A Viewing Guide for “To The Bone”

Ten Things I Want Viewers of To the Bone to Know

Eating Disorder Film Guide [image description: poster for To The Bone]“To The Bone,” Marti Noxon’s semi-autobiographical film about her experience as a young adult living with anorexia, was released today on Netflix and has already stirred up much controversy within the eating disorder community. As a general rule, I do not see things in black and white. As with anything, I see this film in shades of grey – it handles some things well and some things poorly. Many concerns have already been aired widely in both mainstream and social media.  Foremost among these concerns is the movie’s reinforcement of the anorexia nervosa stereotype by portraying an emaciated white female and the weight loss that lead actress Lily Collins underwent to play the role. I will not rehash these here; instead, I hope to shed light on some other important issues and to provide an educational piece to accompany the film.

  1. This film may be triggering. It shows images of severe emaciation and may either be upsetting to those vulnerable to eating disorders, or inspire a competitive desire to be “as skinny”. Often, people with eating disorders don’t feel “sick enough”; anorexia nervosa can be a competitive illness. (Reports are that pro-ana sites are already using images of Lily from the film. While it’s concerning that the film adds to the available library of these sorts of images, this library is already huge – if they didn’t use this image, it would be easy to find another.) Those susceptible must exercise caution when viewing this film and if they are triggered, they should contact their treatment team or contact an organization such as the National Eating Disorders Association for help.
  2. It is difficult to make a film that accurately portrays eating disorders. To depict eating disorders on film, behaviors must be shown. Yet much of the suffering from an eating disorder is internal and harder to depict. This film is not an educational film – it is a piece of entertainment. Nevertheless, I think it does bring eating disorders into the mainstream. The film portrays some things accurately – with others it takes great liberties. Even with these departures, I do think it has virtues that can do some good. I will discuss these more below.
  3. This is one person’s story. Marti Noxon’s aim is to tell her story and she has a right to do so. She has been public that many years ago she suffered from an eating disorder and wanted to both shed light on and draw more attention to the issue. And that she has done! Based on the talkback I attended with Marti Noxon and actors Lily Collins and Alex Sharp, Marti recognizes that she can neither represent the diversity of all people with eating disorders nor speak for the range of people affected. She hopes that her work will open the door for others to tell their own stories, a hope I share. For those interested in a more diverse story about eating disorders, check out the work of Tchaiko Omwale, who is working to complete her film Solace. If you are committed to helping bring more diverse voices forward, you can contribute to help her complete her film.
  4. To The Bone accurately portrays some of the aspects of living with an eating disorder. I do not believe the film overly glamorizes anorexia. It illustrates the mindset and some of the mental anguish of someone with an eating disorder. The film displays a number of common eating disorder behaviors. We see Ellen and her peers engaging in behaviors such as calorie-counting, dietary restriction, overexercise, bingeing and purging, and chewing and spitting. Chewing and spitting is displayed in a restaurant scene in which Ellen goes out to eat with Lucas, her friend from treatment. Chewing and spitting is a lesser-known, but significant eating disorder behavior that is not commonly talked about or assessed by professionals. It is a frequently associated with more severe eating disorder symptoms and suicidal ideation. However, the behavior is more likely to occur in private than in public. It can occur in the context of anorexia nervosa as well as bulimia nervosa or other disorders.
  1. Eating disorders are serious mental illnesses and can be life-threatening. The movie shows Ellen and some of her peers needing medical attention and carefully balances showing the gravity of their situation with building hope for recovery.
  2. To the Bone paints a very Hollywood picture of recovery. While the movie adequately portrays Ellen’s ambivalence about treatment, it implies that things shift when Ellen “decides” she wants to recover. It disturbs me greatly that Dr. Beckham tells Ellen, “I’m not going to treat you if you aren’t interested in living.” Many people with anorexia nervosa have anosognosia, a symptom that causes patients to deny their illness and refuse treatment as a result. We now know that enough food, weight gain, and a cessation of eating disorder behaviors are prerequisites for recovery from anorexia nervosa. Usually some physical restoration is required before a patient can really want to recover – Dr. Ovidio Bermudez calls this a “brain rescue.”
  3. The movie does not model modern eating disorder treatment practices. But realistic treatment would probably not make a good Hollywood story. For starters, I would never suggest a therapy patient change his/her name! More seriously, in eating disorder treatment we prioritize nutritional recovery. This refers not to specific nutrients, but to the development of healthy eating habits including regular meals and adequate amounts of food. This applies to people with all eating disorders, not just anorexia nervosa. People with eating disorders need as a primary element of treatment food – balanced, sufficient, and regular eating. The movie portrays the patients in the residential treatment center as each able to choose their own food. While some patients eat some portion of the meals served, other patients eat nothing (or the one character with BED repeatedly eats only peanut butter out of the jar). I know of no treatment setting that would not have a primary focus on structured regular meals and patients having requirements for meals that can become less restrictive as they progress in treatment.
  4. I worry that the portrayal of Ellen’s family reinforces old myths about eating disorders being caused by families. To reiterate, families do not cause eating disorders. Ellen’s father is unavailable (and never even appears), her mother has had mental health problems (and is involved in a new relationship) and no one is really there for Ellen, except her stepmother who takes her to treatment and her half-sister. I do love the portrayal of the relationship between Ellen and her half-sister. I think this relationship captures the mixture of love, concern, and anger experienced by siblings.
  5. The movie misses the opportunity to depict the family as important allies in treatment. No one is really involved in Ellen’s treatment beyond the family session, and Dr. Beckham states there is no need for any future family sessions on the basis of how badly it went. None of the young people in this house have their parents involved in their treatment (at least that we see). This is very unrealistic in this day and age. Almost every treatment center involves family members to a greater or lesser degree. In reality, parents can play a central role in the treatment of adolescents and young adults, are usually included in treatment, and can even drive the treatment when their youngsters are incapable of seeking treatment on their own or have anosognosia. Parents can also help with nourishing their youngsters back to health (but not in the dramatic way it was portrayed in the film…with a baby bottle). Family-based treatment (also referred to as the Maudsley method and mentioned in passing in the scene where the moms are in the waiting room waiting for their daughters to have an intake with Dr. Beckham as something they have tried) is actually the leading treatment for adolescents and is also effective for many young adults. It focuses on empowering the family to be an important part of the treatment team and able to fight for recovery on behalf of an unwilling or unmotivated youngster and also provide meal support.
  1. Three Things I really like about the film:
    1. I love that Dr. Beckham says, “There is never one cause.” This is true.
    2. I love that it builds hope for recovery by showing Lucas as doing well and actively working on recovery.
    3. I love that it shows a male and an African-American with eating disorders.

