Family-Based Treatment for Anorexia Requires Expertise, Family Buy-In

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Family buy-in is the first major step in beginning a comprehensive treatment process.
Family buy-in is the first major step in beginning a comprehensive treatment process.

Anorexia nervosa is a highly complex psychosocial disorder with a high number and severity of comorbidities, so treatment is typically complex as well.

“There are so many brain changes that happen with starvation as the body loses more weight, and the person suffering has diminished insight into the disorder,” explained Kathryn Pieper, PhD, a child psychologist and director of the Eating Disorders Center at Children's Mercy and the University of Missouri-Kansas City School of Medicine. “The patient cannot stand up to the strong urges from the eating disorder on their own,” she told Psychiatry Advisor.

“They really need to have healthy people take charge of the eating, be accountable, and support their treatment,” Dr Pieper said. “It's really hard for someone who has a brain that's been hijacked by the eating disorder to maintain motivation for treatment and see the scope and severity of their issues.” 

Keys to Treatment: Family-Based Therapy and Multidisciplinary Care

First-line treatment for the psychiatric component of restrictive eating disorders, specifically anorexia nervosa, is Family-Based Therapy (FBT), according to the Society for Adolescent Health and Medicine. FBT relies on the family in an outpatient setting to re-nourish a child. Its 3 treatment phases begin with helping the family restore the teen's weight and stop disordered eating behavior. Then the teen begins gradually taking control over eating behavior again in phase 2. The third phase focuses on physical development, social interaction, and related developmental issues.

“The process of recovery involves a large time commitment from not only the patient but also their family, with frequent therapy sessions taking anywhere from 6 months to a year,” said Rebecca Marshall, MD, MPH, an assistant professor of child and adolescent psychiatry at Oregon Health & Science University (OHSU) in Portland.

“The use of family-based therapy can be difficult for many patients, even those with supportive families,” Dr Marshall told Psychiatry Advisor. “Another challenge is that patients are not infrequently conflicted about whether they really want to get better and restore their nutrition.”

In addition to using FBT, treatment of anorexia nervosa requires an interdisciplinary approach involving a medical provider, a mental health specialist, and a dietitian with expertise in treating eating disorders, explained Marshall's colleague, Jessica C. Serrano, MD, MPH, an assistant professor of adolescent medicine at OHSU.

“The ability to coordinate and assure that all these components are part of every patient's treatment plan can be challenging due to the availability of resources, insurance coverage, and family buy-in,” Dr Serrano told Psychiatry Advisor.

Providing Guidance to Therapists on Family-Based Treatment

The success of FBT relies not only on the family's adherence to the treatment plan but also on the therapist's consistent instruction, delivery, and support of the treatments core tenets. Several studies have found that “ongoing clinical consultation can increase fidelity to an evidence-based treatment compared with provision of a didactic training workshop only,” according to a new qualitative study in the Journal of Eating Disorders.

The research, led by Jennifer Couturier, MSC, MD, FRCPC, and her colleagues at McMaster University in Hamilton, Ontario, Canada, investigated therapists' needs during clinical consultation.

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