SAN FRANCISCO (FRONTLINE MEDICAL NEWS) – Parents have to stay level-headed if family-based therapy is going to work for anorexia nervosa, according to an expert on the technique, James Lock, MD, PhD, director of the Child and Adolescent Eating Disorder Program at Stanford (Calif.) University.

The idea of family-based therapy (FBT) is to guide parents to change behaviors – the patients’, but also their own – that undermine weight gain. Early on, the therapist has a meal with the family to observe dynamics that need to be addressed and encourage behaviors that help. It’s a nonauthoritarian approach, where the therapist helps families help themselves.

“Fundamentally, you want to teach parents not to respond emotionally, either too much by being too supportive or by being angry or removed. Those are three typical responses,” but “none of them are useful.” Parents aren’t effective if they are “involved in the process emotionally,” said Dr. Lock , also a founder and co-owner of the Training Institute for Child and Adolescent Eating Disorders , which teaches the technique.

Heated emotion just opens the door to argument and resistance; patients aren’t rational when it comes to body image and eating, at least at first. Parents also have to learn not to be provoked by the child.

“You just have to ignore it. You don’t argue with the kids,” and “right now, ‘we love you’ just doesn’t go anywhere,” Dr. Lock said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Instead, caregivers are simply supportive. The only messages that matter initially, when weight gain is critical, are along the lines of, “I know you need to eat this. You need to eat it.” Parents “need to support the behavior change and really be kind of neutral about everything else,” he said.

FBT is one of many therapeutic options for anorexia. It has a strong evidence base going back about 30 years. Dr. Lock and his colleagues have been involved in many of the more recent studies and reported a 12-month remission rate of 49% in one ( Arch Gen Psychiatry. 2010 Oct; 67[10]:1025-32 ). There’s growing support for FBT in bulimia, as well.

The earliest goal is to engage the parents in treatment. They are complimented on what they are doing well and told not to blame themselves or their child for the illness. The seriousness of anorexia is also impressed upon the parents if they are in denial about the illness.

The family meal comes early, too. They’re stressful but necessary to learn what parents are trying to do to help and to coach them about what needs improvement. “You, as a therapist, need” to be at the meal and “join the family in their dilemmas,” Dr. Lock said.

Parents are responsible for weight restoration at first, but when steady weight gain occurs, they are taught to hand control of eating and weight back to the child. In time, therapists help with normal adolescent developmental issues and healthy family relationships.

There are maybe 20 sessions over 6-12 months, more or less depending on how it’s going; each one lasts an hour. Single-parent families seem to need more sessions, likely because there’s no spouse to share in the work. There are no meal plans in FBT, because meal plans “are not a normal way to eat. When you try to empower parents to make reasonable decisions about food, a 24-hour meal plan that the adolescent is aware of is just an opportunity for fighting over what it says,” Dr. Lock said.

Dr. Lock has coauthored a treatment manual on using FBT for anorexia.


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