Although I was a consultant for the film, I had no influence on the story.

In conclusion, please View the Nine Truths PSA the cast and crew of To the Bone produced for World Eating Disorders Action Day. While aspects of the film veer far from reality, the filmmakers are committed to the cause and, to support eating disorder education, they made this PSA which aligns with the best current evidence on eating disorders. Most of the messages I would want viewers of the film to come away with would be covered in this fabulous video. You can also read the Nine Truths About Eating Disorders:

Truth #1: Many people with eating disorders look healthy, yet may be extremely ill.

Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.

Truth #3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.

Truth #4: Eating disorders are not choices, but serious biologically influenced illnesses.

Truth #5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.

Truth #6: Eating disorders carry an increased risk for both suicide and medical complications.

Truth #7: Genes and environment play important roles in the development of eating disorders.

Truth #8: Genes alone do not predict who will develop eating disorders.

Truth #9: Full recovery from an eating disorder is possible. Early detection and intervention are important.

Produced in collaboration with Dr. Cynthia Bulik, PhD, FAED, who serves as distinguished Professor of Eating Disorders in the School of Medicine at the University of North Carolina at Chapel Hill and Professor of Medical Epidemiology and Biostatistics at the Karolinska Institutet in Stockholm, Sweden. “Nine Truths” is based on Dr. Bulik’s 2014 “9 Eating Disorders Myths Busted” talk at the National Institute of Mental Health Alliance for Research Progress meeting.

Five Reasons Parents Should be Included in the Treatment of Children and Adolescents With Eating Disorders

I had the honor of presenting a workshop yesterday along with Therese Waterhous, PhD/RDN, CEDRD. and Lisa LaBorde, Outreach Director for Families Empowered and Supporting Treatment of Eating Disorders (FEAST) at the IAEDP Symposium 2016. Our workshop was entitled, From “Worst Attendants” to Partners in Recovery: Empowering Parents as Agents of Change for Children and Adolescents with Eating Disorders.

image description: photo of Therese Waterhous, Lisa LaBorde, and Lauren Muhlheim

A growing body of scientific research demonstrates that parents and caregivers can be a powerful support for a child in recovery from an eating disorder. This model of care is a radical shift from the traditional individually focused therapeutic approach and requires significant changes in how patients and families are treated within a clinical practice.

During my section of the presentation, I presented Five Reasons to Include Parents in treatment for youngsters with eating disorders. I share them here:

  1. The reason to exclude parents was based on theories that have now been debunked.

In the late 1800s Gull suggested that families were “the worst attendants” for their children with anorexia nervosa, and this set the tone for many years. More recent perpetrators of this viewpoint were Hilda Bruch and Salvador Minuchin. In the historical treatment of eating disorders, parents were blamed and the children were taken away to be fixed by professionals. When ultimately sent back home, parents were told, “Step back,” “Don’t get into a battle for independence, “ and “Don’t be the food police.”

These practices were based on early theoretical models for eating disorders that have not been supported by empirical studies. Research has not been able to identify any particular family pattern that contributes to a child’s eating disorder.

  1. Best practices now state to include parents (and not blame them).

As the following clinical guidelines demonstrate, it is no longer the appropriate standard of care to exclude families from treatment.

The Academy for Eating Disorders’ position paper on The Role of the Family in Eating Disorders:

  • The AED stands firmly against any model of eating disorders in which family influences are seen as the primary cause of eating disorders, condemns statements that blame families for their child’s illness, and recommends that families be included in the treatment of younger patients, unless this is clearly ill advised on clinical grounds. 

