Working with Whānau –Treatment Options

for Adolescent Eating Disorders

Heidi Brace

Adolescent Family Therapist

South Island Eating Disorders Service

April 2020

Two Segments

◼Whānau involvement in treatment

across diagnoses

◼Maudsley Family Therapy

Involving Whānau in Treatment

◼ Different levels of involvement

◼ Depending on diagnosis

◼ Depending on age of adolescent

◼ Situation, eg living arrangements

◼ Safety, eg may be contraindicated

◼ Evidence-based research

◼ Continuum of involvement

◼ From parents taking total control initially

through to no or very little involvement

Anorexia Nervosa

◼ Maudsley Family Therapy/ MFBT is the

treatment with the most evidence

◼ Parents take control in Phase 1; handed back

to adolescent in Phase 2/3

◼ Contraindicated in cases of violence or

parental abuse

◼ Primary diagnosis

Bulimia Nervosa

◼ Individual CBT treatment

◼ Depending on age of adolescent, may be

“Individual with Family Involvement”

◼ A version of Maudsley also an option, esp if

severely impacting on the whole family

◼ Psycho-education for family members

ARFID

◼ Avoidant/Restrictive Food Intake Disorder

◼ If living at home, most likely “Individual with

Family Involvement” for younger ages

◼ Psycho-education for family members

Treatment Streams

◼ Individual treatment

◼ CBT or MCT based

◼ Group treatment for BED

◼ Whanau Education and Support Sessions

◼ Individual with Family Involvement

◼ Maudsley Family Therapy

◼ Whānau Education and Support Session

◼ Check confidentiality

◼ Psychoeducation about EDs

◼ Their experience of the ED

◼ Impact of the ED on relationships in the family

◼ How to support the individual and treatment

Whānau Involvement in Individual

Treatment - WESS

Individual with Family Involvement

◼ Potentially in cases where parents can’t ‘step

up’, eg parental mental health, family violence

◼ Some level of insight and motivation needed

◼ Parent(s) may only be involved at the end of

the session, eg how to support the

individual’s treatment goals for the week

Ind with Whānau Involvement

◼ Bulimia Nervosa

◼ Psycho ed re ED cycle, regular eating, purging

as a safety behaviour

◼ Post-meal support

◼ Small changes driven by the individual

◼ Acknowledging vs accommodating the ED

CONSEQUENCES•Physical: tired, hungry •Psychological: low mood, irritable,

obsessive thoughts about food

BEHAVIOUR• Restricting food intake•“thin is in control”•“a better body will make me better”

CONSEQUENCES•Physical: tired, sore throat, sore tummy •Psychological: guilt, shame, self-hatred,

feeling out of control; “I am terrible” “I must do better next time”

BEHAVIOURPurge (self-induced vomiting, over exercising•numbing, relief•lessened fear of weight gain

CONSEQUENCES•Physical: feel full, sore stomach, nausea•Psychological: guilt, shame, self-hatred,fear of weight gain, feeling out of control

BEHAVIOURObjective or subjective binge•feeds body•numbs feelings•nurturance

Adapted from CM Bulik, FA Carter and PR Joyce

The Eating Disorder Cycle

Ind with Whanau Involvement

◼ ARFID

◼ Psycho ed re diagnosis, exposure tasks

◼ Parents more actively involved with exposures

for younger adolescents

◼ Identify motivating factors if possible, eg being

able to eat what friends are eating

◼ If underweight, “Adapted Maudsley” approach

possible, where parents drive it, but less

intensity to help reduce anxiety

◼ Questions so far?

◼ 5 minute break

14

Maudsley Family Therapy

◼ First developed at the

Maudsley hospital by

Christopher Dare, Ivan

Eisler and colleagues

◼ Manualised in 2001 by

James Lock and Daniel Le

Grange; Second Ed 2016

TREATMENT = 1 YEAR

PHASE 1 Intense re-feeding Weekly

PHASE 2 Transition to adolescent control

Fortnightly

PHASE 3 Adolescent issues Monthly

15

Phase One

Intensive Re-feeding

▪ Sessions 1-10

▪ Weekly sessions

▪ The focus is on weight gain and managing the anorexic behaviours

▪ Siblings provide support to adolescent but are not the ‘food police’

Phase Two

Transition to Adolescent Control

▪ Sessions 11-16

▪ Fortnightly sessions

▪ The adolescent is gradually allowed to take more control of the eating.

