Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

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Tag: Adolescents

Tuesday, September 6th, 2016

Parent-Focused Treatment: An Attractive Alternative to FBT

 

The results of a randomized clinical trial (RCT) comparing Parent-Focused Treatment (PFT) and Family-Based Treatment (FBT) for adolescent Anorexia Nervosa (AN) were published this month in the Journal of the American Academy of Child & Adolescent Psychiatry.  As a practitioner of FBT, and as a clinician who is always looking for ways to improve patient outcomes, I read this article with great interest.

Family-Based Treatment (FBT), when applied strictly according to the manual, entails a psychologist or other mental health professional meeting with the family as a whole – the adolescent patient, both parents, and siblings – in a single session.  In contrast, Parent-Focused Treatment (PFT) involves the psychologist meeting privately with the parents, while the patient’s weight, vitals, and mental status are monitored by a nurse.

While FBT and PFT therapy sessions are conducted in different formats, the essence of the treatment – which is implemented by parents in the home – is the same.  Both treatments empower parents to work together to increase their adolescent’s food intake, restore him or her to a healthy weight, interrupt eating disordered behaviors, re-establish normal eating patterns, and return him or her to a state of healthy adolescent development.

The results of this study demonstrated that PFT is more efficacious than FBT.  At the end of treatment, patients receiving PFT were twice as likely to be in remission from AN compared with patients receiving FBT.  In addition to being published in the Journal of the American Academy of Child & Adolescent Psychiatry, the article was summarized nicely by the Murdoch Children’s Research Institute.

As I was reading this article, it occurred to me that I have been utilizing a version of PFT with some families in my private practice for years, as I have adapted FBT to suit the needs of each individual family.   For example, it is not uncommon for an adolescent patient with AN to refuse to attend some or all of the family sessions during Phase I (the re-feeding and weight restoration phase).  Personally, I have not found this to be problematic.  After all, in an FBT model, the parents are the primary agents of change in early recovery from AN.   The patient is more of a passive recipient of care – his or her job is simply to show up at the table and eat.

In my experience, most parents make excellent use of the Phase I sessions to receive support, learn more about AN, brainstorm and problem-solve, and collaborate with their spouse in the re-feeding process.  All of these things can be done with or without the child present, so long as the child’s weight is monitored weekly.  The weekly weigh-ins can be completed at the pediatrician’s office or under parental supervision at home.

As another example, many patients are so anxious about eating high-calorie foods, gaining weight, and eliminating exercise that attending sessions –during which these topics are discussed at length – is just too overwhelming.  Increasing a patient’s anxiety can sometimes be counterproductive to treatment goals.  For instance, if the patient is present during discussions of “fortifying” foods (e.g., increasing the caloric density by adding cream, oil, butter, or Benecalorie) or discussions of weight goals, this may heighten her anxiety to the point that she cannot eat these fortified foods, or she may become even more resistant to gaining weight.    For an underweight patient with AN, talking and listening are over-rated.  Eating and gaining weight are essential.

In my experience, patients who do not attend sessions during Phase I tend to have just as much success in recovery as patients who attend every single session.  Furthermore, the vast majority of the time, the kids who refuse to attend sessions in Phase I will begin to attend sessions voluntarily after weight restoration occurs and their treatment progresses through Phase II and Phase III.  By that time, most patients have the cognitive and emotional capacity to participate in their own recovery process and have some interest in getting better.

On the other hand, there are some cases in which it makes more sense to have the patient attend all of the FBT sessions, cases in which her participation in the treatment enhances her success in recovery.  Often (though not always), these are cases in which the patient is older, more independent, less cognitively impaired, less anxious, more curious about the process, and/or has some degree of personal motivation to recover at the outset.

I have also found that it is also very important for the patient to attend all sessions in cases where the parents are less willing or less able to take full responsibility for their child’s recovery.   For instance, I’ve worked with families in FBT in which both parents have active addictions to drugs or alcohol, families in which another member is coping with a health crisis (e.g., a parent with a recent cancer diagnosis), families in which the parents are going through an acrimonious divorce, and large families with many young children.   These have been cases in which the parents, while supportive in theory, were unable to invest as much time and energy into their child’s recovery as other families.  The patients from these families, in my observation, tended to be more resilient and more autonomous than other teens, likely .as a result of growing up in challenging environments.  I have observed that the adolescents in these more challenging situations have been able to (or perhaps required to) take on a greater degree of independence earlier in the recovery process.

The outcomes of this clinical trial were disappointingly low for both forms of treatment.  At the end of treatment, only 43% of patients receiving PFT had achieved remission, and only 22% of patients receiving FBT achieved remission.   Before you become discouraged, however, please allow me to explain my theories as to why remission rates were so low.

First, I believe that the poor outcomes of this study were, at least in part, due to the fact that families were randomly assigned to one type of treatment or the other.   Of course, in conducting a controlled clinical trial to study the efficacy of treatments, it is necessary to use random assignment to control for confounding variables and increase the validity of the results.  I suspect that if families were able to choose between PFT and FBT based on their own needs, desires, circumstances, and knowledge of their child, the outcomes would have been significantly more promising.  This has certainly proven to be true in my practice.

Consider the “treatment refusers” I described above, with whom I have effectively used PFT essentially by default.  On the other hand, consider the teens who come from more challenging family environments, whose participation early in treatment is instrumental to their recovery.  If the families with “treatment refusers” were randomly assigned to Family-Based Treatment, or if families with other significant challenges were randomly assigned to Parent-Focused Treatment, I suspect that the patient would be much less likely to occur.

Second, the course of treatment in this study was 18 sessions over the course of 6 months.  This sounds woefully insufficient to me.  In my experience, some patients do achieve full remission within 6 months, but this is certainly not the norm.  In my practice, most patients with AN are fully weight-restored within 3 or 4 months, but full remission of cognitive, emotional, and behavioral symptoms generally takes 12-18 months of treatment.   It is not unusual for patients to require 2 or 3 years of treatment in order to attain full remission and become ready to manage their eating independently.

I point out these time frames because I do not want patients or their families to feel discouraged when recovery takes so much longer than they expected.  The patients in these clinical trials who did not achieve full remission at end of treatment are the NORM, not the exception, and this is not due to any failure on the part of the patient or the parents.  Rather, the research study itself places unrealistic expectations on individuals with AN and their families.   Any clinician who has treated many patients with AN could tell you that full remission after 6 months is simply unrealistic for a majority of AN sufferers.  Individuals who have gone through treatment for AN, and parents who have helped their children recover, know all too well that vestiges of AN are often present for many months after weight has been fully restored.

I am confident that the majority of adolescents with AN who are not in full remission after 6 months of treatment will go on to achieve full remission within two or three years, especially when they utilize evidence-based, family-centered care.