The Nine Truths About Eating Disorders consensus document, produced in collaboration with Dr. Cynthia Bulik, PhD, FAED states:

  • Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.

The American Psychiatric Association (APA) Guidelines for Eating Disorders also advises:

  • For children and adolescents with anorexia nervosa, family involvement and treatment are essential. For older patients, family assessment and involvement may be useful and should be considered on a case-by-case basis. (p.12)
  1. Research shows better and faster results when parents are included in mental health treatment for their children.

Randomized controlled trials of adolescents with anorexia nervosa and bulimia nervosa show that adolescents who receive family-based treatment, in which parents play a central role, achieve higher rates of recovery and recover faster than adolescents who receive individual adolescent focused therapy. This result is consistent with findings for other psychological disorders, including Obsessive-Compulsive Disorder (improved outcome is found when families are included in treatment) and schizophrenia (a large scale study found greater improvement when treatment included family education and support as part of more comprehensive care).

  1. Parents are often good allies in fighting eating disorders.

On the one hand, patients with eating disorders (and especially younger patients) are often significantly impacted by malnutrition. Research shows they commonly have a decrease in brain grey matter, cognitive deficits and anosognosia—a lack of awareness that they are ill. Recovering on one’s own is commonly difficult for an adolescent whose brain is not fully developed and may lack the cognitive ability to challenge negative thoughts, change behavior patterns, and resist urges. Furthermore, they commonly lack the independence adult clients have to purchase and prepare their own food.

On the other hand, parents are there to take care of their children. They can do the heavy lifting. They can be authoritative and require children to eat. It can be difficult for a therapist to develop rapport with a reluctant and resistant adolescent; it is much easier for a therapist to develop a therapeutic alliance with the parents who do want their child to recover. In situations where there are multiple treatment providers, parents can help with the communication between team members as they will likely be seeing them all. Lastly, parents typically buy the food for the household so they have the ability to execute the meal plan.

Eating disorders often take years, not months, to fully resolve. There will rarely be a scenario in which a patient leaves home for a residential setting and comes home “cured.” The reality is that any treatment is only the first stop on the road to recovery–full recovery takes sustained full nutrition and cessation of behaviors for an extended time period and the family, in many cases, can help that happen. So whatever treatment model is used, FBT principles and training are vitally important for families.

  1. Parents are powerful.

In the past, mental health treatment was primarily private; the internet has changed that. Parent support and activist groups such as FEAST, Eating Disorder Parent Support (EDPS), March Against Eating Disorders, and International Eating Disorder Action,have connected parents, given them access to scientific information that was not available to parents pre-internet, and given them the tools to organize. Social media has increased the pace of this information. Parents have access to evidence-based information and are demanding treatment that aligns with it. If they are shut out from treatment, they will hear from other parents that this is problematic. They may change providers if they are dissatisfied with the treatment their child is receiving

There is no greater love than the love of a parent for their child. To work with parents and empower them to help their children get well is one of the most rewarding aspects of my work. Family-Based Treatment is at the forefront of treatments that center the role of parents. Learn more about our approach, Family-Based Treatment.

For Teens With Bulimia, Family Based Treatment is Recommended

Teens With Bulimia Family Based Treatment [image description: family looking at book together]My original eating disorder training began in 1991 with learning Cognitive Behavioral Therapy (CBT) for bulimia nervosa (BN) under G. Terence Wilson, the co-author with Dr. Christopher G. Fairburn, of the treatment approach that preceded CBT-E. In 2010 I underwent training in Family Based Treatment (FBT) for Adolescent Anorexia Nervosa (AN) and became certified in FBT by the Training Institute for Child and Adolescent Eating Disorders.

CBT is the most effective treatment for adults with bulimia nervosa. It is an individual approach that focuses on reducing dieting and changing unhelpful thinking patterns that maintain the behavior. FBT is the most successful treatment for adolescents with AN. FBT encourages parental control and management of eating disorder behaviors, but does not address distorted thinking regarding shape and weight. Over the last five years, there has been no clear guideline on which treatment I should offer to adolescents with BN.

This changed in September 2015 with the online publication of “Randomized Clinical Trial of Family-Based Treatment and Cognitive-Behavioral Therapy for Adolescent Bulimia Nervosa” by Daniel Le Grange, Ph.D., James Lock, M.D., W. Stewart Agras, M.D., Susan Bryson, M.A., M.S., and Booil Jo, Ph.D. which has been published in the November Journal of the American Academy of Child and Adolescent Psychiatry.

In this study, researchers at the University of Chicago and Stanford randomly assigned 130 teens between the ages of 12 and 18 years old with BN to receive either CBT-A (CBT adapted for adolescents) or FBT-BN (FBT for adolescent bulimia). The teens received 18 outpatient sessions over the course of six months. Assessments were conducted at end of treatment and at six and twelve month follow-ups. After the completion of the treatment, bulimia abstinence rates were 39% for FBT patients and 20% for CBT patients. By the six-month follow up, these rates rose to 44% for FBT patients and 25% for CBT patients. These differences were statistically significant. By 12 month follow up, while the bulimia abstinence rate continued to rise for both populations, the difference was no longer statistically significant.

