Article 3 PDF

Journal of Family Therapy (2017) 39: 537–562
doi: 10.1111/1467-6427.12086
Clinician perspective on parental empowerment

in family-based treatment for adolescent
anorexia nervosa
Gina Dimitropoulos,a Victoria E. Freeman,b

James Lockc and Daniel Le Granged
This qualitative study explored which core principles of family-based

treatment (FBT) for adolescents with anorexia nervosa (AN) are per-
ceived as most necessary for FBT to be effective in clinical practice.
Paediatric interdisciplinary teams were recruited to discuss the deliv-
ery of FBT in eating disorder programmes in Ontario, Canada
(N 5 6). Thematic analysis was used to analyze the data generated
from focus groups. Three major themes emerged: (i) parental empow-
erment (PE) is the most salient principle of FBT; (ii) various adoles-
cent, parental and family factors are viewed as interfering with or
enhancing PE; (iii) a variety of clinical interventions are utilized by
clinicians to cultivate and increase PE. PE is identified as essential for
adolescents with AN to successfully recover. Greater focus on address-
ing barriers to empowering parents is needed throughout FBT.
Future studies should include measurements of PE to ascertain effects
on treatment outcomes. Training and supervision protocols focused
on promoting PE are recommended.
a
Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto ON; Clini-
cian Scientist and Family Therapy Lead, Toronto General Hospital Eating Disorders Pro-
gram and Cross-appointment with the Hospital for Sick Children, Eating Disorders
Program, 8-Eaton, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4,
Canada. E-mail: gina.dimitropoulos@uhn.ca.
b
Research Associate, Eating Disorders Program at Toronto General Hospital, Toronto,
ON, Canada
c
Director, Stanford Child and Adolescent Eating Disorder Program, Department of
Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, CA, USA
d
Professor, Department of Psychiatry, University of California San Francisco, San
Francisco, CA, USA
V
C 2015 The Authors. Journal compilation V
C 2015. The Association for Family Therapy and Systemic
Practice. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350
Main Street, Malden, MA 02148, USA.
538 Gina Dimitropoulos et al.
Practitioner points
• PE is the most salient principle of FBT.
• Strategies to enhance PE in phase 1 are imperative if there has
been a long illness duration or parents experience mental health
issues/burnout.
• Special clinical attention to individual factors is recommended:
comorbid diagnoses, affect dysregulation and enduring eating
disorder symptoms.
• Efforts to enhance parental involvement throughout the treatment
is paramount to supporting adolescents to recover from AN.
Keywords: clinician; eating disorder; family-based treatment (FBT); parental

empowerment; qualitative study.
Introduction
Eating disorders (ED) such as anorexia nervosa (AN) and bulimia
nervosa (BN) are serious psychiatric illnesses accompanied by severe
medical complications, and are very prevalent among adolescents
(Smink et al., 2012; Swanson et al., 2011). Positive treatment outcomes
can be achieved when adolescents with AN or BN are given family-
based treatment (FBT) (Agras et al., 2014; Le Grange et al., 2007,
2012, 2014; Lock et al., 2012); a manualized outpatient model of ther-
apy that guides parents to be the primary source of encouragement
in the amelioration of their child’s ED behaviour (Le Grange and
Lock, 2007; Lock and Le Grange, 2013).
FBT is an evidence-based treatment that consists of three phases (Le
Grange and Lock, 2007; Lock and Le Grange, 2013). First, clinicians
focus on empowering parents to support behavioural change in the
adolescent with the ED. As weight stabilizes and symptoms reduce the
second phase begins with parents gradually returning responsibility
for age-appropriate meals to the adolescent. In the final phase, the
treatment focuses on re-integrating the adolescent into developmen-
tally appropriate activities. There are five principles that form the
foundation of FBT: (i) an agnostic view of the underlying illness; (ii) a
non-authoritative stance of the therapist; (iii) an initial focus on ED
symptoms; (iv) parental empowerment (PE) and (v) the externalization
of the illness (Le Grange and Lock, 2007; Lock and Le Grange, 2013).
There is scant research on the mechanisms that contribute to treat-
ment outcomes in FBT. Studies examining specific mediators of
change in FBT are limited (Darcy et al., 2013). The Byrne et al. (2015)
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Parental empowerment 539
study demonstrated that a potential mechanism of change in FBT is
an increase in parental self-efficacy. This study found that increased
parental self-efficacy predicted subsequent weight gain in FBT. The
following moderators and predictors of treatment outcome have also
been previously identified:
1. Older adolescents respond better to individual therapy than FBT