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Tuesday, August 2nd, 2016

Fighting Stigma: The Gift of a New Generation

Somehow, sometime in the past several years, I crossed some invisible line from “young adult” to simply “adult.”  Polite strangers call me “ma’am” at least as often as they call me “miss.”  Shopping at Forever 21 now seems scandalously inappropriate.  And I can’t remember the last time I was still awake to watch Saturday Night Live.  Now that I seem to be old enough to complain about the younger generation (They think women’s empowerment is posting bikini-clad selfies!  They use social media excessively! Their pivotal relationship conversations take place over text message!), it seems only fair that I also recognize the strengths of this cohort.  And they do have tremendous strengths.

Teenagers and young adults these days, for the most part, have grown up in an era where it is socially acceptable, even encouraged, to speak openly about mental health issues.  Just about every high school and college student who walks into my office has at least a couple of friends with mental health diagnoses.   Most of my patients have one or more members of their extended family, if not their immediate family, who has dealt with a mental illness.   And they know this because they talk openly about it.

And that excessive use of social media I complained about a minute ago?  Well, social media has allowed famous people to speak candidly to a wide audience about their experiences with mental illness, seeking treatment, and ultimately recovering.   Actress Kristen Bell has struggled with depression.   Writer/producer/actress Lena Dunham has received treatment for OCD.  Singer Demi Lovato has spoken openly about her struggles with bipolar disorder and her recovery from an eating disorderJohn Green, author of The Fault in Our Stars, has chronic anxiety which he is able to control with therapy and medication.  Olympic swimmer Michael Phelps has a diagnosis of ADHD.  These individuals have been extremely successful in their professions and have had the courage to speak publicly about their psychiatric problems.

Even more courageous than these celebrities, though, are the regular people who attend school, play sports, hold down jobs, pay bills, raise families, volunteer in their communities, and maintain friendships while also dealing with mental illness.  These are the people who have a lot to lose from the stigma surrounding mental health issues.  These are also the people who have the most to gain from breaking down the stigma.

The younger generation is fighting this stigma.  Australia’s National Youth Mental Health foundation has created an organization called Headspace dedicated to supporting adolescents and young adults with mental illnesses as well as combating stigma surrounding these issues.  In the UK, Prince William, Princess Kate, and Prince Harry have created Heads Together, a charity dedicated to fighting stigma surrounding mental illness and improving the mental well-being of all citizens.  Here in the US, the National Alliance on Mental Illness (NAMI) is running a Stigma-Free campaign.

The message of these organizations is simple and straightforward: mental illness is common and treatable.  Mental health problems are as much a part of the human condition as any other health problem.  Untreated mental illness can have dire effects on the individual, on the family, on the community, and on society as a whole.  People who have psychiatric diagnoses can overcome them and live fulfilling, successful, meaningful lives.  Learn about it.  Talk about it.  Seek treatment when needed, and support others in doing so as well.  Silence and shame help no one.

I can’t recall ever hearing these messages as a teenager or young adult.  If these messages existed at all back in my day, they were eclipsed by the OJ Simpson trial, overshadowed by the Clinton/Lewinsky scandal, drowned out by the Spice Girls and ignored amidst episodes of Friends.  It is an honor and a privilege for me to treat the teens of this generation, who live their lives with more knowledge, understanding, and acceptance than the generation before them.

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Monday, January 25th, 2016

Iatrogenic Effects

The year is 1892. Emily, age 14, is the second of six children in a Midwestern farming family. One evening in March, Emily’s mother catches a glimpse of her daughter undressing and is taken aback by how slim she looks. Over the next few days, mother notices that Emily eats very little at family meals. She mostly just pushes her food around the plate and slips pieces of her food under the table to the family’s two dogs.

Later that week, Emily’s older sister, Cora, confides in her mother that Emily is no longer getting her monthly cycles. Now mother is greatly concerned, and she has a talk with her husband, who is equally worried. Both parents sit down with Emily and express their concern over her poor eating habits, weight loss, and absence of menstrual cycles. In response to her parents’ talk, Emily bursts into tears. “I just can’t eat,” she cries. “I just can’t.” Mother and father hug their daughter, comfort her, and let her know that they will be taking her to the family doctor the next morning.

When Dr. Benson examines Emily the following day, he is alarmed by his young patient’s gaunt appearance and flat affect. She is no longer the bubbly, robust young girl he has known since birth. Emily’s pulse is much lower than normal, her muscles have wasted, and her adolescent figure has shrunken to a pre-pubescent one.

“Emily is gravely ill and melancholy,” Dr. Benson tells the worried parents. “She is malnourished, and she will need lots of food and rest to recover. She needs complete bed rest for the next three months, plenty of food at each meal, and six tall glasses of milk per day. I will see her again next week.”

Emily cries heavily all the way home, burying her head in her mother’s skirt. As soon as the family gets back to their house, her mother prepares her a large plate of food with extra bread and butter and a tall glass of milk. Mother sits beside Emily and strokes her daughter’s hair as she stares – terrified – at the heaping plate of food. “You will not be doing any chores this spring,” her father tells her firmly. “Cora will do your indoor chores and Ethan will take over your outdoor chores. You will not be returning to school this year – the 2-mile walk is too strenuous for you in this condition. Cora will speak with your teachers and bring home your assignments. You will study from home. You will return to school and chores when you are well.”

“But Papa…” pleads Emily. “I have to –“

“That’s enough, young lady. You know better than to take that tone with me. This is final.” With that, Emily’s father abruptly leaves the room. Tears stream down Emily’s cheeks as she weeps silently. Mother strokes her back and whispers: “Come on, sweetie. Eat.” Hands shaking, Emily picks up her fork and takes a bite. Mother waits with her at the table for the next two hours as she finishes every last bite of food and every last drop of milk.

19th century family

Dr. Benson makes house calls weekly over the next few months. Emily is always lying on her bed, reading and sipping a glass of milk, when he arrives. He watches the young girl slowly put on weight, regain her strength and stamina, begin to smile again, and then blossom into the cheerful teenager she was meant to be. By the time June rolls around, Emily has resumed her monthly cycle and returned to her normal weight. At this point, Dr. Benson gives her permission to begin doing some light chores around the house.

By September, Emily is eating with gusto. She has had three monthly cycles in a row and has regained her curvy figure. She returns to school and resumes all of her farm chores. Her parents are relieved to have their daughter back.

The vignette above illustrates how Anorexia Nervosa (AN) would have been treated several generations ago. Quite a stark contrast from how AN is treated today, isn’t it? The illness itself has remained basically the same throughout time, but the way that people conceptualize it and respond to it has changed dramatically. Consider the following differences between Emily’s treatment in 1892 and the treatment Emily’s great-great-granddaughter Marissa received in modern times:

1.) Emily’s parents are immediately concerned by her weight loss and dwindling food intake. They view weight loss in a growing adolescent as a sign of illness and take her to the doctor immediately. Marissa’s parents are pleased when they notice her becoming slimmer shortly after her 14th birthday. They praise her for foregoing desserts and snack foods. They encourage her interest in athletics and bring her jogging with them in the morning.