The researchers concluded,

FBT-BN is likely a better initial treatment option compared to CBT-A for those adolescents with clinically significant bulimia behaviors. FBT-BN leads to quicker and higher sustained abstinence rates that are maintained up to 12 months posttreatment…It appears that, similar to their adolescent peers with AN, adolescents with BN can benefit from an approach that actively involves their families in the treatment process. However, given that there were no statistical differences between these 2 treatments at 12 months post-treatment, CBT-A remains a viable alternative treatment for this patient population, especially for those families who would prefer a largely individual treatment or when there is no family available to be of help.

In interviews about the study, Dr. Le Grange said, “Parents need to be actively involved in the treatment of kids and teens with eating disorders.”

This study reinforces my experience. Although I have employed CBT for bulimia in working with adolescents, rarely do adolescents fully embrace the work required on their part for CBT to be successful. I have found it more effective to use FBT with their family and to supplement with some individual CBT if the adolescent appears ready and motivated for additional independent work. Bingeing and purging are serious symptoms carrying the risk of heart and esophageal problems and death. Thus administering a treatment that brings a faster rate of remission of symptoms is a priority.

Is Your Young Adult with an Eating Disorder Ready for College?

Is My Young Adult with an Eating Disorder Ready for College? [image description: young adults sitting on grass hanging out together]

You may be wondering: is my young adult with an eating disorder ready for college? Starting college is stressful for even the most well-adjusted young adult. Young adults with eating disorders often have trouble with transitions. Add an active eating disorder on top of the college transition, and you have a potential time bomb.

College brings a multitude of new situations to navigate: living away from parents; living with strangers; loss of personal space and privacy; unfamiliar environment; unfamiliar foods; loss of structure; drugs and alcohol; pressure to fit in; academic pressure; and sororities and fraternities. If a young adult has been struggling in recovery, these additional stressors typically make life even harder.

Young adults who are not completely recovered struggle in situations that healthy adults navigate with ease. Consuming enough food in a dining hall can pose a big challenge to students with eating disorders characterized by inflexible eating. In our experience, students who are not comfortable eating with peers and not comfortable eating a variety of foods (including starches, fats, and desserts) lose weight rapidly in this environment.

The patterns of college life can make it harder to maintain a healthy weight. Students are likely much more active as they walk from place to place over a large campus. Different sleep patterns (all-nighters among them) can also increase energy expenditure. For these reasons, the caloric needs of college students are often substantial; 3000-3500 kcal per day baseline is not unusual. This would translate to needing over 100 fat grams per day. These factors should be considered when evaluating whether the young adult can eat enough calorically dense food on their own to sustain a healthy weight or refrain from bingeing and purging.

College culture brings additional pressure to a student in recovery. Roommates and peers may be dieting, there is fear of the “freshman 15,” and friendships may bond around visits to the gym and yoga classes. It can be harder to refrain from exercise when it is the place that socializing occurs.

Many parents want to send their young adults to school so as not to have them miss out on common milestones and universal experiences. However, the reality is that attending school while still plagued by intrusive eating disorder thoughts and behaviors will rob them of the very aspects of the experience you want them to have. Returning to a “normal” life too soon is a common cause of relapse, further delaying their ability to live a “normal” life.

From our experiences with the preparation of high school seniors to go off to college and the reception of incoming freshman from other eating disorder teams, we have developed the following list of questions for parents to ask when deciding whether a young adult is prepared for a healthy transition to college:

Six months of solid recovery is needed, meaning the young adult has consistently displayed the behaviors included in the checklist over that period of time.

Lauren and Katie’s college readiness checklist:

