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Family-Based Therapy for Pediatric Anorexia Nervosa: Highlighting the

Implementation Challenges

Article  in  The Family Journal · January 2018

DOI: 10.1177/1066480717754280

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Article
The Family Journal: Counseling and
Therapy for Couples and Families
Family-Based Therapy for Pediatric 2018, Vol. 26(1) 90-98
ª The Author(s) 2018
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DOI: 10.1177/1066480717754280
Implementation Challenges journals.sagepub.com/home/tfj

Jennifer Scarborough1

Abstract
Family-based therapy is a recommended treatment for children and adolescents diagnosed with an eating disorder. Despite the
promising results, this model is not without its challenges. Through literature review and treatment exemplars, this article
provides a brief overview of family-based therapy and highlights the many challenges for clinicians and parents implementing this
therapy. Noted challenges are barriers to clinical supervision, inadequate treatment options, time and finances, relationships, and
parental adjustment. This article concludes with implications for research and clinical practice.

Keywords
eating disorders, family based therapy, pediatric, maudsley, anorexia nervosa

Eating disorders have the highest mortality rate of any mental
illness, with 10–20% of individuals succumbing either to the
medical complications of the disorder or to suicide (Crow et al.,
2009; Fisher, 2006; Harris & Barraclough, 1998; Nielsen,
2001). The illness generally presents between the ages of 13
and 19; a time when an adolescent is still usually dependent on
their parents but is also experiencing greater autonomy (Scott,
Biskman, Woolgar, Humayun, & O’Connor, 2011; Smick, van
Hoeken, & Hoek, 2012; Weaver & Liebman, 2011).
Eating disorders can be difficult to treat. This is partly due
to the diagnosed individual’s inability to understand the
severity of their illness (Fisher, Schneider, Burns, Symons,
& Mandel, 2001). Thus, the involvement of parents can
greatly increase the chances of successful recovery (Golan
& Crow, 2004). Family-based therapy is currently a fre-
quently recommended treatment for children and adolescents
diagnosed with an eating disorder (American Psychiatric
Association, 2006; Findlay, Pinzon, Taddeo, & Katzman,
2010; Mitchum, 2010).
Although family-based therapy is a highly recommended
treatment, this intervention is not without its challenges. Pre-
sently, family-based therapy does not explicitly acknowledge
the additional pressures that parents face when engaged in
treatment. Everyday family demands (e.g., finances, relation-
ships) become more challenging with the added demands and
expectations of treatment.
The aim of this article is to highlight the many challenges
that are encountered when attempting to implement family-
based therapy. Understanding these issues is vital for success-
ful implementation. Exploring the potential barriers for parents
and clinicians is necessary in order to improve the chances of
successful implementation of family-based therapy as well as
longevity in treatment. This article is intended to help clini-
cians gain a better understanding of these pressures on parents
and to support their discussions with parents as well as open a
dialogue on the challenges faced in family-based therapy. In
addition, this article will help researchers develop a better
understanding of the parental experience when caring for an
adolescent diagnosed with an eating disorder as well as the
challenges of implementing family-based therapy.
This article begins with a brief overview of family-based
therapy to provide context and a general understanding of
manualized family-based therapy and its expected outcomes.
This is followed by an explanation of the procedures used in
identifying issues such as (1) training and adherence to family-
based therapy, (2) inadequate treatment options, (3) time and
finances, (4) relationship maintenance, and (5) parenting
adjustment and eating disorder resistance. Each discussion of
an issue is supported by literature and illustrated by an exem-
plar from family-based therapy practice. The article concludes
with a discussion of implications and suggestions for
improvement.
1
Faculty of Social Work, Wilfrid Laurier University, Kitchener, Ontario,
Canada
Corresponding Author:
Jennifer Scarborough, Faculty of Social Work, Wilfrid Laurier University, 120
Duke St. W., Kitchener, Ontario, Canada N2H3W8.
Email: jscarborough@wlu.ca
Scarborough
Overview of Family-Based Therapy
This overview section is provided to inform readers of family-
based therapy and the role parents play in this treatment.