2.) Emily’s family doctor is immediately concerned by his young patient’s weight loss, lack of menses, and changed demeanor. At her 15-year-check-up, Marissa’s pediatrician commends her on her 12-pound weight loss. When Marissa’s mother expresses concern to the pediatrician about her daughter’s low heart rate and absence of menses for the past three months, the doctor explains that it is common for female athletes to lose their monthly cycle, and that Marissa’s low heart rate is also due to being a runner.

3.) The prescribed treatment for Emily – full nutrition and complete bed rest – is commenced immediately and aggressively. Eating more food is not recommended, or even suggested, for Marissa. Marissa continues running with the blessing of her doctor and the encouragement of her coach.

4.) The doctor views Emily’s parents as competent agents to re-feed their starving daughter and enforce bed rest for a prolonged period of time. Marissa’s parents are advised to “stay out of the food business” and admonished not to be the “food police.”

5.) Dr. Benson monitors Emily’s condition weekly and supports the family throughout the recovery process. Emily’s menstrual periods return naturally as she restores a healthy weight. Marissa’s pediatrician does not see her again until she develops a stress fracture 5 months later. Marissa has now lost a total of 20 pounds, and her pediatrician gently suggests that she tries to eat a little more. The pediatrician also refers her to a gynecologist, who prescribes birth control pills to re-start her periods.

6.) Emily is expected to comply with the prescribed treatment, and parents are expected to enforce it. Marissa restricts her food intake even more. She is now eating nothing but fruit, vegetables, and chicken breast. Scared to make matters worse, her parents say nothing.

7.) Emily eats hearty meals with her family every day for breakfast, lunch, and dinner, plus plenty of whole milk in between. Unable to watch her daughter starve herself any longer, Marissa’s mother takes her to a local therapist who was recommended by a neighbor. This therapist begins meeting with Marissa weekly, and also refers them to a family therapist and a dietitian. Marissa is now attending multiple appointments each week and following a 1600-calorie exchange plan created by her dietitian. She prepares her own meals, weighing and measuring everything.

8.) The doctor recommends chamomile tea with honey to soothe Emily’s nerves. Neither Emily nor her parents are blamed for her AN. The etiology of the illness is not discussed with Emily or her family, as it is not known. Marissa’s weight does not change, but her mood deteriorates. The therapist refers Marissa to a psychiatrist, who prescribes Lexapro and Klonopin. The family therapist suggests that Marissa’s AN is a cry for attention, as her father works long hours at his law firm and her mother is very preoccupied caring for her younger son with autism.

9.) Emily’s weight was restored to her normal range within three months of commencing treatment. She remains home with her family throughout and maintains good physical and mental health for the rest of her teenage years. By her 16th birthday, Marissa has lost 4 more pounds (a total loss of 24 pounds in 2 years). Her therapist recommends residential treatment at a well-marketed eating disorder treatment center in another state. Marissa spends 3 months at this residential treatment center. The psychiatrist there prescribes two additional psychotropic medications. Within a month of returning home, Marissa relapses and returns to the center for another 3 months.

10.) Emily maintains good relationships with her parents and siblings. She trusts her family to help her when she needs them. By the time she turns 18, Marissa has had three psychiatric hospitalizations, four stays in residential eating disorder treatment, and is taking five different psychotropic medications in addition to Ambien for sleep and birth control pills to regulate periods. She barely speaks to her parents and refuses to sign consents to allow them to access her healthcare information.

Emily and Marissa developed the same illness at the same age but received very different treatments and thus had very different outcomes. Emily’s AN was completely resolved within 6 months, whereas Marissa remains gravely ill and in intensive treatment four years later. Marissa experienced the iatrogenic effects that are so prevalent in modern eating disorder treatment. Iatrogenic effects are harmful outcomes caused by a medical intervention. In other words, a treatment which is intended to help a patient ends up making her condition worse or creating a new problem that wasn’t there before.

Marissa’s story is all too common. The adults around her – with good intentions – inflicted harm by prolonging her state of semi-starvation, prioritizing her adolescent autonomy above her physical health, disempowering her parents, alienating her from her family, subjecting her to time-consuming, costly, and ineffective therapies, prescribing powerful psychotropic drugs that may not have been necessary, isolating her from her primary support system, and surrounding her with other mentally ill teenagers.

modern girl

Clearly, some teenagers with Anorexia Nervosa have complicated presentations with multiple comorbidities which require a team of professionals and specialized care. But there are also many cases in which a simple and straightforward intervention would be far more effective and efficient than the iatrogenic treatments that so many kids and families endure. This is precisely why Family-Based Treatment (FBT) is so effective: it minimizes the iatrogenic effects of other eating disorder treatments. Mainstream eating disorder treatment often morphs Emilys into Marissas.

What would have happened to Marissa if she had been provided with the same treatment as her great- great-grandmother Emily? Would she, too, have regained full health in a matter of six months, and bounced back into a vibrant adolescent life? It’s impossible to know for sure, but it seems likely that she could have. It’s definitely worth a try. Our 21st century Marissas need and deserve treatment that is AT LEAST as effective as 19th century Emilys.

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Friday, September 11th, 2015

After Weight Restoration: What About Body Image?

Body image disturbance is one of the most insidious and painful symptoms of Anorexia Nervosa (AN). In many cases, body dissatisfaction is the last symptom to abate. However, the relationship between body image and recovery from Anorexia Nervosa (AN) is fairly complex. Many individuals with Anorexia Nervosa (AN) do not experience body image problems as a symptom of their illness. Most people with AN, however, do have some degree of body image disturbance which changes in intensity over the course of their illness and recovery.

A recent randomized controlled trial of adolescent AN treatment found that weight and shape concerns did not change significantly over the course of treatment. The authors of the study point out that, on the one hand, these results suggest that weight and shape concerns do not get worse over the course of treatment. This finding may come as a relief to patients who are terrified that they will hate their bodies if they gain weight. The authors conclude that “weight restoration alone is not sufficient to ameliorate the weight and shape concerns characteristic to AN.”

While the authors’ conclusion may be accurate in some cases, my clinical experience with AN patients as well as my knowledge of statistics leads me to a different conclusion. I have observed that the relationship between weight restoration and body image varies dramatically from person to person. When it comes to AN and body image, people tend to fall into one of the following categories:

1.) Those who do not have significant weight or shape concerns.

2.) Those who present for treatment with significant weight and shape concerns, which gradually abate over the course of weight restoration and may even disappear by the end of treatment.

3.) Those who become increasingly dissatisfied and distressed by their weight or shape as they restore weight.

My hypothesis is that the authors of the study found no significant change in body image over the course of treatment because patients in group 2 and group 3 essentially cancelled each other out, while those in group 1 did not impact the results in either direction.

