Family-based treatment (FBT) for adolescents with anorexia nervosa (AN) has been gaining research support as an effective treatment modality for this patient population (Lock et al., 2010), and has been recommended by the American Psychiatric Association (2006) and the U.K.’s National Institute for Clinical Excellence (Wilson & Shafran, 2005). Although the treatment has been manualized and there have been successful efforts to disseminate the approach (Lock & Le Grange, 2012; Loeb et al., 2007), there remains a dearth of clinicians offering FBT.
A recent study by Couturier and colleagues (2013) examined barriers and facilitating factors to therapists implementing FBT for adolescents with AN. This qualitative study involved interviewing 40 therapists who provided therapy to this patient population. The results were rather alarming, with the authors stating, “Although participants expressed a clear and definite commitment to providing their patients with the best possible care, there remains not one participant who reported practicing FBT with fidelity to the model.” (p. 186).
Some barriers to implementing FBT, such as lack of director/administrator support, lack of an organization’s commitment to training, or lack of AN referrals, point to practical organizational and systemic considerations that may hinder a clinician’s ability to offer FBT. However, other reported barriers to implementing FBT seemed to be based on misunderstandings about the treatment model itself or on discomfort with interacting with the eating disorder.
For example, the manualized version of FBT does not include a dietitian. However, only 15% of the therapists interviewed stated that dietitians do not need to be involved in treatment. One therapist said, “I don’t like that piece. I’m not a dietician…I don’t talk about carbs, I don’t talk about caloric intake, I don’t talk about…how many fruits and vegetables…or portion sizes. Because I don’t know that information. So…I would feel like I’m working outside my scope of practice to be doing that piece because I don’t have that information” (p. 180).
The lack of dietitians in the manualized version of FBT can elicit strong reactions from therapists, often due to feeling unqualified to provide nutrition advice to families. Although it is true that therapists do not have the expertise that dietitians have, it is important to remember that FBT therapists are not required to provide specific information about carbohydrates, exchanges, portion sizes, etc. Families are told that most children require 3000-5000 calories per day for weight restoration, and the therapist and physician will guide parents in reaching this calorie goal. During refeeding, having a “balanced” diet that includes a certain number of servings of fruits/vegetables per day is not the focus of treatment. The focus of treatment is on increasing caloric intake, e.g., whole milk rather than skim milk, ice cream rather than frozen yogurt, pasta with cream sauce rather than a salad with light dressing. This is knowledge that many therapists, parents, and people in general already have. FBT therapists are not expected to act as substitutes for dietitians. Rather, they are asked to draw on their knowledge about food in general to guide families in increasing a patient’s calories.
Another reported barrier to implementing FBT was therapists’ discomfort with weighing their patients. In FBT, the therapist weighs the patient at the beginning of each session, and weight gain or loss sets the tone and focus of the rest of the therapy session. One study participant stated, “the dietician does the weight or the family doctor does the weight, we don’t really need to know, it’s ok” (p. 181). This is a commonly cited concern by therapists new to FBT. Some worry that it will damage the therapeutic rapport, while other therapists fear the anger or emotional response that may result from being weighed. Eating disorders are very powerful illnesses that take over a person’s behaviors, thoughts, and emotions when it comes to issues of food, eating, and weight. The goal of FBT is to take this control away from the eating disorder and place it in the hands of the patient’s parents and treatment team. Parents are put in charge of the weight restoration process by making all food-related decisions for their child at the beginning of treatment. In order to know how well parents are doing in this regard and to be able to provide them with appropriate feedback, therapists must be aware of the patient’s weight. This may happen in the face of anger or resistance on the part of the eating disorder. Weighing the patient while remaining calm in the face of this anger sends an important message to the eating disorder that it is no longer in charge, and provides an opportunity for the therapist to model effective behaviors to parents. To beat these powerful illnesses, neither parents nor the treatment team can be scared of the illness. Accommodating the disorder by not weighing the patient sends a message to the eating disorder that it is still in charge, and sends a message to patients that their treatment team is not quite up to the task of helping them recover.
Another circumstance in which therapists might accommodate the eating disorder is by avoiding the family meal. Typically during the second session of FBT, the family brings a meal and eats in the therapist’s office. This provides an opportunity for the therapist to educate parents about the amount of food that will be needed for weight restoration, to observe ways in which the parents interact with their child and with the eating disorder, and to coach parents in more effective ways of managing eating disordered behavior. Although the family meal can be challenging, it is an immensely useful therapeutic tool. However, only 25% of the therapists interviewed reported completing the family meal on a regular basis. In addition to practical issues of space or lack of training, therapists cited “a sense of intimidation and anxiety” as reasons for not doing the family meal. As with weighing a patient, therapists who are scared of the eating disorder will not be able to effectively guide parents in defeating the illness.
When therapists are uncomfortable with certain aspects of the therapy approach and change elements of the treatment, the version being offered is no longer the version that has been shown to be effective in randomized controlled trials. This is problematic because it may result in patients receiving less effective forms of treatment. Equally problematic is when therapists choose not to offer an empirically-supported form of treatment at all. It is true that interacting with a disorder as strong as anorexia nervosa can be very challenging for therapists. However, successfully implementing FBT is empowering for therapists as well as parents, and can increase therapists’ confidence in their ability to carry out this form of treatment. When practical and organizational factors are not hindering the implementation of FBT, it should be offered to families in the form in which it has been found to be effective.
American Psychiatric Association (APA). (2006). Treatment of patients with eating disorders, 3rd ed. American Journal of Psychiatry, 163, 4-54.
Couturier, J., et al. (2013). Understanding the uptake of family-based treatment for adolescents with anorexia nervosa: Therapist perspectives. International Journal of Eating Disorders, 46, 177-188.
Lock, J., & Le Grange, D. (2012). Treatment manual for anorexia nervosa: A family-based approach, 2nd ed., New York: Guilford Press.
Lock, J., et al. (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.
Loeb, K. L., et al. (2007). Open trial of family-based treatment for full and partial anorexia nervosa in adolescence: Evidence of successful dissemination. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 792-800.
Wilson, G. T. & Shafran, R. (2005). Eating disorder guidelines from NICE. Lancet, 365, 79-81.
Renee Hoste, PhD is Director of Clinical Services and Research of the University of Michigan Comprehensive Eating Disorders Program and Clinical Assistant Professor in the Department of Psychiatry. After earning her Bachelor’s degree at the University of Michigan, Dr. Hoste received her PhD from Northwestern University and completed her clinical psychology internship and postdoctoral fellowship at the University of Chicago before joining the faculty as part of the Eating Disorders Program. During her ten years at there, she served as a study therapist on three NIMH-funded treatment studies comparing family based treatment to other forms of psychotherapy. Her research interests include the impact of the family on treatment outcome for adolescent eating disorders, the role of expressed emotion in treatment outcome, and cross-cultural differences in expressed emotion. Her clinical work involves providing empirically-supported treatments to adolescents and adults with disordered eating.