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Family based treatment Family-Based Therapy teen eating disorder

Supporting your Child or Other Loved One with an Eating Disorder Through the Holidays

Supporting Child with Eating Disorder Over Holiday
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By Carly Poynter, AMFT, staff therapist

The holidays are a challenging time to navigate for most people. The holidays are even more challenging for those who struggle with their relationship with food. As we prepare for the holiday feasts and festivities, there are a few things to consider, especially when you have a child or other loved one with an eating disorder. While this list is not all-encompassing, it can serve as a thoughtful reminder to be aware of the challenges others may face this holiday season and some strategies to support them.

Things to Do

Plan ahead. With the holiday season ahead of us, the best thing we can do to support someone struggling with an eating disorder is to plan ahead. Planning ahead includes identifying what could be triggering for your child and developing strategies to deal with these triggers appropriately. Here are some common holiday triggers to consider: buffet-style eating and a surplus or different types of food, expectations from others, comments about food choices and appearance, comments about being overly full or eating too much, fasting for religious reasons, etc. One of the best ways to plan ahead is to talk to your child about what they are most worried about for the upcoming holidays.

Talk about the holidays and traditions that have been triggering in the past. Part of planning ahead is knowing and understanding what your child is anticipating to be anxiety-provoking. One way to identify potential triggers is to ask what was challenging about the holiday in previous years. While your child may be doing better or even be in recovery, holidays pose many challenges that your child may not have practiced in treatment yet. If any specific holiday foods are triggering, this is an excellent time to start practicing with these foods. Your child’s therapist or dietitian can help plan exposures to fear foods.

Ask what support your child needs from you or others. What does your child anticipate needing from you during the holiday season? The conversation about support is part of planning ahead. Some ways you can help support your child include: steering conversations away from talking about food and appearance, making a plate for them (if that help is needed), helping with coping skills before or after meals (discussed later), etc.

Model appropriate eating. While there may be adults and other children around the dinner table who are engaging in dieting or disordered eating, having your child have a good role model will be helpful. Appropriate eating does not mean you have to eat exactly what your child is eating. Appropriate eating means honoring your hunger and fullness cues, choosing a variety of foods, and demonstrating enjoyment of your meal.

Provide distraction or additional support during or after meals. As discussed above, one of the most supportive things you can do is help your child cope effectively. It can be helpful to ask your child what coping skills work best and practice these skills before the holidays. Rather than rushing from one activity to the next, provide time for your child to regulate their emotions. Distraction can take many forms, so you can get creative and plan for things that will engage your child. Some of the best distractions include things that require extra mental effort, such as a game of Scrabble or Bananagrams. Other distractions include watching movies or TV, playing with the family pet, board games, arts/crafts, etc.

Prepare other family members (and set up a family session if possible). Recovery takes the support of many people. While you, as a parent, may know the most about your child’s eating disorder and how to best support them, having others learn how to support your child can be helpful. Preparing other family members can include setting boundaries with specific conversational topics, such as diets and the appearance of others. It can also involve having others help support your child during or after meals or navigating other conversations that may be anxiety-provoking for your child. If your child is in treatment, this is a great time to request a family session to help plan ahead for the holidays and elicit extra support.

Have conversations when you notice eating disorder behavior. The holidays are challenging. You will likely notice increased anxiety or some eating-disordered behavior. While it may feel overwhelming to discuss these behaviors with your child in the moment, it is important to address them. To discuss behavior you are noticing, you should talk to your child away from the meal or anxiety-inducing situation (i.e., the meal, conversation, person, etc.) and then discuss what you are noticing and ask how you can help support them (or suggest a coping skill if your child is overwhelmed).

Things to Avoid Doing

Don’t make comments about appearance. It is never helpful to comment on your child’s appearance or the appearance of others. During this time of recovery, your child is likely hyper-fixated on their appearance and is likely engaging in social comparison more frequently. Due to the preoccupation with thoughts about body weight and shape, it is best to steer the conversation away from how someone looks. Instead of discussing appearance, you can model interest in other characteristics such as hobbies, school or work, or other passions of the person.

