Family Based Treatment for Restrictive Eating Disorders

A Guide for Supervision and Advanced Clinical Practice

Sarah Forsberg, James Lock, Daniel Le Grange

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780815369530
• eBook ISBN: 9781351252003
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Family Based Treatment for Restrictive Eating Disorders unpacks some of the most common dilemmas providers face in implementation of Family Based Treatment (FBT) across the spectrum of restrictive eating disorders. Directed towards advanced clinicians and supervisors, this manual is rooted in the assumption that true fidelity requires ongoing self-reflection and an understanding of the nuances involved in translating manualized interventions into rich clinical practice. Combining the key tenets of FBT with the best practices in supervision, it provides a framework to support each phase of the treatment process. Each chapter contains a wealth of resources, including clinical vignettes, a treatment fidelity measure, and other useful tools to assist both supervisors and advanced clinicians in becoming expert FBT practitioners.

1 Orientation to This Manual

Sarah Forsberg, James Lock and Daniel Le Grange

This manual was developed with the aim of facilitating fidelity to family-based treatment (FBT), and is specifically aimed at guiding supervisors and advanced clinicians. This guideline is rooted in the assumption that supervision is a distinct area of professional competence, and that true fidelity requires ongoing self-reflection and an understanding of the nuances involved in translating manualized interventions into rich clinical practice. Over the past decade, the evidence base for FBT has grown significantly, and currently is the recommended first-line approach for treatment of adolescents with anorexia nervosa (AN) (Agras et al., 2014; Le Grange, Lock, Loeb, & Nicholls, 2010; Lock, Agras, Bryson, & Kraemer, 2005). Preliminary evidence suggests it is also preferable to individual cognitive-behavioral therapy for adolescent BN (Le Grange, Lock, Agras, Bryson, & Jo, 2015), and can be useful in treating atypical AN (Hughes, Le Grange, Court, & Sawyer, 2017). There have been significant and successful efforts to disseminate the model outside the academic institutions in which it was developed (Couturier et al., 2014; Hughes et al., 2014). However, a need-service gap remains and access to the treatment is limited given the significant resources required to provide training that assures the highest level of competence in delivery of the model. As a result, efforts to both improve efficiency and decrease cost of training of mental health professionals in FBT are underway.

Background on Treatment Fidelity

Treatment fidelity is a term utilized in psychotherapy research to describe the extent to which an intervention is delivered as intended (Perepletchikova, 2011). It encompasses adherence to prescribed practices, abstention from proscribed interventions, and the sophistication with which the intervention is delivered. Therapists practicing with fidelity are steeped in the core philosophy and principles of an approach, and are able to flexibly apply interventions to meet a unique patient’s needs, while remaining adherent. Without fidelitous implementation of an approach it is impossible to evaluate treatment efficacy. Many factors, including lack of training, misunderstanding of the mechanics behind core principles, and a tendency in clinical practice to use integrated approaches, may explain treatment failures. In instances of poor treatment outcome, it is not uncommon for clinicians to attribute lack of progress externally to the family/patient, the treatment or a poor fit between the two. Here, we propose that therapists who are interested in practicing FBT with the highest degree of integrity instead turn to this manual, to expert colleagues and supervisors and to introspection with the aim of refining their skillset in delivering the approach. We hope that this framework will enhance one’s confidence and help guide treatment decision making, including decisions about when changing course is indicated.

The Art of Supervision

The practice of clinical supervision is designed to enhance overarching therapeutic skill and promote self-reflection and metacognitive process, and serves an important gatekeeping function in preparing clinicians to practice independently. Historically, supervision has received little attention as a distinct professional entity requiring separate training, and the assumption has been that high levels of clinical proficiency form the basis of quality supervision. This view of “supervision by osmosis” often pervades the field of mental health intervention; however, it has increasingly come under scrutiny given the push for competency-based training. Very few mental health providers receive specific training in supervision and only recently did the American Psychological Association publish its own guidelines for clinical supervision (American Psychological Association, 2015). There are other published guidelines that focus on supervision models that can be applied globally across treatments (i.e., a competency-based approach; Falender & Shafranske, 2014), or specifically within a given model (Milne & Reiser, 2017). However, there is a lack of materials delineating best practices in supervision (Reiser & Milne, 2012). Manuals for therapy promote adherence to treatment protocols; specifically FBT providers referencing the treatment manual had much higher rates of compliance with treatment principles in one survey (Kosmerly, Waller, & Robinson, 2015). Thus the need for a parallel guide for supervisors to prevent drift and enhance adherence is warranted. And yet, there is a significant discrepancy between the strong push for competency-based models of intervention and the lack of coherent training protocols, guidelines and manuals for supervision, even when these are required in RCTs. Attempts to delineate standards for competent supervision have been complicated by diverse viewpoints and difficulties in reaching consensus (Reiser & Milne, 2012).