(Russell et al., 1987) and younger adolescents with a shorter
duration of illness have better outcomes (Lock et al., 2006;
Russell et al., 1987).
2. Greater psychopathology (higher eating-related obssessionality,
comorbid psychiatric symptoms and severe ED behaviour) are
also predictors of poor outcome (Eisler et al., 2000; Lock et al.,
2006).
3. Adolescents with compulsive features responded better to short
inpatient admissions for medical stabilization than to longer
admissions aiming at weight restoration (Madden et al., 2015).
Adolescents with compulsive features also went on to receive out-
patient FBT (Madden et al., 2015).
4. Adolescents whose weight was restored required a longer dose of
FBT than those with a lower weight who were admitted only for
medical stabilization (Madden et al., 2015).
5. Adolescents with greater eating-related obsessionality and binge–
purge symptoms also benefit from a longer dose of FBT than
what is typically prescribed by the model (Lock et al., 2006).
6. Early responders to treatment (rapid weight gain) have been
shown to have better treatment outcomes than those that do
not achieve rapid weight gain (Doyle et al., 2010; Lock et al.,
2006).
7. Observations of in vivo behaviour of the first four sessions of
FBT reveal that the expression of parental confidence in the first
session predicts rapid weight gain in the early phase of treatment
(Darcy et al., 2013).
8. Family structure is a moderator of FBT and sole support parents
appear to benefit from a longer duration of FBT than is typically
prescribed by the model (Lock et al., 2006).
Despite the fact that most paediatric ED programmes in Canada

use FBT as their primary treatment modality (Norris et al., 2013), no
studies have investigated what principles of FBT are viewed as the
most salient when delivering FBT in routine clinical practice. Such
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research would help determine how acceptable FBT principles are to
clinicians and the unique challenges of implementing aspects of this
model. A recent study by Couturier et al. (2013) explored how FBT is
utilized by clinicians in Ontario, Canada. The findings revealed that
75 per cent of clinicians viewed parents as the primary agents of
change, which is consistent with the manualized FBT (Couturier et al.,
2013, p. 182). Another study exploring the use of FBT in clinical
practice in Ontario found that fewer than 60 per cent of clinicians
consistently applied the interventions of FBT (Kosmerly et al., 2015).
These findings are problematic, considering the empirical evidence
supporting the efficacy of a manualized FBT.
To date, no empirical literature has explored which principles
of FBT clinicians perceive as essential to the effectiveness of this
model in their practice of FBT in the developmental phase of ado-
lescence. The degree to which the principles of FBT have face
validity to clinicians will help in the identification of potential chal-
lenges in translating research findings about the effectiveness of
this model into routine clinical practice. The objective of the pres-
ent study was to explore how clinical teams involved in the deliv-
ery of treatment for paediatric EDs utilize the core principles of
FBT. We also explored which principles are seen as fundamental
to the effectiveness of the model. The following questions guided
this research: which principles of FBT do clinicians perceive as the
most important in their work with adolescents of all ages and their
families? What clinical challenges interfere with the application of
the principles of FBT?
Method
Design and sample
The results presented in this article are derived from a larger qualita-
tive study that aimed to ascertain clinical perceptions of how FBT
may be implemented differentially with individuals across the devel-
opmental phase of adolescence in paediatric ED programmes in
Ontario (Dimitropoulos et al., 2015). The study was conducted
between 2012 and 2013. A focus group methodology was chosen for
data collection in order to capture the diversity of ideas that evolve
when participants discuss a phenomenon of interest (Kitzinger,
1995).
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The study received approval from the University Health Network
Research Ethics Board, Toronto, Canada. Six focus groups consisting of
thirty professionals from paediatric treatment teams in Ontario were
included in the analysis for the current study. All paediatric teams in this
study were members of publicly funded ED treatment programmes and
used FBT as their primary treatment modality. Individuals with no for-
mal training or purposeful exposure to FBTwere included in the analy-
sis only if they were clinical members of a treatment team self-identified
as primarily using FBT. Participants were originally recruited through
information disseminated by the Director of the Ontario Community
Outreach Program for Eating Disorders (OCOPED, n.d.). OCOPED is
a publicly funded training organization that oversees the ongoing edu-
cation of clinicians in specialized ED programmes. Clinicians interested
in participating in the study were invited to contact one of the research-
ers via telephone to arrange a time for the focus group. Inclusion crite-
ria for paediatric teams in this study were as follows: (i) they were
affiliated with a provincial network of publicly funded, specialized ED
treatment programmes; and (ii) they identified as using FBT in their
clinical work with adolescents. The following exclusion criteria were
employed: teams from (i) paediatric ED programmes who did not use
FBT; (ii) adult ED programmes and (iii) private practitioners. Of twelve
paediatric programmes in Ontario, six met our inclusion and exclusion
criteria and all six participated in the study.
Data collection
Paediatric treatment teams participated in 90-minute focus groups
conducted by the first author and at least one other member of the
research team. All focus groups were held on site at the participating
treatment facility and a semi-structured interview guide was used.
The research team explicitly informed participants in writing and
verbally that we were seeking their reflections on manualized FBT
(Le Grange and Lock, 2007; Lock and Le Grange, 2013) rather than
other forms of FBT for adolescents.
The participants also completed a self-report form about their clin-
ical training and level of FBT experience immediately preceding the
focus group.
Data analysis
A thematic analysis was used to glean results from the focus group
data. This method allows researchers to use an inductive style of
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analysis where explicit and implicit meaning can be ascertained from
patterns found in the data. The final themes represent findings that
were derived directly from the focus group discussions. We also uti-
lized a thematic network to organize the findings in terms of their rela-
tionship to one another (Attride-Stirling, 2001; Braun and Clarke
2006).
We systemically followed the six steps for thematic analysis outlined
by Braun and Clarke: (i) becoming familiarized with the material by re-
reading the transcripts; (ii) generating initial codes by grouping com-
mon words; (iii), searching for broad themes in the data using the
codes as a guide; (iv) developing themes; (v) reviewing themes by
searching for contradictory information in the data; and (vi) reporting
through publication. All focus groups were digitally audio-recorded
and transcribed verbatim and all identifying information removed.
Two authors (GD, VF) read each transcript to develop a general under-
standing of the data and met to discuss preliminary codes. Saturation
was reached when both reviewers confirmed that no new codes were
emerging from the data. To maximize the trustworthiness of our over-
all data, preliminary findings were presented during a provincial meet-
ing held by OCOPED in December 2013, which most research
participants attended. The findings were similarly presented to a sub-
group of clinicians who had participated in the focus groups to ensure
that the themes resonated with their clinical work.
Results
Tables 3 and 4 and Figure 1 show the frequency counts of thematic
material and a network map of the thematic analysis. Table 5 contains
a summary of focus group quotes to demonstrate each theme.
Each focus group was given a unique numerical code in order to
anonymously represent the site and clinical team.
Theme 1: PE is the principle of FBT that contributes the most to treatment