Don’t make negative comments about food or food choices. It can feel natural to say things like “I am so full,” “I overate,” “I can’t believe I had another piece of pie,” and other comments after eating. However, your child is listening and likely internalizing comments like this. It is important to note that when comments like this slip, you can correct them. If you or anyone else makes a comment like this, you can say something like, “while I am full, I enjoyed my meal,” or change your narrative to something more neutral.

Don’t expect your child to eat or try everything. While your child may be doing better or be in recovery, the holidays or certain food served at the holidays are likely triggering. Your child should still eat their meal plan, but they should not be expected to try everything. Part of planning ahead can include discussing what their plate should look like based on their meal plan. If your child needs to eat before or away from the guests, arrange for that to happen to ensure they complete the meal.

Other Considerations

  • Your child should still follow their meal plan (i.e., 3 meals and 3 snacks). While some people engage in restriction before a holiday meal, your child should still eat all meals and snacks as indicated by their meal plan. It can be helpful to discuss and meal plan with your child’s therapist and dietitian before the holidays.
  • This holiday may not go perfectly. Spend time identifying what went well, and times you noticed that they used coping skills.

Holidays are stressful for most people. As a parent of a child with an eating disorder, ensure you also take time to engage in self-care.

If you have an eating disorder yourself, learn strategies to support yourself over the holiday.

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Family-Based Therapy teen eating disorder Uncategorized

When to Add an Individual Therapist in FBT-Phase 1

Photo by Priscilla Du Preez on Unsplash

When I am working as the Family-Based Treatment (FBT) therapist for a teen in recovery, their parents will often ask whether the teen should also see a therapist individually. Unlike other therapy situations, in FBT there is no expectation that there is both an individual therapist and a family therapist. It’s there in the name: “Family-Based Treatment.” FBT is not just “family therapy” aimed at solving family problems—it is a specific, comprehensive, evidence-based treatment. In fact, the developers state that they called it Family-Based Treatment when they were manualizing the approach because they wanted to distinguish it from being viewed as a type of family therapy.

As I have stated elsewhere, I think most teens who receive FBT will never need individual therapy for an eating disorder. I actively discourage the addition of an individual therapist in Phase 1 (nutritional rehabilitation). When we arrive at Phase 2 (handing back of control to the teen), we can better assess which issues remain unresolved with weight restoration. This is the point at which the adolescent is likely to be more receptive and able to benefit from individual therapy. Even here, I think additional therapy is only needed when there is a specific additional diagnosis or specific problem. Adding an individual therapist when one is not needed adds risk and can even undermine the FBT.

Among the reasons I discourage adding an individual therapist in Phase 1 is that the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT. Additionally, in one case series of families with “failed FBT”, does not believe in or support FBT. Additionally, in one case series of families with “failed FBT” teens later admitted asking for individual therapy as a deliberate strategy to exclude their parents and reduce the pressure for weight gain. I have observed teens who ask for individual therapists in Phase 1 and by Phase 2 no longer make such a request.

Reasons parents sometimes cite for wanting their teen to have an individual therapist include processing the underlying issue and having someone to listen. I do not think these are valid reasons for adding an individual therapist during Phase 1, given the risks that it could deflect from the focus on nutritional restoration. And, as discussed elsewhere, there is not usually an underlying issue to process.

Curious where other providers stand on the issue, I asked a few colleagues under what circumstances they would add an individual therapist in Phase 1 of FBT. These were their replies.

Never, if there isn’t a comorbid issue. I would not ever add an individual therapist to address the eating disorder during FBT treatment. The only time I do it is for some kind of comorbid issue, and even then, I usually don’t do it during phase 1. – Natalie Wingfield, LPC

I strongly discourage it and talk a lot about fidelity to treatment, commitment to the program, and how we want to ensure they are getting the full benefits of FBT. I also talk a lot about lack of research support for adding a therapist and the potential for therapy burnout from seeing multiple providers. But, I’ve had some families where they were very resistant to pausing individual work and I thought a lot about the cost/benefits of them not getting any eating disorder treatment if I remained rigid in my stance. In those rare circumstances, I’ve had success in asking to talk to the individual therapist about the treatment and role delineation/expectations. In my experiences so far, this has resulted in the other therapist either voluntarily pausing their treatment in support of FBT or really good communication between myself and the other therapist to help prevent mixed messages. I could definitely see it going sideways though and it’s not something I casually agree to with families. And it’s always a red flag to me when families won’t back down because it usually means they will be asking for additional changes to the treatment and will struggle with the structure. – Amy Henke, Psy.D.