Family-based therapy is a treatment that encourages and moti-
vates parents to facilitate their child’s recovery by preparing
and supervising meals. Family-based therapy is a weekly out-
patient treatment that is nondirective in nature. The therapist is
more of a consultant asking parents questions to empower them
to arrive at decisions to fight the eating disorder. The purpose
of family-based therapy is to intervene to decrease the chances
for hospitalization.
Families were first included in the treatment of eating dis-
orders by Minuchin and his colleagues (Minuchin, Rosman, &
Baker, 1978). Due to their relative success with the inclusion of
families in treatment, Minuchin developed the model of the
psychosomatic family, which believed that familial dysfunc-
tions or enmeshments lead to disordered eating behaviors. In
addition to Minuchin’s structural family therapy, both the
Milan group and strategic family therapy influenced the devel-
opment of family-based therapy, which led to controlled stud-
ies conducted at Maudsley hospital in London (Loeb & Le
Grange, 2009).
Family-based therapy was eventually manualized by James
Lock, Daniel Le Grange, and colleagues in 2001. They have
since published a manual for bulimia nervosa and a second
edition of the original manual for anorexia nervosa. Family-
based therapy has specific components. These components are
that the therapist take an agnostic view of the illness, which
means that there are no assumptions as to what may have led
to the eating disorder onset. Since family-based therapy focuses
on what needs to be done in the present to quickly move forward
in recovery, the exploration of potential causes is not examined.
Another component of family-based therapy is externalization
of the illness. Additionally, parental empowerment is a key
feature, whereby the therapist is nonauthoritative and acts more
of a consultant to parents to guide and support them in aiding
their child to recovery (Lock & Le Grange, 2013).
Family-based therapy has a recovery rate of about 50–60%
at 6 and 12 months follow-ups, with recovery defined as reach-
ing >95% ideal body weight and within 1 standard deviation of
community norms on the Eating Disorder Examination Ques-
tionnaire (Lock et al., 2010). In family-based therapy, parents
are seen as “functioning similar to an effective inpatient nur-
sing staff—at least during the first phase of treatment—albeit
in the home setting” and are tasked with this role as they “love
their children, know them well, and are highly invested in their
[child’s] survival” (Le Grange & Lock, 2011, p. 230).
Family-based therapy consists of three phases with 15–20
sessions in total over 12 months. These three phases are (1)
weight restoration, (2) returning control to the adolescent, and
(3) establishing healthy adolescent identity (Lock & Le
Grange, 2013).
In Phase 1, weight restoration, the therapist supports parents
in the renourishing of their ill child. The second session in this
first phase involves a supervised meal session where the
91
therapist can view and assist parents in encouraging their child
to eat a meal the parents bring. Throughout Phase 1, the thera-
pist models a noncritical stance toward the ill child and con-
tinues to support the parents in the refeeding process.
Phase 2, returning control to the adolescent, takes place
when the child has begun to show signs of acceptance of
increased food intake from the parent as well as weight gain
and an overall positive change in mood. In Phase 2, the parents
begin to encourage and support their child to regain control
over their eating as developmentally appropriate. Weight gain
remains a focus in this phase.
Phase 3, establishing healthy adolescent identity, is indi-
cated by the adolescent reaching and maintaining a minimum
of 95% ideal body weight. This phase focuses on adolescent
autonomy and establishing developmentally appropriate
boundaries for parents.
While family-based therapy is considered by some the first
line of treatment for eating disorders, there are certain instances
where this treatment may not be appropriate. Firstly, children
who are medically unstable, or suicidal, should be hospitalized
and not begin treatment until stable. Parents with severe psy-
chopathology may also be contraindicated for the uptake of
family-based therapy (Le Grange, Lock, Loeb, & Nicholls,
2010). Despite this, Le Grange, Lock, Loeb, and Nicholls
(2010) mention the importance of family involvement even
in difficult circumstances:
the assessment of families requires close attention to the parents’
competencies, motivation, and history of adverse or traumatizing
events. But even when such adverse circumstances are present, the
development of a play to help and support sufferers and how to
ease family burdens should take precedence over accusation and
blame. Thus, it is our position that families should be involved
routinely in the treatment of most young people with an eating
disorder. Exactly how such involvement should be structured, and
how it will be most helpful will vary from family to family. (p. 4)
While not contraindicated, there are several factors that are
worth mentioning that need to be kept in mind when implement-
ing family-based therapy. Children over the age of 18 or who
have had the eating disorder for longer than 3 years may not fare
as well compared to younger and less chronic children (Le
Grange, 2005; Lock & Le Grange, 2013; Loeb & Le Grange,
2009; Rienecke, 2017). Adolescents with comorbid psychiatric
disorders have higher rates of treatment dropout and lower
remission rates (Lock, Couturier, Bryson, & Agras, 2006). Par-
ents who present as hostile or overly critical may be better suited
for a separated form of family-based therapy, whereby the thera-
pist meets with the child and parents separate from each other
(Dare, Hodes, Russell Dodge, & Le Grange, 2000).