outcomes in adolescents
Throughout all of the focus group discussions (N 5 6), participants
consistently agreed that PE was the tenet of FBT perceived to contrib-
ute most to treatment effectiveness. Clinicians in all six focus groups
identified two essential components of PE: parental control over eat-
ing and meals was mentioned forty-eight times and parental involve-
ment was mentioned forty-four times in all six focus groups. Clinician
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TABLE 1 Interview guide
Question Objective
Describe your programme. How To discover how clinicians are
do you use FBT with adolescents using FBT in their programmes
with EDs and their families?
Do you use FBT differentially To understanding how clinicians
across the developmental phase explain and implement the prin-
of adolescence? ciples and interventions of FBT
with families in adolescence
How is [insert principles and inter- Same as above
vention of FBT] used across
adolescent development?
Probes What adaptations have you To further explore the responses
made (if any at all) to the princi- given by treatment teams
ples and interventions and
phases of FBT-based on age and
development?
FBT, family-based treatment.
participants stated that PE is demonstrated chiefly by parental control

over eating, including responsibility for meal preparation and meal
supervision and implementing plans for monitoring meals. One clini-
cian described the sentiments about parental control: ‘I am thinking
of one girl who did really, really well; her parents re-fed her, moni-
tored her 24/7, came to her school’ (38). In another focus group a
participant said that parental control is evident when parents ‘did it
all; did the meals, and did the support and supervision’ (7). Most of
the focus group participants also argued that PE is present when,
regardless of the age and maturity level of the adolescent, the parents
are confident about using their moral authority to intervene to assist
with eating and meals:
It’s less dependent on the kids, more dependent on where the parents
are at. Parents are still prepared to accept it [their role in helping with
eating]; ‘Don’t really care whether my kid is 17 or 18, she’s still sick and
I’m prepared to do this until she’s well’. (24)
The participants unanimously agreed that parents are empowered
in the treatment when they can relentlessly focus on facilitating
behavioural change and supporting recovery from AN in every
phase of FBT. Parental involvement in every phase of the treatment
was identified as the second most important ingredient of PE (next
to parental control over eating) by all the clinicians in the paediatric
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TABLE 2 Characteristics of study participants
N Range Mean (SD)
Total 30*
Gender
Male 1
Female 29
Age† 27 24–63 42.46 (10.44)
Professional credentials
Social Work (Masters) 10
Psychology (Masters) 8
Psychiatry 5
Other‡ 7
Years working in eating 28 0–26 8.45 (7.12)
disorders†
Years working with adolescents 28 0–27 10.54 (7.91)
Years working with families 28 0–30 10.41 (8.28)
Level of FBT training 6 0 no formal training or
purposeful exposure
13 1 some exposure to FBT,
no formal training
8 2 undergoing FBT certification
3 3 certified FBT therapist
Training in other form of 21 Yes
family therapy 9 No
*To maintain the confidentiality of participating treatment sites, the number of participants per
focus group has not been provided in the table.
†
As the data were self-reported, not all items total 30.
‡
To maintain the confidentiality of all clinicians, all professions with five or fewer representatives
have been combined into the category of ‘other’. FBT, family-based treatment.
focus groups. The clinicians all agreed that parents must remain
engaged in the treatment in phase 2 by incrementally relinquishing
their control of eating and meals back to their child. A decrease in
parental involvement (giving up control too quickly to the child) in
phase 2 is perceived either to be a symptom of parental disempo-
werment or to contribute to the diminishment of PE over time. In
one focus group, a participant surmised the consequences of a
decline in parental involvement in the treatment process:
You have parents that at the end of stage 1 give everything back to the
child and try to start walking away,. [I]t [the illness] could go on and on,
because we’re playing an up and down game [with weight] and that’s
when we run into problems. (59)
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TABLE 3 Results of thematic analysis of focus group data for themes 1 and 2
Frequency of
reference in
Major theme Code each focus group
Parental empowerment Parental control over meals 48 in 6
is perceived as para- must be ongoing through- 44 in 6
mount for treatment out treatment
effectiveness
Perception of factors Patient factors
that influence the Age 37 in 6
cultivation of paren- Individual/autonomy 37 in 6
tal empowerment Chronicity 14 in 6
Comorbidity 9 in 5
Parent factors 13 in 4
Mental illness 11 in 5
Burnout 9 in 5
Parental anxiety 4 in 4
Parent’s ability to tolerate
their child’s distress
Family factors 26 in 6
Family structure 9 in 4
Single parent or separated 3 in 3
families
Minimal employment 3 in 3
control
Limited financial resources
TABLE 4 Summary of interventions outlined by clinicians to increase parental

