Family-Based Therapy for Pediatric Anorexia Nervosa

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 frequently 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. Presently, family-based therapy does not explicitly acknowledge the additional pressures that parents face when engaged in treatment. Everyday family demands (e.g., finances, relationships) 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 successful 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 clinicians 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 exemplar from family-based therapy practice. The article concludes with a discussion of implications and suggestions for improvement.

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 motivates parents to facilitate their child’s recovery by preparing and supervising meals. Family-based therapy is a weekly outpatient 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 disorders 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 dysfunctions 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 development of family-based therapy, which led to controlled studies 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 reaching >95% ideal body weight and within 1 standard deviation of community norms on the Eating Disorder Examination Questionnaire (Lock et al., 2010). In family-based therapy, parents are seen as “functioning similar to an effective inpatient nursing 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 therapist can view and assist parents in encouraging their child to eat a meal the parents bring. Throughout Phase 1, the therapist models a noncritical stance toward the ill child and continues 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 indicated 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 psychopathology 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 implementing 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). Parents who present as hostile or overly critical may be better suited for a separated form of family-based therapy, whereby the therapist 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-based challenges. Through these observations, a number of implementation issues have been identified.

In addition to clinical practice observations, and conversations 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 comprehensive 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 literature 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 challenges, 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 administrative experiences.

Family-Based Therapy Demands on Clinicians

Clinicians who are trained in family-based therapy are fortunate to have the ability to implement the most up to date, evidence-based treatment for families who have a child diagnosed with an eating disorder. Despite having formal training in this therapy, there remain several challenges that have consequences 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 meetings, 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 clinicians 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 therapy 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 treatment. 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 adolescents reported that negative emotions impacted clinician decisions (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 maintaining a nonjudgmental and nonblaming stance toward parents. Yet Couturier et al. (2013) reported that some clinicians had “little sympathies for families who do not attend appointments during normal work hours, because therapists feel families 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 supported the parents’ decisions since the child was not engaging with the family-based therapy clinician and thus was not getting 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 contradicting messages were given from the private therapist about the parents’ role in refeeding. The private therapist recommended that Sam’s parents stop preparing and supervising 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 continued while in private treatment for depression. The private therapist eventually discharged Sam from her care as the medical 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 moderators identified as having an impact on the outcome are (1) the eating disorder’s severity at clinical assessment, (2) diagnosed 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 strongest 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 complements to boost family-based therapy effectiveness or as alternative 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 nonresponse to family-based therapy. Clinicians can also struggle with how to effectively change and manoeuvre between these treatments. As a result, the pressure clinicians may place on parents to adhere to the family-based therapy treatment recommendations may increase frustrations and a sense of hopelessness 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 becoming 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 agreement. 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 implemented for about six sessions, or a month and a half, but his weight loss continued. After a lengthy discussion during clinical 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 sessions as well as how to deal with Justin continuing to make his own meals separate from the family. This, in fact, led to conflict as his parents would attempt to try to implement aspects of family-based therapy despite no longer following this treatment model. Justin’s parents struggled to be supportive of Justin’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 disorders, instead they are seen as part of the solution. However, 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 recommended 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 taking 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 recommended family-based therapy model, it can be assumed that the time demands on caregivers of an adolescent include significantly 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 parents 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, combined 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 anorexia 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 discussing 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 behaviors are addressed and weight is restored (Gilbert et al., 2000). These changes that affect the whole family can lead to resentment, particularly between siblings, which adds another stressor 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 communication 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 procedures 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 additional support and respite for parents, making time for outside relationships is difficult. In addition, parents report that many outside individuals, including extended family members, do not completely understand the illness, and feeling stigmatized from community members is well-documented (Ebneter, Latner, & 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 sessions were focused on repairing relationships within the family with the clinician using emotion focused family therapy techniques. 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).

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 function 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 struggles of mealtimes, often 6 times a day, that are frequently accompanied by distressing behavioral and mood changes. Parents 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 treatment. 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. Leona’s parents struggled to discipline her. They were unsure whether disciplining Leona would be viewed as punishing 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 reaction, her parents began to collaborate with Leona around mealtimes in order to prevent the hostile environment at 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 implement. 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 difficult 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 alternative 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 parents 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. Clinicians need to acknowledge the pressures and challenges that parents will face in family-based therapy and have a clear discussion 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 challenges 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 clinical 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 simply not applying the recommended tasks. This is also a more cost-effective way to provide supervision.

