Innovations in Family Therapy for Eating Disorders

Novel Treatment Developments, Patient Insights, and the Role of Carers

Stuart Murray, Leslie Anderson, Leigh Cohn, Stuart Murray, Leslie Anderson, Leigh Cohn

• Publisher: Routledge
• Year: 2016
• Print ISBN:
  9781138648999
• eBook ISBN:
  9781317233930
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Innovations in Family Therapy for Eating Disorders brings together the voices of the most-esteemed, international experts to present conceptual advances, preliminary data, and patient perspectives on family-based treatments for eating disorders. This innovative volume is based partly on a special issue of Eating Disorders: The Journal of Treatment and Prevention and includes a section on the needs of carers and couples, "Tales from the Trenches," and qualitative studies of patient, parent, and carer experiences. Cutting edge and practical, this compendium will appeal to clinicians and researchers involved in the treatment of eating disorders.

Part I

Innovations in Family Therapy for Anorexia Nervosa and Bulimia Nervosa

1Adapting Family-Based Treatment for Adolescent Anorexia Nervosa across Higher Levels of Patient Care

Stuart B. Murray, Leslie Karwoski Anderson, Roxanne Rockwell, Scott Griffiths, Daniel Le Grange, and Walter H. Kaye

Anorexia nervosa (AN) typically demonstrates poor treatment outcomes, high rates of relapse and treatment dropout (Keel & Brown, 2010), elevated rates of premature death related to both medical complications (Steinhausen, 2002) and suicidality (Pompili, Mancinelli, Girardi, Ruberto, & Tatarelli, 2004), and reduced quality of life (Mond, Hay, Rodgers, Owen, & Beumont, 2005). However, when treated during adolescence, favorable treatment outcomes appear somewhat more attainable (Treasure & Russell, 2011). Thus, recent efforts have focused on treatments targeted at adolescent presentations, with family-based treatment (FBT) showing particular promise (Lock & Le Grange, 2013). However, while efforts to disseminate FBT have largely focused on outpatient settings (Couturier, Kimber, & Szatmari, 2013), there is a dearth of evidence detailing the application of FBT to more intensive levels of patient care.

AN is typically treated across a range of treatment contexts based on illness severity, with some arguing that presentations of AN ought to be delineated by stages of severity in order to allow for the most effective and appropriate treatment (Maguire et al., 2009). Indeed, the continuum of care model ensures that treatment dosage can be matched with illness severity, while significantly reducing the overall cost of treatment (Kaye, Enright, & Lesser, 1998; Wiseman, Sunday, Klapper, Harris, & Halmi, 2001).

A patient’s transition through levels of care is typically determined by symptom severity, medical status, motivational status, treatment history, and logistical concerns, although with fluctuating levels of motivation for change (Geller, Zaitsoff, & Srikameswaran, 2005) and relapsing symptom severity (Strober, Freeman, & Morell, 1997), movement through the levels of care can be bidirectional. The significance of this multi-tiered level of care system is underscored when considering (a) the medically necessary need for urgent weight restoration in severe AN, (b) the management of clinical complexity and comorbidity, and (c) the need to ensure progress sustainability in the context of the high rates of relapse in AN (Strober et al., 1997). However, few treatment settings currently offer all levels of care within the same setting, and the integration of evidence-based treatment throughout varying levels of care in the treatment of AN poses many challenges. This may be particularly important as it pertains to the role of families in treatment, given the differing beliefs as to the optimal role of families in the treatment of adolescent AN (Le Grange, Lock, Loeb, & Nicholls, 2010; Murray, Thornton, & Wallis, 2012a).

FBT is characterized by an agnostic stance towards the origin of AN and a conceptualization of parents as the primary resource in restoring their adolescent back to health. The focus of the treatment is orchestrating a parent-driven intervention to restore healthy eating patterns in the adolescent and then gradually transitioning the adolescent back to eating autonomy (Lock & Le Grange, 2013). Empirical evidence suggests that 50–70 percent of adolescents with AN undergoing FBT are weight-restored within a year of commencing treatment, and up to 40 percent being remitted of cognitive symptomatology (Lock et al., 2010). Follow-up studies and meta-analyses further support the efficacy of FBT, suggesting robust symptom remission over time (Couturier et al., 2013; Eisler, Simic, Russell, & Dare, 2007).

