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 Therapy (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 the only therapist 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 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).

Empirically Validated Treatments

Empirically Validated Treatments For Eating Disorders

Today’s Los Angeles Times contained an article which highlights Family Based Treatment and Cognitive Behavioral Treatment, two treatments I provide:

Today, doctors and therapists focus on a handful of treatments that have been validated by clinical studies. For teens with anorexia, the first-line treatment is something called family-based therapy, in which parents and siblings work with the patient at home to help restore normal eating habits, said Dr. James Lock, an adolescent psychiatrist at Stanford University who specializes in treating eating disorders. Treating patients at home instead of in a hospital setting is less disruptive to their lives and is thought to promote recovery.

The therapy cures about 40% of patients in three to six months, and another 40% to 50% improve but remain ill, studies have found. The remaining 10% stay the same or get worse.

Researchers are still investigating the best way to treat teens with bulimia. Evidence is mounting in favor of cognitive behavioral therapy, which involves helping individuals change their attitudes and thoughts about food and body image. Studies show that about 40% of people with bulimia will recover after three to six months and another 40% will improve but still struggle with the disease; 20% remain the same or get worse, according to a 2010 review in the journal Minerva Psychiatry.

Full article available here:

Traveling With Your Anorexic

Traveling With Your AnorexicBy Lauren Muhlheim, Psy.D. and Therese Waterhous, Ph.D.

Families often ask whether they should proceed with a previously scheduled trip or take a well-deserved “break” during the refeeding process.  We advise that travel during Phase 1 of FBT be avoided if at all possible.  We know several families who have vacationed with a child well along in treatment for anorexia and found their child lost 5 to 10 pounds over the course of a week, erasing months of progress.  Children and young adults with anorexia have difficulty with change; if a child is having difficulty completing meals in the home, it is unlikely that they will be able to do so on vacation, where most meals will be eaten in an unfamiliar setting in the presence of non-family members.

During vacation, parents may be tempted to give in more easily to the anorexic thinking and behaviors because they do not want to upset other diners in a restaurant or because they “don’t want to ruin” the vacation after they’ve invested a lot of money in getting there.  The food may be different than that available at home, or it may be difficult to get the types of foods on which the family has been relying.  Children and young adults with anorexia are inflexible; if the food is different than that to which they are accustomed, they may refuse to eat at all.  Sightseeing often involves a lot of walking, which can burn a lot more calories and require even greater caloric intake to offset.  Many vacations occur in warm climates, where health problems related to malnourishment or dehydration may be magnified.  If families do travel during Phase 1 or Phase 2, they should be cautioned that it may cause a setback and prolong the recovery process. Continue reading “Traveling With Your Anorexic”

Exposure in the treatment of Eating Disorders

Exposure therapy is widely recognized as a necessary (and sometimes sufficient) ingredient of treatment for most of the anxiety disorders including phobias, panic disorder, and obsessive compulsive disorder.  Anxiety is a core psychological feature of anorexia nervosa and bulimia nervosa.  However, instead of being afraid of heights, speaking in public, having a heart attack, or contamination, individuals with eating disorders are primarily afraid of food, eating, and shape and weight.

Both cognitive-behavioral therapy and family based treatment, two empirically validated treatments for eating disorders, employ exposure techniques.  Exposure works through the process of habituation, the natural neurologically-based tendency to get used to things to which you are exposed for a long time.   During exposure, habituation occurs as people acclimate to their fear and come to realize that nothing actually dangerous is occurring. Habituation promotes new learning of safety, tolerance of fear feelings, and extinction of the fear avoidance urge.  Continue reading “Exposure in the treatment of Eating Disorders”

Surviving the first week of re-feeding

Surviving the first week of re-feeding your child using Maudsley Family Based Treatment

Figuring out how to get your starving child to eat and gain weight is a daunting task. Parents often feel overwhelmed and helpless when starting out on a re-feeding program. It is important to remember that your child is literally more afraid of the food than of dying of starvation. But food is the medicine, and it is your job to save her (or his) life.

Anorexia makes children do things they would never normally do and an escalation of behavior is common when parents start to stand up to the anorexia. In fact, an escalation during the first week, although unpleasant and often scary, is usually a good sign that parents are not giving in to the anorexia. Consistent confrontation of the anorexia ultimately brings greater compliance as well as weight gain. It is imperative that parents work together and are well aligned; otherwise the anorexia can split them and gain strength. Continue reading “Surviving the first week of re-feeding”

Family-based treatment for adolescent eating disorders

Eating disorders, including Anorexia Nervosa and Bulimia Nervosa, are affecting greater numbers of adolescents and even children and early intervention is critical. If not identified or treated early, eating disorders can become chronic and cause serious or even life-threatening medical problems. Anorexia Nervosa is the most dangerous, with the highest death rate, of any mental illness: between 5% and 20% of people who develop the disease eventually die from it.

Although eating disorders can be notoriously hard to treat, recent research studies have demonstrated some highly successful treatments. For adolescents with anorexia, the treatment of choice is Family-Based Treatment (FBT). It is also referred to as the Maudsley approach (after the hospital in the UK where it was first applied).

Traditionally, parents of children with anorexia were viewed by mental health professionals as intrusive and were instructed to place their children into individual treatment or residential treatment centers. FBT, in contrast, respects the powerful bond between parents and child and empowers the parents to use their love to help their child. It allows the adolescent to remain at home and enlists the support of the family as a resource in helping them battle their eating disorder. The entire family attends every treatment session.

FBT treatment first focuses on helping the child to return to a healthy weight because the more time spent in starvation, the worse the outcome. The parents take responsibility for providing adequate nutrition for their adolescent during family meals. The therapist supports the parents in this challenging task and also creates a climate where there is no blame: the eating disorder is an outside force that must be fought off by the entire family working together. In the second phase of treatment, the parents gradually give the child more control over her (or his) own eating. The final phase of treatment addresses issues of adolescent identity within the family context.

FBT offers a promising alternative to costly inpatient or day hospital programs. Research out of the University of Chicago and Stanford University shows that at the end of a course of FBT, two-thirds of adolescents with anorexia have recovered; 75% to 90% are weight-recovered at a five-year follow-up. This approach has also been successful with adolescents with bulimia and with college students with anorexia and is most effective for families in which the length of illness is less than three years.

In my clinical practice, I provide treatment based on the most recent scientific research available. I provide FBT to adolescents with eating disorders in a course that usually consists of 20 treatment sessions over 6 to 12 months. Family-based therapy is not appropriate for all families. It is rigorous and requires a strong commitment by the family members. However, I find that the partnerships with families who have this commitment to their child’s recovery are very rewarding to me as a therapist. Families who have used this approach are generally very enthusiastic and grateful to have been a part of the solution.

For more information about Maudsley Family-Based Treatment for adolescent eating disorders and/or to find a treatment professional visit:

www.maudsleyparents.org.

Drs. Lock and Le Grange who brought this treatment to the U.S. have also written a manual for parents based on this approach:

Help Your Teenager Beat an Eating Disorder, by James Lock, MD, PhD and Daniel le Grange, PhD.