Eating Disorders: Workshop 3, 2021 - PowerPoint Presentation

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Eating Disorders:

Workshop 3, 2021

Graduate Diploma of Family Therapy and Systemic Practice

Catherine Sanders

30

th

March, 2021

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Eating Disorders

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Is family therapy the treatment of choice for eating disorders?

The value of family involvement

History – Gull, Minuchin &

Palazzolli

The Maudsley Approach – anorexia and bulimia

Some complementary approaches SOFT – obesityApplication of Bower(method)

Plan

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Anorexia Nervosa (Carr, 2018)

Systematic reviews and meta-analyses covering over a dozen trials and implementation studies show strong results

Half to two-thirds of patients achieve a healthy weight

At 6-months to 6-years follow up - 60–90% fully recovered and no more than 10-15% seriously ill

In the long term, the negligible relapse rate following family therapy superior to moderate outcomes for individually-oriented therapies

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Effectiveness of Family Therapy

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Anorexia Nervosa (Carr, 2018)

Outcome for family therapy is far superior to high relapse rate following in-patient treatment

25–30% following first admission, 55–75% for second and further admissions

Outpatient family-based treatment more cost effective than in-patient treatment

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Effectiveness of Family Therapy

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Bulimia (Carr, 2018)

Maudsley model has greatest empirical support

During a large effectiveness trial, Eisler (2016) found when individual family therapy was combined with intensive multi-family therapy, it was significantly more effective than FT alone

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Effectiveness of Family Therapy

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Bulimia (Carr, 2018)

Three trials of family therapy in adolescence using the Maudsley model show it is more effective than supportive therapy, and there is a more rapid increase in recovery than cognitive behavioural therapy

At six to twelve months follow up, binge-purge abstinence rates were 13% to 44% for family therapy, and 10% to 36% for those who engaged in individual therapy

Treatment of anorexia or bulimia spans 6–12 months, 15-20 sessions, with the first ten occurring weekly and later occurring fortnightly then monthly

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Effectiveness of Family Therapy

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Obesity (Carr, 2018)

Family-based behavioural weight reduction programmes more effective than dietary education and other routine interventions

A 5–20% reduction in weight after treatment, 30% no longer obese at 10-year follow-up

Childhood obesity primarily due to lifestyle factors (e.g. poor diet, lack of exercise) - family-based behavioural treatment programmes focus on lifestyle change

Specific dietary and exercise routines agreed and implemented, and parents reinforce adherence

Therapy may span 10 to 20 sessions followed by periodic, infrequent, review sessions over years

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Effectiveness of Family Therapy

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Risk factor research suggests that family/parenting factors that precede the onset of AN or BN increase risk for psychopathology in general

General risks then interact developmentally with inherent, possibly more specific, sources of biological rooted vulnerabilities that give shape to particular phenotypes of disordered eating

Likely that a multiplicity of risk factors - genetic, developmental, psychological, and cultural - will be shown to influence susceptibility to eating disorders, informing development of empirically supported models of aetiology and prevention

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The Value of Family Involvement

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Research suggests that family involvement appears to be useful in reducing both psychological and medical morbidity, especially for younger patients with a short duration eating disorder - this form of treatment is acceptable to parents and patients alike

Utilizing parents in treatment may explain lower attrition rates in adolescent treatment studies - 15% compared to treatment studies of adults where drop out rates average 50%

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The Value of Family Involvement

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Downs & Blow (2013)

It is particularly important to engage family and especially caregivers in re-feeding, monitoring and supporting recovery of the adolescent

Key strategy involves evoking motivation of caregivers to help child and restructure the family life to makes this feasible

Treatment needs to prioritize issues surrounding the eating disorder (restriction or purging) and only focus on other family issues once eating related issues are under control

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The Value of Family Involvement

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Downs & Blow (2013)

However, in a study of Anorexia Nervosa patients with late age onset, long illness duration, and a history of unsuccessful treatment, Downs and Blow (2013) found no specific advantage from family treatment

Important to consider many factors; onset and duration of the illness, family dynamics, family expressed emotions, and severity of the disorder

Each individual will have a specific context - it’s the clinician’s task to assess and develop the most effective and beneficial treatment plan