empowerment
Frequency of
mentions in
Strategy focus groups
FBT intervention Increasing anxiety and concern 27 in 6
Psychoeducation about the illness 26 in 6
and FBT
Directly encouraging parental 18 in 5
empowerment
Externalization 11 in 5
Agnostic view of the illness 9 in 3
FBT, family-based treatment.
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Figure 1. Thematic analysis network of focus group data. FTB, family-

based therapy; AN, anorexia nervosa.
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TABLE 5 Summary of supporting quotes from focus group data
Practice
Focus group
Theme Subtheme ID no. Quote
Parental empowerment as paramount for treatment effectiveness
Through meal 29 If parents are willing to supervise and monitor . . . it’s not as important
support to get the kid on board. I don’t know that we ever, a hundred per-
cent, have the kid say ‘Yay my mom and dad are going to supervise
me’ . . . the eating disorder knocks out capability in this one area of
decision-making and eating and that’s where parents should be step-
ping in.
Persistence of 7 The ones who are doing well, just thinking of the patient that came to
parental involve- mind, their mom is on it. And [she] was outstanding through all of

ment throughout it.
FBT
Perception of factors that influence the cultivation of parental empowerment
Patient Age impacts on 24 If the onset of the illness was much younger, and the parents have
factor parental been doing FBT for a long period of time, the older the child gets
empowerment the harder it is to keep it [focus on eating meals] up.
Patient Autonomy and inde- 24 The kid is resistant to that [parental involvement in treatment] . . . I
Parental empowerment
factor pendence of older already have a driver’s license, a part- time job, I’ve got a boyfriend
adolescent impacts or girlfriend and I’m living my life, what the hell are you doing?!?!
on parental It’s stacked a bit against you [parents].
empowerment
Patient Chronicity of the 7 If they sadly have already become chronic, then they’re already set up
factor illness against the other ones where [the] family has been able to get them
back on track.. . . When I think of the more chronic, that’s not what
would fit this model.
Patient Comorbid disorders 9 Typically the ones that don’t get better have comorbidity . . . and prob-
factor ably dysregulation that makes it difficult for families.

547
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TABLE 5 Continued
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Focus group
Parent Parental mental 24 I think it’s harder when you have, let’s say, a parent who restricts. I
factor illness think they get is more, that the parent is restricting, they’re less
likely, if the parent doesn’t change their eating behaviours, to have
good outcomes.
Parent Parental anxiety 7 [Clinician’s need to do work] so that you [parents] have more options
factor in front of you in terms of how you can respond to your child. But
the fear gets worse and worse and worse . . . the tension in those
parents, the anxiety, is just really hard to see. [Bringing their dis-
tress level down will] increase their availability in a skillful way.

Parent Distress 9 The clinician is trying to get people to understand the basic principles
factor intolerance of FBT. That it’s parents in charge . . . how to do the meal support
itself when the child is maybe not wanting to eat and how parents
are able to tolerate their distress and move them through that
process.
Parent Burnout 24 The longer they’ve been at it (FBT), you can almost see some of the
factor parents going oh, can we talk to (individual therapist), yes, time for
them to go there, because I really think they’re just tired.
Gina Dimitropoulos et al.
7 I feel like I have to be sensitive to the burnout of the parents to

involve them. I find sometimes they’ll go for a couple of weeks
where I don’t hear from them, or a couple of sessions where—so
they’re involved in the beginning and I kind of use a similar model
of meet with the—involve the parent, if I can get agreement to do
that. Usually they do, because, at the end of the day, they want the
help and the support and the structure of the family even at that
young adult age, for sure. But I find parents often they go through
a phase, like you were sort of saying, at these chronic issues, like
how is it different, and I find for a phase of time they don’t come

and there’s a burnout piece.
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TABLE 5 Continued
Focus group
Family Family re- 9 People are just going their own independent routes and sometimes it’s
factor organization part of what we need to correct. To actually get both parents on
board, to make those changes so that if dad is working till ten that
now he’s making this commitment to helping with eating and dur-
ing meals.
Family Single parent 7 Sometimes with a single parent it feels like, okay, they’re not going to
factor be able to offer the same level of support.
Family Poverty 7 Very quickly we found out that poor parents couldn’t do it.

factor
Family Employment 38 If they take time off work, they don’t get paid. So there are some
factor demands financial dilemmas families struggle with and they can’t be there.
Who am I to judge and say ‘well then get a smaller pay cheque,’ I
mean that’s not okay.
Interventions to increase parental empowerment
Increasing anxiety 59 Their family is so discombobulated by the time they come in, usually
Parental empowerment
and concern about there’s that one parent that’s more connected to the eating disorder,
the illness the behaviours and the home. So kind of giving it full tilt is impor-
tant so that they recognize, ‘Oh my gosh, this is really serious.’
Things are going to be changing a little bit, which in itself is a crisis.
Agnostic view of the 7 Parents aren’t to be blamed, it’s nobody’s fault, we raise their anxiety
illness and empower parents to support their child to recovery, to contain
the symptoms, keep their child safe, get their weight up and be
responsible for the re-nourishing