As you can see from the groupings above, body image disturbance may not even be relevant for the patient (group 1), and if it is, weight restoration alone may be sufficient to improve body image (group 2). For this reason, I typically postpone addressing body image until after weight restoration has been accomplished and the patient has re-established normal eating patterns. By postponing body image work until the end of treatment, the patient and her family save a lot of time, money, and stress, as a substantial proportion of patients do not need it.

Individuals in group 3, however, may benefit from working on their body image in therapy. Helping these individuals improve their body image will be the topic of my next blog post.

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Sunday, September 7th, 2014

After Weight Restoration: The Role of Insight

One of the hallmark symptoms of Anorexia Nervosa (AN) is anosognosia, or a brain-based inability to recognize that one is sick. For this reason, most patients have little or no insight when they first present for treatment. Even months into effective treatment, most patients with AN continue to demonstrate anosognosia from time to time, if not consistently. The irony here is that most patients with AN do not believe they are sick until after they have gotten well.

I am outspoken in my belief that insight is unnecessary, not to mention unlikely, in early recovery from Anorexia Nervosa (AN). I do not expect my patients to have any insight whatsoever early on in their treatment with me. I expect kids with AN to present in my office denying that they have a problem. Their lack of insight does not delay or undermine treatment one bit.

In Family-Based Treatment (FBT), the patient is not required to demonstrate any insight at all during Phase I (Re-feeding and weight restoration). Phase II (returning control of eating to the adolescent) and even Phase III (establishing a healthy adolescent identity) can be successfully completed with a relatively small amount of insight on the patient’s part.

The re-feeding and weight-restoration components of treatment can be achieved without the patient’s consent or compliance. Through FBT and similar family-centered approaches, parents can feed their children complete, balanced nutrition and ensure that they maintain a healthy weight for as long as necessary. In theory, a patient could exist in an externally-maintained state of physical health forever, which would be far better than suffering the long-term medical and psychological consequences of AN. But this is not recovery.

Children and younger teens tend to lack the maturity to develop good insight even after their AN has been in remission for quite some time. Lack of insight is completely normal at this stage of development, even for kids who have never had a brain disorder. It is not necessarily problematic for recovering adolescents to lack insight as long as they are living safely under their parents’ roof.

For older adolescents and young adults, however, there comes a point later in recovery, after physical health is restored and most mental symptoms have subsided, when a patient does need to develop some insight about their illness and “own their recovery.” Patients do not need insight to get well, but they certainly do need insight in order to live a healthy, fulfilling, independent life.

As a side note here, the type of insight I am referring to here has nothing to do with “discovering the root cause” or “learning to love yourself” or “finding your voice” or any of the other talking points commonly referenced in ED recovery circles. The important insights to gain, in my opinion, are the following:

1.) Acknowledging and accepting that you have (or had) an eating disorder, which is a biologically-based brain illness that you did not choose to have and your parents did not cause

2.) Acknowledging and accepting the possibility of relapse

3.) Ability to recognize eating disordered thoughts, feelings, and behaviors in yourself

4.) Understanding the necessity of maintaining full nutrition, every day, for life

5.) Accepting the necessity of maintaining your ideal body weight in order to reduce the risk of relapse

How do you help a person who is recovering from AN to develop insight? It’s tricky, and it varies considerably based upon the patient’s own unique experience of having AN. Unlike full nutrition and weight restoration, insight cannot be thrust upon someone against their will. The patient must be an active participant in the process.

I find it helpful, as a therapist, to have frank conversations with patients and their parents about the biological basis of AN, potential triggers, vulnerability to relapse, and the importance of practicing good self-care. A single conversation at the start of treatment is rarely sufficient. Instead, I integrate these conversations into most of our sessions to help the patient absorb and internalize this information. For the first few months of treatment, these discussions are primarily for the benefit of the parents, as most kids are too malnourished and shut-down to process this information. However, after weight restoration and brain healing, these discussions can have a powerful impact on recovering kids.

Parents often have these insight-building conversations with their recovering teens at home. Often, teens will get defensive, shut down, or lash out when parents bring up these topics. But sometimes kids actually listen!

Many weight-restored patients go through a phase of romanticizing their AN, longing to return to the days of extreme thinness, perpetual motion, and hyper-focus on academics and athletics. While these feelings are understandable and typical at a certain stage of recovery, they need to be counterbalanced with conversations about the negative impact AN had on their bodies, their minds, and their lives. Otherwise, it is all too easy for recovering people to view AN through “rose-colored glasses.”

Bear in mind that the development of insight can take years. Recovered teens who initially presented for treatment at age 13-14 (the typical age of onset) will often show a blossoming of insight around age 17-18, just as they are preparing to leave home for college. This newfound insight is often the result of a variety of factors, including consistent full nutrition, brain healing, normal adolescent developmental processes, maturity, frontal lobe development, and successful therapy. I have worked with many adolescents for whom this happens beautifully, organically, and right on time. These kids go off to college in other states and thrive.

In other cases, however, the timing may be far less convenient. Those who develop AN at 16 or 17 years of age may not be sufficiently recovered to develop the insight needed to manage their illness independently at that magical age of 18. Similarly, who relapse during their junior or senior year of high school may have a setback in the process of insight development and thus may not be ready for independence right after high school.

In some cases, kids are diagnosed in childhood or early adolescence but don’t receive effective treatment until late adolescence. In these cases, it may take even longer for insight to develop if the illness has become entrenched and emotional maturity lags far behind chronological age.

Further, teens who have suffered through months or years of ineffective treatment may have built up an arsenal of bogus myth-based insight that has nothing to do with the reality of their illness. For example:

• “I developed AN as a way to cope with feeling out of control in life.”

• “I have to want to get better on my own. I have to do this for myself.”

• “Re-feeding doesn’t help us discover the root cause of your illness.”

• “I am enmeshed with my parents and this is keeping me sick. I need to become more independent.”

These myth-based “insights” very often result in parental alienation and protracted illness.

As you can see, all insight is not equal. The insights worth having are those that are based in empirical science, those that empower parents to help their offspring recover, and those that serve to help patients achieve and maintain their physical and mental health while living a full and meaningful life.

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Monday, April 14th, 2014

Weight Gain Predicts Psychological Improvement in Anorexia Nervosa

A recent study published in the journal Behavior Research and Therapy demonstrated that weight gain was a significant predictor of improved psychological functioning in adolescents undergoing treatment for anorexia nervosa (AN). In other words, adolescents who gained more weight during treatment did better mentally than those who gained less weight. This study also showed that weight gain early in the course of treatment had a greater impact on psychological recovery than weight gain later in the course of treatment.

This finding is extremely relevant not only to clinicians who treat adolescent AN, but also to the adolescent patients themselves and their families. The process of re-feeding and restoring weight often feels agonizing for patients and may cause tremendous stress to caregivers. Psychological recovery lags behind physical recovery, so patients often feel worse before they start to feel better. This study provides objective evidence that it is in the patient’s best interest – both physically and psychologically – to eat more and gain weight as soon as possible after diagnosis.

