1. Anorexia Nervosa: The Family Connection
Eating Disorder Specific Care Clinic
Brynn Kelly, PhD, Kate MacPhee, PDt, Herb Orlik, MD, Jessica Wournell, RN

2. Outline Historical background
Brynn Kelly will outline Family Based Therapy
Kate MacPhee will describe our special assessment and treatment team
Jessica Wournell will show you statistics of Family Based Therapies carried out so far in our specialty and community clinics.

3. Objectives You will be able to:
contrast past perceptions of the role of the family in anorexia nervosa with recent insights about the family
identify principles, procedures and processes in Family Based Treatment (FBT)
gain a perspective of FBT according to IWK-based experiences so far

4. Disclosures
None of the presenters have any connections to industry or financial connections with regard to today’s topic

5. Acknowledgements
Dr. Brynn Kelly has studied with the team of James Lock, one of the main authors of FBT, at Stanford University
The IWK Mental Health and Addictions Program has made it possible for a number of IWK clinicians to be trained, and in some cases, certified by Dr. Blake Woodside, University of Toronto

6. Connections
There are many “connections” of interest in anorexia nervosa, for example
the biological connection
the psychosocial connection
the feminist connection
the existential connection
the media connection; and so on
Today we want to focus on the family connection

7. History
The disorder has been known and has been described in various forms for hundreds of years
A non-clinical assumption was that it was a kind of religious expression, starvation as asceticism, a devotion to a god or to a religion
A common early clinical theme was that it was a form of hysteria (Gull 1874)

8. History
Family issues had not been described until mainly psychoanalysts explored early childhood and adolescent experiences retrospectively in adult patients
One prominent psychoanalytic theory was that anorexia nervosa was a sort of fear of oral impregnation or a defense against a wish for (upwardly displaced oral) impregnation (Fraiberg 1972, Sperling 1973)
As with other psychiatric conditions, overprotective, controlling, sometimes punitive mothers and ineffectual, absent fathers were seen to be part of the preceding or perpetuating family dynamic

9. history
Much attention then began to be focused on family function in the 1970s and 80’s:
Bruch described the family as functioning as if members could read one another’s minds (Bruch 1973, 1978)
Yager described the family as focused on high achievement, communicating along narrow lines, and failing to recognize the anorexic child’s individuality (Yager, 1981)

10. history
1970’s & 1980’s Cont.:
Sours emphasized the need of the family to maintain harmony and disavow distress or upset (Sours,1980)
Minuchin identified five predominant characteristics of family interaction as excessively present and detrimental to overall family functioning: enmeshment, overprotectiveness, rigidity, lack of conflict resolution and involvement of the sick child in unresolved parental conflict (Minuchin, Baker, Rosman, et al, 1975, 1978)

11. history
Other influential authors, Crisp and Selvini-Palazzoli, also described difficulties within the family (Crisp 1980, Selvini-Palazzoli, 1978)
Although all these authors and the analysts before them described family dysfunctions, they were cautious enough not to claim that these were unitary etiologies for anorexia nervosa.

12. history
Still, one got the strong impression that families, parents, were to blame.
Therapies therefore were devised to 'correct' these family dysfunctions.
Other interventions were geared to isolate if not separate youngsters with anorexia nervosa from their immediate families, leading to so- called ‘parentectomies’ (Peshkin and Tuft 1956, Harper 1983)

13. The English Connection
Individual therapies such as psychoanalytically-derived or psychodynamic therapy and CBT were tried extensively but did not show great results. Working on ‘faulty’ family interactions and blaming parents did not go over well with many families and no longer made sense to many clinicians and researchers
At the Maudsley Institute Christopher Dare then developed a new form of family therapy (Dare 1985, Dare, Eisler, Russell, Smuckler, 1990, Dare, Le Grange, 1994, Dare, Eisler, 1997)

14. The English Connection
The principles are simple and straight forward, though radically different from what had existed so far:
parents are the best treatment resource
parents take over the control of their child’s food intake
therapy initially focuses on weight restoration
parents are not to blame
etiology of the eating disorder is not addressed, is not of concern
the parents’ anxiety is raised to motivate them to intensively engage in the therapy

15. FBT
Subsequently, Dare’s family therapy for anorexia nervosa has become known as “the Maudsley Method”.
Lock and LeGrange adopted this method, improved, expanded it and manualized their new version. They took it from London to Chicago and then to Stanford University. The first manual was published in 2001 in collaboration with Agras and Dare. A companion book for parents, “Help Your Teenager Beat an Eating Disorder” was brought out in 2005 and the second edition of the “Treatment Manual for Anorexia Nervosa, a Family-Based Approach” came out in 2013.
Numerous trials including RCTs have since shown that FBT is the gold standard and that it has the highest level of evidence of effectiveness compared to other interventions in adolescent anorexia nervosa.

