Family-Based Treatment of Eating Disorders: A report from the American Psychological Association Convention
Posted Aug 20 2009 10:21pm
As promised, I wanted to highlight a few key "take away" items from this year's American Psychological Association (APA) Convention that took place this month in Toronto, Canada.
Several sessions about eating disorders were of note, including a symposium entitled, "Role of Culture and Eating Disorders: An International Perspective", and "Evidence for Treating Eating Disorders in Adolescence", the latter of which I will focus on today.
"Evidence for Treating Eating Disorders in Adolescence" was a Clinical Health Psychology Ground Rounds, two-hour research symposium, conducted by Daniel LeGrange, Ph.D. of the University of Chicago.
The focus of the symposium was Family-Based Treatment (FBT) of eating disorders, an approach that is often alternately referred to as "Maudsley Therapy".
LeGrange shared both "the basics" about FBT as well as the results of new research demonstrating its effectiveness.
The basics: FBT encourages parental involvement in adolescent eating disorders recovery. It is an approach that focuses both on weight restoration in anorexia nervosa and the return to normal eating in both anorexia and bulimia nervosa. Parents initially take charge of adolescent weight restoration in the same way that a nurse might in an inpatient or residential treatment program. In time, parents are encouraged to hand the control of eating back to their child in an age-appropriate manner and adolescent developmental issues are also addressed in later stages of this approach.
There are three "phases" to FBT ( Click here for a description of the three phases) that take place over 20 sessions, although the sessions are do not take place over consecutive weeks, rather they transpire over a period of about 7-8 months, on average, when an adolescent is medically stable and when FBT is medically appropriate.
According to LeGrange, the 20th century witnessed the "parent-ectomy" introduced into eating disorders treatment (although experts even as far back as 19th Century physician William Gull reportedly said that "parents make the worst attendants" of anorexia patients), a truly dis-empowering state of affairs that would likely never be tolerated by parents of adolescents with any other illness, medical or psychiatric. Unlike more "traditional" therapies, FBT includes the parents as key players in ED recovery, harnessing the love and experience found within the fundamental role that parents play in their children's' lives - feeding them.
FBT borrows from Minuchin's Structural Family Therapy, Haley's Strategic Therapy, Selvini-Palazzoli's Milan School, and White's Narrative Therapy. Yet at the same time, FBT is decidedly "agnostic" in its approach to eating disorder treatment; no assumptions are made about the origins of an ED, because, according to LeGrange, at the end of the day, it is weight gain and the return of normal eating that is of the essence. Yet it is also important to note that in FBT neither parent nor child is blamed for their illness.
FBT may be familiar to many in its use of a team approach to treatment, yet a large number of eating disorder professionals may not be used to have parents play such a central role on the team! I highly recommend the website www.MaudselyParents.org for more information about parental involvement in eating disorders recovery, FBT, and related resources.
The results: studies have demonstrated FBT to be more effective than supportive psychotherapy for bulimia nervosa (BN) and equally effective as CBT guided self-care for BN, although less cost-effective. For anorexia nervosa: FBT has been found to be successful in a majority of cases, and up to 90% of patients remain recovered even at 5-year follow up ( see here and then scroll down for additional research references). Several new studies are currently underway including those that will examine FBT alongside systemic family therapy, inpatient psychotherapy, and cognitive-behavioral therapy. As additional studies are published, I will update the findings here on Treatment Notes.
LeGrange attests that FBT is "not the be-all, end-all" treatment for eating disorders, yet its effectiveness cannot be ignored. LeGrange asserts that FBT is most appropriate for patients who are medically stable enough for outpatient intervention, and/or after a brief stay at the hospital to resolve any medical conditions; that FBT is probably not appropriate for families in which there is severe parental discord; and he recommends that if a parent shows signs of having their own ED, that this be acknowledged openly and handled accordingly.
FBT is "not for the faint of heart". It certainly requires strength (and courage and patience and determination) on the part of parents, but also asks of healthcare professionals who may not be used to encouraging parents to "be in charge" of their child's eating disorders recovery (control that is ultimately relinquished back to the child). In this way, FBT may turn some of the current healthcare assumptions upside down, yet FBT has been shown to turn families and their children right-side-up, so it deserves our attention.
Questions: Does FBT encourage counting calories or using meal plans? What ages are suitable for FBT? What strategies take place in sessions, and where along the way are these strategies introduced? What is a "coached family meal"?
I hope to address some of these issues in future posts over time, however the best recommendation that I can give to professionals wishing to learn more about implementing FBT is to purchase the training manuals co-authored by LeGrange and Dr. James Lock, one for bulimia nervosa and one for anorexia nervosa and/or to receive additional training in FBT. I also highly recommend the companion manual for parents.