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The Value of Family Involvement

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Detrimental role of parental inaction in the face of a child’s life-threatening malnutrition first suggested in accounts of AN appearing in the late 19th century

Gull’s description of the illness asserted that it was justified, if not essential, to limit parental-child contact during treatment to prevent enabling of the illness by parental complicity in behaviours that had the effect of thwarting refeeding

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It goes back to the 1800’s …

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Lask (2015)

A serious, brain-based illness manifested by intense anxiety and sensitivity and a range of abnormal, often contradictory and paradoxical cognitions … all focused on appearance, weight and shape, with a distortion of, and discomfort with, body image

Leads to determined food avoidance and weight loss, often accompanied by compensatory behaviour such as purging and compulsive exercising

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Anorexia Nervosa

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Commonly, a comorbid mood disturbance with difficulties in emotional regulation and obsessive-compulsive behaviour, tendency to rigid thinking and behaviour, and tendency to being focused on fine details at the expense of seeing the big picture

The physical sequelae are those associated with starvation and dehydration

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Anorexia Nervosa

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Research and therapy in psychosomatic medicine severely handicapped by linear model of psychosomatic illness which links the individual's life situations to his emotions to bodily illness, in a causal chain

The illness is seen as contained within the individual

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The Psychosomatic Family

Minuchin (1978)

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Model of the structure and functioning of families

Three factors necessary for the development of severe psychosomatic illness in children

One, the child is physiologically vulnerable

Two, the child's family has four transactional characteristics: enmeshment, overprotectiveness, rigidity and lack of conflict resolution

Three, the sick child plays an important role in the family's patterns of conflict avoidance, a role which reinforces symptoms

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The Psychosomatic Family

Minuchin (1978)

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A normative model of a well functioning family

Clearly marked boundaries – marital subsystem with closed boundary to protect privacy and parental subsystem, sibling sub-system own boundary and organized hierarchically, and respect for boundary around family

Therapist notes ‘angle of deviance’ and ‘redesigns’ family to more closely fit model-family meal for anorexia

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Minuchin: A Structural Approach

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Selvini Palazzoli (1974)

Describes shift from analytic model to circular cybernetic epistemology, and work with families rather than individuals

Went on to develop ideas in Milan Team where work was designed to challenge family belief systems and disrupt family games - ‘Hypothesizing, Circularity and Neutrality’

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Self-Starvation

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1980’s onwards

Maudsley family-based treatment (MFBT) by Christopher Dare and Ivan Eisler at the Maudsley Hospital in London in the 1980s

Based on principle that families are key resource needed to bring about recovery in AN

Assumes that young person with AN too unwell to manage decisions around food and activity for themselves and parents temporarily need to take responsibility for re-feeding

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The Maudsley Approach

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Model consists of four distinct phases

First phase

involves engagement, multi-disciplinary

systemic, medical and psychiatric assessment and developing therapeutic alliance

Second phase

involves focus on weight restoration through the strict parental control of food and activity

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The Maudsley Approach

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Third phase

begins once weight returned to minimum of 90% of ideal body weight (IBW) and young person less distressed by eating. Responsibility for food and eating is gradually returned to the adolescent, as appropriate to their developmental stage

Fourth phase

focuses on broader adolescent issues and helps family refocus on family life without AN

Treatment typically involves ten to twenty, one-hour sessions over a six to twelve-month period

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The Maudsley Approach

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Success of phase two relies heavily on intensity the model creates and the therapists’ ability to maintain this in the sessions

Achieved by d

iscussions about the serious medical complications of AN and poor prognosis if untreated; weekly appointments; the use of medical and psychiatric reviews; therapist style

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The Maudsley Approach

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Life-threatening nature of AN is openly discussed and parental anxiety is raised as a deliberate manoeuvre to motivate parents to go to extraordinary lengths, and break homeostatic mechanisms that may be maintaining the problem

Parents told they are not to blame for development of eating disorders to stop immobilizing self-blame

Initial intensity key mechanism of change that allows the family to experiment with new patterns of behaviour in order to bring about recovery of child

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The Maudsley Approach

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Not all families respond well - substantial minority drop out or only partially respond