Weight gain is an essential component of treatment for patients with AN. The knowledge that full nutrition is necessary to repair the physical damage caused by AN – including weakened heart, low blood pressure, hypothermia, osteoporosis, stress fractures, lanugo, amenorrhea, infertility, and risk of premature death – helps many patients and families to persevere through the difficult days of re-feeding. Now, patients and families can hold onto hope that weight restoration will bring about psychological improvement as well. This study provides families with direct scientific evidence that gaining weight gives their loved one a greater chance of recovering mentally, emerging from the fog of depression, and reclaiming a meaningful life free from food and weight preoccupation.

Patients in this study were randomly assigned to receive either Family-Based Treatment (FBT) or Adolescent Focused Treatment (AFT). The authors of this study found that weight gain predicted psychological recovery regardless of the type of treatment (FBT vs. AFT) the patient received. This finding may be especially relevant to clinicians who treat adolescent AN using individual therapy. A common criticism of FBT (usually made by clinicians who reject FBT without really understanding it) is that it focuses on weight gain at the expense of the adolescent’s psychological wellbeing. This study clearly demonstrates that weight gain and improved psychological functioning are not mutually exclusive. On the contrary, weight gain and improved psychological functioning are strongly correlated!

It is clear that FBT supports the adolescent’s psychological wellbeing indirectly by promoting regular nutrition and steady weight gain, which help to repair the brain damage caused by malnutrition. I would also argue that FBT has a direct impact on the adolescent’s psychological wellbeing by externalizing the illness, removing any sense of self-blame the adolescent may have, supporting her emotionally, and relieving her of the burden of fighting this deadly illness alone.

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Thursday, February 20th, 2014

Exercise Caution: Physical Activity and Eating Disorder Recovery

Compulsive exercise is often a symptom of eating disorders. It is common for a child who is developing an eating disorder to take a sudden interest in running and other vigorous forms of exercise. Given that exercise is a symptom which is directly related to the energy imbalance that triggers and maintains a restrictive eating disorder, it is important for clinicians and caregivers to monitor and manage patients’ exercise during treatment and recovery.

When a patient has an active eating disorder, it is generally ineffective to use exercise or sports as an “incentive” to get him to eat more or gain weight. Even the patient who absolutely loves soccer, and says he would do anything to keep playing, probably won’t be able to eat enough to make that happen. The malnourished anorexic brain is just not capable of overriding symptoms, no matter how alluring the reward may be.

For people with eating disorders, exercise poses numerous medical risks including stress fractures, osteoporosis, muscle wasting, and heart arrhythmia. Further, exercise can be counterproductive to treatment goals when a patient needs to restore weight. For these reasons, I recommend that patients with Anorexia Nervosa or Bulimia Nervosa abstain from all physical activity until they meet the following criteria:

a.) Complete weight restoration
b.) Complete abstinence from binge/purge behaviors for at least two weeks
c.) Consistently eating complete, balanced meals with little resistance
d.) Sufficient hydration
e.) Willingness and ability to increase nutrition and hydration to compensate for activity
f.) Medically cleared to exercise by physician

Explaining the dangers of exercise to the eating disordered patient is important but rarely sufficient to curb the compulsion. Patients with exercise compulsion need an authoritative source to tell them directly, in no uncertain terms, that all exercise must be stopped until the above criteria are met. In my practice, the hiatus from exercise typically lasts for several months, but this varies widely based upon the patient’s severity of illness and response to treatment.

Abstaining from all physical activity means stopping sports, dance classes, martial arts, and any other extracurricular activity that involves movement. It also means no PE at school, no bike riding, no home workouts, no yoga, and no long-distance walking.

Parents can do a number of things to help prevent their ill child from exercising. They can obtain a doctor’s note to except him from PE class, they can call the coach to inform him that the child will not be able to play for the rest of the season, they can give him a break from his usual chore of walking the dog.

When the exercise compulsion is strong, more serious measures must be taken. Some parents may need to get rid of home exercise equipment, terminate their child’s gym membership, or hide her running shoes. Parents must be extremely vigilant in protecting their child from secretly exercising.

Any time spent behind closed doors presents an opportunity for the patient to succumb to the exercise compulsion. It is not unusual for anorexic patients to exercise in the middle of the night, to sneak out of the house to go running, or to do calisthenics on the bathroom floor. Sometimes it is necessary for parents to sleep in the same room with their child and provide round-the-clock supervision for weeks or months at a time in order to break the exercise compulsion.

Full nutrition and weight restoration often help tremendously in lessening the compulsion to exercise. Many recovering kids will lose interest in exercise once the compulsion has faded. These are often the kids who first began exercising in the context of their eating disorder, but never really enjoyed their activity. Once recovered, these kids will often return to lives that are not particularly active, and decide to pursue other interests instead, such as music, art, or a very busy social life.

For some children, exercise has been a part of their lives since they were very young, but took on a new intensity when the eating disorder arrived. For example, a 12-year-old girl who loves to dance and has taken ballet since preschool may suddenly start taking eight dance classes a week instead of her usual four. As another example, a teenage basketball player may begin rising at 4:00 AM to go jogging in addition to afternoon practices with his team. These kids suffer tremendously as the activities they love become tools for their eating disorder to use against them.

In my experience, these patients are often able to return to the sports and activities they previously enjoyed without compromising their recovery, so long as they are physically and mentally ready to do so, and so long as their activity is monitored and limited. The young dancer described above may return to her studio, once weight-restored and back in school, for three or four classes per week. The recovering teenage basketball player may be permitted to practice with his team, but would not be allowed to exercise outside of scheduled practices.

While it’s rarely effective to use sports as an incentive for a sick patient to get well, sports can be a great incentive for a recovered patient to stay well. Many patients, once physically and psychologically recovered, feel motivated to do whatever it takes to maintain their exciting new life. I have found that exercise contracts work well for these patients.

For example, my former patient, whom I will call Andy, played on a competitive year-round traveling soccer team. When Andy developed Anorexia Nervosa at age 14, his parents and I agreed that he would need to take five months off from soccer to restore his weight and focus on his recovery. Once he was feeling better, Andy became excited to rejoin his team.

Andy’s family and I supported his return to soccer so long as it did not interfere with his recovery. We developed a written contract which stated that Andy may participate in club soccer so long as he maintained his weight, ate all of his meals and snacks, drank 8 glasses of water per day, abstained from exercise outside of team practices, and attended monthly therapy sessions. We also agreed that he would drink a smoothie after each soccer practice and that one of his parents would travel with him to all tournaments to ensure that he ate enough to fuel his activity.

Certain solo long-distance endurance activities, such as cross country running and competitive swimming, pose particular risks for patients predisposed to eating disorders. This is in part due to their very high energy requirements, in part due to their solitary nature, and in part due to the extreme rigor of the activity which demands a high level of dedication. Not only do these factors attract young people who are competitive, driven, and dedicated (read: predisposed to eating disorders); they also create the perfect formula for triggering and perpetuating an eating disorder.