The impact of the financial, relational, and emotional pressures 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.

Footnotes

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, authorship, and/or publication of this article.

References

American Psychiatric Association. (2006). Treatment of patients with eating disorders, 3rd ed. American Journal of Psychiatry, 163, 4–54.

Coomber

King

R. M.

(2013). Perceptions of carer burden: Differences between individuals with an eating disorder and their carer. Eating Disorders, 21, 26–36.

Couturier

Kimber

Jack

Niccols

Van Blyderveen

McVey

(2013). Understanding the uptake of family-based treatment for adolescents with anorexia nervosa: Therapist perspectives. International Journal of Eating Disorders, 46, 177–188. doi:10.1002/eat.22049

Crow

S. J.

Peterson

C. B.

Swanson

S. A.

Raymond

N. C.

Specker

Eckert

E. D.

Mitchell

J. E.

(2009). Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry, 166, 1342–1346.

Dalle Grave

Calugi

Doll

H. A.

Fairburn

C. G.

(2013). Enhanced cognitive behaviour therapy or adolescents with anorexia nervosa: An alternative to family therapy? Behaviour Research and Therapy, 51, R9–R12. doi:10.1016/j.brat.2012.09.008

Dare

Eisler

Russell

G. F. M.

Szmukler

G. I.

(1990). Family therapy for anorexia nervosa: Implications from the results of a controlled trial of family and individual therapy. Journal of Marital Family Therapy, 16, 39–57.

Doyle

P. M.

Le Grange

Loeb

Doyle

A. C.

Crosby

R. D.

(2010). Early response to family-based treatment for adolescent anorexia nervosa. International Journal of Eating Disorders, 43, 659–662. doi:10.1002/eat.20764

Ebneter

D. S.

Latner

J. D.

O’Brien

K. S.

(2011). Just world beliefs, causal beliefs, and acquaintance: Associations with stigma toward eating disorders and obesity. Personality and Individual Differences, 51, 618–622.

Fitzpatrick

K. K.

Moye

Hoste

Lock

Le Grange

(2010). Adolescent focused psychotherapy for adolescents with anorexia nervosa. Journal of Contemporary Psychotherapy, 40, 31–39. doi:10.1007/s10879-009-9123-7

10.

Findlay

Pinzon

Taddeo

Katzman

D. K.

, Canadian Paediatric Society, & Adolescent Health Committee. (2010). Family-based treatment of children and adolescents with anorexia nervosa. Guidelines for the community physician. Paediatrics and Child Health, 15, 31–35.

11.

Fisher

(2006). Treatment of eating disorders in children, adolescents, and young adults. Pediatric Review, 27, 5–16.

12.

Fisher

Schneider

Burns

Symons

Mandel

F. S.

(2001). Differences between adolescents and young adults at presentation to an eating disorders program. Journal of Adolescent Health, 28, 222–227. doi:10.1016/S1054-139X(00)00182-8

13.

Gilbert

A. A.

Shaw

S. M.

Notar

M. K.

(2000). The impact of eating disorders on family relationships. Eating Disorders, 8, 331–345.

14.

Godart

Berthoz

Curt

Perdereau

Rein

Wallier

… Jeammet

(2012). A randomized controlled trial of adjunctive family therapy and treatment as usual following inpatient treatment for anorexia nervosa adolescents. PLoS One, 7, e28249. doi:10.1371/journal.pone.0028249

15.

Golan

Crow

(2004). Parents are key players in the prevention and treatment of weight-related problems. Nutrition Reviews, 62, 39–50.

16.

Griffiths

Mond

J. M.

Murray

S. B.

Touyz

(2015). The prevalence and adverse associations of stigmatization in people with eating disorders. International Journal of Eating Disorders, 48, 767–774. doi:10.1002/eat.22353

17.

Harris

E. C.

Barraclough

(1998). Excess mortality of mental disorder. The British Journal of Psychiatry, 173, 11–53. doi:10.1192/bjp.173.1.11

18.

Highet

Thompson

King

R. M.

(2005). The experience of living with a person with an eating disorder: The impact on the carers. Eating Disorders, 13, 327–344.

19.

Hillege

Beale

McMaster

(2006). Impact of eating disorders on family life: Individual parents’ stories. Journal of Clinical Nursing, 15, 1016–1022.

20.