Strength of eating disorder specific obsessions and psychopathology are moderators of treatment outcome

Short history of illness respond better

Greater degree of weight loss pre-treatment and more severe eating-disordered cognitions predictive of poorer response

If comorbid psychiatric illnesses, more vulnerable to dropping out and poor response to treatment

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The Maudsley Approach

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Response to treatment is influenced by family factors

Most robust finding is that high levels of expressed emotion, including maternal criticism, related to treatment drop out and poorer response to treatment

Parental control is predictive of response to treatment and may be most critical dimension in model that needs to be enhanced in the face of a poor treatment response

Non-intact families appear to need longer treatment

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The Maudsley Approach

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Strategies have been developed to address these such as …

Use of separate sessions for parents and patient to reduce the effect of high expressed emotion

Models that utilise mutual influence and solidarity between families - multiple family treatment and multi-family groups

Working intensely with 6-8 families who participate in a daily programme for 4-5 days and have follow-up meetings over a year

Families have additional sessions with therapist between group meetings

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The Maudsley Approach

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The Family Admissions Programme admits family to a more home-like environment where families learn skills to re-feed their child

Level of intensity around intervention and re-feeding is also increased through a structured daily programme and shift in the locus of control from hospital staff to the child’s parents

Therapist remains non-authoritarian and neutral regarding how the parents should re-feed their child

Parents responsible for choosing meals, preparing food and re-feeding

Setting health targets, goals of treatment and management of other AN-related issues as they arise

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The Maudsley Approach

Innovations at

Westmead

(Wallis et al., 2012)

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Key difference to previous approaches is view of family’s role in aetiology

Paradigm shift directed attention away from models that presumed a central etiologic and maintaining role of family dynamics to see family as a potential resource in therapy

This eases parents’ burden of guilt, and promotes an attitude of inclusion

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The Maudsley Approach

Differences

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Anorexic client restricts eating as psychological survival tool to preserve sense of control and boundaries needed for stability and identity in their family context

Symptoms of starvation become markers of success in desperate, search for a sense of stability and safety

In established cases, become addicted to starvation which must be addressed

Treatment approaches tend to focus either on the body (restoring weight by behaviourally reinforced feeding), or the mind/family dynamics

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The Maudsley Approach

Critique of Maudsley-

Churven

(2008)

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Dysfunctional treatment regimes, like dysfunctional families, get ‘stuck’ in a vicious cycle doing more of the same ineffective problem solving, while the ‘patient’ reciprocates with more of the same pathology

Anorexic women too easily enter a chronic cycle of powerlessness in the face of their addiction, aggravated by the medical readmissions their starving state requires

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The Maudsley Approach

Critique of Maudsley-

Churven

(2008)

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Clinicians identified two core components of Parental Empowerment: control over management of eating behaviour, and involvement in all phases of treatment

Clinicians also identified barriers to PE and the use of various interventions and other principles of Family Based Treatment to bolster PE

They identified patient (age, duration of illness and comorbid diagnoses), parent (a severe mental illness), and family factors (changing roles and the hierarchy in the family) as contributing to decreased PE in FBT

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Parental Empowerment

Dimitropoulos

(2017)

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Evidence suggests a significant relationship between family mealtime interactions and disordered eating in young persons

Mealtime conflict, high parental control and critical parental comments are positively associated with disordered eating

Parental support, mealtime structure, healthy communication and a positive atmosphere are negatively associated with disordered eating

The family meal should be a major focus for intervention, as in the Maudsley model of family-based treatment for anorexia nervosa

In general, family therapists should aim to disrupt unhelpful patterns of interaction during mealtimes and replace them with more helpful and adaptive ones

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The Family Meal

Godfrey et al. (2013)

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Twenty-three AN adolescents aged 12–20 years were randomly assigned to two forms of outpatient family therapy (with [FTFM] and without [FT]) using the Family Meal Intervention, and treated for a 6-month duration

Majority of patients in both groups improved significantly at end of treatment, and changes sustained through follow up

Family Meal Intervention did not appear to convey specific benefits in causing weight gain

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The Family Meal

Herscovici

et al. (2017)