16. Family Based Treatment (FBT)
Brynn Kelly, PhD

17. Family Based Treatment (FBT)
Outpatient, team approach
FBT therapist
Consulting team: physician, nurse, nutritionist or dietician
Focused on behavior, rather than underlying cause
Parents are the agents of change
So I’ll be providing you with a brief overview of FBT, based on the FBT treatment manual and my training in the model both in the Stanford Eating Disorders clinic and while at the IWK.
What drew me to FBT, aside from the great evidence base, which I’ll discuss more later, is its focus on empowering the parents and uniting the family to directly address and change the disordered eating behavior, and highlighting the important role of the family right from the get-go. As an outpatient treatment, it puts the parents in charge and responsible for being the agents of change, as opposed to relying on a treatment team to re-feed their child, as is done in many residential treatment programs. It is acknowledged that all children eventually return to their homes, so it’s more efficient to use a team to support the parents in helping their child recover at home. By being the agents of change responsible for their child’s recovery, parents feel empowered and are in a good position to help their child maintain progress over time and avoid future relapse.
While much of what I’ll be describing will pertain specifically to the therapy sessions between the FBT therapist and the family, it’s important to understand that FBT is a team approach, with a primary therapist conducting the FBT and a consultation team of other health care professionals – typically including a physician, nurse, and nutritionist or dietician. All members of the treatment team need to be on the same page, following the FBT clinician’s lead and communicating with one another regularly about progress and recommendations to make sure that the family gets consistent messages.
Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford.

18. FBT: Phases Phase I: Weight restoration 10+ sessions, weekly
Phase II: Returning independence to the adolescent
Consider transition to Phase II when:
At least 90% of EBW
Patient compliant with parental meal monitoring
Parents feel empowered to manage AN
Approx. 2-6 sessions every 2-3 weeks
FBT has 3 phases, each of which I’ll describe in more detail in a moment.
The first, and most intensive phase, is weight restoration – and this is where the bulk of the change happens and where most sessions are focused.
The second phase focuses on returning independence to the teen, and occurs once parents have made significant progress with getting their child to gain weight and their child is no longer resisting their parents’ efforts at renourishment. By this point, the parents know what they need to do to address the anorexia, and they can quickly step back in if their child doesn’t handle the increased independence well.
The final phase of FBT focuses on getting the family ready for termination and ensuring the teen is getting back on track developmentally. We typically transition to this phase when the teen is completely or almost fully weight restored.
As you’ll see on the slides, the number of overall sessions and the frequency of sessions decrease with each phase of treatment, so that the family becomes less dependent on the therapist and tx team over time and is ready for termination.
Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford.

19. FBT: Phases Phase III: Return to healthy adolescent development
Consider transition to Phase III when:
Weight restored and maintained between % of EBW with adolescent in control
Family able to discuss non eating-related adolescent issues
Patient is re-aligned with peers
Approx. 1-4 sessions every 4-6 weeks
FBT has 3 phases, each of which I’ll describe in more detail in a moment.
The first, and most intensive phase, is weight restoration – and this is where the bulk of the change happens and where most sessions are focused.
The second phase focuses on returning independence to the teen, and occurs once parents have made significant progress with getting their child to gain weight and their child is no longer resisting their parents’ efforts at renourishment. By this point, the parents know what they need to do to address the anorexia, and they can quickly step back in if their child doesn’t handle the increased independence well.
The final phase of FBT focuses on getting the family ready for termination and ensuring the teen is getting back on track developmentally. We typically transition to this phase when the teen is completely or almost fully weight restored.
As you’ll see on the slides, the number of overall sessions and the frequency of sessions decrease with each phase of treatment, so that the family becomes less dependent on the therapist and tx team over time and is ready for termination.
Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford.

