Family Therapy for Adolescent Eating and Weight Disorders

New Applications

Katharine L. Loeb, Daniel Le Grange, James Lock, Katharine L. Loeb, Daniel Le Grange, James Lock

• Publisher: Routledge
• Year: 2015
• eBook ISBN: 9781134697366
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Family-based treatment (FBT) for eating disorders is an outpatient therapy in which parents are utilized as the primary resource in treatment. The therapist supports the parents to do the work nurses would have done if the patient were hospitalized to an inpatient-refeeding unit, and are eventually tasked with encouraging the patient to resume normal adolescent development. In recent years many new adaptations of the FBT intervention have been developed for addressing the needs of special populations. This informative new volume chronicles these novel applications of FBT in a series of chapters authored by the leading clinicians and investigators who are pioneering each adaptation.

Chapter 1
Introduction

The Role of the Family in Eating Disorders

Katharine L. Loeb, Daniel Le Grange, and James Lock

The role of the family in understanding the psychopathology of eating disorders, particularly anorexia nervosa (AN), and by extension in interventions developed to ameliorate these pernicious syndromes, has been a topic of controversy since AN was first identified in the nineteenth century. As with many mental disorders in the history of psychiatry and psychology, eating disorders have fallen prey at times to the seductive, clinically face-valid (Bulik, 2005) parent-blaming attributions that have ultimately been disproved in other cases of severe psychopathology, such as schizophrenia and autism. The conceptualization of AN as a radical, maladaptive, unconscious ploy for autonomy and self-determination in the context of enmeshed family dynamics has historically led to clinical recommendations for minimal or no parental involvement in the recovery process; in its most extreme form, this strategy is known as a “parentectomy.” In the late twentieth century, however, a new, innovative family-based intervention took form at the Maudsley Hospital in the United Kingdom that defied this clinical lore in its agnostic stance concerning the etiology of eating disorders; in its content and structure by enlisting parents as agents of change in their child’s renourishment and symptom resolution; in its focus on family strengths over vulnerabilities; in its target of treatment as the externalized illness, not systems-level or individual pathology; and most importantly, in its promising early results for young patients (Russell, Szmukler, Dare, & Eisler, 1987). Beyond these factors, its relative success in achieving and/or maintaining weight restoration on an outpatient basis was remarkable for a disorder that typically required intensive hospitalization. This maverick treatment, an amalgam of established models and techniques of family therapy and pragmatic, disorder-specific methods, has over time and across continents since been subjected to academic research in the form of randomized controlled trials and case series, to media scrutiny, and to partnership with parent and patient advocacy efforts. In light of its explicit agenda of blame reduction toward parents as a clinical tactic, it has also prompted great debate about eating disorders research and clinical priorities, particularly the nature and degree of focus on familial factors (Strober & Johnson, 2012). Notably, an appreciation of the strengths (and limitations) of family-based treatment for child and adolescent eating disorders is fully compatible with caution in not throwing the proverbial “baby out with the bathwater” and ignoring the import of genetics, of epigenetics, and of passive gene–environment correlations, such as a genetically influenced family environment, in the development of eating disorders (Bulik, Reba, Siega-Riz, & Reichborn-Kjennerud, 2005; Le Grange, Lock, Loeb, & Nicholls, 2010; Strober, Peris, & Steiger, 2014). In particular, understanding such risk factors can have significant implications for the development of targeted interventions to prevent the onset of AN and bulimia nervosa in vulnerable individuals (Striegel-Moore & Bulik, 2007), the ultimate goal of our field.