Procedures
The origin of this article emerged from observations of family-
based therapy through clinical practice, supervision of other
clinicians implementing family-based therapy, and agency-
92 The Family Journal: Counseling and Therapy for Couples and Families 26(1)
based challenges. Through these observations, a number of
implementation issues have been identified.
In addition to clinical practice observations, and conversa-
tions with parents, clinicians working in the field of pediatric
eating disorders have echoed these difficulties when applying
family-based therapy. Once themes had been identified, a com-
prehensive literature search and review was completed focused
on these issues.
Using Primo, a library catalog search procedure, the key
words “parents, caregivers, family-based therapy, Maudsley,
eating disorders, children” were used to find appropriate liter-
ature about family-based therapy implementation challenges.
Once this literature was reviewed, pertinent material was then
combined with the author’s practice experiences, leading to
the identification and discussion of issues and challenges
within the family-based therapy model as presented in this
article. To effectively convey family-based therapy chal-
lenges, the article is organized into sections containing a
review of literature pertinent to the issues identified, followed
with an exemplar from practice, supervision, or agency admin-
istrative experiences.
Family-Based Therapy Demands on Clinicians
Clinicians who are trained in family-based therapy are fortu-
nate to have the ability to implement the most up to date,
evidence-based treatment for families who have a child diag-
nosed with an eating disorder. Despite having formal training
in this therapy, there remain several challenges that have con-
sequences for clinicians and clients.
Family-based therapy training and adherence for clinicians. Current
evidence in the treatment of eating disorders for adolescents
shows that outpatient treatment using a family-based approach
is effective in returning adolescents to health (Lock et al.,
2010). For this reason, a training institute to ensure quality of
care and proper training in the use of family-based therapy in
practice has been developed (see Training Institute for Child
and Adolescent Eating Disorders, 2017).
In order to be considered a certified family-based therapy
therapist, 2 days of training and 25 hr of individual supervision,
with tape recordings of sessions and in-person or phone meet-
ings, must be completed. In Canada, there are only five fully
certified family-based therapy therapists listed on the Training
Institute for Child and Adolescent Eating Disorders website.
This lack of fully certified family-based therapy therapists is
not surprising, as many agencies are unable to fund their clin-
icians in the full course of certification. What often happens is
just the 2-day workshop (Level 1) is completed. Due to this,
clinicians are often attempting to implement family-based ther-
apy without supervision.
A study by Couturier et al. (2013) found that several of the
key aspects of family-based therapy were not being adhered to
in agencies, such as weighing the adolescent at the start of all
sessions as well as the family meal which takes place in the
second session of Phase 1. Reasons for not implementing
certain key aspects of family-based therapy were due to various
factors such as the clinician’s scope in practice (e.g., weighing
of the patient is viewed as a medical role) or by organizational
barriers such as a lack of space to complete family meals within
the agency. For these reasons, parents are provided with more
of an informed family-based therapy rather than the manualized
model. In some cases, many therapists are using therapeutic
techniques that are not suggested or recommended by the
family-based therapy manual (Kosmerly, Waller, & Lafrance
Robinson, 2015).
