Treatment (FBT) parents are told “we know that family relationships do not cause anorexia” relationship problems underlying anorexia gives the therapist a 'tin ear' for the published treatment manual by Lock and Le Grange ( pp. 71). The therapist then moved on, turning to talk to the children. Expecting parents to take a lead in managing their child's eating in the early stages of treatment Change in the relationship between therapist and family Appendix G – Comparison of three family therapy treatment manuals for child and. Can Child Adolesc Psychiatr Rev. Mar; 12(2): 50– PMCID: PMC Treatment Manual For Anorexia Nervosa - A Family- Based Approach. As a family therapist, I found this book presented interesting theoretical and phase of the adolescent and parents negotiating a new pattern of relationships, to the last.
Similar improvements in terms of psychological factors were also noted for these patients. Clinical and research endeavors by The University of Chicago and Stanford University have shown promising results in their FBT studies, which are comparable to the positive outcomes that were initially established in the Maudsley studies.
The Maudsley Approach The Maudsley approach can mostly be construed as an intensive outpatient treatment where parents play an active and positive role in order to: Strict adherents to the perspective of only individual treatment will insist that the participation of parents, whatever the format, is at best unnecessary, but worse still interference in the recovery process.
The Maudsley Approach opposes the notion that families are pathological or should be blamed for the development of AN. On the contrary, the Maudsley Approach considers the parents as a resource and essential in successful treatment for AN. Weight restoration The Maudsley Approach proceeds through three clearly defined phases, and is usually conducted within treatment sessions over a period of about 12 months. A family meal is typically conducted during this phase, which serves at least two functions: The way in which the parents go about this difficult but delicate task does not differ much in terms of the key principles and steps that a competent inpatient nursing team would follow.
Most of this first phase of treatment is taken up by coaching the parents toward success in the weight restoration of their offspring, expressing support and empathy toward the adolescent given her dire predicament of entanglement with the illness, and realigning her with her siblings and peers. Quite the contrary, the therapist will work hard to address any parental criticism or hostility toward the adolescent. This phase of treatment focuses on encouraging the parents to help their child to take more control over eating once again.
Although symptoms remain central in the discussions between the therapist and the family, weight gain with minimum tension is encouraged. In addition, all other general family relationship issues or difficulties in terms of day-to-day adolescent or parenting concerns that the family has had to postpone can now be brought forward for review.
One group consisted of adolescents with AN who had a short duration of illness, defined as less than 3 years, and an early age of onset, defined as on or before the age of 18 years. Furthermore, these gains were maintained at 5-year follow-up. In EOIT, the therapist met with the adolescent weekly and had bimonthly collateral sessions with the parents. Few differences were found between the two groups on measures of eating attitudes, depression, ego functioning, and family relations.
Various forms of FBT have also been studied. Because patients in the Russell et al study 29 were hospitalized for weight restoration prior to beginning treatment, the study can be conceptualized as a relapse-prevention study.
Therefore, efforts were made to examine the efficacy of FBT without prior hospitalization of patients. Le Grange et al 34 and Eisler et al 35 each compared two forms of family treatment among adolescents with AN. In conjoint family therapy, the adolescent and parents are seen together with the therapist. In separated family therapy, the adolescent is seen alone by the therapist and the parents are then seen separately.
Le Grange et al found no differences between the two treatment groups. No significant differences were found at the end of treatment between the two groups. However, nonintact families and patients with higher levels of eating-related obsessive—compulsive symptoms did better in the long-term version.
Specifically, patients with high levels of eating-related obsessive—compulsive symptoms gained more weight in the long-term treatment, and patients from nonintact families had lower global scores on the Eating Disorder Examination if they participated in the long-term treatment. No moderators of maintenance of treatment effects were found. This information is then shared with the therapist, who spends the rest of the session meeting alone with the parents.
The primary outcome variable was full remission, as defined in Lock et al. A question arising at this point is: In SFT, the focus of treatment is on the family system and on the relationships and interactions that develop among family members. Normalization of eating and weight is not a specific focus of treatment, but is addressed if the family raises the issue.
The authors found no significant differences between treatment groups in percentage expected body weight at the end of treatment or 1-year follow-up. There is preliminary evidence to suggest that FBT is effective for older populations in addition to adolescents. FBT-Y also resulted in improvements in eating-disorder psychopathology, eating-related obsessions and compulsions, other Axis I disorders, and global functioning.
The primary outcome variable was abstinence from binge eating and purging over the previous 28 days. In addition, reduction in symptoms occurred more rapidly for patients receiving FBT.
However, this difference was no longer significant at 12 months, and there were no differences between the groups in frequency of vomiting at either assessment point. Multifamily therapy for AN Despite evidence that FBT is an effective form of treatment for adolescents with eating disorders, 45 not all families respond to treatment, and some need a different or more intensive level of intervention. Multifamily treatment MFT for eating disorders has been developed in Dresden, Germany 46 and London, UK, 47 and provides a promising alternative for some families.
MFT shares a conceptual focus with FBT, in that the family is mobilized to draw on their strengths to help the adolescent recover from the eating disorder. This is followed by a 4-day intensive workshop with five to eight follow-up sessions over the next 6—9 months, with separate FBT sessions between follow-up visits as needed. At the end of treatment, there were no differences between the groups in mean percentage BMI, eating-disorder psychopathology, depression, or self-esteem.
