The Family Based Treatment: treating eating disorders in adolescence

Florence. Early October. Two training days held by dr. Armando Cotugno on the treatment of Eating Disorders in adolescence through the Family Based Treatment protocol (FBT; Lock, Le Grange, 2018; Treasure, 2010, 2017).

 

Eating disorders (AD) can be defined as persistent behaviors aimed at controlling body shapes and weight, which damage physical health or psychological functioning and which are not secondary to any known medical or psychiatric condition (Fairburn et al., 2003 ).

In general, the maintenance factors are manifold and related to: feeding behavior and alterations of the central nervous system, in particular reduction of the gray matter and altered modulation of the hunger-satiety system (Kalivas & Volkov, 2005), distortion of the body image, style cognitive, emotional style, interpersonal style. Patients do not perceive actions, thoughts and emotions as originating from themselves, the needs are therefore heteroderminated and there is a difficulty in identifying internal sensations and mental states. In an adolescent phase, around 13-15 years, bodily changes modulate the perception of who we are, how we are accepted, of our self in the world.

The Family Based Treatment believes that these changes can increase, also in relation to the responses of the environment, our sense of ineffectiveness, of perceived vulnerability. In the adolescent period there is particular attention to the perceived image and the social image, if the perception of the self-image is not congruous with the image of us in the world, the feeling of vulnerability increases and when a sense of uncertainty is experienced usually the behavioral response is to increase control. But how does the adolescent prefer to control food over many other dysfunctional responses? Treasure and colleagues argue that if the nuclear self scheme is based on the effective-competent / ineffective-incompetent construct and the domain in which this aspect of the self develops is that of the body image, then there is an overestimation of weight and body shapes and it is plausible to develop a Eating Disorder. If my forms respect certain social canons of thinness then my self is effective, without this equation I perceive a sense of uncertainty, I feel vulnerable, I am afraid, I increase the feeling of uncertainty in the world, I have to control my diet to reduce the sense of vulnerability / danger. In the case of Bulimia Nervosa or Uncontrolled Feeding Disorder (DAI), the perceived vulnerability would trigger emotional dysregulation leading to loss of control. Importantly, the feeling of efficacy / ineffectiveness changes throughout life. When life domains are restricted over time, in the face of an increase in the complexity of life contexts, it is possible that a pathology occurs. The pathology that arises depends on the relationship between the image of the self and the domain of life, or domains, of reference.

On a social level, a basic temperamental vulnerability is accentuated by a disabling living environment creating the vicious circle described above. As regards the behavioral aspect, hyper-control is connected with a poor agency capacity (Fassino et al., 2002; Dimaggio, Ottavi, Popolo, Salvatore, 2019). In relation to the medical aspect, a DA causes significant somatic and physical consequences that seriously endanger the health of those who suffer from it and makes these disorders very serious and dangerous.

In DAs, the body experience is altered, the lived body is perceived in an ego-dystonic way therefore multitasking tasks put these patients in difficulty because they make them less aware since their attention is focused: they do not have the ability to self-perceive and pay attention to multiple things at once. Using objective measures (scale, size, centimeter, cup, spoon, etc …) helps this type of patient to create a bridge between their body and perceived reality by amplifying the awareness of their connection with the world around them.

The FBT (Lock, Le Grange, 2018; Treasure, 2010, 2017) is an Anglo-Saxon model and is based on the fact that in front of a teenager with an eating disorder, parents, and the family in general, are a possible source of support and for management assistance. The dynamics that are created in the family environment, in daily life and in particular during meals, would not be so much the cause of the disturbance, but contribute to their maintenance. Over-criticism and over-involvement of the parenting modality worsens the disease since there is no containment function, but the avoidance of problems is present (Lock, Le Grange, 2018). The FBT initially provides support to parental figures who are invested in restoring the weight of the adolescent with an eating disorder. Parents can count on the therapeutic team on an intervention of education, support and validation for their effort. The team therefore includes psychiatrist, nutritionist and FBT therapist. The agreement between these three figures is a strength, but also a potential weakness. Strength because the more cohesive the team, guided by the same principles, the more the prognosis is favorable. Of weakness because the agreement itself is often not easy to maintain, it requires many joint meetings to discuss clinical cases, suitable spaces and timescales.

Parents are involved for children under the age of 18. In the first phase, attention is paid to the specific aspects of AD and to the distortion of the body image. In the second phase of the treatment we work on interpersonal difficulties, clinical perfectionism, low self-esteem, intolerance to emotions. The primary objective is to restore weight, and this is the responsibility of the parents, and only secondarily improve the adolescent’s autonomy and release process.