I wouldn’t for the reasons stated above and more. If they are in phase 1 and therefore undernourished, they are not likely going to be able to engage productively in therapy anyway. I can see a lot of processing how difficult phase 1 of FBT is, and expressing a ton of distress which naturally most therapists would feel compelled to solve. This could only lead to the individual therapist interfering in the FBT process or at the very least introducing doubt about its usefulness to the client and family. Overall, “0/10 would not recommend” is my stance. I think it also confuses the idea that renourishment is really the key to resolving many of the presenting behavioral and psychological symptoms. If one therapist is talking about regular meals and the other is talking about self-esteem, 9 times out of 10, an overwhelmed parent is going to pick self-esteem as the issue to address. Then we risk losing the client to something that is not going to help them. – Christine Knorr, LCSW, CEDS

Usually I don’t recommend that as it creates a lot of cooks in the kitchen. We know how challenging the beginning of FBT can be for the whole family, I think as clinicians we just support them. – Shelly Bar, MD

Agree with recommendation to hold off adding an individual therapist in Phase I. I haven’t seen that ever go well. I have a few cases now where the individual therapist was brought in Phase I. I’m constantly trying to uphold the power to the parents, because therapists want to find a way to give voice and choices to the child. – Katie Grubiak, RDN

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Family based treatment Family-Based Therapy

With a Little Help From My Family: Who is FBT For?

 

Dall.e

Family-Based Treatment (FBT) is the leading evidence-based treatment for adolescents with anorexia nervosa and bulimia nervosa. One of the common misbeliefs I hear is that it’s “only for kids or younger teens.” However, I think it has a much wider applicability. In fact, I would say that my FBT training has significantly improved my effectiveness in treating eating disorder patients of all ages.

While there have not been studies of FBT that pull it apart and pinpoint the elements that drive its success, I have a few theories. One of the key underpinnings of FBT is meal support. People with eating disorders experience such crippling anxiety before, during, and after meals that it is no wonder they would do anything they can to avoid eating. When the brain is in a state of overwhelming anxiety, a person with an eating disorder cannot make logical decisions about what to eat—or even to eat. And yet, without eating there can be no recovery. Treatment centers understand this—providing regular meals has been the mainstay of residential and partial hospitalization (PHP) eating disorder treatment for some time. FBT is the in-home parallel to this treatment.

In FBT, parents are charged with nourishing their teens back to health by providing regular nutrient-dense meals and preventing purging, excessive exercise, and other eating disorder behaviors. Parents plan, prepare, serve, and supervise meals and after meals, if purging is an issue. They make all the food decisions. They sit with their struggling child during those terrifying meals and help their teens cope with eating amounts sufficient for them to get well. Over time they return control to their teens, building their capacity to fight the eating disorder on their own. It takes effort and time to change brain pathways that have made eating a scary experience. For this reason, even those patients with eating disorders who go on to higher levels of care usually don’t remain there long enough to develop the autonomous ability to eat enough to sustain recovery. They often continue to need meal support for some time after more intensive treatment.

I think FBT has applicability that spreads wider than just children and teens. There is preliminary evidence of its successful use with transition-age youth up to age 25. Many parents have reported successfully using it with their college-age children. I have used it with this age and the primary variation is that the young adult plays a bigger role in their own treatment. They must agree at least in theory to accept their parents’—or other caregivers’—support. The young adult may choose who will support them during meals. Some, for example, may have a college roommate provide support. Some parents do meal support via FaceTime when the young adult lives far away.

