders: The Journal of Treatment & Prevention recently published a series of articles on family-based interventions for eating disorders. This Edition featured “hot off the press” work from eating disorders experts around the world, describing the novel ways in which clinical programs are treating and healing individuals and loved ones affected by eating disorders.

For a limited time, the Journal laudably made a few of the articles freely available (links provided). Below is a list of the articles included and bulleted notes on their “take home points.” This blog will be posted in three parts to cover the three categories: Anorexia Nervosa, Bulimia Nervosa, and Engaging Carers in Treatment.

A Sneak Peak

Part 1: Anorexia Nervosa

Dissemination and Implementation of Manualized Family-Based Treatment: A Systematic Review, by Couturier and Kimber

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  • FBT can be delivered effectively to families at academic sites other than that at which it originated.
  • Implementation models are currently studying the ways in which “to move FBT into clinical practice.”
  • Four sites in Ontario, Canada are undergoing training in the use of FBT.
  • Without an active approach to dissemination, evidence-based treatments will be underutilized and, at times, used inappropriately by clinicians.
  • Active, purposeful, and supportive implementation may improve treatment fidelity and help people get better quicker.

Who’s in the Room? A Parent-Focused Family Therapy for Adolescent Anorexia Nervosa, by Hughes, Sawyer, Loeb, & Le Grange

  • Parent-focused treatment (PFT) is an approach to working with parents of children and adolescents with eating disorders without the child in the room.
  • Developed at the Royal Children’s Hospital Specialist Eating Disorders Program in Australia, this treatment is described as a separated form of FBT that combines parent-only therapist sessions with brief weight monitoring and supportive counseling by a nurse or medical practitioner.
  • Adhering to the FBT manual tenets, goals, and phases of treatment, PFT consists of 18 sessions delivered over 6 months.
  • In PFT, although the therapist does not see the whole family together, he/she receives information from the medical provider monitoring the weight and medical status of the adolescent before every session. This medical provider meets with the adolescent for 15 minutes prior to the parent session. Parents are then seen for 50 minutes.
  • Therapists delivering treatment note the following benefits: simplification of some aspects of FBT, e.g., having to manage fewer people in the room and absence of the FBT in-session family meal; reduced exposure of the adolescent to parental criticism and distress as well as patient distress; more open discussion about struggles among adolescents and parents; strong reinforcement of parents’ role in recovery
  • But, challenges were noted as well: lack of direct interaction between the therapist and adolescent requiring more frequent and prompt communication amongst treatment team members; need to obtain detailed retrospective accounts of family meals to obtain data about family meal dynamics.
  • When offered the option to have PFT or FBT, 1/5 families choose PFT. However, research on outcomes is ongoing.
  • Per past research on separated vs. conjoint FBT, PFT may be beneficial for families high in expressed emotion.

Adapting Family-Based Treatment for Adolescent Anorexia Nervosa Across Higher Levels of Patient Care, by Murray, Anderson, Rockwell, Griffiths, Le Grange, & Kaye

