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

BY: Cristin Runfola, PhD

DATE: August 6, 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.” Last week’s post, Part 1, focused on Anorexia. This week, Bulimia Nervosa is highlighted.

Part 2: Bulimia Nervosa

The Integration of Family-Based Treatment and Dialectical Behavior Therapy for Adolescent Bulimia Nervosa: Philosophical and Practical Considerations, by Anderson, Murray, Ramirez, Rockwell, Le Grange, & Kaye

Free access NOW!

  • BN, being characterized by binge eating and drastic weight control techniques which may be (in part) a means for coping with various emotional states, may be ideally treated with an integrated DBT and FBT approach.
  • Independently, DBT and FBT have show to promote recovery among (at least some) adolescents with BN. Together, the approaches may more comprehensively address BN symptoms, better facilitating recovery.
  • Strategies for a blended approach are as follows:
    • Diary Card Review – with families, review the diary card which includes all target behaviors and discuss parent/child similarities and discrepancies in observations.
    • Family Behavior Chain Analysis – conduct a “family-wide analysis” to identify the thoughts, feelings, and behaviors related to target behaviors, highlighting the various points of intervention.
    • Family Crisis Plan – Develop a crisis plan for the patient, but make sure to include family members at each step in the plan. Thus, the crisis plan will encourage adolescents to reach to parents for support (i.e., emotional validation and distraction) until urges subside.
    • Multifamily Skills Training – in a group format, teach emotion regulation skills to both adolescents and their caregivers. These skills will help both parties regulate emotions so that they can better work together towards recovery and change.
    • Interpersonal Effectiveness Strategies – collaboratively develop strategies for promoting effective interpersonal communication among family members, focusing specifically on the ways in which families communicate around the eating disorder.
    • Telephone Consultation – enable phone coaching for both the adolescent and parent, assisting them during acute emotional crises.
    • Parent Training and Contracts – establish behavioral contracts.
  • With this integrated approach, therapists may offer both behavioral symptom remission and improved emotion regulation for the adolescent and his/her family.
  • Research is needed to test whether the above approach is efficacious above and beyond current treatment modalities or for certain populations.

Multi-Family Therapy for Bulimia Nervosa in Adolescence, by Stewart, Voulgari, Eisler, Hunt, & Simic

  • The Child and Adolescent Eating Disorders Service, South London and Maudsley NHS Foundation in London developed Multi-Family Therapy –BN (MFT-BN) to address BN in adolescents aged 13-18 years over a 20 week period. Sessions are 1.5 hours long, initially spaced out weekly and then fort-nightly. Medical monitoring is provided.
  • MFT-BN incorporates systemic therapy, CBT, and DBT strategies. Most sessions are in multi-family format, but separate parent/adolescent groups occur as needed.
  • There is an “introductory evening” where families meet each other, treatment team goals and expectations are shared, and a formal presentation of BN physical consequences/risks are discussed.
  • Given that motivation to participate in therapy with parents may be low in adolescents, separate groups are held for parents and youth for two sessions. Adolescent groups focus on enhancing motivation for recovery and reaching out for support. Parent groups provide space for expression of difficulties and frustrations to prevent high levels of expressed negativity and criticism in the room with adolescents. Both groups also provide psychoeducation on the binge/purge cycle.
  • Systemic elements of the approach include: 1) use of family as a resources; 2) shared experience among families to gain exposure to new ways of thinking; and 3) exploring ways of addressing difficulties. Strategies used include cross-generational interviewing and “foster families.”
  • CBT elements include developing a CBT formulation of the binge/purge cycle, identifying automatic irrational thinking patterns and replacing them with healthier alternatives, and exposure activities.
  • DBT elements of the approach include skills training in distress tolerance (e.g., developing a distraction plan, a self-soothe box, and “cope ahead” skills), emotion regulation, and mindfulness (e.g., discussion of wise mind, emotion mind, and reasonable mind concepts). Parents are taught how to validate emotions.
  • Unlike FBT, parents are not encouraged to take a highly active role in their child’s feeding; instead, the adolescent is encouraged to regain control over eating his/herself. The family members all negotiate ways in which each member can support the adolescent.
  • All family members practice skills outside of session.
  • The MFT-BN program has been delivered five times over the past 5 years with preliminary observations showing it is acceptable to families and feasible to implement. A qualitative study of participants is underway. Preliminary data suggest the program helps reduce eating disorder and depressive symptomatology while increasing use of adaptive coping skills. However, dropout rates in the MFT-BN program appear higher than MFT-AN programs.

Part 3, our final part in this series, will be posted next week. Stay tuned!