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Clinical observation suggests the value of a flexible stance in implementation of the FMI for the severely undernourished patient with greater psychopathology

Investigation underscores value of focusing on the core objectives of a family approach that have been shown to predict greater weight gain: parents taking a united stance, not criticizing the patient, and externalizing the illness

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The Family Meal

Herscovici

et al. (2017)

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Family Based Therapy (FBT) treatment of choice for adolescent anorexia nervosa but

substantial proportion of patients do not experience remission by the end of therapy or may relapse following remission

Attachment-Based Family Therapy (ABFT) may serve as a good augmentation to FBT

ABFT aims to repair factors that impact relational security (i.e., parental criticism, low parental warmth, familial conflict, and adolescent affect intolerance), which are same factors that affect the outcomes of FBT

ABFT can be introduced after physical stability achieved

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Attachment Based FT as an Adjunct

Wagner et al.(2016)

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Study explored parent-related mechanisms of change throughout treatment in adolescent eating disorders

During treatment, parents experienced increase in self-efficacy and adolescents experienced a reduction in symptoms

Maternal and paternal self-efficacy scores also predicted adolescent outcomes throughout treatment

Results are consistent with the philosophy of the family-based therapy model and add to the literature on possible mechanisms of change in the context of family-based therapy

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Parental Efficacy

Robinson et al. (2012)

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Couples with personal histories of eating disorders may face unique challenges in their role as partners and parents

A parental eating disorder is associated with more negative expectations of

parental efficacy, as well as specific difficulties in couple communication over the child’s feeding, shape and weight

5-8% of women still have active symptoms or develop an eating disorder during pregnancyPartners may may accommodate symptoms in an attempt at emotional co-regulation – reinforces eating disorder and patterns of secrecy

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Impact of Parental History of ED

Sadeh-Sharvitt

et al. (2020)

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Programs therefore intervene with the couple subsystem, and during the pre- and post-natal periods

Uniting Couples in the treatment of Anorexia Nervosa (UCAN) – incorporates CBCT and DBT and targets communication around symptoms, interpersonal problem-solving and emotional regulation skills

Parent-based Prevention (PBP) focuses on improving parental functioning – enhancing parental efficacy and couple communication to reduce risk of feeding issues and issues in parent-child relationship. Also addresses the child’s characteristics and involvement of expended family members

Maudsley Model additionally incorporates support of partners

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Couple/Parenting Programs

Sadeh-Sharvitt

et al. (2020)

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Bulimia nervosa (BN) characterized by recurrent binge eating episodes followed by compensatory behaviour (purging or over-exercising)

Dangerous cycle of out-of-control eating and attempts to compensate which become compulsive and uncontrollable over time - feelings of shame, guilt and disgust

Often linked with comorbid issues - depression, anxiety and deliberate self-harm

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Bulimia Nervosa

Hurst et al. (2015)

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CBT has been treatment of choice BUT requires accountability and motivation to take full responsibility and management of food and eating - may not be developmentally appropriate for children and adolescents

Le Grange et al. (2004)

suggested that family-based treatment (FBT) be considered for adolescents

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Bulimia Nervosa

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Manualized treatment similar to Family Based Treatment for AN – proceeds through three distinct phases of treatment over 6 months

Phase 1: Re-establishing regular pattern of eating with focus on helping adolescent and parents unite in creating strategies to confront the ED and hold it has on adolescent and family

Phase 2: Return control of eating to adolescent in graduated and supported way, under parental supervision

Phase 3: Increased autonomy for adolescent and return to normal family functioning and boundaries

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Bulimia Nervosa

Le Grange and Lock (2007)

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Hurst et al (2015) suggests combining CBT and Family Based Treatment to derive benefit of both

Adolescents with comorbidities or complex presentations may benefit most from combining two modalities to develop additional skills and strategies

Families possess significant skills, commitment a d unique knowledge of their children to assist in recovery

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Bulimia Nervosa

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Much less focus than AN or BN despite 63% Australian adults and 25% of children overweight/obese

Management of childhood obesity commonly based on lifestyle interventions where nutrition, physical activity and behaviour modification main targets

Empirically supported family-therapy-based treatment, Standardized Obesity Family Therapy (SOFT) based on systemic and solution-focused theories - positive effects on child with respect to degree of obesity, physical fitness, self-esteem and family functioning in several studies

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Obesity

Norwicka

&

Flodmark

(2011)

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Focus on therapeutic alliance

Involve family members

Neutrality

Normalizing, non-blaming position

Assume motivation - families WANT to change

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Obesity

SOFT Program

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Intervene with questions

Using scaling questions

Use contextual markers (e.g. ‘people say you are less hungry if you eat breakfast, what do you think of that advice?’)