▪ Parental control and the role of the siblings is faded very gradually

Phase Three

Adolescent Issues

▪ Sessions 17-20

▪ Monthly sessions

▪ The aim of Phase 3 is to return to discussing and focusing on normal adolescent and family issues that have been put on hold because of the anorexia.

CORE PRINCIPLES

1. Agnostic View of AN Aetiology

◼ Causes of AN are not the focus of treatment

◼ Dispels notion family is to blame

◼ Family are not viewed as the cause of AN and

are not pathologised directly or indirectly

◼ Addresses parental guilt and blame that may be

preventing them from taking action

2. Anorexia is Externalised

◼ Separates the child from the Anorexia

◼ The adolescent is not to blame, and is viewed as

having very little control over Anorexia

◼ Allows for anger to be expressed (against AN)

and empathy to be developed (towards the

child)

3. Family is the best resource to bring about

recovery

◼ Central to the model is the belief that the family have skills and resources to overcome AN and return their child to health

◼ This focus on strengths and harnessing resources is influenced by Strength-Based/ Solution Focused Therapy

◼ Why use the family?

◼ Because they know the young person best

◼ They have the most invested in his/her recovery

◼ There is likely evidence of past resourcefulness

4. Hospitalisation does not bring about

sustained recovery

◼ Hospitalisation is a temporary solution aimed at medical recovery; i.e. it is “resuscitation” rather than treatment

◼ Irrespective of length and intensity of hospital treatment, the young person with Anorexia will always return to the family

5. Anorexia is the target of treatment

◼ The initial and primary focus is weight restoration

◼ Model intentionally over-focuses on eating and

stays with this for a long period of time

◼ Other issues are put on hold until the young

person is weight restored

6. Structural changes are made to defeat AN

◼ Attention is given to the development of a strong

parental alliance, strengthening the sibling sub-system

and fostering open communication

◼ Indirect therapeutic effects may occur but are not the

goal of treatment

SUMMARY

◼ By adherence to these principles the Maudsley

approach offers a form of family therapy that is:

◼ highly focussed and staged

◼ emphasises behavioural recovery rather than insight

and understanding

◼ an indirect approach to improving family functioning

◼ supports a gradual independence from therapy

Prof James Lock Stanford University USA

41/2 years cognitions/behaviours hardwired

20% develop severe and enduring illness

The Role of Hospital

◼ Hospital is used initially in order to medically stabilise patients and establish regular eating

◼ Hospital does not cure the Anorexia. It is only one part of overall treatment

Reasons for Admission During MFT

◼ Strength of the Anorexia (and parental burnout)

◼ Pattern of weight loss (which may or may not have led to medical instability)

◼ Failure to gain weight (“stuckness”)

◼ Safety issues that cannot safely be managed by the parents

Does it mean MFT has failed if a patient

needs an admission?

◼ No!

◼ Given the severity of AN and how unwell many patients are at the commencement of MFT, it is to be expected that for a minority of patients admission(s) will be required. MFT can continue post-discharge

Adjustments to the Model

◼ Older adolescents

◼ More collaborative approach if they have insight and/or motivation to recover

◼ Critical or ‘high EE’ parents

◼ Parent-only time

◼ Single parent; only child; parent with MH diagnosis

◼ Increased support; 1-1 time; youth worker

◼ Contraindicated in cases of abuse/ violence

What can I do to support treatment?

◼ Understand and support the model & principles

◼ Learn about EDs and their impacts, eg starved brain

◼ Reinforce the young person is not to blame

◼ Reinforce the family is not to blame

◼ Use externalising language

◼ Support the message that school comes second to treatment

◼ If hospitalised, reinforce this is temporary and they will still need to (and can!) get well at home

What else can I do?

◼ Refer early

◼ Research shows prognosis is best if weight restored within first 3 months of treatment

◼ Role model and promote size acceptance

◼ What messages did you receive growing up?

◼ Do I need to challenge my own thinking?

◼ What social media or messages am I endorsing?

◼ What social media messages can I challenge?

In summary

◼ It’s important to involve whānau when you are

working with someone with eating issues

◼ Levels of involvement can vary

◼ Psychoeducation can increase empathy and

understanding

◼ Support treatment models to prevent splitting

Questions?