Family Based Treatment NHS Lanarkshire CAMHS Mary Graham, Specialist ED Dietitian, CAMHS

Overview What is FBT FBT: first line treatment Pre-FBT Three phases of treatment The role of the Dietitian in FBT

What is FBT? The family working together to help the young person recover from Anorexia Nervosa Focus on weight restoration Parents take charge of eating initially Some families may need to take time away from work/school

Background to FBT Developed at the Maudsley Hospital in London in the 1980s Refined at the University of Chicago and Stanford University James Lock and Daniel Le Grange manualised FBT

The Model Theoretically agnostic Externalisation Distinct roles for parents and siblings Empowerment – family is a resource Team approach Therapist joins with family Food is medicine, priority is weight restoration

FBT: first line treatment NICE Guidance, May 2017 Consider FBT for all young people with AN Typically 18-20 sessions over 1 year Psychoeducation re malnutrition and re-feeding

First Line Treatment for AN Approximately 80% significantly improve and 50% achieve full remission when treated with FBT Lock, J (2011). Evaluation of family treatment models for eating disorders. Current Opinion in Psychiatry, 24:274-279

First Line Treatment for AN CAMHS Matrix 2015 There is increasing evidence for family-based treatments of adolescent Anorexia Nervosa over individual treatments, particularly in long-term maintenance of treatment gains and notably low attrition rates – a common problem in ED trials14,36 14 Couturier, J., Kimber, M., & Szatmari, P (2013). Efficacy of family-based treatment for adolescents with eating disorders: A systematic review and meta-analysis. International Journal of Eating Disorders, 46(1), 3-11 36 Hay, P.P. (2013). A systematic review of evidence for psychological treatment in eating disorders: (2005-2012. International Journal of Eating Disorders, 46(5), 462-469

Suitability for FBT – the patient Most families are considered suitable for FBT Most patients with AN are considered suitable for FBT

Pre-FBT Medical assessment and stabilisation as required CAMHS assessment Diagnosis of AN/EDNOS given Dietetic assessment of re-feeding syndrome Re-feeding issues to be resolved prior to FBT

Three Phases of FBT Phase 1 Phase 2 Phase 3 James Lock, MD, PhD Three Phases of FBT Parents in charge of weight restoration Phase 1 (Sessions 1-10) Parents hand control over eating back to the adolescent Phase 2 (Sessions 11-16) Discuss adolescent developmental issues Phase 3 (Sessions 17-20)

Phase One Parents take control of weight restoration 5-10 sessions (usually paced weekly) Designed to help parents do what nurses on re- feeding unit do at home Aim to help parents disrupt AN Includes family meal – one extra bite

Phase Two Patient eats without significant struggle Parents report they feel empowered to manage illness Assist parents in managing the ED and in navigating return of control Transfer food/weight control to adolescent

Phase Three Weight restored but some shape and weight concerns may remain Focus on normal adolescent development establish that patient is back on normal trajectory in all domains Relapse plan

The Role of the Dietitian The FBT manual encourages minimal Dietetic intervention ‘The therapist may say… “You know how to feed a starving child and you don’t need expert nutritional advice” in an attempt to bolster parent confidence’ (Lock & Le Grange, 2012, p. 89) ‘The therapist should leave most of the decisions as to how to accomplish weight restoration to the parents’ (Lock & Le Grange, 2012, pp. 61-62) In a poll of FBT therapists, only 15% agreed with the FBT model of not including a dietitian (Couturier, Kimber, Jack, Niccols, Van Blyderveen, & McVey, 2013)

The Role of the Dietitian Establishing weight history Managing re-feeding risk pre-FBT Psychoeducation regarding starvation and Anorexia Nervosa Education re; nutritional rehabilitation growth and development age and stage

The Role of the Dietitian

The Role of the Dietitian Usually involved at the start of treatment for 1-3 sessions Consult with colleagues throughout treatment Often brought back later in treatment Involved where there are complicating factors: Diabetes Vegetarian/vegan Those very involved in sport

The Role of the Dietitian

The Role of the Dietitian

When is the Patient Well Physically back to normal Menstruation Temperature Energy levels Attitude to food has returned to normal, conversations are relaxed They can have pizza and Haribo nights!