549
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TABLE 5 Continued
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Focus group
Externalization 38 I think [externalization] can be helpful for all family members
because . . . it’s just a good strategy for any mental illness because
it’s so frustrating for people to deal with and try to avoid that
anger going towards the child and instead having it projected
towards the eating disorder. The impact on the parents in
understanding the struggles and the challenges and the constant
chatter that’s going on, via that external eating disorder is really
significant because it makes it less scary. Because you have this
one person acting as the eating disorder and every parent’s like

‘‘oh my God, that is my kid’’ . . . everyone is like ‘oh it’s not me
as a parent because we’re all very good parents.’
Directly challenging 54 They’re living under your roof, they’re living in your house,
disempowerment 9 they still have to follow your rules and you’re not just going
to sit and watch your kid die. It’s not negotiation per say, but
conversation between myself and the parents around convincing
them they can set limits.
Psychoeducation 9 [How do you work with challenges?] Just continuing to emphasize
Gina Dimitropoulos et al.
that it’s a mental illness . . . and that their child’s not capable in this
one area and they need to take charge . . . saying out loud to the
parents some of these things like we know it’s not normal to have to
feed your 17-year-old, but in this case she has a mental illness, she
can’t make decisions around food that are appropriate or not
affected by the eating disorder.
FBT, family-based therapy.

A decrease in parental involvement in the treatment process was
identified by the following: irregular attendance of sessions; only one
parent attending when typically both were present in phase 1;
parents relinquishing their control over eating rapidly to their child;
engaging in discussions that are not behaviourally focused in phase 2
and not assisting with the exploration of developmental issues in
phase 3. In summary, parental control and parental involvement
were identified as intricately connected components of PE that reflect
the active participation of parents in all three phases of FBT with a
persistent commitment to eradicating disordered eating behaviour.
Theme 2: Individual, parent and family factors that affect PE1

Individual factors. A variety of factors pertaining to the affected adoles-
cent were identified as contributing to parental disempowerment,
such as their older age (16–19) (thirty-seven mentions in six focus
groups), the degree of individuation and autonomy (thirty-seven
mentions in six focus groups) in the adolescent, the longer the dura-
tion or chronicity of illness (fourteen mentions in five focus groups)
and the presence of comorbid disorders (nine mentions in five focus
groups). Clinician participants unanimously agreed that parental con-
trol over ED behaviour and consistent parental involvement are more
difficult to cultivate and sustain in families with older adolescents with
AN. The most commonly agreed upon explanation for this impres-
sion is that older adolescents have begun the process of individuating
from their families, spend greater time external to the family (that is,
extra-curricular activities, work, school and socializing with peers)
and increasingly make autonomous decisions with less parental input.
In addition to being older, clinician participants in five of the paediat-
ric focus groups observed that parents become increasingly disem-
powered the longer the illness persisted. Finally, clinician participants
noted that comorbid diagnoses (anxiety, depression and substance
abuse) in the adolescent can also make it challenging for parents to
focus exclusively on the ED behaviour, which inevitably results in
diminishing their influence over the AN.
Parent factors. Clinician participants identified three factors that con-

tribute to and exacerbate parental disempowerment: parental mental
illness such as an ED or severe depression (thirteen mentions in four
focus groups); burnout (eleven mentions in five focus groups) and
the inability to tolerate the distress of their child (four mentions in
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three focus groups) and their own (nine mentions in five focus
groups). First, the presence of a psychiatric diagnosis in a parent was
seen to significantly impact on PE:
It’s difficult when a parent has their own issues with either an ED or
their own mental health issues. We’re asking a lot of parents, to really
step up to the plate, and when we do our assessment and find out, ‘Oh,
Dad is recovering from a pretty significant depression or anxiety’ – it’s
important because we are asking them to really create structure in the
household. (59)
Clinician participants perceived parents with difficulties tolerating
distress as becoming overwhelmed by their child’s emotional
responses to increasing their eating. One clinician participant stated:
‘[I]t’s about the parents holding strong. Their tolerance of their child
being distressed is so distressing for them’ (59). Another participant
from the same focus group concurred: ‘For whatever reasons, [some
parents] just cannot handle when their child is upset . . . it’s not about
the food, it’s about their tolerance of their child being distressed’ (59).
Clinician participants strongly indicated that parents who were
unable to tolerate their child’s distress were more likely to accommo-
date to the ED. Clinician participants also acknowledged that some
parents lacked the knowledge and the skills to know how to respond
to their child’s distress, especially if the adolescent becomes emotion-
ally dysregulated.
Finally, parental burnout was mentioned eleven times in five focus
groups. Clinicians consistently discussed that the need for constant
vigilance of ED behaviour and the supervision of meals may lead to
burnout in parents. Fatigue may result in parents prematurely relin-
quishing control of eating over to their child. Burnout in parents was
also been identified as a barrier to the ability of parents to intervene
when conflict arises with their child about eating and increasing the
quantity or quality of food. One clinician participant summarized how
burnout can contribute to decreased PE:
I’m calling it burnout – what I’m seeing with the parents, it just makes
that empathy piece really hard. So I try to develop empathy. I’m always
feeling like I’m not sure it’s working and it’s falling a little of deaf ears
and that if I can get this parent to feel some compassion for themselves
and lift some burnout in them, that they’re going to be more available
to do it to their child. (7)
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Family factors. In all six focus groups there was a discussion of the fam-
ily factors that contribute to parents feeling unable to manage ED
behaviour, especially in the early phase of the treatment. The need to
change the structure of the family was mentioned thirty-two times in
all six of the focus groups. According to the participant clinicians, the
families of adolescents re-organize themselves to accommodate to the
emerging independence and autonomy of their teenager and often
parents negotiate with their child over curfews and spending time
with friends. Clinician participants argued that parents may initially
experience distress about re-asserting their authority and controlling
what their child eats, especially if the adolescent has achieved consid-
erable independence and the parent–child relationship has become
more egalitarian during the developmental phase of adolescence. As
one clinician participant said (59):
Parents are already detaching and they’re already giving that independ-
ence to their child so to ask them to back in [to help with re-feeding] it
doesn’t feel as welcoming as it does with the younger families.
and another participant noted:
I think parents are often a little bit more reluctant to step in and take
full control because they’ve had three, four, sometimes five years of giv-
ing the kid more autonomy in just about every other areas of their life.
(29)
The crisis of the illness was believed to be more difficult for parents if
they were required to make significant changes to the organization
and structure of the family. In fact, clinician participants constantly
reported that the inevitable adaptations needed in the family in order
for them to ascertain control over the ED behaviour can be as difficult
as the illness itself for some parents.
Theme 3: clinical interventions employed to cultivate and increase PE

