Transcript HaltomMaudsleyEDRCOct52007 - Eating Disorders Recovery

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
 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
Research support for FBT
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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)
Overview
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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
Parents are necessary
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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
Parent
Parent
Parents
united
against ED
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 familybased 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
Why Family-Based
Treatment?
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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
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Less costly
Not worried about “Why?”
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Helps parents not blame themselves: no one to
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blame
Helps parents overcome helplessness
Where does the work take
place?
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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
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
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
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
2. Parent-empowerment
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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
2. Parent-empowerment
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•
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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
FBT can be demanding …it
takes time and focused effort.
3. Focus on restoring healthy
eating habits
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Initial task is focus on healthy eating
habits and normalizing eating at home:
parents manage the eating disorder
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Family encouraged to work out for
themselves how to best manage eating
disorder symptoms: restore healthy eating
and curtail purging
4. Separate illness from child
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Adolescent is ill rather than obstinate:
prevent criticism of patient
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Illness is externalized: symptoms don’t
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Parents sympathize with the plight the
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Therapist models sympathy and
belong to child, illness overtakes child
illness has created for their offspring
understanding
5. Therapist as consultant
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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
Other professionals on the team:
biopsychosocial approach
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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
Three phases of treatment with
Maudsley approach or FBT
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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)
Phase III: Address family and normal
adolescent developmental issues (Sessions
17-20 or as needed)
Phase I:
The eating
disorder
rules
Phase III:
Adolescent has
mastered the
symptoms
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
Duration of FBT
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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)
Weight gain over time: 14 y/o Height: 67 in.
FBT Approach
150
Weight in lbs.
145
140
135
130
125
120
0
5
10
15
20
Weeks
25
30
35
Traditional family treatment
model: similarities
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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
Key differences between
traditional family and FBT
approaches
Traditional approaches:
 A combination of individual and family
sessions are included from the beginning.
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Strong emphasis placed on developing
assertiveness, autonomy, and self-control
in adolescents from early stage.
May involve child meal planning
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
Traditional approaches:
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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
Weight change over time 14 y/o 64 in.
Traditional family approach
130
125
Weight in pounds
120
115
110
105
100
0
10
20
30
Weeks
40
50
60
Harnessing parents’ anxiety
with FBT
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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
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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
Therapist harnesses the
anxiety
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Therapist validates, joins, and enhances anxiety
in early phase of treatment: use anxiety as
motivational tool
Families are relieved from their
helplessness: therapist gives direction, control
and clear responsibility to parents under
watchful eye of therapist.
Get family organized, consistent, persistent
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Families are relieved to have therapist join their
primary focus on managing and
eliminating eating disorder
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.”
What family characteristics
need to be facilitated with
FBT?
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Parental unity: parental agreement needs to
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Willingness to take control or supervise:
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be present
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
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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
When not to use FBT
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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
Weight gain over time: 14 y/o Height: 67 in.
FBT Approach with anorexia
150
Weight in lbs.
145
140
135
130
125
120
0
5
10
15
20
Weeks
25
30
35
Important differences in AN
and BN
(LeGrange and Lock, 2007)
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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 illnesses
with 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
Important differences in AN and BN
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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)
FBT in phase I
1.
Take weights with patient individually,
then join family in session
2.
Harness anxiety to motivate family
3.
4.
Take a history from each family member
about the impact of ED
Give parents permission to involve
themselves actively with adolescent’ s
eating
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
Phase I: Family picnic
5. Family picnic: forbidden foods +
healthy amounts of food
Role play
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
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
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
Patient binge/purge log
(LeGrange and Lock, 2007, p. 29)
Day
1
2
3
4
5
6
7
Binge
Purge
#
O
F
P
U
R
G
E
S
Or
B
I
N
G
E
S
Therapist binge/purge charts
(LeGrange and Lock, 2007, p. 30-31)
8
7
6
5
4
3
2
1 2
3
4
5
6
7
Date of session or session number
8
9
10
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:
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
Dealing with parental hostility
The Effective Meal Support for Family and
Friends video: British Columbia Children’s
Hospital
How to deal with parents’
hostility
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Model non-critical acceptance of patient and symptoms
Help parents blame the illness, not the child
Carefully identify ways instance of
criticism/hostility got in the way of progress – look
at pain underneath hostility, e.g., parents overburdened,
exhausted, frustrated
Find alternative ways to handle hostile interaction:
“The eating disorder (rather than child) is a very selfish
illness right now – it is trying to stop you from eating.”
