The role of families in the treatment of mental illness has always been a tenuous one. Often blamed (think refrigerator mothers), but also expected to provide continuous care for the afflicted loved one, families carry a significant burden. Nowhere is this dichotomy more visible than in the treatment of anorexia nervosa (AN), where it has long been assumed that “enmeshed families” and overbearing parenting styles create an environment for the development of eating pathology. For far too long, treatment consisted of long-term hospital stays, and treatment approaches generally excluded families in the belief that the “parentectomy” was the correct course of action for the welfare of the child.
The Maudsley Model
Fortunately, in recent years there has been increasing focus on empowering families to take an active role in a child’s weight restoration and treatment. This change resulted from the increasing empirical support for family-based therapy (FBT), often referred to as “The Maudsley Model” from its historical roots at the Maudsley Hospital in London where it was developed. The therapeutic techniques themselves draw from narrative, systemic, and strategic family therapy theories.
However, the genesis of the therapy came from the experiences of hospital staff who noted that patients achieved weight restoration as inpatients, but failed to maintain these gains when discharged. The problem? Parents do nursing staff on an inpatient unit does. The solution? Train families to feed their starving child using the same mix of firm, compassionate, and focused resolve. Thus, rather than pathologizing or marginalizing families, FBT places them at the center of their child’s treatment, with a mandate to create an environment that fosters rapid renourishment.
The Fundamentals of Family-Based Treatment
The basic tenets of FBT are relatively simple: 1) families are uniquely positioned to assist their children in making and maintaining healthy behavioral choices; 2) families possess the skills to help their children and can be instrumental in this process; 3) families help maintain patients in their home environment and encourage continued participation in activities of daily living, and 4) focusing on current illness optimizes recovery and fits with an agnostic approach to the cause of the illness.
It is important to remember that FBT has been developed for use with children and adolescents who are stable enough for outpatient treatment. In the outpatient setting, treatment consists of 10 to 20 50-minute sessions that take place over six months to one year.
Treatment is divided into three phases:
Phase 1 involves psychoeducation and a mandate for parents to renourish their child.
Phase 2 transfers control over food, eating, body image, and weight concerns back to the adolescent in a developmentally appropriate and sustainable manner.
Phase 3 addresses issues of adolescent adjustment and relapse prevention.
The treatment manual describing this approach is widely available (Lock J et al, Treatment Manual for Anorexia Nervosa: A Family Based Approach. New York, NY: The Guilford Press; 2001).
Phase 1 of Treatment
Phase 1 (sessions one to 10) focuses on parental renourishment efforts. AN, by definition, is a disease in which the patient most often denies the seriousness of the illness. This can be difficult for families, even for clinicians, as it is the only Axis I disorder that is ego-syntonic. This means that the very behaviors that patients seek to amplify and maintain are the ones placing them in the greatest danger. Within FBT, disrupting the cycle of restricted intake, excessive exercise, and other illness-maintaining factors becomes the primary goal. Although often thought of as parental “force feeding,” the goals of Phase 1 are to help families understand the nature of AN, and use their skills to disrupt these behaviors and provide the nourishment necessary for their child to recover. Stated simply, rather than the child being “forced” to eat, FBT uses the strength of the parental relationship to insist upon increased intake.
In the first session of treatment, the therapist takes a directed history, focusing on the development of AN and engaging all members of the family to understand the ways in which the disease has touched them. The goal is to assess familial skills and efforts toward recovery and to better understand what has, and has not, worked in helping the patient recover. The family is held in positive regard and the use of both a nonjudgmental and agnostic approach assists with this. With an agnostic approach, a therapist puts aside ideas about the cause of illness and instead focuses on the current symptoms. This lack of judgment of families is critical to exhorting the family to action. The history gathering can assist the family in externalizing the illness from the patient and highlighting the ways in which the child may be “operating under the influence of AN” and yet be doing quite well in other areas of his or her life.
The call to action is furthered by the therapist painting an “intense scene” outlining the serious potential risks of the illness, including the increased risk for death. At the end of the session, parents are charged with the task of renourishing their ill child and instructed to “bring a meal you feel your starving child needs to eat to overcome AN” to the next session. Families are not provided with further instruction on meal preparation, and further coaching occurs in the second session.
In the second session of FBT, the parents prepare and bring a meal that is shared by the family (but not the therapist). This provides the therapist an opportunity for direct instruction around appropriate intake to speed weight gain, and helps the family learn how to get the child to eat “one bite more.” In this capacity, the therapist can guide both the types of meals the family prepares, and provide direct coaching on how to increase calorie density and the amounts and frequency of eating behaviors. In addition, the therapist coaches the parents to take an empowered and unified approach against AN, while urging increased food intake. Such coaching helps families engage in selective ignoring of non-nourishing behaviors, encourages positive behaviors, changes the physical arrangement of the family to bring parents in closer to the identified patient, and assist in keeping a solid focus on eating behaviors.
The rest of the sessions in Phase 1 reinforce these skills and assist families in problem-solving around challenges with an effort toward continued weight gain of one to two pounds per week. Parents are strongly encouraged to monitor all meals and may choose to take family leave to spend more time at home. Siblings are asked to support the patient, but are not involved in direct renourishment efforts.
Phase 2 of Treatment
Families are ready to transition to Phase 2 when the patient has reached approximately 90% of ideal body weight and is eating with relatively little struggle. In addition, parents should feel sufficiently empowered to take over renourishment efforts if they are concerned their child might relapse. While parents have been firmly in control over food choices, meal times, and structure during Phase 1, during this second phase the emphasis shifts toward supporting the child or adolescent in making independent choices. This process occurs slowly; for example, adolescents prepare their plate of food with parental monitoring before progressing to independently serving their meals. Families are encouraged to experiment with increased flexibility, such as incorporating take out or restaurant meals, varying types of food, and decreasing structure around meals to allow for greater autonomy. Consistent with the patient demonstrating greater skills in these areas, sessions are extended to every other week.
Phase 3 of Treatment
When the adolescent has made a return to fully normal and independent eating, the final phase of treatment—consisting of three sessions over the course of three months—focuses on education about normal adolescent development, relapse prevention, and the end of therapy. Some families may choose to continue with other methods of treatment at this stage, but they should resolve any issues related to eating disorders.
The empirical evidence for FBT indicates that this treatment is effective for both children and adolescents, can be completed in a six-month period, and is more effective at bringing patients to recovery than a strong individualized approach. FBT can be done in two ways: in sessions with the parents only or conjointly with the patient also present. The separated models are best for families with high levels of criticism. FBT has been used with children and adolescents presenting with subthreshold AN (EDNOS AN) and is efficient and effective in this population as well. Current research is exploring the benefits of FBT to treat adolescents with bulimia nervosa (BN), in young adults, and in a pediatric obesity sample. Training, supervision, and certification are available from the Training Institute for Eating Disorders run by James D. Lock, MD, PhD, and Daniel le Grange, PhD (www.train2treat4ED.com).
Table 1: Family-Based Treatment for Anorexia Nervosa