I should clarify that FBT is a manualized evidence-based treatment. To be done with fidelity it must comprise certain components, including a therapist who guides the parents in organizing their strategies to fight the eating disorder. Parents refeeding their child without a therapist’s oversight often state they are “doing FBT”. In this case, it is more accurate to say they are providing FBT-informed or carer-supported feeding. Regardless of the words we use to describe this support and whether or not a therapist is involved, I think it provides a core benefit that we can expand to other populations.

These principles can also be applied to adult treatment. I personally have supported an adult who was in PHP during the day and needed more support with meals outside of treatment hours. I applied the skills I learned in my FBT training to provide meal support to this person. It worked just like it did with teens. Obviously this adult was an active participant in their recovery who asked for my support. This does not mean that I did not encounter the same kind of anxiety and resistance that parents meet around meals.

Take another case —a 20-something patient who still lives with her parents. She has been doing so much better since she asked for help, trading in the restrictive foods she had been eating on her own for several years for family meals prepared by her parents. Or the case of a college student who gets support via FaceTime from her parents who live in another city. When working with young adults with eating disorders who are in loving relationships, we often work to help their significant others develop strategies to support them during meals.

My experience is not unusual. Many other FBT-trained clinicians report success with providing FBT-informed treatment to people from all walks of life. One dietitian has reported great progress working with an employed single adult who moved home to live with his parents so they could support with meals. Sadly, previous providers had pathologized his moving home as a sign of enmeshment. One therapist shared, “I am doing FBT with a 79-year old. She is now in phase 2. She can now go out on dates—she just has to send pictures of her food to her adult children who are taking charge of her recovery and have been in charge of plating her food.”

Many have realized that in-home meal support is a common need for patients, and naturally, it is starting to become a big business with several treatment programs now providing this service. Offered as a service, this individualized meal support can be very expensive. Far more convenient, cost-effective, and loving is meal support provided by parents, other family members, or significant others.

I personally see it as a sign of strength when an adult admits they need more help. There is no shame in needing meal support during your recovery no matter what your age. Moving back home to live with family for support is nothing to be embarrassed by. This disorder robs people of their ability to make decisions around food—outside support is needed by definition. If you struggle around mealtimes with deciding what to eat, only feel safe eating a narrow range of food, have been struggling to make progress in your recovery, or cannot manage urges to purge after eating, you are not alone. You may benefit from the addition of meal support. It may feel scary or embarrassing to ask for help and you may worry you are being a burden. But asking for help is a brave step and you will likely find that there are some people in your life who can do this for you. It sometimes requires a little creativity, but you may find that it makes a big difference in your recovery.

The short answer is: FBT can be for people of any age.

Sources

Chen, E. Y., Weissman, J. A., Zeffiro, T. A., Yiu, A., Eneva, K. T., Arlt, J. M., & Swantek, M. J. (2016). Family-based therapy for young adults with Anorexia Nervosa restores weight. International Journal of Eating Disorders49(7), 701–707.
Dimitropoulos, G., Freeman, V. E., Allemang, B., Couturier, J., McVey, G., Lock, J., & Le Grange, D. (2015). Family-based treatment with transition-age youth with anorexia nervosa: a qualitative summary of application in clinical practice. Journal of Eating Disorders3(1), 1.
Dimitropoulos, G., Landers, A. L., Freeman, V., Novick, J., Garber, A., & Le Grange, D. (2018). Open Trial of Family-Based Treatment of Anorexia Nervosa for Transition Age Youth. Journal of the Canadian Academy of Child and Adolescent Psychiatry27(1), 50–61.
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Eating Disorders Family based treatment Family-Based Therapy

When Your Child With an Eating Disorder is Sick….

Guest post by Dr. Jennifer Johnson

Dall.e

When parents are renourishing a child with an eating disorder and that child gets sick, parents often don’t know what to do. Some families may back off on feeding every time a child gets any illness, which can be a risky practice. Especially during Phase 1 of FBT, ensuring eating is a priority. To help parents, I’ve asked Jennifer Johnson, MD, a medical doctor who specializes in treating patients with eating disorders, to share some advice.

