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

BY: Cristin Runfola, PhD

DATE: August 13, 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 last section, focused on carers of those with eating disorders, is the final part in our three-part series.

Part Three: Engaging Carers in Treatment

Couple-Based Interventions for Adults With Eating Disorders, by *Kirby, *Runfola, Fischer, **Baucom, & **Bulik

  • Couple-based interventions for adults with eating disorders are being developed at the University of North Carolina at Chapel Hill. These interventions focus on leveraging the support of a loved one in treatment to improve recovery and outcome.
  • To maintain egalitarian relationships, partners are taught to reach joint decisions regarding treatment and recovery; this approach differs from FBT, which has a family member take control over the re-nourishment process.
  • UCAN is a couple-based intervention specifically for anorexia nervosa, consisting of 22 weeks of multidisciplinary treatment (couple therapy, individual therapy, nutritional counseling, and medical monitoring).
  • UCAN integrates cognitive-behavioral couple therapy and CBT for AN to reduce secrecy and avoidance behaviors associated with AN and to give the couple tools for effectively targeting the disorder over three phases.
  • Phase 1 focuses on assessment and psychoeducation to bring the AN out of the shadows, enhance understanding into the causes/maintenance factors of AN, and develop treatment goals. This phase also includes communication skill training, both in emotional expressiveness and collaborative decision making, so they can discuss the eating disorder and ways to address it well. This aspect of treatment also promotes open honest dialogue, validation of feelings/perspectives, and support from the other partner.
  • Phase II then works with the couple on developing strategies for resuming a healthy body weight, developing a healthier approach to eating, improving body image, and addressing challenges around intimacy/sex. Following exposure principles, the couple works through more challenging behaviors over time.
  • Phase III focuses on relapse prevention, both individual and couple-related approaches to managing slips and relapses around the eating disorder and relationship (i.e., communication partners, distancing).
  • To reduce stress, the overall relationship functioning and ineffective communication patterns are addressed throughout treatment
  • UCAN is undergoing extensive testing, but pilot findings are promising with a much lower drop out rate and greater rate of weight gain observed in UCAN than other clinical trails. Further improved general psychological and relationship functioning was also observed.
  • Since UCAN, a couple-based intervention for binge-eating disorder (UNITE-BED) has been developed and is in pilot testing. This treatment includes components of not only CBCT and CBT for BED, but DBT given the role binge eating plays in emotion regulation. It is also offered over 22 weeks as an adjunct to individual therapy and nutritional counseling (if needed).

 Collaborative Care: The New Maudsley Model, by Treasure, Rhind, Macdonald, Todd

  • The New Maudsley, Collaborative Care model is an adaptation of FBT “to address the complex needs of families in the severe stage of anorexia nervosa” and to be appropriate for adults.
  • The intervention is delivered by family therapy experts and an “expert patient” (i.e., individual recovered from anorexia nervosa) to “carers” in workshop format, with six 2-hour workshops comprising the program.
  • “Carers” include parents, children, partners, relatives, friends, or neighbors.
  • Unlike FBT, which is atheoretical, it conceptualizes eating disorders from the carer coping model based on the standard stress coping model, which emphasizes that neurobiological changes due to prolonged malnutrition, compounded by psychopathology, increases carer stress.
  • Theoretical targets include: 1) reducing caregiving burden and 2) reducing expressed emotion and accommodating and enabling behaviors in order to decrease carer anxiety and develop a team approach to treat the eating disorder.
  • Guided self-help materials have also been created, including a manual, five instructional DVDs, and a series of telephone coaching sessions.
  • Carers are taught the “C”style, which is characterized by compassion, co-operation, collaboration, and consistency with close others.
  • Carers are taught to reflect on their own potential role in maintaining the illness (even if unintentional), ways to utilize emotional intelligence, extinction learning, and how to reduce enabling and accommodating behavior. They are also taught how to set appropriate agreed-upon boundaries (e.g., that eating is non-negotiable).
  • Carers are taught how to communicate well and regulate emotion (using the “animal metaphors” to describe common reactions). Metaphors are as follows: over-emotional style (jellyfish), avoidant style (ostrich), critical style (terrier), hostile style (rhinoceros), and over-protective, avoidant style (kangaroo).
  • Preliminary data have found the approach to be feasible, acceptable, and efficacious for reducing distress and burden in carers. Levels of expressed emotion reduced and patients described positive benefits.

Parent Coaching Model for Adolescents with Emotional Eating, by Knatz, Braden, Boutelle

  • Emotion-focused parent training for youth with emotional eating (EFPT-EE) was developed at the University of California, San Diego (UCSD) for delivery in individual or group format over 8 sessions to help parents become their child’s “emotion coach” for the purpose of assisting children (13-17 years) with better responding to emotional experiences, thereby reducing the likelihood of EE episodes.
  • Adapted from emotion-focused family therapy (EFFT), EFPT-EE is based on emotion-focused therapy theoretical principles. From a biosocial model, it suggests that youth with EE have a predisposition to high emotional sensitivity – with a tendency to experiences emotions intensely and for a long duration – and, when in an environment that mismatches responses to emotional experiences, may struggle to regulate emotions and choose maladaptive ways, such as EE, to help reduce negative emotional states.
  • EFFT-EE works with caregivers to respond to their child’s emotions in a validating way while promoting healthy techniques for “down-regulating” or “re-regulating” emotion. Thus, EFFT teaches caregivers how to recognize and respond to their child’s emotional experiences effectively.
  • To do so, parents first learn about the biosocial model as it relates to EE and then participate in sessions focused on building emotion coaching skills including (a) attending to emotional experiences, (b) labeling the emotion, (c) validating the emotional experience, and (d) meeting the emotional need.
  • Parents learn ways to respond to specific emotions (verbally, nonverbally, and behaviorally) in an appropriate way, such as by responding to sadness through soothing.
  • When the child is taught how to regulate their emotions effectively, they will be less likely to turn to food to cope with specific negative emotional states.
  • Parents learn how to self-assess their success in helping their child.
  • Research on the efficacy of this program is currently underway

 Features: How I Practice

The Venus Fly Trap and the Land Mine: Novel Tools for Eating Disorder Treatment, by Hill & Scott

Free access NOW

  • This article is short but a must read. It providers two excellent experiential activities to add to the therapist toolbox, and draws from research on the neurobiology of eating disorders. Readers are encouraged to read the article in full at the “free access now” link above.

If interested in therapy materials, readers may find contact information for the corresponding author on the respective manuscript. Although some may be unable to share materials at this time, others may be able to send printed or electronic copies.