Clinician participants endorsed implementing a variety of interven-
tions to increase PE (see Table 4). Most interventions were either the
other principles of the FBT model, such as externalization and taking
an agnostic view of the illness, or were interventions specifically
described in the FBT manual, such as increasing concern about the
ED behaviour to propel parents to take charge of facilitating behav-
ioural change in their child; psychoeducational material about the ill-
ness. One clinician participant summarized the use of FBT
interventions to increase PE:
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we educate about eating disorders, we lift blame, we raise anxiety, we
externalize the illness . . . we make it clear that the illness is putting these
obsessive thoughts and feelings into the youth’s head and that parents
are responsible for protecting their child from that and helping to con-
tain symptoms in a supportive and compassionate way. (7)
Discussion
The purpose of this study was to explore the perceptions of clinicians
on the most salient features of FBT in routine clinical practice.
Enhanced knowledge of the clinical impressions of what facilitates and
interferes with the application of the principles of FBT may assist in
the development of training and supervisory protocols to improve the
uptake of FBT in routine clinical practice. The findings of this study
indicate that clinicians in paediatric ED treatment teams from across
Ontario perceive PE to be the most salient feature of FBT and the pri-
mary principle that makes this treatment effective. In all the focus
groups, the clinicians identified two core components of PE: parental
control over the management of eating behaviour and parental
involvement in all phases of the treatment. However, the clinicians
also identified barriers to PE and the use of various interventions and
other principles of FBT to bolster PE. They identified patient (that is,
their age, duration of illness and comorbid diagnoses), parent (that is,
a severe mental illness) and family factors (changing roles and the
hierarchy in the family) as contributing to decreased PE in FBT.
It is not surprising that the clinicians view PE, through parental
control and involvement in the re-nourishment process (feeding,
supervising) in adolescents with EDs as necessary for recovery. This
finding is supported by an observational study that found that paren-
tal self-efficacy predicted patient outcomes in FBT (Byrne et al.,
2015). In comparison to all the other principles of FBT, parental con-
trol of eating has been found to be the strongest predictor of outcome
and lower treatment attrition (Ellison et al., 2012). Parental responsi-
bility for meal preparation and meal times has been shown to
decrease the likelihood of developing eating psychopathology in nor-
mal, non-clinical adolescents as well (Haycraft et al., 2014) and paren-
tal encouragement to eat through warmth and firm prompts has
been found an important predictor of outcome in clinical samples of
adolescents with AN (White et al., 2014). The expression of parental
confidence to re-nourish their child in session one has also been
V
Practice
found to predict rapid weight gain in the first 4 weeks of treatment
(Darcy et al., 2013).
The participants also identified a myriad of barriers to the develop-
ment of PE through FBT that spanned patient, parent and family fac-
tors. Clinician participants indicated that the child’s older age, the
chronicity of the illness, comorbid diagnoses and the greater degree
of individuation and autonomy in adolescence contributes to parental
disempowerment, which interferes with the effectiveness of FBT. To
the best of our knowledge, there are no studies examining the degree
to which autonomy and individuation achieved in adolescence is a
barrier to PE in FBT. The clinical perception that parents experience
greater disempowerment with older than younger adolescents with
AN, and with adolescents experiencing a more chronic illness course,
is consistent with other research that finds that the adolescent’s older
age and a longer duration of illness predict lower remission rates (Le
Grange et al., 2012; Lock et al., 2006). The clinician perception that
parental control over eating is reduced in the presence of comorbid
psychiatric diagnoses is consistent with reports that adolescents with
obsessive compulsive features have poor treatment outcomes in FBT,
and a study that found that comorbid psychiatric diagnoses predicts
drop out (Lock et al., 2006).
The clinicians identified a number of parental factors as being pos-
sible barriers to the development of PE during FBT, including paren-
tal mental illness, tolerance of distress and the need to reorganize the
structure of the family to support recovery in the adolescent. Com-
pared to some patient factors (obsessive compulsive features and
severe eating psychopathology), there is no empirical evidence to
support the clinical perception that parental mental illness is a moder-
ator of treatment outcomes in FBT for adolescents with AN. How-
ever, it is important to emphasize that the participants did not suggest
that parents with mental illnesses cannot do FBT. Instead, a severe
mental illness was perceived to diminish PE because it depletes the
internal resources necessary to sustain a relentless focus on re-feeding
and weight restoration. In addition to experiencing stigma, parents
with severe mental illnesses may also have difficulties accessing
resources.
The influence of parental EDs on the feeding practices of infants
and schoolchildren has been investigated previously (Haycraft et al.,
2014), but, no similar studies have been conducted in adolescents. The
potential impact of altering the structure of the family as potentially
stressful and therefore disempowering for families has been discussed
V
Practice
only theoretically (Minuchin et al., 1978) and it not examined empiri-
cally. In this study, the clinicians unanimously agreed that families may
require significant time to identify and practice different patterns of
communicating and relating as they work in and out of therapy to
identify effective ways to re-nourish their adolescent. For instance, the
family may need to adapt the structure of their family to accommodate
to a new routine for assisting with meal preparation and supervision
and attending medical and family therapy appointments.
Clinicians endorsed increasing PE using FBT interventions such as
raising anxiety and concern about the illness, educating parents about
the impact of the illness on the adolescent, and emphasizing that
parents are not to blame for the illness and that they can play an
important role in re-nourishing their child. The interventions fav-
oured by the clinicians in our study are supported by a recent
Canadian study that found the provision of only 2 hours of a psycho-
education group for parents about the illness and the importance of
parental involvement in treatment increased the self-efficacy of
parents to support their child to overcome AN (Spettigue et al., 2014).
Further, parent-to-parent support, where caregivers who have com-
pleted FBT speak to parents considering FBT, has been found to be a
useful intervention for parents and was shown to expedite the rate of
weight restoration in adolescents (Rhodes et al., 2008).
Clinical applications and future directions