First, let me say that in general, minor illness should not cause a kid with an eating disorder to lose weight. Parents who are refeeding their child know that even missing a meal or a snack makes a difference in their progress. Don’t let illness throw you off course. As you know, failure to gain as expected may occur if nutrition is even a bit compromised. It is absolutely not a given that illness or surgical procedure must cause weight loss. When I hear that someone has lost 3 pounds “because they had a cold” the previous week, I ask a lot of questions – that should not have happened.

Second, plan ahead. After you’ve read through my answers and looked at other parents’ recommendations, be proactive. Make a plan with your child and treatment team about what you will do if they get sick (which they inevitably WILL at some point during recovery). They should know that they WILL still be eating. But talk about what foods they tend to like when they are ill, and think about how to plug maximum nutrition into them. Buy any non-perishable supplies and stock up on over the counter medications for colds, coughs, and fever. (And please have a thermometer on hand! A $10 digital one is plenty good to give us doctors valuable information.)

What should parents do in terms of feeding when a child with an eating disorder has a head cold or sore throat and loses their appetite? Is it necessary to avoid dairy?

If your child is listless and feeling unwell, they will often not be very hungry for a couple of days. A sick child needs care and comfort. Caring for a sick child who has an eating disorder includes keeping up the nutritional intake. You don’t want the eating disorder to think that illness is a good way to sneak through the back door. And, there are other times when your child is not hungry, just from refeeding itself, and they have to eat anyway. So, push ahead, but gently. Present nutrition dense food and beverages that will be particularly appealing to your child. Does a milkshake sound appetizing? You can add a packet of Benecalorie. (There’s nothing wrong with dairy, by the way.) Chicken noodle soup? Maybe add some extra pasta. There are lots of helpful posts from parents on the Around the Dinner Table Parent Forum.

What about if they have a fever?

Having a significant fever (101 or above) increases fluid needs as well as metabolic rate (more calories are burned). Your child will feel better if you control the fever with regular doses of acetaminophen or ibuprofen. Giving the medication at regular intervals, say every 6 hours for acetaminophen, may prevent the fever from getting as high as it otherwise might. This also helps with the headaches that usually accompany fever. Keeping your child hydrated, particularly with something like Gatorade, will also help them feel better – and thus more likely to have some appetite. Some kids maintain their appetite when they have a fever and of course, it’s fine to continue refeeding. Otherwise, know that keeping up nutrition during an illness helps your child feel better sooner, and push on. Again, it’s helpful to adjust what you give them based on their preferences.

What about when kids in recovery have the stomach flu?

What do you do if they’re vomiting?

Generally, vomiting is worst at the onset of an episode of stomach flu and becomes less frequent over the next 24 hours. A parent’s main goal when a kid is vomiting is to keep them hydrated. I recommend not giving anything by mouth for 2 hours after they’ve thrown up. Then you can give them ice chips or a couple of teaspoons of water. This liquid will get absorbed from the mouth. Do this every 5 minutes or so for half an hour. If they haven’t vomited again, you can have them try slightly larger amounts of liquids at less frequent intervals. They should be able to keep down about 2/3 of a cup of liquid, and be hungry, before you try a very small amount of food. Slowly increase the amount you give them. Kids may become ravenous and eat a huge meal, but then throw up everything they’ve just eaten. A kid who throws up a day or two into recuperation may have just overdone it. In that case, you’ll need to let up a bit before pushing back into refeeding.

What about diarrhea?

For kids with diarrhea, we don’t generally recommend giving any medications that are designed to decrease the number of stools (bowel movements). No major food restrictions are needed. There is nothing magical or beneficial about the so-called BRAT diet (bananas, rice, applesauce, toast), which is of low nutritional density. Studies have shown that having diarrhea for a few days does not make someone lactose intolerant. We know that eating when you have a “stomach bug” with diarrhea will generally increase the number of diarrheal stools. But we also know that at the end of the illness, people who have continued to eat will end up better nourished (= digested more calories). And that, of course, is the ultimate goal.

One thought: you may want to speak with your child’s doctor about a proactive prescription for a small number of anti-emetic tablets (that dissolve in the mouth) to have on hand in case your child gets stomach flu. I don’t normally recommend this but refeeding is an exception. We want to minimize the duration of nausea and vomiting to make it easier for your child to eat. Also, many of my patients who have eating disorders are afraid of truly fearful of vomiting (a condition called emetophobia), which only makes stomach flu worse for everyone. If your doctor is willing to do this, they undoubtedly want you to call before you give the medication.