20. Phase I: Weight restoration/renourishment
Family role
Parents take charge of meals:
What, where, how much
↑ portion size, frequency & caloric content (without calorie counting!)
3 meals, 2-3 snacks
Re-introducing “trigger” foods
Close supervision
Coaching and support
Parents prevent purging/ exercise
Siblings provide emotional support
So now I’ll talk about Phase I in a bit more detail, to give you an idea of what the renourishment process actually looks like.
We make it clear from the beginning that we expect the parents to completely take charge of their child’s meals – the same way that they would have when they were a toddler. We give them general guidelines in terms of needing 3 meals and 2-3 snacks, and letting them know that their child may need more food than they’re anticipating in order to gain weight, but we avoid giving them a meal plan or specific caloric recommendations, in order to encourage them to access their own expertise. We emphasize that they are skilled parents who know how to feed their child – because they’ve done it for their child’s whole life – and that they can use this expertise they have to figure out how to get their child to eat now, what they’d like to eat, and how much they’d likely need – based on what they ate before the eating disorder. Our goal is for eating to return to whatever is normal for the family, with perhaps a bit of extra food added if their child isn’t gaining weight. As part of a “normal” diet, the parents will need to figure out how to re-introduce higher fat foods that their child may have started to reject as they developed anorexia. We emphasize that food is medicine, and that we’re charging parents with making sure that the medicine gets in, that a sufficient dosage is given, and that it isn’t purged through exercise, vomiting, laxatives, or other methods.
Throughout this we emphasize that the patient’s siblings are NOT in charge of re-feeding, and that their primary role is to offer emotional support to their ill sibling, who is going to have a very hard time with the re-feeding.
Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford.

21. Phase I: Weight restoration/renourishment
Clinician goals
Understand impact of AN on family
Understand impact of family dynamic on fighting AN
Engage family
Empower parents
Mobilize sibling support for patient
Keep family focused on AN
In order to do all of this, it’s important for the therapist to really understand the impact that the anorexia has had on each member of the family, how the family can utilize some of their strengths to get at the AN, and what potential issues within the family could get in the way if we’re not careful.
The therapist does this by taking a careful history in the initial sessions, and engaging each family member in the process.
Throughout the sessions the therapist is emphasizing the parents’ important role, and helping them identify and draw upon past parenting successes and knowledge. The important role of each sibling is also emphasized, and the siblings’ own feelings about how the AN has impacted them and affected their ill sibling and family is validated. Often the siblings have been dealing with a lot of their own struggles – like worrying about their sister, while also feeling sidelined, and feeling angry or guilty about their feelings.
One of the main jobs of the FBT therapist during Phase I is to keep the family focused on the anorexia at all times – So, not becoming distracted by other stressors or non life-threatening mental health concerns, and not letting down their guard when the anorexia may just be in hiding and secretly undermining parents’ efforts – such as exercising at night when everyone is asleep, or hiding food in their pockets at meal time
Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford.

22. Phase I: Weight restoration/renourishment
Therapeutic strategies
Weigh patient & plot progress
Create “Intense Scene”
Externalize the illness
Address each family member
“Charge” the parents
In-session family meal
Aligning parents toward “one bite more” and/or normalizing eating
Aligning patient with sibling(s)
Evaluate progress; problem-solve
Redirect focus back to AN
Modify family criticisms of patient
I’ve listed here some of the key strategies a therapist will use during Phase I, but will just highlight a couple because I’ve already discussed some of this with the earlier slides.
The first thing that I’ll mention is that every session begins with weighing the patient, and plotting their progress on a graph for the family to see. This is used to set the tone of the session, and determine whether the parents’ efforts during the past week have been successful or not. When there’s progress, we’re helping the parents identify what they did that worked, and what the next steps will be. When there isn’t progress, or if weight is lost, we help them try to figure out what went wrong, what they can try differently, and where the anorexia may be hiding and undermining them.
We’re also externalizing the anorexia throughout – highlighting that it is an illness, like cancer, which isn’t anyone’s fault but which must be addressed. This helps take blame away from the patient, as well as from their parents – as both might have worried that they caused the anorexia, and that guilt or shame is counterproductive.
The family is also provided with psychoeducation throughout, and this is used to mobilize them and understand the serious medical ramifications of anorexia if left untreated.
One of the most important interventions throughout Phase I is facilitating an in-session family meal, during which the therapist can help with highlighting any issues that may interfere with renourishment, and coach parents in addressing these difficulties in the moment – such as coaching their child to eat one more bit of food than she was initially willing to, in order to teach them that they are capable of handling resistance.
Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford.