As this family-based treatment (FBT) generated professional and public attention, two published manuals (Le Grange & Lock, 2007; Lock & Le Grange, 2013), a collection of studies in support of its utility (Couturier, Kimber, & Szatmari, 2013), and an established training institute for dissemination, it simultaneously inspired a number of creative modifications and adaptations for different patient populations, psychiatric comorbidities, and treatment settings. In a prime example of the cyclical and synergistic relationship between science and practice, the realities of clinical challenges have driven new FBT formats, applications, and research endeavors; at the same time, efficacy and other FBT study findings have yielded a paradigm shift in treatment selection in the clinical realm for youth with eating disorders. That all this occurred in a relatively accelerated timeline for a newer psychological intervention speaks to the sense of urgency in the field to thwart the default trajectory of AN as a chronic disorder with a high risk of mortality (Crow et al., 2009; Papadopoulos, Ekbom, Brandt, & Ekselius, 2009). This book was thus inspired by the growing professional, collaborative network of researchers and clinicians sharing ideas, protocols, observations, and preliminary results, and the need for their cutting-edge work to be made available as a resource in a single volume. The adaptations and new applications described in this book therefore vary in their stages of development and testing.

The book begins with the voice of Ivan Eisler and colleagues from the Maudsley Hospital on the origins of FBT, its roots in family therapy, the essence of the approach, and its evolution since the first published study. As a “parent” of family therapy for adolescent AN, Eisler provides a unique and important perspective that sets the tone and frame for the chapters that follow. Specifically, Andrew Wallis, Elizabeth Dodge, and he speak to the core elements of the treatment model and the imperative to favor fidelity to its principles over rigid manual adherence in achieving optimal outcomes, particularly with complex cases.

Part I

The section that follows contains six adaptations of FBT relevant for the original target population of children and adolescents with AN. In Chapter 1, Fitzpatrick and colleagues describe how behaviors during the family meal contribute to recovery. The family meal is seen by some as a controversial intervention, especially as its role in outcome is unclear. This chapter provides clinicians with a comprehensive overview of how changing mealtime behaviors can enhance FBT treatment. Next, Hughes and colleagues describe a “parent only” version of FBT building on the research framework of the effectiveness of separated family therapy. The approach described focuses expressly on helping parents change their behaviors and interventions to promote weight restoration without the direct input of the adolescent. Knatz and colleagues describe a five-day intensive program for families based on the principles of FBT. Included in this five-day intensive program are assessment, multi-family groups, individual family sessions, and parent training programs. Models like these facilitate rapid training in FBT, a valuable option for families from geographical areas in which there are no FBT providers. In their chapter, Hildebrandt, Bacow, and Greif describe how FBT can be conceptualized and adapted as an exposure-based intervention, illustrating this through both research and clinical materials. Additional information about the potential role of multi-family groups (MFG) in the treatment of eating disorders in youth, Eisler and Simic describe the evolution and refinement of MFGs in the United Kingdom, Canada, Germany, and the Czech Republic. On a related theme, Binford and colleagues describe the important role that parent support groups can have to encourage and facilitate change in families who are involved in FBT.

Part II

This section contains seven chapters applying FBT principles and strategies to specialty populations in eating and weight disorders. In the first two of these chapters, Katharine Loeb and her colleagues provide a detailed description of the adaptation of FBT for two rather different clinical populations; FBT for prodromal AN as well as a transdevelopmental approach of FBT for child and adolescent overweight and obesity. These chapters extend from protocols developed in two recently completed randomized clinical trials. In the only chapter that focuses on a nonadolescent population, Gina Dimitropoulos and her colleagues highlight their Toronto-based reworking of FBT for emerging adults with AN (i.e., persons older than age eighteen making the transition to adult clinical services). DSM-5 has introduced Avoidant Restrictive Food Intake Disorder, and Kara Fitzpatrick and colleagues embark on this novel road to provide an understanding of how FBT strategies may operate and change to support families facing food neophobias. In another unique reworking of FBT, Danielle Colborn and Kara Fitzpatrick outline the therapeutic steps for families whose overweight adolescent is to embark on a surgical intervention for weight loss. The final two chapters of Part II focus on the challenges of affect dysregulation in adolescents diagnosed with an eating disorder. Kelly Bhatnagar and Lucene Wisniewski, experts in dialectical behavior therapy, highlight how the techniques from this therapeutic approach may be integrated with or work adjunctively to FBT. In the final chapter here, Nancy Zucker more broadly expands on the topic of emotional experience and regulation in eating disorders, explicating its theory, evidence, and translational application to family treatment.