Honey

Halse

(2005). Parents dealing with anorexia: Actions and meanings. Eating Disorders: The Journal of Treatment and Prevention, 13, 353–367.

21.

Honey

Halse

(2006). The specifics of coping: Parents of daughters with anorexia nervosa. Qualitative Health Research, 16, 611–629.

22.

Kosmerly

Waller

Lafrance Robinson

(2015). Clinician adherence to guidelines in the delivery of family-based therapy for eating disorders. International Journal of Eating Disorders, 48, 223–229.

23.

Krautter

T. H.

Lock

(2004). Treatment of adolescent anorexia nervosa using manualized family-based treatment. Clinical Case Studies, 3, 107–123.

24.

Kyriacou

Treasure

Schmidt

(2008). Understanding how parents cope with living with someone with anorexia nervosa: Modeling the factors that are associated with carer distress. International Journal of Eating Disorders, 41, 233–242.

25.

Lafrance Robinson

Dolhanty

(2013). Emotion-focused family therapy for eating disorders across the lifespan. National Eating Disorder Information Centre Bulletin, 28, 1–4. Retrieved from http://emotionfocusedfamilytherapy.org/wp-content/uploads/2016/07/NEDIC.EFFT_.pdf

26.

Lafrance Robinson

Kosmerly

(2014). The influence of clinician emotion on decisions in child and adolescent eating disorder treatment: A survey of self and others, eating disorders. The Journal of Treatment & Prevention, 23, 162–176. doi:10.1080/10640266.2014.976107

27.

Lask

Roberts

(2013). Family cognitive remediation therapy for anorexia nervosa. Clinical Child Psychology and Psychiatry. Advance online publication. doi:10.1177/1359104513504313

28.

Le Grange

(2005). The maudlsey family-based treatment for adolescent anorexia nervosa. World Psychiatry. 4, 142–146.

29.

Le Grange

Eisler

Dare

Hodes

(1992). Family criticism and self-starvation: A study of expressed emotion. Journal of Family Therapy, 14, 177–192.

30.

Le Grange

Lock

(2011). Eating disorders in children and adolescents: A clinical handbook. New York, NY: Guilford Press.

31.

Le Grange

Lock

Agras

W. S.

Moye

Bryson

S. W.

Kraemer

H. C.

(2012). Moderators and mediators of remission in family-based treatment and adolescent focused therapy for anorexia nervosa. Behaviour Research and Therapy, 50, 85–92.

32.

Le Grange

Lock

Loeb

Nicholls

(2010). Academy for eating disorders position paper: The role of the family in eating disorders. International Journal of Eating Disorders, 43, 1–5. doi:10.1002/eat.20751

33.

Lock

Agras

S. W.

Bryson

Kraemer

H. C.

(2005). A comparison of short- and long-term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 632–639. doi:10.1097/01.chi.0000161647.82775.0a

34.

Lock

Couturier

Bryson

Agras

W. S.

(2006). Predictors of dropout and remission in family therapy for adolescent anorexia nervosa in a randomized clinical trial. International Journal of Eating Disorders, 39, 639–647.

35.

Lock

Le Grange

Agras

W. S.

Dare

(2001). Treatment manual for anorexia nervosa: A family-based approach. New York: Guildford Publications, Inc.

36.

Lock

Le Grange

(2013). Treatment manual for anorexia nervosa: A family based approach (2nd ed.). New York, NY: Guilford Press.

37.

Lock

Le Grange

Agras

W. S.

Moye

Bryson

S. W.

(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.

38.

Loeb

K. L.

Le Grange

(2009). Family-based treatment for adolescent eating disorders: Current status, new applications and future directions. International Journal of Child and Adolescent Health, 2, 243.

39.

Månsson

Parling

Swenne

(2016). Favorable effects of clearly defined interventions by parents at the start of treatment of adolescents with restrictive eating disorders. International Journal of Eating Disorders, 49, 92–97.

40.

Minuchin

Baker

Rosman

B. L.

Liebman

Milman

Todd

T. C.

(1975). A conceptual model of psychosomatic illness in children: Family organization and family therapy. Archives of General Psychiatry, 32, 1031–1038.

41.

Minuchin

Rosman

B. L.

Baker

(1978). Psychosomatic families: Anorexia nervosa in context. Cambridge, MA: Harvard University Press.

42.

