When Family-Based Treatment Fails
Vol. 31 / No. 4 — Eating Disorders Review
Family-based treatment (FBT) for adolescents with AN is well established, but does not always work. There may be a variety of explanations for this, including failure by the therapist. As a result the family and teen may not adhere to the original guidelines and may alter or modify the suggested treatment, or drop out of treatment altogether. What can be done?
Kellie R. Lavender of the New Zealand Eating Disorders Clinic, a private specialist outpatient clinic in Auckland, New Zealand, has shared her experiences with “rebooting” nine failed FBT cases between 2017 and 2019 (Front Psychiatry. 2020; 11:68). All nine families and their children agreed to try FBT a second time. One family dropped out; four families are still in treatment, and four other families have successfully completed treatment. After studying her results, Dr. Lavender emphasized five crucial areas essential to achieving successful FBT.
Getting it right from the beginning
All the families reported knowing what FBT entailed and had done extra reading, met with support groups, and participated in online forums. However, although all family members, including the patient’s siblings, had attended at least the first two sessions, further investigation showed that the family lacked the depth of understanding and knowledge of the core principles of FBT. When the sessions were redone a second time, each family commented that they had not really “gotten” the information the first time around about the nature of anorexia and how it affected their child. In the second treatment attempt, extra time was spent helping the parents understand the connection between what they knew about anorexia and how it affected their child. The second session, the meal session, was one that most families wanted to skip because they had experienced so much anxiety during the previous meal session. In response, the therapist slightly reduced the time for the meal session, but included it the second time.
Empowering the parents
Although all patients had achieved a weight gain of 2.3 kg or more during the first month of treatment, which was established as a key predictor of success, the need to “re-feed” their child sometimes became the parents’ sole goal. After this early success, most parents reported that they had felt “stuck”—three families reported that they were unable to transition to phase 2 of treatment. When they were seen for the second time, all parents told Dr. Lavender that they were exhausted, and felt hopeless and sometimes guilty about being a “failure” at parenting or being unable to feed their daughters.
Parental empowerment is more than being in charge of food, the author noted. Instead, it is a complex concept that involves parents becoming more confident when making decisions required for their child to recover from AN. One of the critical issues that required careful attention when starting FBT for the second time was determining whether the parents felt empowered. To do so requires actively identifying the family’s perspectives and strengths, reinforcing healthy decision-making, and setting clear expectations for treatment tasks and goals.
Attending to anorexic behaviors, not just weight regain
Sometimes the focus on weight restoration may eclipse taking care of anorexic behaviors and habits. The families also reported that despite their daughter’s weight gain, eating disorder cognitions and body image concerns had remained unchanged. The families as a whole seemed to be lacking the understanding needed to challenge and help change eating-disorder-related behaviors. Many of the teens admitted that they had hidden food and used water-loading and hidden weights or had secretly exercised during the first FBT treatment sessions.
In the second FBT sessions, the therapeutic discussion turned to food and eating behaviors and then to gradual transfer of responsibility from the parents to the teen. The first task for the families was to be aware of anorexic behaviors or to uncover behaviors they had overlooked the first time around. The parents also learned to solve problems and to stop unwanted behaviors in a systematic way. Often these anorexic behaviors had been missed and were habit-based, and the teens were initially anxious about having to “give them up.” However, as the behaviors lessened over time, the teens reported being less anxious and agitated. Dr. Lavender commented that in time the teens became very active participants in the sessions. During the first FBT sessions, the focus had been on increasing the amount of food they were supposed to consume. The parents hadn’t noticed that this was distressing to their child, which in turn led to a lack of faith and trust in the parents.
Where was the therapeutic alliance?
Nearly all parents were concerned about their perception of a lack of therapeutic alliance between the previous therapist and their child. In seven cases, families had transitioned to individual treatment when they thought FBT was failing.
Rebooting FBT after a teen patient has undergone individual treatment is always challenging, the author noted, because of the reluctance of the teens to renounce their perceived control and autonomy. For five of the families who restarted treatment, the young person (the teens were older than 17) was given more individual time at the beginning of sessions. At first, this was approximately 15 minutes of the 60- to 70-minute treatment sessions. However, the author noted that it was important to stress to parents and patients that this was not individual treatment, and the therapist made certain to continue to empower the parents, to avoid being drawn into divisive behaviors, and to continue to reiterate the need for parents to be part of the decision-making conversations.
Full completion of treatment
Finally, none of the families had experienced the third phase of FBT, and this was a new concept for them. Some felt that once their child’s weight was recovered, and exercise and eating behavior achieved, further work wasn’t needed. And, some studies have suggested that phase 3 may not be needed for some families (Adolesc Psychiatry. 2005; 44:632). It took persistence by the therapist to convince families not to skip phase 3. Dr. Lavender pointed out that phase 3 is meant to be brief and to ensure that the adolescent is on track developmentally. It also helps families to identify areas of need that may have left their child vulnerable the first time around. Phase 3 was not focused on the eating disorder per se but on other life issues and offered a means to model age-appropriate independence.
Dr. Lavender noted that the most critical point to consider is that it was possible to achieve full recovery by repeating FBT treatment, even after “failed” FBT. More broadly, this report underscores the value of careful and faithful administration of treatments such as FBT.