  • Has your young adult maintained a steady weight in the healthy range (according to childhood growth records) and menstruated consistently (if female-bodied) for six months?
  • Has your young adult been free of eating-disordered behaviors such as bingeing, purging, laxative use, and excessive exercise for six months?
  • Is your young adult able to independently and consistently prepare/choose meals (in a variety of settings) that contain enough energy-dense foods to maintain this weight?
  • Is your young adult able to serve themselves snacks and desserts?
  • Does your young adult consume beverages other than water (juice, milk, lattes)?
  • Is your young adult able to eat at a variety of restaurants, ordering and eating a balanced meal that is not simply the lowest calorie item on the menu?
  • Is your young adult able to go into a cafeteria and eat from the different food stations comfortably (sandwich bar, grill, etc.) and not just from the salad bar?
  • Is your young adult comfortable eating hot breakfasts (other than oatmeal)?
  • Does your young adult use condiments comfortably (dressing with fat, ketchup, mayonnaise, etc.)?
  • Is your young adult comfortable eating with friends?
  • Does your young adult eat at a normal pace?
  • Has your young adult reincorporated the majority of previously feared and avoided foods?
  • Is your young adult able to go without exercise at least every other day, or not at all if medically contraindicated?
  • If your young adult has returned to exercise, do they understand the need to add additional fuel following exercise?
  • Is your young adult able to eat in front of other people who aren’t eating? (There is no guarantee roommates will not be eating disordered – so taking care of one’s own needs and handling the self-consciousness inherent in doing so is an important recovery skill.)
  • Will your young adult be able to cope with potentially having a scale in the room and roommates who weigh themselves and discuss weight/dieting?
  • If your young adult misses a meal for any reason at all, are they able to make it up that day or the next day at the latest? Making it up may mean having larger portions at other meals, two extra snacks, or the equivalent of an extra meal across a 24- to 36-hour period.
  • Is your young adult able to increase their daily calories substantially to account for mileage logged when walking around campus?
  • Can your young adult be restful? Does he or she sit when everyone else is sitting?
  • Is your young adult able to be alone around processed and highly-palatable foods without having an urge to binge?
  • Has your young adult demonstrated an ability to tolerate anxiety without resorting to restriction, bingeing, or purging?
  • Does your young adult openly acknowledge their eating disorder and have insight about the need to construct a life and schedule that supports recovery?
  • Have you discussed with your young adult that any situation that puts them in a state of negative energy imbalance or weight loss could trigger a relapse?
  • Does your young adult understand that alcohol calories “do not count” towards energy needs?
  • Are temperamental traits (perfectionism, rigidity, comparing, etc.) acknowledged and appropriately managed?

How to prepare a young adult for college

If your young adult meets most of the above criteria and there is still time before they are expected to leave for college, there are things you can do to prepare them.

  1. Practice eating with them in different self-serve cafeteria-type settings including a variety of restaurants for breakfast, lunch, and dinner. Good options include Souplantation, Indian restaurants that have lunch buffets, and hospital cafeterias. Have them practice building a meal that will meet their dietary needs. Revisit the same places again with the expectation that they will choose different options.
  2. Have them practice walking five miles per day for a week (to simulate the amount of physical activity they’re likely to have on a college campus) and adding sufficient calories to keep weight steady.
  3. Do ‘surprise’ food exposures for a few months – at random times take your young adult to unexpected food locales/situations and make sure they can tolerate it. For example, make a spontaneous stop at Cold Stone Creamery and offer them a snack.
  4. Do a week of sauces and butter on everything.
  5. It is a good idea to have a college contract in place. This is an agreement between the parents and the student that specifies criteria required for staying in college (things like maintaining a healthy weight, not engaging in eating disorder behaviors, and having regular weigh-ins) and what the parents will do if these things are not met (for example, increase supervision, bring the child home, etc.).  A sample college contract can be found here.
  6. Make sure they have a meal plan that includes three meals per day in the dining hall.

If your young adult does not meet the criteria listed above, then please consider having them defer college or start at a local college while living at home. It is better to delay their starting than to have them start and get overwhelmed by their symptoms and need to drop out. Life is not a race. College can wait. Your young adult will get more out of the experience when she or he is fully recovered. By contrast, sending them to college when they are not ready may reduce their chance for a full recovery.

Thanks to Rebecka Peebles, MD, Therese Waterhous, PhD/RDN, CEDRD, and JD Ouellette for their helpful feedback and contributions to this piece.

Download copy of article here: Is your young adult ready for college?

Presentation at NEDA 2015 conference

image description: Lauren and Katie presenting NEDA 2015

Katie and I had the honor of presenting in the Individual, Family, and Friends track at the National Eating Disorder Association Conference in San Diego yesterday.  The title of our talk was:  Family Based Nutrition Therapy:  Creating A Supportive Environment.  It was a chance to share the way we work to support families who are helping children with eating disorders.

Here are some of the key points of our talk:

FBT Insights from the Neonatal Kitten Nursery

Parents feed children in FBT Kitten Collage [image description: collage of kittens being bottle-fed]I recently began volunteering at the Best Friends Neonatal Kitten Nursery. Best Friends Los Angeles opened its neonatal kitten nursery in February 2013.  The nursery is staffed with a dedicated coordinator and supported by volunteers who sign up for two hour feeding shifts 24 hours a day to help the kittens grow and thrive.

If you were an abandoned kitten in the Los Angeles area, or even a kitten with a mother, you’d be lucky to make your way to the Best Friends Neonatal Kitten Nursery.

The most vulnerable animals in the Los Angeles shelters are newborn kittens, often abandoned at birth, or turned into shelters from accidental litters. Because the kittens cannot feed themselves, they will die without someone to bottle feed them.

In the mommy and me section of the nursery, mothers nurse their kittens. In the other sections, kittens are bottle-fed, tube-fed, or syringe-fed until they are able to eat gruel on their own. Kittens are weighed before and after each feeding. If their weights are not steadily going up, the interventions increase. They are very fragile at this age.

The other night, the nursery coordinator, Nicole, was tube-feeding some kittens who were ill. As she explained, they were feeling too sick to eat on their own. Although acknowledging that her tube feeding was making them angry, Nicole was resolute. No kitten would starve to death on her watch. Of course, I connected this back to my families working to re-feed their children with anorexia.