What if your child has no appetite (due to illness)

Biology is on our side. When a kid (or another human being) eats less due to a minor illness, appetite typically returns with a vengeance and we make up for what we’ve missed. For a kid in the early refeeding phase, of course, it is normal to not feel hungry. So you may not know whether your child is not hungry because they’re not feeling well or because they’re refeeding. In either case, your eating disordered child needs you to continue to push forward. Refeeding is the mainstay of treatment and you’re the team leader. Go for it!

Please note that none of the above should be construed as medical advice. If you have concerns about your child’s health, contact their doctor. Some examples of when you should call the doctor are: Bloody diarrhea, high fever (102 or above), vomiting that continues more than 24 hours, weakness, severe dizziness or fainting, or very little urine.

About Jennifer Johnson, M.D., MS, FAAP

Dr. Johnson is a medical doctor. She has more than 20 years’ experience as a pediatrician and adolescent medicine specialist. She practices in Newport Beach (Orange County), California.

Dr. Johnson is certified by the American Board of Pediatrics in Adolescent Medicine as well as in Pediatrics. Dr. Johnson also has an advanced degree in public health. She has been a professor in the Department of Pediatrics at the University of California, Irvine School of Medicine, where she served as director of the adolescent medicine program. Dr. Johnson has taught medical students, residents, faculty, and community physicians, for whom she continues to present educational programs. She has presented at national meetings of many organizations, including the American Academy of Pediatrics and the American Academy of Family Practice. Dr. Johnson has written many research articles and book chapters related to adolescent and young adult medicine.

Dr. Johnson is an advocate for adolescents and young adults. She is a Fellow of the American Academy of Pediatrics (AAP). She has led many activities in the Academy’s Section on Adolescent Health and served as its chairperson. Dr. Johnson is active in the Orange County chapter of the AAP, as well. Current projects include the Teen Safe Driving Initiative and healthcare for GLBTQ teens.

Dr. Johnson has also been active in the Society for Adolescent Medicine. As a member of the medical advisory board for Teengrowth, Dr. Johnson wrote many articles and answers to reader questions. Articles and webcasts by Dr. Johnson are posted at Healthology.com, medbroadcast.com, and the New York Daily News. 

Dr. Johnson is on the medical staff of Hoag Hospital in Newport Beach.

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College Mental Health Family based treatment Family-Based Therapy

On Empowering Parents—Not Pathologizing Them

I often write about the importance of including parents in the treatment of adolescents and young adults. My work is informed by my training in Family-based Treatment (FBT), which as a central part of treatment seeks to empower parents to help their ailing children with eating disorders to return to health. When asked why families should be the center of treatment, I usually cite the AED guidelines on the role of the family, The Nine Truths About Eating Disorders, and the vast evidence base underlying FBT. I often discuss how providers who see families with children with eating disorders get a distorted view of the family: they do not have the benefit of having seen how it functioned prior to the eating disorder. Parents’ behaviors are often pathologized when they are actually the normal response of healthy parents to a child in distress.

This post is different—here I will share a more personal perspective.

Recently, one of my children (anonymized here because the story is theirs to tell) stumbled. My child was fighting a mental health issue that was not an eating disorder. The experience of watching my child struggle, and struggling to help my child, has further informed my thinking on this issue.

Sadly, it remains common for parents of children, adolescents, and young adults with mental health problems to be judged, labeled, blamed, and excised from the child’s treatment. This has happened to families with whom I have worked. Parents have sometimes been labeled as “enmeshed” or “overprotective.” This is not productive.

I’m writing this blog to share how beneficial it was personally to be included in my young adult child’s treatment. First, let me give you some background.

For Most of My Parenting Years, I Was Balanced

I care for my children deeply and have chosen a career that has allowed me the flexibility to be present in their lives and to be their primary caretaker. At the same time, I have been anything but a coddler. All three of my children were sleep-trained at less than six months, left at a young age with non-family babysitters, and dropped at preschool on the first day. I shed some tears, but I was not a parent who stayed and watched outside of the classroom for months; I went to work.