The Application of Family-Based Treatment across the Continuum of Care

The lack of clinical research on the efficacy and feasibility of FBT across the continuum of care is particularly important when considering (a) the volume of adolescents with AN who require non-outpatient-based treatment at some stage of their treatment trajectory (Katzman, 2005), and (b) recent findings underscoring the importance of theoretical consistency across treatment providers and levels of care (Murray et al., 2012a; Murray, Griffiths, & Le Grange, 2014). With recent findings documenting that (a) rapid intervention and early treatment mechanisms are indicative of overall treatment outcome (Doyle, Le Grange, Loeb, Doyle, & Crosby, 2010; Le Grange, Accurso, Lock, Agras, & Bryson, 2014), and (b) those with more severe AN psychopathology typically report greater benefit from FBT than those with less marked symptomatology (Le Grange, Lock, Agras, Bryson, & Kraemer, 2012), there appears to be a clear rationale for applying FBT to intensive treatment settings.

However, there are many challenges inherent in practicing FBT across levels of care while maintaining treatment fidelity. Given that higher levels of patient care warrant greater professional involvement, there is a risk of undermining the FBT treatment approach that centralizes parental involvement and decentralizes professional expertise. Indeed, while current clinical practice has advocated the use of FBT in higher levels of care (e.g. Girz, LaFrance Robinson, Foroughe, Jasper, & Boachie, 2013; Henderson et al., 2014; Hoste, 2015), little theoretical guidance exists in its application. We therefore aim to outline a theoretical framework of how FBT may be applied across higher levels of patient care, outlining several key challenges and explicating how the theoretical underpinning of FBT may be applied in a way that ensures treatment fidelity.

Establishing the Role of Parents and the Treatment Team Throughout the Continuum of Care

The central premise of FBT posits that parents ought to be the central architects of their child’s recovery, providing a sustainable agent of change that persists beyond any treatment context (Lock & Le Grange, 2013). However, higher levels of care are typically characterized by reduced parental involvement in treatment, despite emerging evidence demonstrating that mechanisms of symptom remission in FBT appear to be driven by empowering parents to take control of their child’s eating (Ellison et al., 2012). Thus, any adaptation of FBT to more intensive levels of patient care ought to carefully consider the dialectic of balancing the empowerment of parents while also ensuring thorough clinical management of medical instability.

Clinical Options

Restoring medical stability, offering respite for parents, and delaying the onset of FBT. The clinical reality in inpatient hospital settings is that urgent medical stabilization and caloric restoration take full priority. To this end, strict medical guidelines exist in expediently and safely curtailing the potential scope for medical complications in AN (Katzman, Peebles, Sawyer, Lock, & Le Grange, 2013). In this context, the time required to mobilize disempowered parents into active symptom resolution may likely contravene medical best practice, which urges the most immediate restoration of medical stability. Thus, greater illness severity often necessitates swift medical intervention at the expense of parent-driven symptom reduction.

However, a key distinction was recently drawn between hospital-based medical stabilization and hospital-based weight restoration, with current evidence supporting inpatient medical stabilization and an expedient stepdown into less intensive levels of care and parent-assisted weight restoration (Madden et al., 2014). Thus, inpatient hospital settings might be most suited to the urgent medical stabilization of acute AN that might preclude full parental involvement, followed by the commencement of FBT once the adolescent is medically stable and parents may play a more central role in treatment. However, with emerging evidence supporting shorter periods of inpatient hospitalization for adolescents with AN and swifter transitions into FBT (ibid), it is important to caution against offering respite for parents beyond a point when they could feasibly be involved in the feeding of their child. Indeed, parental respite beyond this point may alleviate the necessity for swift parental intervention, undermining subsequent treatment (ibid).

Increasing parental involvement as adolescents progress through levels of care. While keeping in mind the medical gravity of severe AN, exploring creative ways to involve the family as much as possible, even at higher levels of care, may be particularly congruent with FBT.

Inpatient hospital settings. While inpatient settings are necessarily oriented towards urgent medical stabilization, these settings are also uniquely placed to orient families towards the early goals of FBT. For instance, FBT clinicians may work alongside medical teams in: (a) raising parental anxiety, which will further mobilize parental resources once FBT commences, and (b) working to create unity between the parents. Concurrently, the medical team may assume the role as expert on the patient’s medical status and communicate that information to the parents, further assisting in generating parental anxiety. Similarly, while dietitian involvement is not typically prescribed in outpatient FBT, the imminent weight gain requirements in critically unwell adolescents, coupled with the risk of re-feeding syndrome, may necessitate dietitian involvement. However, integrating parental involvement within the context of dietetic assistance is plausible, for instance by having dietitians convey the calculated caloric requirements and consulting with parents as to how these calories are provided (Katzman et al., 2013).