23. Phase II: Transitioning control
Support family in reaching the following goals:
Parents monitor & gradually step back, dependent upon progress
Patient eating well
Patient gaining weight
Patient gradually takes control of food & weight
Explore relation between adolescent developmental issues & AN
Once there’s been progress with weight restoration and the patient is complying with her parents, the family is ready to move to Phase II. During this phase the parents will be supported in gradually stepping back and letting their child take back control of eating. As they make progress with this, the therapist can gradually start introducing other topics into sessions, and specifically highlighting areas where the patient may have gotten off track developmentally, and helping the family figure out what they can do to support her in getting back on track.
Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford.

24. Phase II: Transitioning control
Therapeutic strategies
Support parents & patient in managing transfer of control
Evaluate progress
Continue to:
Weigh patient & plot progress
Shifting from “gain” to “maintain”
Externalize the illness
Highlight signs of re-emergence of patient & separation from AN
Modify parental & sibling criticism
Normalize difficulties with return of independence
Gradually shift focus to issues of adolescence
Specifically, the therapist will help parents identify what level of independence their child is ready for, and how they’re going to evaluate whether she’s successful with her independence.
The weigh-ins at the start of the session remain important here, as they provide a metric for assessing progress – if progress with weight is going well when more independence is given, then the patient can likely handle that level of independence – and if not, then parents need to step back in.
The therapist will also work with the treatment team to communicate to the family when the patient is ready to shift away from a focus on weight gain, to maintaining a healthy weight, and when they’re ready to start incorporating physical activity back into their routine. This can be a difficult time for families, because they have to figure out whether and how daily food intake needs to be adjusted to meet intake needs – and the therapist’s job is to support them throughout this and give broad psychoeducation, without telling families exactly how to do it.
Continuing to externalize the illness is also important here, because as the patient starts to get well the family can forget that they still have anorexia and that they’re not responsible for set-backs that occur as a result of the illness, such as lying about eating lunch at school. When these set-backs occur, we help parents remember that they may need to step up their efforts again and support their child in the internal struggle they’re dealing with.
As the patient gets better and things go more smoothly, that’s when the therapist can help the family shift their focus to other aspects of wellness, such as getting back on track with peers, romantic relationships, or extracurricular activities – most of which was stolen from their child during the height of the illness.
Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford.

25. Phase III: Return to healthy development
Support family in reaching the following goals:
Communicating without AN being the focus
Discussing and problem-solving issues of adolescence
Terminating treatment
Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford.

26. Phase III: Return to healthy development
Therapeutic strategies
“Mini-lecture” on adolescent development, highlighting relevant themes
Involve family in review of adolescent issues as they relate to patient
Check in on how parents are doing as a couple
Planning for future issues
Saying goodbye, reviewing progress, highlighting strengths
Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford.

27. Effectiveness
The only AN treatment for adolescents meeting the Level 1, ‘well established’, criteria
Meta-analysis of RCTs showed better long-term remission rates for FBT than for individual treatment
Rate of full recovery about 2x as high as for individual treatment
Best Predictor of Success: Weight gain
At least 2-3kg / lbs gain by session 4 predicts recovery by EOT
Reaching 95% of EBW by end of FBT is strong predictor of recovery at longer-term follow-up
So now that you have an overview of FBT, I’ll briefly review some of the research demonstrating its effectiveness. As Dr. Orlik mentioned, FBT is considered to be the “gold standard” treatment approach for adolescent anorexia nervosa, and is currently the only treatment meeting Level 1, or well-established treatment criteria. It has been shown to be superior to individual treatment, both CBT and a more psychodynamic, insight-oriented approach.
One predictor of reaching full remission by the end of FBT that has been replicated in a few studies is early weight gain. Estimates of sufficient gain vary, and would depend on the individual adolescent, but on average gaining at least 4-7 pounds within the first 4 weeks of FBT is considered to be a good marker of being a treatment responder.
Not surprisingly, those who reach at least 95% of their EBW by the end of FBT are also most likely to sustain recovery at long-term follow-up.
Qs:
Rate of recovery for FBT:
About 50% full recovery (both in terms of weight restoration & other ED sx)
About 80-90% partial remission
Meta-analysis: only 6 studies, so very preliminary
Courturier, Kimbler, & Szatmari, 2013; Doyle et al., 2010; Eisler et al., 1997; Lock et al., 2010; Lock, 2015; Lock et al., 2013; Le Grange et al., 2014