Family-based treatment in higher levels of care The efficacy of FBT has led to efforts to incorporate FBT principles into higher levels of care, such as partial hospitalization programs PHPs. While it is important to note that FBT is an outpatient form of treatment that cannot be replicated in higher levels of care, it is possible to remain true to the basic tenets of the treatment approach in different treatment settings. Hoste 53 described the development of a family-based PHP, outlining various considerations that should be taken into account when incorporating FBT principles, such as how to involve parents in treatment and the role that the treatment team should take in supporting the family.
Preliminary outcome data for this program show improvements in eating-disorder psychopathology and parental self-efficacy. Other descriptions of family-based PHPs show promising preliminary outcomes. Implementation of family-based treatment Despite evidence supporting the efficacy of FBT and manualization of the treatment for both AN and BN, 1617 in clinical practice the treatment is often not carried out in accordance with the manual.
Themes raised during these interviews were divided into six categories. Interventional barriers to the use of FBT included the time commitment required of therapists and families, the lack of a dietitian on the treatment team, the requirement that the therapist weighs the patient at each session, and the family meal. Interpersonal factors related to reluctance to provide evidence-based practice involved a belief that one approach does not fit all families, and that it is not desirable to commit to a particular form of treatment without considering each family individually.
Systemic barriers to treatment included a lack of awareness in the community about eating disorders and treatment options. There was also a belief that patients participating in treatment studies have fewer comorbidities and are not representative of the general population; therefore, using just one form of treatment would not be desirable for more complex patients.
Cluster analysis revealed that one third of clinicians used techniques not recommended by the FBT manuals, including individual therapy, mindfulness techniques, and motivational work. Three components of FBT that caused some of the most significant discomfort for therapists in the Couturier et al study 56 were weighing the patient, the lack of a dietitian, and the family meal.
PFT 38 may be a good alternative for these clinicians, as there is no family meal and a nurse is responsible for weighing the patient. It would also be useful to determine whether these components of FBT are critical to good treatment outcome.
Although dismantling studies have not been conducted, Ellison et al 58 examined some of the core objectives of FBT, including parents taking control of eating, parents being united against the eating disorder, parents not criticizing the patient, externalizing the illness, and sibling support of the patient, and assessed how they were related to treatment outcome.
All objectives except for sibling support predicted greater weight gain. A review of the family meal in three different models of family therapy found that firm conclusions cannot yet be drawn about the usefulness of the family meal in treatment. Without dismantling studies to identify the critical components of FBT, it is difficult to state the consequences of nonadherence to the treatment manual. What can be said is that nonadherence to the treatment manual will result in the delivery of a non-empirically supported form of treatment.
Couturier et al 56 point out that it is important to determine in these situations whether one should prescribe following the treatment manual as written and risk rejection of the manual by therapists who do not feel qualified or equipped to implement it, or whether there is room for some flexibility to allow clinicians who are uncertain about components of the treatment to administer it according to their comfort level.
However, it could be argued that discomfort with certain elements of FBT could prove detrimental to treatment outcome. For example, despite the manual clearly stating that the patient should be weighed by the therapist prior to every session, and that weight loss or weight gain sets the tone for the session, over one third of therapists in the Couturier et al 56 study said that they did not weigh their FBT patients.
Although the reasons for this were not detailed in the study, Waller and Mountford 60 outlined several reasons given by therapists for not weighing their patients in the context of CBT.
FBT therapists in training have also reported being fearful of the reaction of the eating disorder. Either one can be problematic. Although patients may become anxious when being weighed, the FBT therapist is there to support patients and help them process their reaction to being weighed, thereby building therapeutic alliance and rapport. Likewise, avoiding therapist anxiety could be equally problematic. The therapist models an uncritical, supportive, and compassionate stance toward the patient, along with taking a firm, zero-tolerance approach toward eating-disordered behavior.
Treatment Manual For Anorexia Nervosa - A Family- Based Approach.
It will be difficult for therapists to model this firm stance toward the eating disorder if the therapist is scared of it. If the therapist avoids weighing the patient because of fear of the wrath of the eating disorder, this therapist will not be as effective in treatment. The issue of treatment implementation is an important one.
Effective therapies do not help patients if they are not effectively implemented. The majority of therapists in Couturier et al 56 requested additional training in FBT. Additional studies are needed to assess whether the level of training in FBT improves treatment adherence. Adaptations to family-based treatment Even when practiced with full adherence to the manual, FBT is not effective for all families.
Now that the efficacy of the treatment has been established, research can turn to the question of what to do with families for whom FBT does not work.
In a study of early response to treatment, it was found that 2. In the first of these three additional sessions, the failure to achieve adequate weight gain is presented to the family as a crisis situation, and the family is reinvigorated to make the behavioral changes necessary to result in weight restoration. In the second IPC session, the therapist meets the parents alone to identify barriers to successful weight restoration.
The third session consists of a second family meal, after which point manualized FBT resumes. There were no differences in attrition rates, number of sessions, treatment suitability and expectancy ratings, or clinical outcomes between the two treatment groups, indicating the feasibility and acceptability of IPC. Mothers of patients who responded early to treatment had higher levels of self-efficacy than nonresponders at session 2, but after the additional IPC sessions, parental self-efficacy scores no longer differed between the two groups.
After session 4, when IPC was introduced in the Lock et al study, 62 the weight trajectories begin to differ, and at the end of treatment patients in the IPC arm were significantly higher in terms of weight than patients from the Agras et al RCT.