Create a positive climate by reframing

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SOFT Program

Language

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Tools used to support families

Highlight exceptions to the problems

Focus on small changes

Identify resources in the family

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SOFT Program

Process

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Teamwork – multi-disciplinary

Intensity – few sessions, average 6 visits

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SOFT Program

Setting

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Research regarding family-based online treatments for eating disorders is still limited

The authors suggest that challenges are patient safety and privacy, internet connectivity, and alliance building

Medical monitoring challenge addressed by regular contact with medical providers online

Parent weighs child, therapist joins patient virtually for weighting, or weights obtained by medical providers

Family meal viewed virtually, more clarification re food served and eaten requested

Reframe as opportunity to practice re-nourishment efforts in home context

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FBT via Telehealth

Matheson,

Bohon

& Lock (2020)

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Actively mobilize the family as a key treatment resource to promote changes in eating disorder behaviours early on in treatment

A coherent model of treatment (ideally operationalized in a treatment manual) provides consistency in the way treatment is delivered, with enough flexibility to tailor the treatment to the specific needs of individual families

Delivered by clinicians with significant expertise in eating disorders, within a specialist multidisciplinary team context; a setting which engenders a sense of safety and trust in which adolescents and parents can take on new learning and new behaviours

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Common Features of Treatments

Jewell (2016) found the most effective treatments

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Task

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Based on the research/theoretical material presented, use Bower(method) to analyze an eating disorder

On this basis, where would you focus your intervention?

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Task

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Bower(method)

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Discussion.Any questions?

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Downs, K., & Blow, A. (2013). A substantive and methodological review of family-based treatment for eating disorders: The last 25 years of research.

Journal of Family Therapy, 35 (Suppl. 1):

3–28.

Jewell, T., Blessitt, E., Stewart, C., Simic

, M., & Eisler, I. (2016). Family therapy for child and adolescent eating disorders: A critical review.

Family Process, 55,

577–594.

Le Grange D., Lock J. (2007). Treatment manual for bulimia nervosa: A family-based approach. New York: The Guilford Press.Le Grange D., Eisler I. (2009). Family interventions in adolescent anorexia nervosa. Child Adolescent Psychiatry Clin N Am, 18, 159–173. Lock J., Le Grange D. (2005). Help your teenager beat an eating disorder. New York: Guilford Press.

Lock, J., and Le Grange, D. (2013)

Treatment manual for anorexia nervosa. A family based approach

(2nd

edn

). New York: Guilford.

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References

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Matheson, B. E., Bohon

, C., & Lock, J. (2020). Family‐based treatment via videoconference: Clinical recommendations for treatment providers during COVID‐19 and beyond. 

International Journal of Eating Disorders

, 53(7), 1142-1154.Minuchin S., Rosman B., & Baker L. (1978). Psychosomatic families:

Anorexia

Nervosa in

context

. Cambridge: Harvard University Press.Nowicka, P., & Flodmark, C. (2011). Family therapy as a model for treating childhood obesity: Useful tools for clinicians.Clinical Child Psychology and Psychiatry, 16(1), 129–145.

Sadeh-Sharvit

, S., Sacks, M. R.,

Runfola

, C. D.,

Bulik

, C. M., &. Lock, J. D. (2020). Interventions to

emplower

adults with eating disorders and their partners around the transition to parenthood,

Family Process, 59

, 1407-1422.

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References

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Thank you.From the Bower Place team

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Contact us.For information

Level 2, 55

Gawler

Place Telephone 08 8221 6066 info@bowerplace.com.au

bowerplace.com.au