I would say yes to both questions. The profession deserves credit (well, not the profession as a whole, but the professionals who created FBT and those who practice it) because it runs counter to the way things had been done for decades, and because it helps people get well. FBT is also a manualized return to traditional practices that have served our species well for millions of years. Perhaps that’s part of why it works well.

You write:
“There is no evidence that professionals have made any overall improvements in the treatment of anorexia nervosa during the past century.”

That statement is false. Professionals – psychiatrists and psychologists (Lock, LeGrange, Agras, and Dare) – developed FBT, which has made a significant improvement in the treatment of AN to those patients and families who have undertaken it. Further, Walter Kaye, a psychiatrist, has done excellent research on brain imaging which has advanced our understanding of AN.

I completely agree with you that parents should be in charge and that the clinician should be subservient. I tell parents at our first meeting: “You are the head of your child’s treatment team. I will serve as a consultant to you.” I strongly encourage parents to do their own research, to ask questions, to speak up if they disagree with something I recommend.

The thing is, most parents come to me desperate for guidance. They want so badly to help their child but they don’t know what to do. They are, on the whole, very well-educated people and excellent parents who have simply been thrown for a loop by this very challenging illness. Common sense is not enough. Most parents don’t know exactly how to respond when their child develops AN, which is why they seek professional help.

I agree that professional involvement in eating disorder treatment should be reduced. I don’t think it is effective to have “too many cooks in the kitchen.” Often times in these cases patients get mixed messages, the left hand doesn’t know what the right hand is doing, the various professionals disagree with one another, and the poor kid has to attend multiple appointments each week. It’s expensive and time consuming. My idea of the perfect team is the parents, one psychologist, and one pediatrican: weekly FBT sessions plus medical monitoring as needed.

Finally, while I agree with you that the majority of eating disorder treatment that exists today is ineffective or harmful, there are some exceptions. There are some clinicians who are scientifically minded, who support and respect parents, who are well-informed about recent developments in the field, and who can think objectively. They may constitute a small minority of the field, but they do exist.

You write that in your practice Phase III “typically” addresses eight different issues: normal adolescent development, relationships among family members, residual psychological symptoms, working through trauma, addressing grief, relapse prevention, and evaluating and getting treatment for co-morbid conditions. You say, at the same time, that you agree with Lock and LeGrange that “four sessions of Phase III is sufficient for most families.” If it’s true that Phase III typically involves four 50-minute sessions, and you address eight broad issues during that time, then you devote an average of about 25 minutes to each of the eight issues. You are correct to acknowledge that this is uncharted territory. There is no evidence this approach is necessary or helpful. To the contrary, in my opinion, most parents who have successfully helped their kid to beat anorexia nervosa (something that most eating disorder professionals are unable to accomplish consistently) have already demonstrated they are highly competent, probably more so than most eating disorder professionals. It is reasonable for these parents to conclude that they don’t need to pay money to a stranger to spend about 25 minutes evaluating whether the relationships within their family are “healthy” or not. To recommend that approach is really quite arrogant and condescending.

I also do not agree with your assertion that anorexia nervosa is a psychiatric disorder. I think the evidence is now strong to support the view that AN is a temporary alteration in the biological forces governing eating behavior. The emotional and cognitive consequences of semi-starvation are unique to each individual and are fully resolved by full nutrition for an extended period of time. The tools of psychiatry — medications and talk therapy — have not been shown to be effective in treating anorexia nervosa. Thus, I think it’s a mistake to characterize AN as a psychiatric disorder and for parents to defer to professionals who have been trained in a model that assumes it to be a psychiatric condition. One reason FBT is effective, in my opinion, is that it places parents, not professionals, in charge. Parents are generally not burdened with the kind of training most eating disorder professionals have received.

Finally, I can see how you would view my comments as “pitting parents against professionals.” In my opinion, however, it is healthy for parents to be skeptical of eating disorder professionals, even to “pit” themselves against professionals. Your profession has probably done more harm than good during the past several decades, and the consequences have been bad. Most eating disorder professionals have a history of mental illness, which makes them unfit for the job. Most eating disorder professionals do not understand, or like, evidence or the scientific method, and are unable to separate their personal, subjective, experience from objective reality. Most have developed rigid ways of thinking, coupled with arrogance and a patronizing stance. Their training generally consists of passing on myths and distortions from one generation to the next, then they tend to mislead parents by passing on those same myths to them. There is no evidence that professionals have made any overall improvements in the treatment of anorexia nervosa during the past century. There is no evidence that the treatment of anorexia nervosa is any better in those countries that have a large population of eating disorder professionals than in those countries that do not. I think most parents are better off rejecting — or limiting the involvement of — professionals in most circumstances, and instead focusing on using their parental common sense to simply feed their kid if their kid is semi-starved, and then to use their own knowledge to help their kid re-establish normal eating patterns. The idea of “collaboration” between parents and eating disorder professionals in this endeavor implies a relationship of equality which, at this stage in the development of your profession, is a fantasy and a waste of parents’ time. An alternative view, which I advocate, is that parents should simply be in charge, and the role of the professional should be subservient. This is very different from the kind of collaborative relationship you appear to be recommending.