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  • Little research exists on how to adapt FBT for levels of care other than outpatient (e.g., inpatient)
  • Several practical and theoretical considerations for delivering treatment consistent with FBT principles across levels of care exist, including:
  • Adapting outpatient FBT to more intensive levels of care requires carefully balancing “empowerment of parents” with appropriate medical management and stability.
    • One option for doing so is to delay onset of FBT until medical stability, ensuring only brief inpatient medical stabilization occurs followed by less intensive treatment with the family. This approach would aim to increase parental involvement in treatment as the adolescent steps down to less intensive forms of care.
    • Another option is to use this period of intensive treatment to raise parental anxiety and mobilize parental resources in preparation for FBT while fostering “unity between the parents.” To do so, the medical team can immediately share with parents the medical results, consequences, and ongoing risks related to their child’s eating disorder. Parents can also become involved in nutritional planning, with dietitians communicating their child’s caloric needs while eliciting feedback from parents on how to efficiently delivery energy needs.
    • In residential and day treatment settings, clinicians can encourage parents to attend regular family meetings, play a role in treatment planning, and participate in family meals (with parent coaching).
    • In day treatment options, including partial hospitalization and intensive outpatient program settings, the parents can take a more active role with the physician taking a step back, serving as a consultant to parents and the FBT clinician and intervening medically when necessary.
  • The “double-bind” at the outset of FBT needs to be planned carefully when delivered in intensive treatment settings. The double-bind consists of heightening parental anxiety while simultaneously motivating the parents to intervene and treat the disorder. Options for doing so:
    • Hold several parental mobilizing meetings geared toward enhancing parental anxiety, intervening during treatment plateaus, and enhancing treatment adherence.
    • These meetings can occur throughout treatment and around level of care transitions.
  • Unlike in the outpatient setting, child weight status may not be the most appropriate method for indexing parental efficacy in higher levels of care; thus, alternative measure may need to be used.
    • In day treatment programs, weight change over the weekend may be used to indicate parental efficacy. However, another option is to hold family meals on the unit and observe parental behavior and child feeding to determine efficacy.
  • Build parental skills and efficacy around re-feeding their child by involving them in meal planning, preparation, and supervision of program-based meals.
    • Parents can be involved in making decisions regarding what their child will eat in a given meal/day.
    • Parents can prepare and bring their child’s meals for the day.
    • Parents can eat with their child on the unit.
    • Providers can consult parents about how to best promote child feeding during meals—e.g., what to say to be encourage “one more bite” or when their child is struggling—prior to meals or in vivo (via phone).
    • Parents can be “on call” during meals and called (by phone) to provide coaching to their child.

A Brief, Intensive Application of Multi-Family-Based Treatment for Eating Disorders, by Knatz, Murray, Matheson, Boutelle, Rockwell, Eisler, & Kaye

  • Emerging research suggests multi-family therapy is efficacious for treating eating disorders. The University of California, San Diego developed an intensive multi-family therapy program (IFT) for families (up to six at a time) that provides up to 9 hours of treatment/day over a 5 day period (for a total of 40+ hours of treatment).
  • IFT is based on FBT for AN principles, conceptualizing parents as a necessary and critical resource in facilitating their child’s recovery from an eating disorder.
  • The goals of IFT are to educate and prepare parents on managing the eating disorder at home while motivating the child/adolescent to accept help from their parents in engaging in recovery-oriented behavior.
  • Unlike FBT, which is agnostic, in IFT, parents are taught about the neurobiological underpinnings of eating disorders, to view the illness as a medical problem to reduce blame and increase empathy.
  • IFT consists of six primary treatment components: multi-family and single-family sessions, supervised family meals, parent management training, behavioral contracting, patient skills training, and psycho-education.
  • In the multi-family groups, families serve as consultants to each other (vs. therapists), enabling further “decentralization” of the therapist.
  • Multi-family groups provide opportunities to learn from one another, receive feedback, do inter-family role play, and cross-generational interviews
  • Families receive in vivo guidance during family meals (15-20 over course of 5-day span), emotional “outbursts,” and difficulty in family interactions.
  • Parent training draws from the Parent Management Training Program (PMT, Kazdin, 1997), teaching parents basic behavioral principles, including use of praise, reinforcement, and contingency management to facilitate behavior change.
  • Patient training draws from dialectical behavioral therapy (DBT), helping the child/adolescent learn how to better manage emotion and to tolerate distress, particularly that related to the eating disorder.
  • Before discharge, each family leaves with a very specific, individualized behavioral contract outlining guidelines for mealtimes and eating behavior, weight restoration, and other factors pertinent to recovery.
  • Families have found the program “suitable.”
  • Research shows preliminary efficacy of the program for a broad age range (8-27 years), eating disorder diagnoses, and phases of treatment.

 Stay tuned for Part 2 of this helpful research series coming soon!