28. Efficiency Hospitals implementing outpatient FBT report ↑ efficiency
↓ Time spent in hospital (stabilization vs weight restoration)
↓ Admissions & re-admissions
Ex. RCH in Melbourne, AUS: Admissions ↓56%
Readmissions ↓75%
# Days in Hospital ↓ 51%
1 RCT showing abbreviated FBT (10 sessions) is just as effective as standard FBT (20 sessions)
Unless high in obsessive & compulsive features or single- parent/divorced family
FBT has also been shown to be quite efficient.
When hospitals have invested in outpatient FBT, they’ve found significant drops in inpatient admission and re-admission rates, and shorter stays when patients do need to be admitted, likely due to the changed emphasis from fully weight restoring youth in hospital to releasing them as soon as they are medically stable and letting their families complete weight restoration with an FBT therapist.
There’s also preliminary evidence that an abbreviated form of FBT, with only 10 sessions, may be just as effective as standard FBT – Meaning that it has potential to be even more efficient. The only times when the abbreviated treatment is counter-indicated are when there are significant obsessive and compulsive features or when there’s a single parent or parents are divorced.
So, given FBT’s demonstrated track record in improving patient outcomes and efficient use of resources, the IWK made a full commitment to this treatment approach in 2015, with support for not only implementing FBT, but developing an FBT training clinic. So on that note, I’ll hand things over to Kate, who will describe our team in more detail.
Hughes et al., 2014; Lock et al., 2005

29. Eating disorders special assessment and treatment team
Kate MacPhee, PDt

30. Background & changes to care delivery model
Where we were:
Eating Disorder Team at IWK Main Site
Psychiatry Lead
Eating Disorder cases were treated mainly within the team at the IWK
Psychiatry (ED team/Garron)
1.0 FTE
Social work
Psychology ED team
0.5 FTE
Psychology in CMHA
Dietitian (ED team/Garron/CMHA)
2.0 FTE
Total of 5.0 FTE

31. Current state
Current IWK Eating Disorders Specific Clinic consists of:
Eating Disorder Specific Care Clinic at IWK 4-Link
Psychiatry lead
CMHA Psychologists
Psychiatry
0.5 FTE
Psychology
Dietitian (EDSCC/Garron/CMHA)
1.0 FTE
Nursing
Total of 3.8 FTE
Sackville CMHA
0.4 FTE
Halifax CMHA
0.2 FTE
Dartmouth CMHA

32. ED Training clinic overview
Certified:
Dr. Amber Johnston (Halifax), Dr. Susan Jerrott (Sackville), Dr. Brynn Kelly (EDSCC)
Advanced Learners:
Dr. Laura Connors (Dartmouth), Dr. Elizabeth Quon (Dartmouth)
Learners:
Dr. Orlik (EDSCC), Jessica Wournell RN (EDSCC), Melissa Kemp RN (EDSCC), Kate MacPhee PDt (EDSCC/Garron), Tracy Bourdages RN (Garron)

33. ED Training clinic overview
Family Based Treatment (FBT) workshop, leading into weekly peer- supervision with Dr. Blake Woodside
Increased capacity in the treatment of eating disorders within CMHA

34. FBT Training clinic data
September 2015-Present
Jessica Wournell, RN

35. Let’s take a look at the data…
48 patients have been given or are currently participating in fully manualized FBT
16 patients have completed and are fully weight restored
25 patients are in ongoing treatment
7 patients did not complete treatment
16 required inpatient admission for medical stabilization

37. NOTE: this data includes AN, Atypical AN, and BN data

38. NOTE: this data includes AN and Atypical AN data ONLY

39. NOTE: this data includes AN and Atypical AN data ONLY

41. Avg. increase in body weight
Body weight data
Disorder
Avg. % EBW at Ax
Avg. % EBW at end of Tx
Avg. increase in body weight
Anorexia Nervosa
83%
101%
19%
Atypical Anorexia Nervosa
91%
102%
11%
Combined AN & Atypical AN
84%
18%

42. Complicating factors in treatment
Family not on board
Parental blocks (EFFT*) may be needed)
Scheduling
Complicated family dynamics (i.e. split families, poor relationship with youth)
Stigma
*EFFT = Emotion-Focused Family Therapy
Suicidality/ Self harm
Should be assessed on an ongoing basis.
If active SI with plan/ intent that takes priority and treatment may need to go on hold until resolved

43. Questions?