Of course it is possible (and in fact likely!) that 105 hours of individual therapy is not necessarily a good idea for adolescents who have recovered completely from AN. Just to clarify – I used the phrase “whether that is 5 sessions or 105 sessions” as a figure of speech. I simply meant that there is a great deal of variability in terms of how much treatment each patient needs, and 105 sessions would be on the extreme end of that spectrum.

In my opinion, it would NOT be in the best interest of most adolescents to have a large number of individual therapy after fully recovering from AN.

You also wrote:
“Implicit in your comments is the assumption that professionals have some special knowledge and skill — that parents lack — to help an adolescent recover from a co-morbid disorder after Phases I and II of FBT have successfully been completed. Is there any evidence to support that stance?”

The question you ask sounds a bit like pitting parents against professionals. Good treatment for adolescents doesn’t do that. Good treatment involves parents and professionals working collaboratively on the adolescent’s behalf. Good adolescent CBT does involve the parents precisely because they have special skills and knowledge about their child. So it’s not an either-or situation.

But to answer your question, here’s the evidence: An adolescent who has fully recovered from AN is not much different from an adolescent who has never had AN. There is good empirical evidence to support CBT for anxiety disorders and depression in adolescents, meaning that CBT is superior to no treatment and superior to nonspecific supportive counseling. This is the same level of evidence we have supporting FBT for adolescent AN.

I’m not sure how one would go about confirming or refuting the hypothesis that professionals have special skills and knowledge which parents lack. Perhaps that’s why there’s no evidence on that one. I think it’s widely understood that parents have special skills and knowledge about their children, and that professionals have skills and knowledge in their area of expertise by virtue of their training.

I agree with your opinion that it is reasonable for many families to be finished with eating disorder treatment after a successful Phase I and Phase II. I also agree with Locke & LeGrange that four sessions of Phase III is sufficient for most families.

I maintain my assertion that some patients need and benefit from more treatment than the 20 sessions recommended by the FBT manual. In my experience, when a patient needs more than 4 sessions in Phase III, it is usually not to address the AN itself, but rather to address a co-morbid disorder that interferes with her return to normal adolescent development.

Also, it has been my experience that the duration of illness is often associated with the duration of Phase III, which makes logical sense. People who have been ill for more than a couple of years will often take more time to return to normal life, where as kids with a shorter duration of illness often bounce back much more quickly.

Treatment manuals have to specify a certain number of sessions. Families participating in RCTs have to receive a certain number of sessions in order to create a well-controlled experiment. In private practice, however, there is quite a bit of individual difference among patients with AN when it comes to the speed of recovery. My own practice is comprised of a very diverse group of children, adolescents, and young adults with AN – from those who have been ill for only a few weeks and don’t yet meet full criteria for AN, to those who have been ill for 5 or 10 years prior to starting treatment with me. I believe that it is important to pay attention to these differences and provide each patient with what she and her family need for full recovery, whether that is 5 sessions or 105 sessions.

For those families engaging in Phase III, the Manual recommends only four sessions (sessions 17-20), equalling less than four hours of time.

My personal opinion is that by the time the family has successfully gone through Phases I and II, which, by definition means the patient has achieved a weight in the normal range (e.g. 95% expected weight), all self-starvation has abated, and control over eating and exercise have been successfully returned to the adolescent without a relapse into AN, it is reasonable enough for a family to conclude that it is finished dealing with eating disorder treatment and with eating disorder professionals.

Thank you for your very detailed analysis of the articles I cited. You are indeed correct – these studies do not prove that individuals with AN who have been through Phases I and II of FBT continue to struggle with comorbid conditions in Phase III. The studies merely demonstrate that many individuals who recover from AN continue to experience psychological distress in the form of anxiety or depression, for reasons that are not entirely clear. You are also correct that my hypothesis is merely a hypothesis – there are no specific experimental data to support it or refute it. This is part of that “uncharted territory” you mention in a previous comment.

If you’ll notice, I did revise the wording of the 5th paragraph of this blog entry to clarify that the extended version of Phase III is NOT part of the manualized treatment, but simply something I often offer in my practice for patients when I believe it is warranted.

I completely agree with you that it is reasonable for parents to question the recommendation for more psychotherapy in Phase III beyond what is written in the manual. Parents SHOULD question their clinician when they need clarification on something or when they want to know why a particular treatment is being offered or altered. I also agree that it is, and should be, up to the parents to decide whether, and for how long, they wish to pursue an extended version of Phase III. This is how I do things in my practice – I leave it up to the parents. If the parents believe that it would not be helpful, or would be counterproductive, to engage in treatment beyond what is manualized, then I fully support them in that decision.