If a recovered person who had been a runner or a swimmer prior to getting sick expresses a desire to return to athletics, it may be preferable for him to choose a different sport. Team sports such as volleyball or basketball may be more conducive to sustained remission.

Activities with an artistic or aesthetic element, such as gymnastics, dance, figure skating, and diving, can pose a risk for those in recovery from eating disorders, particularly if body dissatisfaction and drive for thinness were major symptoms of the patient’s illness. If a former dancer/gymnast/athlete wishes to return to these activities, certain factors must be considered. In addition to the criteria for resuming exercise that I listed above, these young people should attain a certain level of body acceptance prior to returning to their activity. They need to feel at least somewhat comfortable in a leotard, and they must be strong enough to challenge or ignore any negative body thoughts that may arise. If a young person experiences a noticeable increase in eating disordered thoughts or behaviors upon returning to her activity, this is an indication that she likely needs more time off to recover before she can safely return.

It is important for dancers and athletes to return to a nurturing environment that does not encourage food restriction, weight loss, or winning at all costs. It is helpful for parents to speak with coaches and trainers to alert them of their child’s vulnerability and ensure that the atmosphere is conducive to health and well-being. There are dance teachers and coaches who encourage full nutrition, healthy body image, self-care, and a balanced approach to life. These adults can be positive forces in helping a young dancer or athlete sustain remission.

It is of utmost importance that family members and treatment professionals convey, through their words and their actions, that the patient’s physical and mental health are the number one priority. Participation in activities that jeopardize health or fuel emotional distress should be avoided. Participation in activities that bring joy and enhance well-being should be encouraged.

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Tuesday, December 4th, 2012

A Seat at the Table: Understanding and Helping the Siblings of Eating Disorder Patients

I feel honored to serve on the Professional Advisory Panel for FEAST, a nonprofit organization which provides support and information to the parents and families of people with eating disorders. Last weekend, I had the privilege of presenting at the second annual FEAST conference in Alexandria, VA. I spoke to a group of parents about understanding and helping their other children while also caring for their eating disordered child. Below are some of the major points from my presentation.

Eating disorders can impact the patient’s siblings from various angles:

• Through their parents. When a child is ill with an eating disorder, her siblings often receive less attention from their parents. The parents may be physically absent from the home, traveling to faraway treatment centers and attending many different appointments locally. Parents often feel worried, stressed, and irritable, and these emotions can easily spill over into their relationships with their other children.

• By impacting family life. Family meals with an eating disordered person can be tense or explosive. For this reason, siblings may begin to dread family meals or avoid them altogether. Family trips may be cancelled or ruined by the eating disorder. The financial burden of ED treatment impacts the entire family, including siblings.

• Through their social environment. Parents may not be available to drive siblings to their lessons, sports events, and social activities when they are spending long hours preparing and supervising meals and driving the ill sibling to appointments. Siblings may feel embarrassed to invite friends over when their ill sister or brother is acting particularly bizarre. Siblings may have to deal with gossip from friends and neighbors. They may feel conflicted about telling their friends about their family’s situation, and they have to deal with the stigma of mental illness.

• Through the change in eating habits. Parents are encouraged to serve their anorexic children high-calorie foods to restore their weight. Sometimes siblings over-indulge in these foods and gain unneeded weight.

• Through their genes. Biological siblings of eating disorder patients are 10 times more likely to develop an eating disorder compared to the general population. Additionally, siblings of eating disorder patients may inherit genes that predispose them to other psychiatric illnesses, including depression, OCD and other anxiety disorders, substance abuse, ADHD, and autism.

Brothers and sisters may experience a variety of emotions while their sibling is ill with an eating disorder. They may worry that their sibling will get sicker or die. They may grieve for the loss of their sibling’s true personality while she is consumed by the illness, and they may miss her terribly if she is away from home for a lengthy hospitalization or residential treatment stay. They may worry about their own risk for developing an eating disorder. They may feel angry at their sibling for putting the family through hell or making mealtimes miserable. They may feel jealous because of all of the attention their ill sibling is getting. Siblings may react by withdrawing from friends and family members, having difficulty at school, or acting out. They may feel sad or hopeless. They may have difficulty concentrating. Very young siblings may manifest their distress through physical symptoms (e.g., tummy aches, trouble sleeping).

It may not be possible for parents to shield siblings completely from the impact of the eating disorder. However, there are some steps that parents can take to minimize the damage and help siblings cope:

• Immediately upon diagnosis, provide siblings with age-appropriate information on their sibling’s diagnosis, symptoms, and treatment. Explain that the disorder is biologically-based and that the child did not chose to have it. I have a Sibling reading list, as well as a list of Q & A for siblings of AN patients. Even preschool-age siblings can understand a few basic points: “Your sister has a disease in her brain called anorexia which has made her very sick. She is acting different because of her sick brain; it is not her fault. We need to help her get better. Mommy and Daddy will be very busy taking care of her, but we still love you very much.”

• Be frank with siblings about the seriousness of the eating disorder, including the possibility of death. This honesty helps siblings understand why it is so important that the family intervenes immediately and aggressively, and why other activities have to take a back seat for now.

• Be honest with siblings about the reality of dealing with the eating disorder. Acknowledge that, for a period of time, the whole family will be under stress, family life will change, and you may not be able to spend as much time with them.

• Bring siblings to some Family-Based Treatment (FBT) sessions so that the therapist can explain the eating disorder to them, describe the treatment process, answer their questions, and tell them how they can support their ill sister or brother.

• Make a point of scheduling one-on-one time with each sibling and talking with them about their lives apart from the eating disorder.

• Talk with siblings about their feelings and reactions to the eating disorder. Let them know that it is totally normal and understandable for siblings to feel worried, angry, jealous, resentful, or sad in this type of situation.

• Ensure that siblings remain in a support role, rather than taking on a parent’s role. Lock and LeGrange, authors of the FBT manual, call this process “maintaining intergenerational boundaries.” Siblings can help their ill sister by providing her with distraction before, during, and after meals, by being good listeners and providing empathy, and by engaging her in normal sibling activities. Siblings can help by taking over kitchen chores that the eating disordered person is not well enough to do, such as setting the table or doing the dishes. Do not involve siblings in the actual process of re-feeding or supervising meals, as this can put them in a delicate position of being torn between “loyalty” to their ill sister and the responsibility of reporting ED behaviors to their parents.

An eating disorder can also impact siblings in a positive way. For example, they may grow closer to their ill sibling and value her more after almost losing her. They may feel needed and important in the process of supporting their ill sister or brother. Siblings may become more aware of EDs and other psychiatric illnesses in their friends and try to intervene whenever they see concerning behaviors. They may have improved body image after witnessing the disturbing body image distress of their ill sibling. Often, siblings benefit from having more frequent family meals and structured eating habits. They may grow and mature from the experience, developing more autonomy when parents’ focus is on the eating disorder treatment. Siblings benefit from strengthened parental unity. If a sibling develops an eating disorder or another illness in the future, their parents tend to intervene immediately and are much more equipped to deal with it.