Part III

Part III addresses the challenges and solutions in the dissemination and implementation of FBT. Although research supports the effectiveness of FBT, a variety of difficulties arise when applying the approach practically in real-world settings. Woodside and colleagues describe how the principles of FBT can be utilized in complex settings, such as hospitals and day programs, while in contrast, Doyle and colleagues describe how FBT can be effectively and efficiently implemented in a specialty eating disorder outpatient practice. Jones, Jacobi, and Taylor describe the development, content, and utility of a Web-based prevention program for parents whose children are at risk for developing AN. More general challenges related to implementation of FBT are illustrated by Kimber and Couturier, including training, fidelity to the treatment approach, as well as the impact of clinical practice and support services. Finally, Fitzpatrick and colleagues describe the specific challenges in describing, assessing, and maintaining fidelity to FBT. This important chapter reconciles the multiple challenges of supporting the dissemination of an effective intervention while minimizing therapist drift from aspects of the treatment that may represent its active mechanisms and maximizing the potency of each therapeutic maneuver.

Future Directions

This edited volume very aptly demonstrates a tremendous spirit for innovation in the treatment of adolescents with eating and weight disorders. Our hope is that many young sufferers and their families will benefit from these various reworkings of the original family therapy for adolescent AN spearheaded by Ivan Eisler and his colleagues in London. Much of the work described here is in the process of examination in more formal, systematic research designs. Not to discount the tremendous value of this compilation of rich and informative clinical material, it is fair to suggest that each one of these adaptations should stand the scrutiny of rigorous tests of its efficacy. Although several of these adaptations are the result of such scientific endeavors, we hope that this book inspires additional treatment research to in turn inform best practices for eating and weight disorders.

References

Bulik, C. M. (2005). Exploring the gene-environment nexus in eating disorders. Journal of Psychiatry and Neuroscience, 30, 335–339.

Bulik, C. M., Reba, L., Siega-Riz, A. M., & Reichborn-Kjennerud, T. (2005). Anorexia nervosa: definition, epidemiology, and cycle of risk. International Journal of Eating Disorders, 37, S2–S9.

Couturier, J., Kimber, M., & Szatmari, P. (2013). Efficacy of family-based treatment for adolescents with eating disorders: A systematic review and meta-analysis. International Journal of Eating Disorders, 46(1), 3–11.

Crow, S. J., Peterson, C. B., Swanson, S. A., Raymond, N. C., Specker, S., Eckert, E. D., & Mitchell, J. E. (2009). Increased mortality in bulimia nervosa and other eating disorders. The American Journal of Psychiatry, 166(12), 1342–1346.

Le Grange, D. & Lock, J. (2007). Treatment bulimia in adolescents: A family-based approach. New York: Guilford Press.

Le Grange, D., Lock, J., Loeb, K., & Nicholls, D. (2010). Academy for Eating Disorders position paper: The role of the family in eating disorders. International Journal of Eating Disorders, 43(1), 1–5.

Lock, J., & Le Grange, D. (2013). Treatment manual for anorexia nervosa: A family-based approach (2nd ed.). New York: Guilford Press.

Papadopoulos, F. C., Ekbom, A., Brandt, L., & Ekselius, L. (2009). Excess mortality, causes of death and prognostic factors in anorexia nervosa. The British Journal of Psychiatry, 194(1), 10–17.

Russell, G. F. M., Szmukler, G. I., Dare, C., & Eisler, I. (1987). An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44, 1047–1056.

Striegel-Moore, R. H., & Bulik, C. M. (2007). Risk factors for eating disorders. American Psychologist, 62, 181–198.