Parents are led to believe that they may be receiving the
recommended treatment; however, in order to confidently
expect outcomes similar to those indicated in research, the
manualized treatment protocol must be followed. One of the
major issues with this informed family-based therapy is that
there is a lack of data on mixing therapeutic techniques. This
informed family-based therapy may mislead parents into
believing that they are receiving the evidence-based treat-
ment. Should the therapy fail, these parents may end up
believing that the best treatment to date was not enough to
help them, when in fact they never received the manualized
treatment in the first place.
In addition to this, supervision of clinicians implementing
family-based therapy is vital given that clinician anxiety has
been shown to lead clinicians to stray away from evidence
based the protocol (Waller, Stringer, & Meyer, 2012). In fact,
eating disorder clinicians working with children and adoles-
cents reported that negative emotions impacted clinician deci-
sions (Lafrance Robinson & Kosmerly, 2014, p. 10).
Supervision does exist specifically for the clinical blockages
that may hinder treatment progression (Lafrance Robinson &
Dolhanty, 2013). However, some agencies may be unable to
access this supervision due to financial limitations.
Supervision of treatment implementation is necessary to
help clinicians be aware of judgments they may have when
working with families. Part of family-based therapy is main-
taining a nonjudgmental and nonblaming stance toward par-
ents. Yet Couturier et al. (2013) reported that some clinicians
had “little sympathies for families who do not attend appoint-
ments during normal work hours, because therapists feel fam-
ilies would not hesitate to attend if their child was diagnosed
with a serious physical illness (e.g., cancer)” (p. 182).
Exemplar. In the case of Sam, a 15-year-old female with
anorexia nervosa, a referral to an outside, private therapist to
treat her depressive symptoms was made as her parents felt that
these emotions were the precursor to the development of the
eating disorder. Sam’s family-based therapy clinician sup-
ported the parents’ decisions since the child was not engaging
with the family-based therapy clinician and thus was not get-
ting enough emotional support through the process.
In the family-based therapy protocol, it is recommended that
all other forms of counseling be halted while in treatment. The
reason for this is demonstrated in Sam’s case, where contra-
dicting messages were given from the private therapist about
the parents’ role in refeeding. The private therapist
Scarborough
recommended that Sam’s parents stop preparing and supervis-
ing Sam’s meals as this was contributing to Sam’s depression.
Sam felt that she was being treated like a toddler. The private
therapist assured the parents that Sam had learned skills to cope
with the depressive thoughts, which were similar to the eating
disorder thoughts. The parents then withdrew from family-
based therapy treatment, so Sam could pursue her individual
treatment for depression. A closing letter from the family-
based therapy clinician to the family doctor recommended
medical monitoring.
Sam eventually returned to the eating disorder agency. Her
eating disorder behaviors never ceased and weight loss contin-
ued while in private treatment for depression. The private
therapist eventually discharged Sam from her care as the med-
ical urgency of her weight loss became too pressing. When Sam
and her family returned to the agency, a referral was made to an
inpatient eating disorder program as her weight loss was too
extreme to manage on an outpatient basis.
Inadequate treatment options. For anorexia nervosa, family-
based therapy has a nonresponse to treatment rate of 15–30%
(Krautter & Lock, 2004; Lock et al., 2010). Some of the mod-
erators identified as having an impact on the outcome are (1)
the eating disorder’s severity at clinical assessment, (2) diag-
nosed comorbidities, (3) being an older adolescent, and (4)
parents with high emotional expression (Dare, Eisler, Russell,
& Szmukler, 1990; Le Grange et al., 1992, 2012; Murray & Le
Grange, 2014).
In terms of nonresponse to family-based therapy, Doyle, Le
Grange, Loeb, Doyle, and Crosby (2010) found that the stron-
gest indicator for remission was a weight gain of 2.88% by the
fourth session (approximately 1 month into therapy) of the
manualized treatment. For patients unable to achieve this
weight gain, another treatment model may be required. A key
challenge for clinicians is the lack of treatment options and
training for these treatment models that currently exist. As a
result, clinicians may desperately try to continue to use family-
based therapy and not know when, or how, to switch to another
form of therapy (Steiger, 2017).