I do want to point out, though, that my experience has often been the opposite – the parents request more treatment for their child than what is written in the manual, precisely because their child is struggling with anxiety or body image or something else, and the parent feels confident in my ability to help their child with that problem based on the positive work we did together in the first two phases.

When I am dealing with clinical situations in which there are no specific experimental data to guide me, I look at the data that are available and use my training and experience to bridge the gaps, based on the needs of the particular patient and family. It is logical, reasonable, and within the realm of evidence-based practice to do this.

Consider the following:
1.) The data show that FBT is the most effective treatment for adolescents under 18 who have been ill for less than 3 years.
2.) Some adolescents who have gone through Phase I and Phase II of FBT continue to struggle with psychological symptoms such as anxiety, depression, and body dysmorphia.
3.) The data show that CBT is the most effective treatment for anxiety, depression, and body dysmorphia in adolescents and adults.
4.) I am trained in CBT.
5.) During Phase III, the parent requests that I provide their child with additional therapy to address remaining anxiety or depression because their child is still suffering and the parent wants to help alleviate that suffering.
6.) I agree to continue working with the child and/or the family to address remaining issues, using the best evidence-based approach for those remaining issues (which is typically CBT).

This all seems perfectly logical to me. It is not haphazard or myth-based. It is using the best available evidence, along with my clinical judgment, to meet the particular needs and desires of the individual patient and family.

I am most certainly not recommending that, as you state: “a large number of additional, expensive, time-consuming therapies be added to the FBT manual as a general approach to treatment.” I would not consider 8 or 10 one-hour CBT sessions, occuring once a week or every other week, billed at $160 per hour (or considerably less for families with financial difficulties), to be “a large number of additional, expensive, time-consuming therapies.” In some modern nations, such treatment is subsidized by the government and free to citizens.

Finally, I fully agree with your assertion that more therapy is not necessarily better and could potentially be harmful. However, I also believe that, in some cases, more therapy, delivered skillfully and based on the best available evidence, helps people get better.

You hypothesize that manualized FBT “rarely” is sufficient because, you claim, a high rate of co-morbidity generally persists into Phase III, and, you contend, the manual doesn’t adequately address co-morbid conditions. You propose, therefore, that a large number of additional, expensive, time-consuming therapies be added to the FBT manual as a general approach to treatment.

The only way to test your hypothesis would be systematically to observe patients who have successfully gone through Phases I and II and then measure levels of comorbidity as the patient enters Phase III. To the best of my knowledge, such a study has never been done.

The two studies you cited, Wagner (2006) and Holtkamp (2005), certainly did not do that. Neither one involved patients who had been given FBT (at least there was no such indication) and neither
study therefore was able to involve an assessment of the patient’s psychological health during Phase III. Therefore, I don’t think it can be said that the experimental data from Wagner and Holtkamp supports the hypothesis that most patients who have successfully gone through Phases I and II of FBT will experience co-morbidity during Phase III.
The Wagner study, by the way, involved a very small group of former AN patients (21 individuals). Many were self-selected and recruited through advertisements and therefore did not necessarily represent a random cross-section of former AN sufferers. The average age was 23.8; these were not children or adolescents. The small group of former AN sufferers scored higher than the control group on some indications of co-morbidity, but lower on others. The sample size was too small, however, to allow for generalization.
The Holtkamp study involved 39 former anorexia nervosa patients. The objective was to try to determine whether depressive, anxious and obsessive symptoms persist 10 years after weight restoration. The study showed that in some cases it did, and in other cases it did not. It is significant to note that the subjects in the Holtkamp study had been treated for anorexia nervosa in a psychiatric hospital, not by their parents using the FBT model. The authors acknowledged that it might actually have been the long-term hospitalization, and resulting isolation from peers and disturbance of normal psychosocial development during adolescence, that caused the patients to become anxious, depressed, and obsessive, not the anorexia nervosa itself. In other words, it was possible that it was not anorexia nervosa, but instead the treatment that was given, that was responsible for the co-morbid conditions observed in some of thepatients. This is consistent with other studies showing that adolescents who are institutionalized for significantly long periods of time for any number of medical or psychiatric conditions tend to develop psychological problems due to the hopitalization itself. Manualized FBT does not entail psychiatric hospitalization. Consequently, the Holtkamp study does not tell us whether FBT patients who have been treated at home, and have successfully moved through Phases I and II, can be expected to suffer the same rates of co-morbidity in Phase III that are experienced by anorexia patients who have been treated with long-term psychiatric hospitalization.
In summary, I think it is reasonable to conclude that your hypothesis is still merely a hypothesis. It has not been established by experimental data. Therefore, it’s not unreasonable for parents to question the recommendation for more psychotherapy in Phase III beyond what’s written in the FBT manual. If a family feels it would be in the best interests of their child and their family, then that is their decision. If the family feels it would not be helpful, however, and would actually be counter-productive, then they can confidently conclude there is no empirical data to show they are wrong.