In the neonatal nursery, we don’t spend time thinking about why the kitten is not nursing or eating in the expected fashion. If they are sick, they are treated for that, but in the meantime, every kitten is fed around the clock and those who don’t have mothers are bottle fed, those who won’t nurse from their mothers (often when they are too congested) are tube-fed, and those who won’t eat gruel independently are syringe-fed.

How does this relate to parents doing Family Based Treatment (FBT) for Eating Disorders with children who have Anorexia?

Of course, parents do not literally force food down human children’s throats, but they do set up contingencies to require eating even if the child doesn’t feel well and even if they rail and resist and are angry about it.

This is the heart of FBT Phase 1. When children are not able to eat on their own (due to an eating disorder) parents are instructed to nourish their starving child back to health. Parents need to step in and help their children make steady weight gains until they are able to eat on their own. Parents need to be resolute and not worry about their children being angry at them. They also should not spend time exploring why their child is not eating.

For further information on parental direction over eating in FBT, check out this prior blog post.

 

Parental direction works, but don’t expect your kid to be happy about it: Research on The Family Meal in FBT

image description: a table set for a mealParents charged with helping their children to recover in Family-Based Treatment often wonder 1) how to actually get their children to eat and 2) whether they will harm their children or the parent-child relationship by requiring them to eat. A recent study addressed these concerns by looking at the family meal.               

How do parents of adolescent patients with anorexia nervosa interact with their child at mealtimes? A study of parental strategies used in the family meal session of family-based treatment

Hannah J. White BSc (Hons), Emma Haycraft PhD,*, Sloane Madden MD, Paul Rhodes PhD, Jane Miskovic-Wheatley DCP/MSc, Andrew Wallis MFAMTher, Michael Kohn MD and Caroline Meyer PhD (Article first published online: 26 JUN 2014)

The above study in the International Journal of Eating Disorders looked at the family meal in Family-Based Treatment (FBT), the best-researched outpatient treatment for adolescent anorexia. In FBT, the family plays a central role in treatment. Parents take responsibility for weight restoration and interruption of eating disorder behaviors, and family meals are an essential part of this process. Typically the second session of Family-Based Treatment is a family meal in which the family brings a picnic meal to the therapist’s office. The goal of the session is for the therapist to empower the parents to get their child with anorexia to eat one bite more than the child was prepared to eat.

The strategies used during mealtimes by parents of adolescents with anorexia have not been previously documented. Some believe that the eating habits of these adolescents have regressed and that the adolescents should be viewed as younger children who need more feeding assistance from their parents. Thus, parental strategies used to encourage eating would be similar to the strategies used by parents of younger children with and without feeding problems, which have been studied: these parents have been noted to use both encouragement and pressure to eat. Little is known about the response of adolescents with anorexia to their parents’ attempts to get them to eat.

The purpose of this study was to examine the strategies used by parents and the results. The study included 21 families with children between the ages of 12 and 18 who were undergoing FBT for adolescent anorexia.

The main aims of the study were:

1)   to identify mealtime strategies used by parents during the family meal session of FBT.

2)   to explore the relationships between these strategies and parental ‘success’ in encouraging eating.

3)   to explore the relationships between these strategies and their results with the emotional tone of the mealtime.

While this research was conducted in an artificial setting – a therapist’s office and in the presence of the therapist – the findings should be applicable to family meals occurring in the home.

Specifically, the researchers found:

1)   parents used a variety of strategies to prompt the child to eat: direct eating prompts (e.g., “You’ve got to eat all your eggs” or “Pick it up and eat it”), non-direct eating prompts (e.g. “Keep going” or “Why don’t you eat some more pasta?”), physical prompts (e.g., pushing a plate of food towards the adolescent), autonomous comments (e.g., “Do you want another one?” or “Which one do you want?”) and information provision (e.g., “Your body needs the calcium” or “This will make your bones strong”).

2)   direct, non-direct, and physical prompts were more successful in getting adolescents to eat than providing information about the food or offering food-related choices to the adolescent.

3)   in general, the more the parents prompted the child to eat and the more successful they were, the more negative the adolescents became. It makes sense that attempts to encourage eating, which contradict the anorexic tendencies, would cause psychological distress and a more negative emotional tone.

The authors conclude “It is interesting that a behavioral focus on eating (i.e., verbal and physical prompting) was associated with parental success as opposed to other strategies such as offering choices to the adolescent or consequences. This indicates that parents implementing a direct focus on food may be central to eating behavior and supports the emphasis on behavioral change rather than insight which is central to FBT.”

Keeping in mind that this is only one small study, the results are consistent with my observations of family meals in my practice and reports from parents refeeding their adolescents:

  1. parents need to directly prompt or pressure their child with anorexia to eat.
  2. offering choices and providing information is generally less effective in getting children with anorexia to eat.
  3. the more the parents pressure the child and the more the child eats, the more negative and upset the child becomes.

This study highlights the paradox parents face in implementing FBT. When a child is in distress, the parental instinct is to try to soothe them. Intentionally upsetting the child runs counter to a parent’s nature. However, for children with anorexia, food is medicine. The best measure of the parent’s success in FBT is the amount of food consumed. Parents should expect that their child will have a negative reaction to both pressure to eat and the eating itself. This negativity is not a sign of failure, but a reaction to a treatment that is working.