Other treatments do exist for adolescents, either as comple-
ments to boost family-based therapy effectiveness or as alter-
native treatments to family-based therapy. They include (1)
adolescent focused psychotherapy (see Fitzpatrick, Moye,
Hoste, Lock, & Le Grange, 2010), (2) cognitive behavioral
therapy (see Dalle Grave, Calugi, Doll, & Fairburn, 2013),
(3) cognitive remediation therapy (see Lask & Roberts,
2013), and (4) emotion focused family therapy (see Robinson,
Dolhanty, & Greenberg, 2013).
There is a need for clinicians to have a variety of treatment
intervention options when working with families with a child
diagnosed with an eating disorder. However, to have a breadth
of training and knowledge in the various modalities can be
costly for agencies. It can also be confusing to clinicians in
selecting which treatment to implement when there is a non-
response to family-based therapy. Clinicians can also struggle
with how to effectively change and manoeuvre between these
93
treatments. As a result, the pressure clinicians may place on
parents to adhere to the family-based therapy treatment recom-
mendations may increase frustrations and a sense of hopeless-
ness when the model is proving to be noneffective. Switching
to another treatment can be confusing to parents and may send
mixed or contrasting messages if the course of treatment differs
greatly from family-based therapy.
Many of these alternative treatments do contradict family-
based therapy and focus on the adolescent as an individual. The
parent role is seen as secondary, perhaps having only once-a-
month progress sessions or 15 min at the end of a session for
support. This puts parents in a confusing position of going from
the prime role in the recovery to taking a back seat and becom-
ing a supportive bystander.
There are no clear protocols as to how to end family-based
therapy and transition to alternative treatment, but generally
treatment termination is based upon agency/institutional agree-
ment. Thus, it is recommended that at the outset of family-
based therapy treatment, the explicit limits of the program be
communicated to parents. Should there be an “inability on part
of the family to mobilize weight gain,” it may be beneficial for
teams to meet with parents to discuss progress and to reevaluate
the fit of family-based therapy for the patient and family
(Woodside, Halpert, & Dimitropoulos, 2015, p. 368).
Exemplar. Justin was a 16-year-old male who frequently
exercised to burn calories and restricted his caloric intake,
although his weight loss had not yet put him in the diagnostic
criteria for anorexia nervosa. Family-based therapy was imple-
mented for about six sessions, or a month and a half, but his
weight loss continued. After a lengthy discussion during clin-
ical rounds and with Justin’s parents, it was decided that Justin
would try adolescent focused psychotherapy. Justin’s parents
found this helpful and less stressful as sessions were individual
for Justin and collateral sessions for parents were infrequent.
However, over time, Justin’s parents began to struggle with
their lack of knowledge about what Justin was saying in ses-
sions as well as how to deal with Justin continuing to make his
own meals separate from the family. This, in fact, led to con-
flict as his parents would attempt to try to implement aspects of
family-based therapy despite no longer following this treat-
ment model. Justin’s parents struggled to be supportive of Jus-
tin’s “self-directed change” (Fitzpatrick et al., 2010, p. 35).
They felt they could not watch their child struggle in front of
them while they did, in their words, “nothing,” especially after
recalling the importance of parental involvement in family-
based therapy treatment.
Family-Based Therapy Expectations
of Parents
Research on adolescent interventions for eating disorders
recognizes that the involvement of parents in treatment
improves the chances of recovery (Godart et al., 2012). Parents
are no longer considered to be part of the cause of eating dis-
orders, instead they are seen as part of the solution. However,
94 The Family Journal: Counseling and Therapy for Couples and Families 26(1)
family-based therapy can place high demands on already
exhausted parents and the pressure to implement the treatment
and monitor their child may prove to be daunting. There is a
responsibility and pressure for parents to follow the recom-
mended treatment, regardless of how taxing it may be, and
failure may be seen as caused by the parents’ inability to carry
out the treatment. In addition to caring for their ill child, parents
face external pressures when engaging in treatment.
Time and Finances
In family-based therapy, the expectation is that the entire family
will attend treatment sessions. For parents, this may mean tak-
ing time off work every week (Plath, Williams, & Wood, 2016).
A study of caregivers with a loved one above the age of 18
diagnosed with an eating disorder found that 40% of caregivers
reported having high (>21 hr per week) face-to-face contact
with their child, most of which was spent giving emotional and
nutritional support (Raenker et al., 2013). Given the recom-
mended family-based therapy model, it can be assumed that the
time demands on caregivers of an adolescent include signifi-
cantly higher face-to-face contact and support with their child.