This study found that the principles of FBT have face validity for clin-
ical teams providing treatment to adolescents and their families. The
most salient principle of FBT is PE, which must be the focus of paedi-
atric teams working with adolescent EDs. The clinical implication of
this study is that clinical teams require comprehensive training and
ongoing supervision to address and reduce barriers to PE in FBT.
Supervision should also focus on enhancing the efforts of clinicians
and teams to assist parents with the task of re-nourishing their child,
despite their age, the chronicity of illness or their level of maturity.
Increased attention in clinical supervision to PE during the family
meal is highly recommended, given recent evidence that the proc-
esses during this session may enhance parental self-efficacy over eat-
ing (Ellison et al., 2012; Godfrey et al., 2014). Clinical teams may also
require assistance on how to bolster empowerment in the face of
parental burnout and psychological distress and comorbid mental ill-
nesses in both parent and child.
V
Practice
Clinicians may consider asking parents at the start of each session
to identify how empowered or disempowered they think they are in
relation to AN. They may consider using the parent versus anorexia
nervosa scale; an instrument designed to assess how parents feel or
think in relation to AN (Rhodes et al., 2005). Using this instrument,
clinicians may ask parents to rate the knowledge they have acquired
and the strategies they have gained during the process of assisting
their child with recovery at every session. The responses can then be
used clinically to gauge how empowered parents may feel in the treat-
ment and assist parents (and other supportive individuals) as needed
when their efficacy diminishes in the face of AN or other factors iden-
tified by the family.
It is imperative that clinical teams focus on how to facilitate PE,
especially in the first phase of treatment, since previous studies show
that rapid weight gain within the first few weeks contributes to better
treatment outcomes (Darcy et al., 2013; Doyle et al., 2010; Ellison
et al., 2012; Le Grange et al., 2014). Interdisciplinary teams may need
to proactively consider how to support parents when they are faced
with the competing demands of addressing AN and other psychiatric
illnesses. The importance of normalizing eating and weight gain to
facilitate psychological improvements needs to be kept at the fore-
front of treatment, especially in phase 1. A unique contribution of this
study is the finding that clinicians report requiring more assistance to
support parents with severe mental illnesses and families who need to
re-organize their family structure and re-assert their moral authority
and power to support recovery from AN, even when the adolescent
has achieved autonomy and independence. It is important to note
that assistance with re-organizing the structure of the family occurs
only to increase PE to assist with ED behaviour and not because of
any assumption of pathology in the family.
To avoid blaming and pathologizing families, clinicians must engage
in ongoing supervision to assess how their own reactions to the progress
(or lack thereof) of treatment may be interfering with the empower-
ment of parents. Although clinician variables were not discussed in the
focus groups in this study, research demonstrates that a therapeutic alli-
ance with parents is important in the early phase of FBT (Forsberg
et al., 2014) and that a maternal therapeutic alliance predicts drop out
in this treatment (Ellison et al., 2012). Research also shows that clinicians
have strong emotional reactions that may hinder them from weighing
patients in family-based treatments (LaFrance Robinson and Kosmerly,
2015). Clinicians who lack experience, obtain insufficient training in
V
Practice
family therapy and lack confidence in directly addressing AN behaviour
may also require assistance from their colleagues and trainers to gain
the skills necessary to support parents and young people with AN in
FBT. Hence, we would strongly recommend that supervision be utilized
to identify clinician factors as well as adolescent, parental and family fac-
tors that facilitate or undermine PE in FBT.
Future studies on the role of PE in FBT are needed as well as an
investigation into what mechanisms of FBT contribute to enhancing
parental control of ED behaviour and meals. To augment FBT,
adjunctive interventions specifically targeting PE should be developed
and evaluated for families of adolescents whose weight gain may be
slow in the first phase of treatment. Further research is required to
confirm the clinical impressions that emerged from our qualitative
analysis. The findings of this study should inform clinical supervision,
highlighting possible challenges experienced by clinicians delivering
FBT in paediatric tertiary care clinics. It will be important for future
studies to examine the perspectives of parents on what contributes to
PE in FBT. Finally, we think it is imperative for researchers to con-
sider the influence of clinician variables on PE in FBT.
Strengths and limitations