I also developed a certain toughness to set limits. During my kids’ early years, I worked at Los Angeles County Jail, where I encountered numerous inmates demanding sleeping medications or “more desirable” housing assignments and then threatening suicide when they didn’t get their way. I became a pro at placing inmates on suicide watch and walking away despite their sometimes yelling at the top of their lungs that they would tell the entire jail, “It’s because of you, Dr. Muhlheim, that I will kill myself.”

I am not a perfect mother, but I am a highly dedicated, devoted one. I have sought to balance my joy in raising my children with time to pursue my own interests and career.

When My Child Started to Struggle I Became Highly Involved

When I work with parents of teens and young adults with eating disorders, I encourage parents to trust their instincts. “Parents know their kids best,” I tell them. During the transition to college, when my child was supposed to be individuating, I knew something was amiss, so I hovered more than usual.

Fortunately, when my child wobbled, I was prepared. I trusted my instincts. I was fully present: watching, standing close, getting my child help. I helped save my child’s life. There are powerful cultural expectations that parents should back off and allow their child to individuate. There is less support for parents who choose to step in at this moment. Observing my behavior at that time, I may have been labeled as overprotective.

Even my child, who recognized the need for parental help, was fighting against it. This was confusing to their therapist, who later wrote in a report, “There is a weird dichotomy between the child and the parents. The child refuses to sign a release of information for the therapist to speak to the parents, but the child appears to reach out to the mother for support.”

Rather than pathologizing hovering parents, we need to recognize that they are doing it for a reason.

Professionals Supporting, Not Blaming Parents

The hardest moments of this whole journey were those times that, on top of his worry for our child and whether they could or would actually recover, my husband blamed himself for causing the problems our child was facing. This tendency of parents—to blame themselves for any problem that befalls a child—is typical, whether or not the problem could be attributed to parenting. I noticed that when my husband started to blame himself, we both became hopeless and lost focus on helping our child. These were dark times—it was hard to have our own faith and be present for our child.

Fortunately, we had the means to seek out high-quality treatment. Our child was treated in a center that specializes in treatment often used for a problem for which parents have historically been blamed. In this program, we as parents were given much-needed support and services as well. Importantly, the clinicians never indicated they believed that we had caused our child’s problems. Instead, we were validated, supported, and given a framework for understanding our child’s problems that did not point the finger at us.

Made/Makes All the Difference

Further, our responses to our struggling child were validated as a reasonable response to experiencing our child’s struggles. We were supported in our child’s recovery, empowered to play a role, included in the treatment, and seen as parents doing our best. This was profound. I think it made all the difference.

Our child worked hard and so did we. With the proper help and our support, our child is now healthy and firmly back on track. My hope for other parents of floundering adolescents and young adults is that they are treated with the same respect that we were.

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Eating Disorders Evidence-based treatment Family based treatment Family-Based Therapy Los Angeles Psychotherapy Uncategorized

FBT Insights from the Neonatal Kitten Nursery

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.

 

Categories
Eating Disorders Family-Based Therapy Health at Every Size Los Angeles Weight bias

Ten Facts About Weight Stigma – Guest post by Liliana Almeida, Ph.D.

 