Mitchum

(2010, 10 5). A new gold standard for Anorexia Treatment. Retrieved from https://sciencelife.uchospitals.edu/2010/10/05/a-new-gold-standard-for-anorexia-treatment/

43.

Mond

J. M.

Robertson-Smith

Vetere

(2006). Stigma and eating disorders: Is there evidence of negative attitudes towards anorexia nervosa among women in the community? Journal of Mental Health, 15, 519–532.

44.

Murray

S. B.

Le Grange

(2014). Family therapy for adolescent eating disorders: An update. Current Psychiatry Report, 16, 1–7.

45.

Nielsen

(2001). Epidemiology and mortality of eating disorders. Psychiatric Clinics of North America, 24, 201–214.

46.

Plath

Williams

L.T.

Wood

(2016). Clinicians’ views on parental involvement in the treatment of adolescent anorexia nervosa. Eating Disorders, 24, 1–19.

47.

Raenker

Hibbs

Goddard

Naumann

Arcelus

Ayton

… Treasure

(2013). Caregiving and coping in carers of people with anorexia nervosa admitted for intensive hospital care. International Journal of Eating Disorders, 46, 346–354.

48.

Rienecke

(2017). Family-based treatment of eating disorders in adolescents: Current insights. Adolescent Health, Medicine and Therapeutics, 8, 69–79. doi:10.2147/AHMT.S115775

49.

Rhodes

Baillie

Brown

Madden

(2005). Parental efficacy in the family-based treatment of anorexia: Preliminary development of the parents versus anorexia scale (PVA). European Eating Disorders Review, 13, 399–405.

50.

Robinson

A. L.

Dolhanty

Greenberg

. (2013). Emotion-focused family therapy for eating disorders in children and adolescents. Clinical Psychology & Psychotherapy. Advance online publication. doi:10.1002/cpp.1861

51.

Scott

Briskman

Woolgar

Humayun

O’Connor

T. G.

(2011). Attachment in adolescence: Overlap with parenting and unique prediction of behavioural adjustment. Journal of Child Psychology and Psychiatry, 52, 1052–1062.

52.

Siegel

D. J.

(2010). Mindsight. New York, NY: Bantam Books.

53.

Smick

F. R.

van Hoeken

Hoek

H. W.

(2012). Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Report, 14, 406–414.

54.

Steiger

(2017). Evidence informed practices in the real-world treatment of people with eating disorders. Eating Disorders, 25, 173–181.

55.

Stewart

M. C.

Keel

P. K.

Schiavo

R. S.

(2006). Stigmatization of anorexia nervosa. International Journal of Eating Disorders, 39, 320–325.

56.

Stewart

M. C.

Schiavo

R. S.

Herzog

D. B.

Franko

D. L.

(2008). Stereotypes, prejudice and discrimination of women with anorexia nervosa. European Eating Disorders Review, 16, 311–318.

57.

Stillar

Strahan

Nash

Files

Scarborough

Mayman

… Lafrance Robinson

(2016). The influence of carer fear and self-blame when supporting a loved one with an eating disorder. Eating Disorders, 24, 173–185.

58.

Training Institute for Child and Adolescent Eating Disorders. (2017, 2 7). Retrieved from www.train2treat4ed.com

59.

Treasure

(2010). How do families cope when a relative has an eating disorder? In Treasure

Schmidt

MacDonald

(Eds.), The clinician’s guide to collaborative caring in eating disorders: The new maudsley method (pp. 145–159). East Sussex, London: Routledge.

60.

Treasure

Murphy

Szmukler

Todd

Gavan

Joyce

(2001). The experience of caregiving for severe mental illness: A comparison between anorexia nervosa and psychosis. Social Psychiatry and Psychiatric Epidemiology, 36, 343–347.

61.

Waller

Stringer

Meyer

(2012). What cognitive-behavioral techniques do therapists report using when delivering cognitive behavioral therapy for the eating disorders? Journal of Consulting and Clinical Psychology, 80, 171–175.

62.

Weaver

Liebman

(2011). Assessment of anorexia nervosa in children and adolescents. Current Psychiatry Report, 13, 93–98.

63.

Woodside

Halpert

Dimitropoulos

(2015). Implementing Behavioural family therapy in complex settings. In Loeb

K. L.

Le Grange

Lock

(Eds.), Family therapy for adolescent eating and weight disorders: New applications (pp. 361–371). New York, NY: Routledge.