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Sunday, July 29th, 2012

Navigating Phase III

Last week, I blogged about navigating Phase II of Maudsley Family-Based Treatment (FBT). Today I present a roadmap for Phase III, which is equal to Phase II in its importance as well as its ambiguity.

A common but ill-informed criticism of FBT is that it only addresses eating and weight. This is a misconception. Phase I focuses on establishing normal eating habits and restoring normal weight and Phase II focuses on helping the patient eat on her own in an age-appropriate way, but Phase III has nothing to do with food or weight at all. A wonderful thing about FBT is that the life-threatening eating disordered behaviors are treated first, which frees up the therapist, the patient, and the family to focus on any remaining issues in Phase III.

The goal of Phase III is establishing a healthy adolescent identity. An eating disorder engulfs an adolescent’s identity, creates extreme stress for the entire family, and strains the relationships between family members. Phase III is about restoring healthy, age-appropriate family relationships and returning the adolescent to normal life. Anything that stands in the way of these goals must be dealt with in order for the patient to recover fully.

Phase III begins when the patient is able to eat normally, with age-appropriate independence, while maintaining a healthy weight and not engaging in any eating disorder behaviors. Essentially, once all food issues have been resolved, the patient is ready for Phase III.

The authors of the FBT manual (Locke & Le Grange, 2001) advise that Phase III entails a handful of sessions scheduled several weeks apart. In my clinical experience, many patients do quite well with just a few sessions in Phase III, but others continue to struggle with anxiety, depression, body image, perfectionism, or other problems. Therefore, I offer to provide patients and families with an extended version of Phase III when I believe it is warranted. Length of illness, severity of illness, and co-morbid conditions all influence whether a patient may benefit from more treatment than the FBT manual prescribes.

In my practice, Phase III typically addresses the following issues:

1.) Returning the patient to normal development.

An eating disorder can interrupt normal adolescent development. Often, when a patient enters Phase III, she is at the same developmental level as when the illness first began. Phase III entails helping the patient develop the maturity and social-emotional skills that were lost as a casualty of ED. Depending on the age of the patient, this may entail returning to sports or other activities, getting a driver’s license, going out with friends, dating, returning to college, or developing new hobbies and interests.

2.) Re-establishing healthy relationships amongst family members.

An eating disorder can wreak havoc on family life. It is not uncommon for spouses to have major marital conflict emerge as a result of ED. Siblings may feel neglected by their parents or jealous of the patient. The patient and her parents may develop a codependent relationship over the course of treatment, which can be advantageous in the first two phases, but must be corrected in Phase III so that the patient and parent can each return to their own lives. Healthy boundaries amongst family members can be damaged by ED, and it is crucial for these boundaries to be re-established at the end of treatment.

3.) Addressing any remaining psychological symptoms of the eating disorder.

There are numerous psychological symptoms related to an eating disorder. For example, body dysmorphia, perfectionism, poor self-esteem, anxiety, and cognitive rigidity may predispose people to AN and perpetuate the illness once it has begun. For many patients, these symptoms abate or resolve on their own during the first two phases. For many others, however, targeted treatment is needed at this phase. Cognitive-behavioral therapy (CBT) can be helpful in this regard.

4.) Working through the trauma of experiencing an eating disorder.

While many treatment programs address traumatic experiences that precipitated an eating disorder, few acknowledge that the experience of having eating disorder is itself very traumatic. Caring for a child with an eating disorder can be almost as traumatic as experiencing one. In many cases, the patient or her parents (or both) experience post-traumatic stress reactions at this point, such as disturbing nightmares, intrusive memories, and avoidance of stimuli associated with the eating disorder.

It is not uncommon for parents, drained and burnt out from the exhausting work of Phase I and Phase II, to have their own breakdowns at this point. Their child is well enough that they are no longer operating in crisis mode and they have some room to breathe. Once the survival instinct is no longer employed on a constant basis, parents have permission to experience their own reactions. Some parents fall into a depression; others feel disillusioned and cynical; still others suffer from extreme anxiety or lash out in anger. These are all normal, expected reactions to the trauma of almost losing a child. It is important for parents to get their own therapeutic support at this juncture if needed.

5.) Addressing grief.

Another often neglected aspect of eating disorder treatment is grieving what the eating disorder has taken. Not all patients and families experience this grief, but some do. I believe that when there is grief associated with the eating disorder, it should be discussed openly and addressed as part of the healing process. Patients often lose friends to their illness. They may have to take a hiatus from their favorite sport, or give it up altogether. Some patients miss a semester of school. Most are isolated from society for some time. At this stage, patients can feel the pain and injustice of losing a piece of their youth irretrievably.

Some parents may mourn the loss of their child’s innocence. They mourn the loss of life as they knew it. Many parents take time off from work and become isolated from their social circle as they help their child recover. Some parents mourn the loss of dreams they once had for their child which have been thwarted by ED.

No one emerges from the hell of an eating disorder unscathed. That said, some people are able to close that chapter in their lives and move forward, whereas others remain trapped by anger, sadness, or bitterness. It is important for patients and parents to work through their grief so that they can move forward in a life unencumbered by ED.

6.) Relapse prevention.

It is important for the patient and her parents to be aware of possible signs of impending relapse and to know what to do if these signs emerge. I find it very useful to discharge patients with a written relapse prevention plan which I have developed in collaboration with the patient and family.

7.) Evaluating the patient for co-morbid conditions.

Many patients with eating disorders experience co-morbid psychiatric conditions. Patients who continue to struggle with emotional or behavioral problems after the eating disorder has been resolved should be evaluated to determine whether they suffer from a comorbid disorder. The most common comorbid disorders are the anxiety disorders (including OCD, generalized anxiety disorder, panic disorder, PTSD, and social anxiety disorder), followed closely by mood disorders (depression and bipolar disorder). Other comorbid conditions may include autism spectrum disorders (such as Asperger’s), ADHD, substance abuse, and personality disorders.

8.) Getting the patient appropriate treatment for co-morbid conditions.

If the patient does indeed suffer from a co-morbid condition, it is important for her to get treatment for it. Treatment for a co-morbid disorder may include individual therapy, psychotropic medication, or a combination thereof. Cognitive behavioral therapy (CBT) in particular has been found to help many people recover from anxiety disorders, mood disorders, and numerous other conditions.

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Wednesday, July 6th, 2011

Why Clinicians Are Resistant to Maudsley FBT

Research has shown that the Maudsley Method of Family-Based Treatment (FBT) is more effective than any other treatment for anorexia nervosa (AN) or bulimia nervosa (BN) in patients under age 18. Despite this fact, many clinicians who treat eating disorders are very resistant to using FBT to treat their patients. There are a variety of reasons for this resistance – some legitimate, some personal, some inexcusable, and some bred from ignorance.