Call on less critical parent/caretaker to support and
assist in decreasing critical comments, finding
alternatives
Returning autonomy to
adolescent:
phase II
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In Phase II, use treatment to begin introducing
return to normal adolescent development:
foster autonomy
Parents’ anxiety reduced and confidence in
managing illness is high
In case of AN, patient has surrendered to the
parents’ demands in Phase I
In case of BN, begin to return control of
eating and related purge behaviors to
adolescent under parental supervision.
Phase II: When?
 Patient able to eat without cajoling by
parents
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The hold of the AN or BN over excessive weight
preoccupation, diet strategies, and binge and
purge behaviors broken by collaborative efforts
in Phase 1: Binge/purges less than 1-2
times per month.
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Family ready for increased independence
from therapist
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Healthy weight is restored/weight stable
Phase II
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Use of diet supplement drinks or bars
discouraged heading into phase II
Sessions more spread apart: every 2-3
weeks OK
Examine relationship between adolescent
issues and development of ED
Therapist introduces previously set aside
non-eating-disorder-related issues
Continue to monitor and modify criticism
of adolescent by parents or sibling
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Weights and binge/purge behaviors
continue to be monitored until Phase III
Continued reinforcing of the difference
between illness-driven thinking and
healthy thinking
Monitor parents’ increased temptation to
criticize patient as she or he takes over:
support best efforts of patient.
Healthy eating habits and absence of
purging behavior remain the focus of
treatment even as parent supervision is
phased out
Ways to decrease parental
supervision
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
meal preparation
Decreasing parental
involvement
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
Role play
Phase II
Pitfalls of negotiating
Phase II
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Patient sees the lull coming out of Phase I
as a long-awaited opportunity to resume
unhealthy eating and purge behavior and
therapist/parents fail to renew supervision
With AN, family and/or therapist mistake a
suboptimal plateau in weight as adequate for
moving to Phase II: encourage appropriate
anxiety about relapse
Therapist influenced by other team
members
Other pitfalls
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Parents/therapist too exhausted to move on and
wish to stop treatment once health restored: make sure
adolescent well on the way to normal adolescence before
moving on, e.g., adolescent realigned with peers while
parents refocused on normal adult lives
Failure to see connections between adolescent issues
and development of ED: must understand ways in which
ED is a form of communication, currency in family
Therapist takes too much responsibility for family
problem solving: therapist must advocate family arriving
at their own solutions, assist the family process
Parents too traumatized/anxious to let go of
control: become critical
An artificial deadline for “getting finished” looms: e.g.,
college
Weight change over time: 17 y/o Height: 70 in.
140
135
Weight in lbs.
130
125
120
115
110
105
100
0
5
10
15
20
25
Weeks
30
35
40
45
50
What parents have to say
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Helpful: Laura Collins, “Olympia’s mind came back
incrementally. It was one bite at a time.” (p. 142)
Anxiety-provoking to have so much responsibility
In beginning difficult to let go of pursuing “why” ED
occurred.
Parents say they second-guess themselves about letting
go of supervision, e.g., give adolescent a choice then act
disappointed
Parents sometimes say they didn’t know what their child
was eating before FBT: chaotic meal times
Parents find occasional nutrition consultation important
Parents usually need consultation about restricting
exercise: how much? how often?
What patients have to say
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Two studies (Krautter and Lock, 2004 and le
Grange and Gelman, 1998) have found both
patients and parents find FBT helpful and
successful, although many adolescents reported
a need for more individual therapy.
Observations of patients:
- Adolescents appreciate seeing their parents
relieved 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’ reactions to FBT
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 for Anorexia Nervosa: A Familybased Approach. NY: The Guilford Press. p. 21.)
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