This leaves little time for parental self-care and preservation as
well as time for other children or other aspects of living.
In family-based therapy, parents are expected to take charge
of their child’s weight restoration and interruption of symptoms
(i.e., exercising, vomiting, and restricting). Parents are often
spending more time preparing meals, waiting hours over these
meals for their child to finish, and monitoring their child if there
is compulsive exercise or other harmful behaviors (Findlay
et al., 2010). A recent study by Månsson, Parling, and Swenne
(2016) identified that parent directive tasks for family-based
therapy include having the child stay home from school, having
all meals with a parent, and not allowing the child to exercise or
vomit. While parents who could implement these tasks had
children who gained weight more quickly, the time required
to do these tasks, coupled with the emotional turmoil that par-
ents experience while intervening, is significant.
If parents are to intervene and effectively interrupt eating
disorder symptoms, it may be required that the child be
removed from school and a parent take a leave of absence from
employment (Hillege, Beale, & McMaster, 2006). The finances
lost by taking time off work, gas mileage, and parking, com-
bined with (for some parents) needing to buy additional high
energy items (i.e., homogenized milk, boost-plus drink, and
high-calorie granola bars) can create added stress on parents
during an already challenging time. Single parent families may
need a longer duration in family-based therapy treatment,
meaning a longer duration spent in financial strain with only
one income (Lock, Agras, Bryson, & Kraemer, 2005).
ExemplarMegan was a 14 year old with a diagnosis of anor-
exia nervosa purging subtype. She had purging symptoms via
vomiting and excessive exercising. Her family consisted of her
father who worked as a car mechanic, her mother (Susan) who
worked at a grocery store, and two siblings aged 16 and 12.
Given the severity of Megan’s difficulties, Susan took a leave
of absence from work to be able to prepare all her meals and
provide supervision postmeals. Megan was also removed from
school at the beginning of treatment while her parents
attempted to refeed her.
During a session, Susan was tearful when explaining that
because she was not working, their family budget could not
accommodate soccer for her other two children. The siblings
were reportedly very angry and blamed Megan. The agency
was able to provide funding for the two children to attend
soccer; however, Susan stated that she was not sure whether
she or her husband had the energy or time to drive each child to
their soccer games while also being present for Megan.
Megan’s dinner would often take several hours to complete,
going well into the time when soccer would begin. When dis-
cussing if other parents of the soccer team members would be
able to bring the children to games, or if their father could take
over a meal role, Susan explained feeling guilty that all her
time and her husband’s was spent on Megan and that the other
two children were feeling neglected.
In the end, the siblings did not enrol in soccer. The siblings
were encouraged to continue to attend family-based therapy in
order to express their own frustrations and have their voices
heard; however, they often stated that they did not wish to
attend as they had other activities and homework they would
rather spend their time on than go to therapy.
Relationships
It is well-documented that eating disorders create tension and
challenges in family relationships (Gilbert, Shaw, & Notar,
2000; Highet, Thompson, & King, 2005; Hillege et al., 2006;
Honey & Halse, 2006). The demand family-based therapy has
on parents is exacerbated by potentially neglected relationships
with other family members. Maintaining relationships with
family members and friends is overshadowed by the reality
of the illness as well as the family-based therapy treatment and
its requirements. In family-based therapy, the whole family,
including siblings, are required to attend treatment, and family
vacations are often cancelled while the eating disorder beha-
viors are addressed and weight is restored (Gilbert et al., 2000).
These changes that affect the whole family can lead to resent-
ment, particularly between siblings, which adds another stres-
sor that parents need to manage.
Parents living together report that stress and strain increases
in their marriage (Hillege et al., 2006). This is a particularly
impactful reality of treatment, given that successful family-
based therapy requires parental unity and consistency. The
maintenance of the marital relationship and effective commu-
nication is crucial for successful treatment, yet time spent on
the couple relationship becomes less frequent. Parents are
under pressure to focus on creating consistent parenting proce-
dures and supervision of the child with an eating disorder.
