Intermountain Project ECHO

Dementia Care

FAMILY BASED THERAPY

for Adolescent Anorexia Nervosa

Charlene Smith, LCSW

Clinical Social Worker/Therapist
Uzima Counseling, PLLC
Disclosures

The speaker has no significant financial

conflicts of interest to disclose.
 HISTORY
• Maudsley Hospital London; “The Maudsley Approach”- 1970s/1980s

o Dr.Christopher Dare and colleagues first to implement philosophy and intervention

and begin conducting research.

o Maudsley Service Manual for Child and Adolescent Eating Disorders (revised 2016)

o http://www.national.slam.nhs.uk/wp-content/uploads/2011/11/Maudsley-
Service-Manual-for-Child-and-Adolescent-Eating-Disorders-July-2016.pdf
 HISTORY
• Manualized in United States

o Daniel LeGrange, PhD and James Lock, MD (1990s on).

o Treatment Manual for Anorexia Nervosa; A Family Based Approach (2nd edition 2013).

o Training Institute for Child and Adolescent Eating Disorders.

o http://train2treat4ed.com/
 Philosophy – Out with the old in with the new
• Old Philosophy
o Ed is a result of dysfunctional family dynamics (blaming parents).
o Adolescent chose to have an eating disorder and will need to want to get better (blaming client).
o Therapy must address the root cause before the client will get any better.
o Individual therapy and in-patient care.

• New philosophy
o Parents nor client are to blame.
o Parents are a key resource for recovery and are the experts on their children and their family.
o Full nutrition is necessary for recovery from Anorexia Nervosa.
o Parents can and must require their child to eat the types and amounts of food needed to recover.
o Outpatient therapy.
o Therapist is a consultant/coach to the family as they work toward recovery.
 RESEARCH OUTCOMES
• 20 plus years and continuing.

• Illness for short period of time (less than 3 years) and early onset (under 18).

• Supports efficacy of FBT for treatment of Anorexia Nervosa in adolescent

population.

• Quicker return to healthy weight and normal eating behaviors.

• Higher percentage in remission at follow up.

 OVERVIEW
• Outpatient
• Parents take charge of food until adolescent can take it over.
• Therapist is a consultant to the family coaching them in re-feeding and
returning to pre-eating disorder.
• Entire family is involved
• 3 Phase treatment
• 15-20 treatment sessions over a 12 month period
 PHASE ONE – Weight Restoration
THERAPIST
• Provides psychoeducation on dangers of associated severe malnutrition.
• Assesses families typical interaction patterns and eating habits.
• Family meal in therapist office.
• Models non critical and non-confrontational approach.
• Session focus: What is working, what is not, and therapist supports/coaches parents and client in
finding and implementing solutions. Empower parents.
• Treatment with family as opposed to treatment of family.

PARENTS
• Take charge of food: make and plate types and amount of food needed for weight restoration.
• 1-3 pounds a week.
• Client is not in charge of food: what, where, when, how.
• Client is required to eat what is provided.
• Re-align client with siblings and family norms around food.
 PHASE TWO: Returning control of eating over
to adolescent
Client demonstrates ability to eat what is provided, steady weight gain of about 1-3
pounds a week, improvement in client and family mood, decrease in ED behaviors,
and generalized anxiety around ED.

• Client begins step by step to take charge of his or her eating (developmental and
family norms apply).
• Weight is monitored and should continue to increase toward maintenance.
• Continued coaching and exploration into day to day family dynamics/client barriers
that interfere with parents' ability to support continued weight gain and the decline
of ED behaviors.
 PHASE THREE: Establishing healthy
adolescent identity
Adolescent demonstrates ability to keep weight at maintenance and ED behaviors
have subsided; eating on own.

• Support family and client in re-establishing identity outside of ED.

• Support relapse prevention plan and strategies for continued success with
recovery behaviors.
• Identify and address client’s existing mental health needs, absent of the ED.
• Identify and address existing family therapy needs, absent of the ED.
• Potentially refer client and/or family out.
 ROLE of ED TEAM
Physician: Due to medical complications associated with Anorexia
Nervosa client will always work directly with a medical doctor.

Dietician: Utilized on an as needed basis. Will join therapy session with

therapist to coach parents if needed.

Weight Checks: Traditionally in therapist office, not blind.

 CONTRAINDICATIONS
• Complicating family dynamics (ED parent, substance use, abuse...)

• Logistics (work, single parent...)

• Comorbidity ( Autism, significant self-harm behaviors, severe

persistent mental illness)
 THE FUTURE
• Research being conducted on FBT for BN as well as young adults.

• Fidelity – Are therapists using the manualized protocols?

• Expansion on the current models.

• Continued research on alternative interventions.

 APPLIED FBT
Two case studies to explore…
 REFERENCES
• Le Grange, D., and J. Lock. 2005. The dearth of psychological treatment studies for anorexia nervosa. International Journal of Eating Disorders, 37, 2005, 79-91.
• LE Grange, D., and Eisler, I. Family interventions in adolescent anorexia nervosa. Child and Adolescent Psychiatric Clinics of North America, 2009, 18, 159-173.
• 2) Eisler, I., Dare, C., Hodes, M., Russell, G., Dodge, E., and D. Le Grange. 2000. Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family
interventions. Journal of Child Psychology and Psychiatry, 41, 727-736.
• Le Grange, D., Eisler, I., Dare, C., and G. Russell. 1992. Evaluation of family treatments in adolescent anorexia nervosa: a pilot study. International Journal of Eating Disorders, 12, 347-
357.; Russell, G. F. M., Szmukler, G. I., Dare, C., and I. Eisler. 1987. Family therapy versus individual therapy for adolescent females with anorexia nervosa and bulimia nervosa. Archives
of General Psychiatry, 44, 1047-1056.
• Eisler, I., Dare, C., Russell, G. F. M., Szmukler, G. I., Le Grange, D., and E. Dodge. 1997. Family and individual therapy in anorexia nervosa: A five-year follow-up. Archives of General
Psychiatry, 54, 1025-1030.
• Le Grange, D., Binford, R., and K.L. Loeb. 2005. Manualized family-based treatment for anorexia nervosa: A case series. Journal of the American Academy of Child and Adolescent
Psychiatry, 44, 41-46.
• Lock, J., Agras, W.S., Bryson, S., and H. Kraemer. 2005. A comparison of short- and long-term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child
and Adolescent Psychiatry, 44, 632-639.
• Lock, J., Le Grange D., Agras, WS., Moye, A., Bryson, SW., and B. Jo. 2010. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for
adolescents with anorexia nervosa. Archives of General Psychiatry, 67, 1025-32.
• Lock, J., Le Grange, D., Agras, W. S., C. Dare. 2001. Treatment manual for anorexia nervosa: A family-based approach. New York: Guildford Publications, Inc.
• Le Grange, D., Lock, J.D., Loeb, K., & Nichols, D. (2009). Academy for Eating Disorders Position Paper: The Role of Families in Eating Disorders.
• Lock, J.D., Le Grange, D., Agras, S., Moye, A., Bryson, S.W., Jo, B. (2010). Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for
adolescents with anorexia nervosa. Archives of General Psychiatry, 67, 1025-1032.
• Renee D Rienecke (2017) Family based treatment of eating disorders in adolescents: current insights. ​Adolesc Health Med Ther. 8: 69–79.
Continuing Education
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