While these interactions often lead to more short-term conflict and distress, parents must persist and weather the storm in order to support their child’s recovery.  Over time, this persistence will challenge the anorexia and encourage change and recovery.

 

Recognizing and Managing the Subtler Signs of Starvation in Children with EDs

This interaction on twitter caught my eye:

Signs of Anorexia [image description: a twitter interaction]

Watching cooking shows, collecting and reading recipes, and cooking for others (but not eating it oneself) are some of the earliest signs of anorexia that are often missed and misinterpreted by parents. 

In Keys’ landmark study “The Biology of Human Starvation” male volunteers were put on starvation diets.  According to Keys, food became “the principal topic of conversation, reading, and daydreams.”  The volunteers studied cookbooks and collected cooking utensils.  Three of them went on to become cooks even though they’d had no interest in cooking before the experiment.  When starving, people may obtain vicarious satisfaction from cooking and watching others eat.

In my own experience, I contracted severe food poisoning during my second pregnancy.  Unable to eat without severe consequences, my doctors instructed me to forgo solid food for a full week.  I remember clearly that I spent the week lying in bed (entertaining my toddler) and watching cooking shows.  It seemed nonsensical to me at the time, like an unusual form of self-torture.  But, now I know it was an attempt to vicariously soothe my intense hunger.

In her book Brave Girl Eating, Harriet Brown discusses how her daughter went through a “foodie” phase during the onset of her anorexia.  I have seen a similar profile in a number of my young clients.  Parents do not usually think these are signs of trouble and are more often impressed by their child’s sophistication.  Some of the less obvious early signs of starvation parents should watch for include:

  • Reading recipes
  • Blogging about food
  • Cooking food they do not eat
  • Watching cooking shows

Of course, not every child who shows a strong interest in cooking has or will develop anorexia, but it is something that should pique a parents’ interest.

My own daughter went through a phase where she was obsessed with cooking and watching cooking shows.  It so happened that she was not eating enough at this time, which coincided with the start of her adolescent growth spurt.  I did an early FBT-like intervention and she gained and grew; as she did, the obsession with cooking abated.  Was this merely a passing phase or anorexia averted?  I’ll never know, but I’m glad I intervened.  (More about that in future post.)

When a child with a diagnosis of anorexia shows these behaviors, I recommend that they be stopped.  In FBT, parents take charge of their child’s food and food environment.  Food is the child’s medicine and the number one priority.  For this reason, vicarious gratification of hunger should be removed.  Children with anorexia should not be watching cooking shows, reading recipes, or cooking.  I usually recommend that children do not participate in preparing their own food at all in Phase 1.  In Phase 2, children gradually get involved in food preparation again, but the usual rule I recommend is that if they make something, they must eat it.

Highlights from #ICED2014: The FBT Debate

Drs. Le Grange and Strober
Drs. Le Grange and Strober

ICED 2014 in New York provided a wonderful opportunity to connect with colleagues from around the world who share a commitment to providing treatment to those suffering from eating disorders. Among the highlights for me were the well-attended, first-ever tweetUP and my official appointment as Board Director for Outreach of the Academy for Eating Disorders.

Among the workshops, I was very excited to attend A Comprehensive and Measured Critique and Discussion of Maudsley and Family Based Therapy: The Civilizing Influence of Rigorous and Impartial Debate.   In this workshop, UCLA Eating Disorders Program director Dr. Michael Strober, one of the more vocal critics of Maudsley Family Based Treatment (also known as FBT), went head to head with Dr. Daniel LeGrange, director of the University of Chicago’s Eating Disorder Program and one of the developers of FBT. As one of a handful of therapists in Los Angeles certified in FBT, I am highly aware of Dr. Strober’s criticisms of the treatment.

Dr. Strober introduced the packed-room debate by saying, “there will be no flowing of blood at the FBT debate.” Dr. LeGrange presented first and cited the empirical evidence for FBT, admitting “it is no panacea” as there are only 7 published controlled trials. He reported the “most compelling” study of FBT showed that 45% of those who received FBT fully remitted, versus only 20% of those who received Adolescent Focused Therapy. He noted that FBT is particularly helpful in rapid weight restoration and in a reduction of the need for hospitalization.

Dr. Strober countered by stating, “there is [only] a sprinkling of evidence in support of FBT.” He argued that the evidence for FBT was actually weak, with only 3 published comparative studies. He pointed out there was no statistically significant end of treatment outcome for FBT. Strober concluded that there is a lack of evidence to suggest FBT is the treatment of choice for all patients. He cautioned that the “glossy language” used by FBT’s proponents needs nuance: “The public discussion is the problem; well-trained clinicians have been accused of acting unethically by not recommending FBT.” Strober stated that his questions regarding FBT’s efficacy have led to hostile, finger-pointing treatment from others. “It’s not that ‪FBT lacks value but that [any critique or questioning of it is dismissed as unethical & unfounded]”. He conceded that FBT should not be dismissed: “I recommend it at times when the rationale is sound.” He joked, “I have been asked why I hate families; as far as I can tell the only family I hate is mine; I quite fancy the others.”