Parents also report isolation from others (Treasure et al.,
2001). While relationships outside the home may offer addi-
tional support and respite for parents, making time for outside
relationships is difficult. In addition, parents report that many
Scarborough
outside individuals, including extended family members, do
not completely understand the illness, and feeling stigmatized
from community members is well-documented (Ebneter, Lat-
ner, & O’Brien, 2011; Griffiths, Mond, Murray, & Touyz,
2015; Mond, Robertson-Smith, & Vetere, 2006; Stewart, Keel,
& Schiavo, 2006; Stewart, Schiavo, Herzog, & Franko, 2008).
This may be particularly difficult for single parent families who
are tasked with refeeding without support from an immediate
partner.
ExemplarIn the case of Megan’s family, there were many
reports of relationship difficulties and struggles beyond the
siblings’ resentment of Megan and the time and attention she
received from her parents. Susan (Megan’s mother) often felt
that she was alone in the refeeding, despite her husband being
available at breakfast and dinners as well as on weekends.
Susan spoke of how her husband was the sole income earner
and was unable to wait for Megan to complete her breakfast as
time spent waiting for her meal to finished would make him
late for work. At dinnertime, Susan’s husband was often
exhausted from his job as a mechanic and would become short
and angry with Megan when she would not comply with her
meal. Susan felt this caused more stress in the family and in
their marital relationship.
When discussing how to create time to connect with her
husband, Susan struggled. Even in the evenings, it was difficult
to connect as Susan was sleeping in her daughter’s room
because Megan would exercise in the middle of the night.
Planning couple evenings out was also a struggle. Extended
family lived out of province and Susan’s friends really did not
understand the seriousness of the illness and how to support
Megan.
Susan continued in isolation refeeding her daughter with
great difficulty. The therapist recommended that Susan call the
agency and speak with a clinician when she was struggling,
feeling isolated, or just needed to vent. Often, after hours,
Susan would leave voice messages explaining the difficulties
she had that day.
Megan did regain weight to a healthy range and later ses-
sions were focused on repairing relationships within the family
with the clinician using emotion focused family therapy tech-
niques. This required additional sessions beyond those outlined
in manualized family-based therapy.
Parenting Adjustment and Eating Disorder Resistance
Family-based therapy requires that parents monitor all meals
for the ill child in order to achieve weight gain. For many
parents, this poses a challenge since adolescence is generally
a time of autonomous exploration, yet treatment requires that
parents put autonomy development on hold for their child’s
health. Parents have to learn a new way to discipline and raise
their adolescent. For some parents, the struggle is how to parent
a child whom they no longer recognize. For example, Treasure
et al. (2001) noted how an introverted and worrisome child had
turned into having a volatile personality with “violent mood
swings” (p. 345).
95
Many parents find it difficult to differentiate what is normal
adolescent behavior and what is distress caused by the eating
disorder. For this reason, parents struggle to determine how to
discipline their child’s (at times) violent or abusive reactions
(Honey & Halse, 2005). Due to these reactions, parents may not
challenge or set boundaries for their child’s behaviors and are
often described as walking on eggshells around the adolescent
(Gilbert et al., 2000; Highet et al., 2005). Siegel (2010) noted
that when parents experience intense emotions, such as fear,
they may lose their innate caregiving knowledge. For example,
the fear of reintroducing a challenging food item that may
result in severe distress in their child may lead a parent not
to introduce the food at all (Stillar et al., 2016). For parents, the
pressure to push their child to eat resisted foods, or a higher
volume of food, may prove to be too difficult and produce fear
in parents. In family-based therapy where parents are to func-
tion as nursing staff, it is almost impossible for them to do so
without becoming emotional. In fact, this is what makes the
task challenging. It can be particularly hard for parents to
remain focused on refeeding when their child is threatening
self-harm or suicide.
Eating disorder treatment can also be a lengthy process
lasting from 6 to 12 months. Parents are faced with the strug-
gles of mealtimes, often 6 times a day, that are frequently
accompanied by distressing behavioral and mood changes. Par-
ents are the target of the child’s verbal and at times physical
backlash (Treasure, 2010). Kyriacou, Treasure, and Schmidt
(2008) found that comorbid behaviors combined with the
child’s rejection of help contribute to caregiver strains.