Here are some of the most common reasons why clinicians who treat eating disorders are resistant to using FBT, along with my rebuttals to each:

1.) “I work with adults. FBT is not applicable to most adults.”

While FBT has not been adequately studied in adults, the reality is that there are no evidence-based treatments for adults with AN yet. I believe that patients over age 18 need to have loved ones fully informed about their illness and actively involved in their treatment just as much as young patients. The basic principles of FBT (with some age-appropriate modifications) are now being applied to older patients with very promising results.

As Cynthia Bulik’s recent study on Uniting Couples Against Anorexia Nervosa demonstrated, the principles of FBT can be applied very successfully to adults, using spouses or significant others for support rather than parents.

Also, there is some preliminary evidence that a modified version of FBT can be useful for college-aged patients who are temporarily living at home with parents during recovery. There may very well be a time in the not-too-distant future in which a modified form of FBT is an evidence-based treatment for adults.

2.) “Some families can’t do it.”

This statement is absolutely true – some families can’t do it. However, I believe that the true percentage of families who “can’t do it” is actually much smaller than one may think. FBT can be successful in divorced families, step-families, single-parent families, families with many children, families where both parents work full time, and families in which a parent suffers from a mental illness.

The only real contraindications for FBT in patients under18 are cases in which the patient has been physically or sexually abused by a parent, or both parents are so mentally or physically ill that they are unable to care for their children. Both of these contraindications are relatively rare, and even in these cases, one would hope that the patient would be living in a safe environment with other adults (e.g., relatives, foster parents) who could participate in FBT with the patient.

What happens too often is that parents don’t purse FBT because they aren’t aware it exists, or aren’t aware of the evidence behind it. It is also common for parents to be discouraged from doing FBT with their child because the child’s clinician (who is not really familiar with FBT or who doesn’t agree with it) tells the parent that it won’t work for their particular child for some reason.

In sum, I would estimate that maybe 10 % of families really can’t do it (I have no data to support this percentage; it is just an educated guess). The majority of families can do it if they have the proper clinical support and encouragement. The majority of parents love their children immensely and will do anything to help them recover if given the opportunity. It is up to us, the clinicians, to give families that opportunity.

3.) “Some adolescents don’t improve with FBT.”

I have no counterpoint to this one. The reality is that FBT is not effective for everyone. This is not a shortcoming unique to FBT, as there are no treatments that work for 100% of patients. I doubt that there will ever be one treatment that works for everyone in the same diagnostic category, because each individual patient is unique and has their own set of circumstances. Therefore, we must continue to research other forms of treatment and work to improve upon the existing treatments. When a patient does not improve with FBT, we must offer something else – residential treatment, day treatment, cognitive behavioral therapy – whatever is most appropriate for that particular patient and that particular family.

4.) “My training and inclination is as an individual therapist. Making the switch to working with families is intimidating. Learning FBT would be like starting from scratch.”

I don’t see it as starting from scratch. Rather, I see it as adding another (very effective) tool to your existing toolbox. You certainly don’t need to abandon individual therapy just because you’ve added a new treatment to your repertoire.

While some patients will recover fully with FBT and never need individual therapy, most patients do have co-morbid disorders or other issues which need to be addressed with individual therapy. In these cases, individual therapy comes after FBT. Many times I have transitioned to individual therapy with a patient after the patient has successfully recovered with FBT. The great thing about this approach is that the eating disorder has already been fully addressed through FBT, so you and the patient can focus all your time and energy on other things, such as depression, OCD, body image issues, perfectionism, and social difficulties.

5.) “My training is in psychodynamic therapy and relational approaches. FBT is pretty concrete and behavioral. Adopting FBT would seem to remove the very things that made me want to become a therapist in the first place – the focus on depth and the therapeutic relationship.”

FBT is more concrete and behavioral than other types of therapy, and I believe that is part of why it is so effective in treating these malignant illnesses which demand immediate behavioral management in order to save the patient’s health. That being said, the therapeutic relationship is just as essential in FBT as it is in other types of treatment. The parents and the therapist must develop trust in one another, and mutual respect is key, because the parents and therapist are allies working together against the illness on behalf of the child. It is extremely rewarding to be able to offer this kind of assistance and support to terrified, confused, guilt-stricken parents, who blossom with confidence as you educate them about the illness and empower them to do what needs to be done to help their child recover.

And the kids! It is nothing short of amazing to watch the therapeutic relationship evolve and unfold so quickly as recovery progresses. In the first few sessions, the kid typically presents as catatonically depressed, curled up in a fetal position under a blanket, sobbing quietly; or the kid reacts with extreme anger and resistance, yelling and hurling insults and dropping f-bombs before running out of the room. Entire tissue boxes are gone through in one session; stuffed animals need to be placed back on the shelves after being thrown. And within a few months, the kid is smiling, laughing, so happy to see you, chattering on about their trip to Disney World or their new boyfriend or how much they love ‘90’s music exclaiming “Wow, Dr. Ravin, it must have been so cool to be a teenager back in the ‘90’s!” The transformation is astounding.

Furthermore, there is lots of room for a tremendous amount of depth when continuing to work with the patient individually after FBT has been successfully completed. In fact, is even more feasible to go into greater depth in these cases, because the eating disorder is in remission and health-threatening behaviors have long-since been eliminated, so treatment can focus exclusively on other (often more interesting!) issues.

6.) “FBT is agnostic on etiology, and I think etiology is very important.”

Yes, FBT is agnostic with regards to etiology. In other words, the clinician states clearly at the outset of treatment that we don’t know exactly what causes eating disorders, and that it is not relevant for the purposes of this treatment. I believe this agnostic stance is one of the strengths of FBT: it does not waste time on “why” but instead focuses on “how” to help the patient recover.

I agree that etiology is very important because our ideas about etiology (for better or for worse) have a huge impact on how we treat patients. Therefore, clinicians and researchers must continue to have professional discussions about etiology amongst themselves.

My concern is not the discussion of etiology amongst professionals in the field. Rather, my concerns are 1.) When clinicians have a particular presumption about etiology which is not consistent with recent scientific evidence, 2.) When that particular presumption guides the use of treatments that are less effective, and 3.) When those presumptions about etiology cause harm to patients and their families by subtly or overtly blaming the patient or the family.

In my opinion, when clinicians discuss etiology with patients and their families, these discussions should be limited to the following points:

A.) Clarifying that neither the patient nor the family is to blame for the illness.

B.) Dispelling common myths about etiology (e.g., media, control issues, overprotective parents)

C.) Discussing the “Four P’s:” predisposing factors (e.g., genetic predisposition), precipitating factors (e.g., weight loss through dieting or illness), perpetuating factors (e.g., malnutrition has a calming and mood-elevating effect on those who are vulnerable to eating disorders), and prognostic factors (e.g., importance of early and aggressive intervention, maintenance of optimal body weight).

This is all the information patients and families need to know about etiology, because let’s be frank: this is all we really know about etiology. Anything else is just a distraction.

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