As a distinct professional activity, supervision involves the provision of education and training to support the development of a high quality of clinical practice. Supervisors not only are responsible for ensuring that their supervisees are competent in the particular therapeutic approach but also guide their professional development. They monitor supervisee adherence to ethical and legal guidelines, as well as their upholding of the values of their respective field of practice. As such, they are leaders and gatekeepers responsible for protecting the well-being of patients, the professional field and society at large (Falender & Shafranske, 2014).

Delineating the Utility of This Manual

There are a few distinctions to be made in considering how this manual is to be applied in clinical practice. First, it is important to distinguish between supervision and consultation. Many involved in dissemination of FBT serve as consultants to licensed mental health providers interested in certification in FBT. The crux of this distinction is that the consultee does not need to accept the directives or advice of the consultant, whereas supervisors are responsible for comprehensive knowledge of the entire case, and are ethically and legally responsible for the patient’s welfare. Supervisees operate under their supervisors’ professional licenses and thus are required to follow through on directives provided in supervision (whether there is disagreement and how to manage this are separate issues). The manual here provides specific guidance around supervision practices; however, the guidance around structure and helping supervisees walk through common dilemmas will be equally applicable in the consultant-consultee relationship. Those who are qualified to provide supervision in FBT are those who have a specific expertise in the model and aspire to practice with the highest degree of competency. This manual is also directed at assisting such advanced practitioners in enhancing self-reflection and adherence to the model. The foremost purpose of this manual is to enhance fidelity to the FBT model with the aim of improving clinical outcomes.

What This Manual Is Not

This manual is not meant to provide a thorough review of supervision best practices or a review of various models of supervision, or to expand upon universal dilemmas encountered in psychotherapy supervision. We highly encourage supervisors to turn to well-established resources designed to enhance the overarching practice of supervision. We recommend the following guidelines derived from a competency-based perspective of supervision (Falender & Shafranske, 2004) and evidence-based perspective (Milne, 2009).

Best Practices in Supervision

As noted earlier, the APA and others interested in elevating the art of clinical supervision have published guidelines (American Psychological Association, 2015; Falender & Shafranske, 2014; Milne & Dunkerley, 2010). The practice of supervision generally is assumed to include self-assessment (by both supervisee and supervisor), whereby bidirectional feedback is encouraged, and goals with regards to establishing competency and skill acquisition are identified and monitored directly. Different governing bodies have unique requirements one must meet in order to practice. For example, the APA requires minimum training and continuing education for those who wish to practice supervision. Competency in supervision is thought to require a focus on models and theories of supervision, relationship formation, rupture and repair, diversity and multiculturalism, and decision making regarding the developmental level of the supervisee (Bernard & Goodyear, 2014; Falender & Shafranske, 2014, Newman, 2013). Other guidelines exist around remaining sensitive to issues of diversity that arise in the patient-therapist relationship, and supervisor-supervisee relationship. The emphasis is on creating a collaborative environment, whereby expectations are communicated clearly and reviewed on an ongoing basis, and differences with regards to diversity are openly discussed. Supervisors are expected to model professional behavior and thereby socialize individuals into the field (and to “think like” an FBT therapist, in this case). Feedback to supervisees is critical and should be timely and directly linked to FBT competencies. Supervisors create an environment in which therapists feel comfortable providing their own feedback on the supervision process, especially recognizing the tendency for supervisors to overestimate their competence (Walfish, McAlister, O’Donnell, & Lambert, 2012). In this way, supervisors are sensitive to the inherent power differential in the supervisor-supervisee relationship, which is influenced by a range of factors (developmental level, diversity issues, sources of privilege and oppression) (American Psychological Association, 2015). Many of these expectations for the process of supervision can be outlined in a supervision contract to be reviewed with the supervisee when the relationship is established, and supervisors adhere to institutional standards with regards to provision of a contract.

In this manual, we discuss the ways in which supervisors can set the supervisory framework, which includes orientation to required training, methods of evaluation and the structure of supervision.

Who Is This Manual For?