This study has a number of strengths. It is the first to examine what
clinicians view as the most salient features of FBT and the barriers
and facilitators to the achievement of PE. Secondly, focus groups with
six different treatment teams in the province of Ontario who primar-
ily use FBT allowed for heterogeneous treatment teams from both
rural and urban areas to take part, ensuring that diverse yet repre-
sentative data were collected on the use of FBT in inter-professional
treatment teams in Ontario, Canada. Finally, the data were collected
using a standardized interview guide, which allowed for reliability
during data collection.
There were a number of limitations to this research study. The par-
ticipants were self-selected and therefore may be different from clini-
ciansand their teams that did not participate in this research study. All
focus groups were conducted in programmes that had intensive day
and inpatient programmes and may differ from programmes that
provide only outpatient treatment to families of adolescents with EDs.
The participants may have concealed the views they held that differed
from other members of their team, despite the efforts of the facilita-
tors of the focus groups to encourage a variety of clinical opinions. An
V
Practice
important limitation of this study is that we did not inquire about cli-
nician factors such as therapeutic alliance with the parents, which
may facilitate or impede family empowerment. This limitation has
been identified in a recent review article that demonstrated that ther-
apist variables are minimally examined in process-oriented research
in EDs (Brauhardt et al., 2014). It was also beyond the scope of this
study to assess whether the participants were adhering to the manual-
ized version of FBT. Given that we utilized a structured interview
guide with open-ended questions, the research team could not
respond to issues unless they were raised by the clinicians or focus
groups themselves. It is important to note that there are a number of
other factors, such as culture, ethnicity, race and gender, which
may have affected the empowerment of parents. Finally, it is also pos-
sible that our interview and interview process was biased, although
every effort was made to ensure that the research team utilized a
standardized interview guide and that open-ended questions were
employed.
In summary, clinical teams treating adolescents with EDs indicated
that the principles of FBT have face validity. They strongly endorsed
PE as one of the most fundamental features of FBT. The clinicians
also described a number of barriers in the development of PE and
proposed strategies to assist families in overcoming these challenges.
Future studies should explore the direct impacts of PE on outcomes
in FBT, and different ways of measuring PE. Ultimately, an improved
understanding of how core principles of FBT are perceived in clinical
practice and how to facilitate PE will lead to refined training and
supervision to assist clinicians to support parents in their efforts to
assist their child to normalize their eating and gain weight.
Acknowledgements
Data were collected at ED programmes in Ontario, Canada. The
authors have no financial relationships to disclose. This study was
assisted by the Ontario Mental Health Foundation, with funding from
the Ontario Ministry of Health and Long-term Care.
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Journal of Family Therapy (2017) 39: 537–562

Clinician perspective on parental empowerment

Gina Dimitropoulos,a Victoria E. Freeman,b

This qualitative study explored which core principles of family-based

Keywords: clinician; eating disorder; family-based treatment (FBT); parental

1. Older adolescents respond better to individual therapy than FBT

Despite the fact that most paediatric ED programmes in Canada

Theme 1: PE is the principle of FBT that contributes the most to treatment

participants stated that PE is demonstrated chiefly by parental control

TABLE 4 Summary of interventions outlined by clinicians to increase parental

Figure 1. Thematic analysis network of focus group data. FTB, family-

C 2015 The Authors. Journal compilation V

C 2015. The Association for Family Therapy and Systemic

C 2015 The Authors. Journal compilation V

7 I feel like I have to be sensitive to the burnout of the parents to

C 2015. The Association for Family Therapy and Systemic

C 2015 The Authors. Journal compilation V

C 2015. The Association for Family Therapy and Systemic

C 2015 The Authors. Journal compilation V

C 2015. The Association for Family Therapy and Systemic

Theme 2: Individual, parent and family factors that affect PE1

Parent factors. Clinician participants identified three factors that con-

Theme 3: clinical interventions employed to cultivate and increase PE

Clinical applications and future directions

Strengths and limitations

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