A study by Coomber and King (2013) found individuals
with an eating disorder underestimate the level of burden that
their loved ones experience. While for other illnesses, parents
may receive some response of appreciation for the sacrifices
they have made, in the case of eating disorders this is often not
the norm. This consistent lack of appreciation from the child,
and in fact more of a negative response to parental efforts,
contributes to parents doubting their role in their child’s treat-
ment. This leads to a greater chance of disillusionment with the
recommended treatment and a higher risk of burnout.
ExemplarLeona was a 13-year-old female diagnosed with
anorexia nervosa. Her parents described her as a child
that never yelled and never needed to be disciplined.
However, once the family began family-based therapy,
Leona became extremely violent, hitting her head on the
table and screaming at her parents during mealtimes. Leo-
na’s parents struggled to discipline her. They were unsure
whether disciplining Leona would be viewed as punish-
ing her for a symptom she could not control. Leona’s
parents continued to ignore the violent outbursts, but
when she began to threaten suicide, her parents stated
they could not continue to push her to eat high-calorie
meals. Despite Leona admitting to the clinician that she
was not suicidal and it was a desperate emotional reac-
tion, her parents began to collaborate with Leona around
mealtimes in order to prevent the hostile environment at
96 The Family Journal: Counseling and Therapy for Couples and Families 26(1)
the dinner table. This collaboration led to continuous
weight loss as Leona took control of her meals, knowing
that her parents were fearful of challenging her.
Discussion
Although family-based therapy is a promising treatment for
adolescents diagnosed with an eating disorder, many factors
still need to be explored in terms of clinician barriers and
parental challenges that make this treatment difficult to imple-
ment. As stated by Rhodes, Baillie, Brown, and Madden
(2005), “given the establishment of the efficacy of the
[Family-Based Therapy], there is now a need for researchers
to turn their efforts to the question of how it can be improved”
(p. 400). By acknowledging these potential difficulties,
researchers and clinicians can create better supports for parents
in the treatment process.
The feasibility of resolving the barriers discussed in this
article is challenging. Additional finances for agencies are dif-
ficult to come by which affects proper training and supervision
for family-based therapy clinicians. For parents, a major issue
is what they can realistically give up without creating excessive
financial hardship. Agencies could potentially implement alter-
native session hours that are more in line with parent work
hours, but this requires agency staff to adjust their personal
lives and family responsibilities.
It would be useful for clinicians to frankly discuss with par-
ents the realities of life while in treatment and what they may
have to give up. As parental motivation is necessary for family-
based therapy, it is of importance to explore with parents what
could be demotivating to adopting this therapy model. Clini-
cians need to acknowledge the pressures and challenges that
parents will face in family-based therapy and have a clear dis-
cussion with parents on how to best support them through these
challenges. Making this a mandatory part of the initial clinical
assessment could be useful in starting the dialogue about chal-
lenges and how to problem solve issues as they arise. It may also
be beneficial for researchers to focus on how clinicians can
discuss these challenges with parents without shame or blame
and while maintaining hopefulness in the treatment.
Clinicians would benefit from supervision during family-
based therapy practice to uncover the ways in which their own
anxieties and judgments may impede them from implementing
the treatment. Supervision may also help with the transitioning
between treatments should there be a nonresponse to family-
based therapy. Agencies may benefit from implementing clin-
ical rounds that are focused specifically on the difficulties with
implementing family-based therapy, discussing specific cases
and problem-solving around these identified barriers. This
would help clinicians to remain true to the manualized model
of family-based therapy and to discuss key aspects of family-
based therapy that they struggle to implement rather than sim-
ply not applying the recommended tasks. This is also a more
cost-effective way to provide supervision.
The impact of the financial, relational, and emotional pres-
sures on parents is important for future research to explore. It is
also important to examine how parental experiences affect the
implementation of family-based therapy and long-term results.
By doing so, the field can better understand the challenges
parents face and how improvements could be made in order
to prevent dropout, parental burnout, and helping to combat the
potential chronicity of the illness.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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