Advanced clinicians practicing FBT have expertise in the treatment of adolescent eating disorders (ED) and have received specialized training in the model, which includes ongoing supervision specifically focused on evaluation of fidelity. FBT supervisors are highly trained experts who have treated numerous families using the approach, and have become supervisors by virtue of their strong theoretical grounding in the model and high-quality clinical work experience. Standards for supervisors have not yet been articulated, but over time will be promulgated. This manual serves as a guide both for those advanced clinicians who seek to elevate their practice of FBT and those who are providing supervision, and reflects competencies that need to be developed for those who are interested in growing into a supervisory role. At a minimum, supervisors are expected to be familiar with the professional standards governing the practice of supervision in their field, and are well versed in the ethical and legal standards of care governing the practice of psychotherapy. Note that the term “clinician” is used throughout to describe any professional treating a family in FBT and also encompasses supervisees.

How to Use This Manual

The structure of this supervision manual generally parallels the structure of the published treatment manual and is divided according to treatment phases: Orientation and assessment, Phase I, with an emphasis on Sessions 1 and 2, as well as middle and ending sessions in this phase. It will focus on common problems that arise during Phases II and III and will address the process of termination (Lock & Le Grange, 2015). Throughout the manual, the parallel process between supervision and treatment is highlighted—for example, as a clinician would work to orient a family to the in-session and overarching structure of treatment, so too does a supervisor take a similar approach to orienting his or her supervisees to the supervision process. The manual therefore highlights the structure and process of supervision, the overarching theoretical model upon which treatment goals are formulated, principles of family engagement, and common supervisor dilemmas that arise reflecting common barriers in provision of treatment. Clinical case vignettes associated with each phase of treatment are integrated throughout to help supervisors and advanced clinicians develop strategies and language to address common challenges in the approach. FBT is a present-focused, solution-oriented model, and so too do supervisors work to address problems clinicians may have in important areas of implementation (e.g., engaging families in the treatment process, understanding family patterns that maintain anorexia nervosa (AN), designing interventions collaboratively with families to promote parental empowerment and understanding and addressing barriers to success). Further, more recent efforts to codify fidelitous delivery of FBT have led to the development of a fidelity-rating tool for Phase I. This measure has been found to be reliable and valid and may support supervision efforts (Forsberg et al., 2015). The measure is included as are suggestions for its use in supervision.

An Important Note About Diagnostic Focus

This manual primarily focuses on the treatment of restrictive eating disorders (R-EDs), including anorexia nervosa (AN), atypical AN and other specified EDs that are restrictive in nature. Many of the dilemmas faced in treatment of R-EDs parallel those faced in FBT for individuals with bulimia nervosa (BN), for example. However, there are also some distinct nuances involved in treating this population that are beyond the scope of this manual. For example, individuals with AN and BN may share similar degrees of body image disturbance, but the focus of addressing this via weight restoration in AN is replaced with an emphasis on disrupting binge/purge episodes and normalizing eating patterns in BN where individuals may alternatively need to maintain weight.

Background Summary

At the beginning of each chapter a summary of the focus of the phase and important background considerations are outlined. In the background section, you will also find information on developmental considerations, to assist you in evaluating the experience level of the trainee and/or exploring your own developmental goals as a clinician.

Common Dilemmas

As you proceed, you will note a review of carefully selected dilemmas the authors chose to review based on their common occurrence in FBT. The challenge will be described and supervisory interventions will be introduced to support resolution of these dilemmas.

Supervisory Tools

Worksheets, guidelines and other resources will be provided throughout, as will case examples to illustrate helpful strategies. These tools may be used to support the structure of the supervision process as well as promote adherence to FBT principles and interventions. For example, we include a fidelity instrument developed for the first phase of treatment. This instrument may serve multiple functions:

• Help therapists prepare and guide them during the session to ensure nothing is left out;
• Help both the supervisor and therapist in supervision to structure the discussion;
• Serve as a guide to monitor progress and allow for self-reflection. For example, you can utilize this to encourage anticipation of challenges based on training background and personal style, problem-solve around common challenges (e.g., the supervisee finds him- or herself attracted to causal discussion, or is uncertain about how to invite siblings to participate in a supportive role), and evaluate progress in learning.

References

Agras, W. S., Lock, J., Brandt, H., Bryson, S. W., Dodge, E., Halmi, K. A., … Woodside, B. (2014). Comparison of 2 family therapies for adolescent...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• 1 Orientation to This Manual
• 2 Orientation to FBT Supervision: Notes From the Field
• 3 Beginning Well
• 4 Session 1
• 5 Session 2
• 6 Remainder of Phase I
• 7 Transition to Phase II
• 8 Phase II Issues
• 9 Phase III and Termination
• 10 Additional Considerations and Future Directions
• Appendices
• Index