  1. Photo featuring plus-size model by Michael Poley of Poley Creative for AllGo, publisher of free stock photos featuring plus-size people.
    Weight stigma is a bias or discrimination relating directly to weight. Despite the fact that more than half of U.S. citizens are larger-bodied, our society holds a strong negative bias against fatness.
  2. The media reinforces weight stigma. The media, such as news media, displays persons in larger bodies in stigmatizing ways by depicting them sitting and eating unhealthy foods, wearing ill-fitting clothes, headless, or with their abdomens showing.
  3. Weight stigma is based on the belief that weight is under one’s personal control. This belief suggests that larger persons are undisciplined and inactive. However, when weight is attributed to uncontrollable factors such as diabetes or hypertension, people’s attitudes change. 
  4. Weight stigma exists in romantic relationships. Romantically, people in larger bodies are less preferred.  They are less preferred in comparison to those who are in wheelchairs, mentally ill, or those who have sexually transmitted diseases.
  5. Weight stigma starts as early as preschool.  Children ages 3-5 negatively characterize larger children as mean, ugly, stupid and sloppy. As children get older they start believing their larger peers are lazy, less popular, and less happy. College students report that their peers in larger bodies are lazy, self-indulgent, and less attractive, with low self-esteem and deserving less attractive partners.
  6. Teachers have a weight bias towards heavier students. They believe their larger students lack self-control and are less likely to succeed.
  7. Health professionals are also biased. Health professionals treating individuals with eating disorders report believing that larger patients do not comply with treatment recommendations and perceive poor treatment outcomes. Those strongly biased believe larger body sizes are the result of overeating and lack of motivation.
  8. Individuals in larger bodies have internalized stigma. The most common anti-fat bias among larger individuals is the belief that they are lazier and less motivated than thinner individuals. The failed attempts of individuals in larger bodies to lose weight may cause them to begin to internalize society’s beliefs that they are lazy and lack willpower.
  9. Weight stigma increases binge eating. Weight stigma causes psychological distress such as depression, anxiety, and low self-esteem. It is also associated with poor body image and increased fear of fat.
  10. Weight stigma experiences are as common as other forms of discrimination. In women, it is as common as racial discrimination. In some cases, it is more common than gender and age discrimination. 

References 

Ashmore, J.A., Friedman, K.E., Reichmann, S.K., &Musante, G.J. (2008). Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults. Eating Behaviors, 9, 203-209.

Chen, Eunice & Brown, Molly. (2005). Obesity Stigma in Sexual Relationships.  Obesity Research, 13, 1393-1397.

Cramer, P., & Steinwart, T. (1998). Thin is good, fat is bad: How early does it begin? Journal of Applied Developmental Psychology, 19, 429-451.

Friedman, K., Reichmann, S., Costanzo, P., Zelli, A., Ashmore, J., & Musante, G. (2005). Weight stigmatization and ideological beliefs: relation to psychological functioning in obese adults. Obesity Research, 13, 907–916.

Latner, J., Wilson, T., Jackson, M., & Stunkard, A. (2010). Greater history of weight-related stigmatizing experience is associated with greater weight loss in obesity treatment. Journal of Health Psychology, 14, 190-199.

Puhl, R., Andreyeva, T., & Brownell, K. (2008). Perceptions Of Weight Discrimination:Prevalence And Comparison To Race And Gender Discrimination In America. International Journal of Obesity, 992-1000.

Puhl, R., & Latner, J. D. (2007). Stigma, obesity, and the health of the nation’s children. Psychological Bulletin, 133, 557-580.

Puhl, R., Latner, J., King, K., & Luedicke, J. (2013). Weight bias among professionals treating eating disorders: attitudes about treatment and perceived patient outcomes. International Journal of Eating Disorders, 1-11.

Puhl, R., Lee Peterson, J., DePierre, J., & Luedicke, J. (2013). Headless, hungry, and unhealthy: A video content analysis of obese persons portrayed in online news. Journal of Health Communication, 1-17.

Stice, E., Presnell, K., & Spangler, D. (2002). Risk factors for binge eating onset in adolescent girls: a 2-year prospective investigation. Health Psychology, 21, 131-138.

Tiggemann, M., & Wilson-Barrett, E. (1998). Children’s figure rating: relationship to self-esteem and negative stereotyping. International Journal of Eating Disorders, 23, 83-88.

Wang, S. S., Brownell, K. D., &Wadden, T. A. (2004). The influence of the stigma of obesity on overweight individuals. International Journal of Obesity, 28, 1333-1337.

 

Categories
Eating Disorders Evidence-based treatment Family based treatment Family-Based Therapy

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

Parents 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.

 

Categories
Early Intervention Eating Disorders Family based treatment Family-Based Therapy

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

This interaction on twitter caught my eye:

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.

Categories
Evidence-based treatment Family based treatment Family-Based Therapy

Highlights from #ICED2014: The FBT Debate

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.

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