Residential settings. A feature of residential programs is the temporary removal of adolescents from their home until symptom remission is indicated, which may impinge upon the prescribed and empirically supported role of parents throughout FBT (Ellison et al., 2012). As such, FBT in residential contexts may be inherently challenging, particularly when residential settings are not in the same geographical region as the family home. Endeavors towards this end may include encouraging parents’ temporarily residing in the local area, including regular family meetings, the co-construction of treatment goals, and multiple family meals and parent coaching.

Patient hospitalization program/intensive outpatient program settings. Perhaps more amenable to an FBT framework, patient hospitalization program (PHP) and intensive outpatient program (IOP) settings feature day-based clinical treatment, coupled with home-based symptom management outside of program hours. Such settings allow for treatment goals to be oriented towards family psychoeducation and weight restoration in a manner consistent with outpatient FBT, although at a more intensive treatment dose and with more stringent medical monitoring. With respect to the broader treatment team, the physician (typically a pediatrician or psychiatrist), may not necessarily occupy the most central role at this level unless there are imminent medical concerns, instead serving as a consultant to the parents and FBT clinician while monitoring medical status (Katzman et al., 2013). Similarly, dietetic involvement may be downwardly adjusted in conjunction with increasing parental involvement over meal provision. For instance, dietitians at this level of care may serve primarily as a consultant to the family therapist as needed, especially in cases with complicated dietary features (e.g. diabetes, celiac disease, etc.), or in cases in which treatment is not progressing as expected (e.g. weight gain is not occurring, despite the family appearing to appropriately manage their child’s behaviors). Furthermore, since patients in PHP/IOP typically attend most meals in program without the support of siblings, an individual therapist might play a role in a PHP/IOP setting by supporting the patient in the same way siblings are encouraged to support the patient in outpatient FBT. Additionally, due to the high level of psychiatric comorbidities in higher levels of care, the individual therapist may concurrently provide other types of evidence-based treatment to address these issues.

Mobilizing and Empowering Parents throughout Treatment in Hospital and Partial-Hospital Settings

Prior to beginning treatment, it is commonplace for many families to feel disempowered and ambivalent about the challenge of weight restoring their child with AN. Indeed, many families report inadvertently accommodating an array of AN-type behaviors in an attempt to allay their child’s anxiety (Eisler, 2005). Thus, a crucial tenet of FBT posits that parents ought to be immediately ushered beyond any anxiety or avoidance and charged with the responsibility of urgent intervention in their child’s behaviors.

To this end, a therapeutic “double-bind” at the outset of FBT aims to simultaneously elevate parental anxiety and implore parental intervention in reversing their child’s symptoms (Dare et al., 1995; Lock & Le Grange, 2013). This is accomplished through a somber discussion of the medical complications of AN, which aims to render the anxiety parents feel about not confronting their child’s AN greater than any anxiety around confronting their child’s symptoms.

However, the timing of this therapeutic double-bind may need adaptation for clinical settings that foster greater staff than parental involvement and thus afford less scope for parental responsibility in symptom reduction. Raising parental anxiety and imploring them to intervene in these settings may contraindicate the empowerment FBT advocates. For instance, it is possible that elevated parental anxiety at the outset of treatment may be more allayed by the child’s involvement with the intensive staff-driven program than by their own increasing sense of mastery in managing their child’s symptoms. In this respect, therapeutically elevating parental anxiety, when coupled with reduced scope for parental involvement and staff-driven reductions in parental anxiety, may potentially deepen a sense of reliance on staff-driven symptom reduction, which contravenes the mechanism by which the therapeutic double-bind was intended to operate in outpatient settings. Thus it is important that this double-bind at higher...

Table of contents

• Cover
• Half Title
• Endorsement
• Title Page
• Copyright Page
• Contents
• About the Editors
• About the Contributors
• Foreword
• Acknowledgments
• Introduction
• Part I Innovations in Family Therapy for Anorexia Nervosa and Bulimia Nervosa
• Part II Special Topics in Family Therapy for Eating Disorders
• Part III Carers
• Part IV Tales from the Trenches: Personal Accounts
• Part V “How I Practice”
• Index