Strober, M., & Johnson, C. (2012). The need for complex ideas in anorexia nervosa: Why biology, environment, and psyche all matter, why therapists make mistakes, and why clinical benchmarks are needed for managing weight correction. International Journal of Eating Disorders, 45(2), 155–178.

Strober, M., Peris, T., & Steiger, H. (2014). The plasticity of development: How knowledge of epigenetics may advance understanding of eating disorders. International Journal of Eating Disorders, 47(7), 696–704.

Chapter 2
What’s New Is Old and What’s Old Is New

The Origins and Evolution of Eating Disorders Family Therapy

Ivan Eisler, Andrew Wallis, and Elizabeth Dodge

Any historical account has to choose a focal point in time that marks the start of its “history,” a time point that is inevitably somewhat arbitrary. We start our account of the development of eating disorder focused family therapy (sometimes described as “Family-Based Treatment” or the “Maudsley model”¹) with the series of studies undertaken from the 1980s onwards at the Maudsley Hospital/Institute of Psychiatry in London. These not only had a major influence on the treatment of adolescents, and to some extent adult eating disorders, but also on the changes in family therapy beliefs around the family being a resource in treatment rather than a dysfunctional system to be treated. More than thirty years have passed since the first Maudsley trial, and there have been significant developments regarding thinking about the etiology (Jacobi et al., 2004; Keel & Forney, 2013; Konstantellou, Campbell, & Eisler, 2012) and treatment of eating disorders (Eisler, 2005; Eisler, Lock, & Le Grange, 2010), the development of the evidence base for the effectiveness of family therapy (Couturier, Kimber, & Szatmari, 2013; Downs & Blow, 2013), the importance of the context in which the treatment is delivered (House et al., 2012), and, of course, the cultural and social contexts in which the families, patients, clinicians, and researchers live and work. Most of the story concerns the developments in the family therapy for adolescent anorexia nervosa (FT-AN), which is the focus of this chapter.

1 In recent years the acronym FBT has started to be used widely to refer either to the Lock and Le Grange (2013) treatment manual or more generically to what we describe here as eating disorder focused family therapy. The term FBT has several disadvantages. In addition to the ambiguity of whether it is referring to the Lock and Le Grange manual (or studies using the manual) or to other works which have not used the manual or used a different manual, it is sometimes (mis)understood as implying that it is an atheoretical treatment, disconnecting the approach from the conceptual frame of systemic family therapy. Outside of the field of eating disorders, FBT is also used to mean a multimodal treatment (including individual, family, and wider systems work with a central focus on the family). We have therefore used the term FT-AN throughout the chapter.

This chapter sets out to summarize the developments in FT-AN since the first trial, the broader themes in family therapy that were influential, and the core concepts that have been and continue to influence family therapy practice in eating disorders across the world. Future challenges and the different expressions of practice are highlighted with the unifying theme that parents are the key resource in the young person’s life and therefore need to be mobilized and strengthened to take leadership over the illness in order to restore the young person’s health, well-being, and psychosocial development.

Family Therapy of the Time—The Origins of Family Therapy for Anorexia Nervosa

Influential Developments in Family Therapy

The original Maudsley trials were conducted in London in the 1980s during a time of formative theoretical and model development in family therapy, and they drew heavily on the developments that had occurred since the early 1950s. The major shifts in family therapy are noted here and form a foundation for appreciating the development of family therapy for anorexia nervosa.

The early family therapists developed an understanding of problems as interpersonal rather than ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• About the Editors
• About the Contributors
• 1 Introduction: The Role of the Family in Eating Disorders
• 2 What’s New Is Old and What’s Old Is New: The Origins and Evolution of Eating Disorders Family Therapy
• PART I Innovative Adaptations of Family Therapy for Eating and Weight Disorders
• PART II Specialty Populations
• PART III Dissemination and Implementation
• Index