In his rebuttal, Le Grange agreed with Dr. Strober, “It concerns me too that FBT is being touted as the be-all-end-all.” However, he noted that it was still the approach that currently has the best evidence supporting its overall efficacy. LeGrange acknowledged “we are clutching at straws” to find effective treatments for eating disorders. “I agree we need to move forward, with much more rigor, to continue to evaluate the efficacy not just ‪ of FBT but also other ED treatments.”

In summary, there was more agreement than disagreement. Both experts acknowledged that while FBT has value, the research is still young. The audience encouraged them to write a paper together on the strengths and limitations of FBT, with the objective of depolarizing the eating disorder community.

For my part, in the outpatient setting in which I work, I will continue to offer FBT to adolescents with eating disorders and their families when the illness duration is under three years, when the adolescent is medically stable and cleared for outpatient treatment, and when the home environment is stable and the parents are committed to FBT. If early weight gain is not achieved, I always recommend a higher level of care.

FBT Meal Strategies Gleaned from Ziplining

Understanding and Responding to Your Youngster’s Fear: A Metaphor

FBT Meal Strategies Gleaned from Ziplining
The author on the zipline

I often explain to parents that for a youngster suffering from an eating disorder, a meal can feel dangerous – like jumping out of an airplane. A couple of years ago I had the opportunity to (almost) live out this metaphor on a family vacation. This experience led me to reflect on the experience of both the teen and their support team:

Recently our family went zip-lining for the first time. I was terrified. But as I was zip-lining, I paid close attention to how I felt and behaved and what helped me get through the experience.

Despite the excitement I had felt when we initially planned the activity, when I saw the length and height of the zip-lines, I had misgivings. I imagined that this is how many of my patients must feel before many meals. Imagine, though, that they face this fear up to six times daily!

During the zip-lining adventure, I felt most comfortable going after my children and before my husband. Even though once I was on the zip-line I was alone, rushing through the air at speeds of up to 50 miles per hour, so fast my eyelashes were blowing into my eyes – somehow taking the plunge in this order made me feel like I was snugly nestled between them.

The calm and assurance of the line attendants was comforting. They knew what they were doing. At every single end of each of the eight lines, I felt compelled to tell the attendant that secured or unstrapped me exactly how terrified I was. I was relieved when they joked and told me they knew I would be fine. I also felt supported when my kids received me at the end of each line and reminded me that the next one wouldn’t be any harder. Knowing that my kids and husband were there with me and that we were doing it together made this fear something I wasnt facing alone.

So, how does this apply to supporting a young person with an eating disorder?

Physical Placement of Support

During the zip-lining adventure, I felt most comfortable going after my children and before my husband. One of the basic premises of FBT is that the support of the family during mealtimes provides a supportive environment for recovery. Parents often find that sitting at the table on either side of their adolescent during mealtimes provides additional structure and support. It is an act of love to support a child through a meal when they are terrified.

Confidence

If the zip-line attendants had expressed hesitation or anxiety about what they were doing I probably would have refused to go. Calm and confident parents inspire trust in their children, making it easier for them to eat. Sometimes parents have to fake it until they do feel confident.

Validation

At every single end of each of the eight lines, I felt compelled to recount my terror to the attendant that secured or unstrapped me. I didn’t need to hear any response in particular. It just relieved me to express how scared I was and to know that the attendants heard me. When parents hear their child say he or she doesn’t want to eat, it is more helpful to simply hear it and stay calm than it is to get upset and try to argue or reason.

Reassurance

If the zip-line attendants had tried to reassure me by giving me detailed factual information about the strength of the lines and so on, my attempts to parse this information in my state of anxious activation might have only increased my anxiety. Parents can empathize with the fear and express confidence that their adolescent will be okay. “I know you are scared. I know you can do this.” Parents know their youngster and know whether joking will work. It is usually best to avoid getting into the content of the fear, such as how many calories are in the food, why they need fats in their diets, etc.

Togetherness

I also felt supported when my kids received me at the end of each line and reminded me that the next one wouldn’t be any harder. Knowing that my kids and husband were there with me, and that we were doing it together, made this fear something I wasn’t facing alone. The presence and support of parents and siblings and extended family during and after meals is critical.

 

At the end of my zip-lining experience, my nerves were spent and I felt exhausted. But, I was happy and proud I had faced my fear with the support of family. In the far more essential activity of eating, families can provide similar support to make fears bearable and provide an environment that allows teenagers with eating disorders to recover and flourish.

Parents usually get the best results when they are like the zip-line attendants: calm, empathizing with the fear, and never engaging the source of the fear (in this case, the eating disorder). Avoid getting pulled into the content of the eating disorder thoughts. When your adolescent says they are worried about the caloric content of food, think about what they are really expressing: their anxiety about eating. It is much better to empathize with how scared they are than to debate whether food is healthy for them (spoiler alert: it is).