FBT sessions, according to the Anglo-Saxon model (Lock, Le Grange, 2018; Treasure, 2010, 2017) always take place in a family setting if we are dealing with a minor under 18 years of age. The treatment lasts 6-12 months, about 10-20 sessions. There are mainly three stages:

The treatment is preceded by an assessment phase of about 1 month, where medical tests are prescribed, psychological tests are administered and the first interviews are carried out (with the patient and separately with the parents). Subsequently, each session of the treatment opens with a note of the weight and a graph is updated week by week. The first session is focused on psychoeducation and on establishing the primary (exit from the disease) and secondary objectives of the treatment (cognitive change and autonomy). The management of everything related to food passes into parental hands. It is given the task of making at least one meal a day shared (even in the presence of separation between the parents) with the whole family. The second session is dedicated to the shared meal. We work on those who prepare meals, who decides what to eat, who makes the portions, usually must always be one of the two parents. The family must bring everything they need for the meal, from provisions to various courses up to drinks. Table and chairs are provided. The shared meal is videotaped and in the following sessions it is possible to view together some clips in order to improve the functioning and share together moments of difficulty, which will also occur at home, and moments of resolution of the problems. Parents’ ability to help the patient is observed. At the end of the course one of the two parents is asked to ask the patient to “eat an extra spoon” and observe the dynamics and behavior of all family members, the difficulties in managing the patient’s refusal, we begin to build a draft of a family relational scheme. If there is any member on the sidelines, especially in difficult situations, they are asked to try to say something to help other family members. Sometimes brothers are an excellent resource. At the end of the session all family members are validated for the effort made and the results achieved. In the following sessions we work on the material that emerged and on what the family brings in relation to what happens at home during meals and in daily life, we help the patient to get rid of the beliefs about his body gradually also through the use of the mirror in session, up to the return of food control to the patient and to be able to work on everything that emerges that is relevant. If there is any member on the sidelines, especially in difficult situations, they are asked to try to say something to help other family members. Sometimes brothers are an excellent resource. At the end of the session all family members are validated for the effort made and the results achieved. In the following sessions we work on the material that emerged and on what the family brings in relation to what happens at home during meals and in daily life, we help the patient to get rid of the beliefs about his body gradually also through the use of the mirror in session, up to the return of food control to the patient and to be able to work on everything that emerges that is relevant. If there is any member on the sidelines, especially in difficult situations, they are asked to try to say something to help other family members. Sometimes brothers are an excellent resource. At the end of the session all family members are validated for the effort made and the results achieved. In the following sessions we work on the material that emerged and on what the family brings in relation to what happens at home during meals and in daily life, the patient is helped to get rid of the beliefs about his body gradually also through the use of the mirror in session, up to the return of food control to the patient and to be able to work on everything that emerges that is relevant. Sometimes brothers are an excellent resource. At the end of the session all family members are validated for the effort made and the results achieved. In the following sessions we work on the material that emerged and on what the family brings in relation to what happens at home during meals and in daily life, we help the patient to get rid of the beliefs about his body gradually also through the use of the mirror in session, up to the return of food control to the patient and to be able to work on everything that emerges that is relevant. Sometimes brothers are an excellent resource. At the end of the session all family members are validated for the effort made and the results achieved. In the following sessions we work on the material that emerged and on what the family brings in relation to what happens at home during meals and in daily life, the patient is helped to get rid of the beliefs about his body gradually also through the use of the mirror in session, up to the return of food control to the patient and to be able to work on everything that emerges that is relevant.

The theoretical bases of reference come from various reference theories such as DBT (Linehan, 2011; Swenson, 2018), CBT (Beck, 1984), CBT-E (Dalle Grave, 2012), Control Mastery Theory (Weiss, Sampson, 1999; Gazzillo, 2016) using behavioral techniques and mindfulness techniques. The FBT has 5 basic assumptions:

The therapist’s attitude is active, not controlling. The therapist is an expert consultant, supports the autonomy of the parents, is cooperative.

The advantages of FBT treatment are manifold including: avoiding residential hospitalization, reconsidering the socio-affective role of the family as a clinical priority and adopting a scientifically validated protocol. The disadvantages lie above all in the faithful application of the Anglo-Saxon protocol with all the difficulties inherent in any cultural differences.

According to the authors, the patient can mainly perform two behaviors: supplication or threat. Faced with a patient who begs, the family is entangled, hypercovolved, inhibits the release and infantilizes. They are called “kangaroo families”. When the patient implements the threat, the family appears to have critical attitudes, is disengaged from the rules, there is coercion and a strong conflict: they are called “rhino families”. In these difficult situations the protection or attack system goes haywire and the care becomes disorganized. The parent finds himself in the circle of impotence made up of guilt, anger, fear, shame, anxious hyper-involvement and hostile criticism. The goal of the FBT is to help the parent, validating him, to help his child in acquiring functional autonomy.

Mindful techniques are used, such as observing, describing and being without judging, finding what is effective at that moment, not what is right. The FBT is not a therapy based mainly on the family dynamics that led to the disorder, but primarily and hierarchically we leave the DA and only later we work on the dynamics related to the disorder. It is important to grasp and note, for a later moment, any blame, reversed care, all the dynamics present. The therapist’s active, metacognitive and mindful attitude, outsourcing and shared dialogue, modulate the family’s fear and criticism. The DA is seen as a deficiency of the reality test, the patient is sick and one must exit from the state of danger.

Food symptoms are signs of deep anxiety, and dysfunctional attempts to cure them, especially to cure a pervasive sense of personal ineffectiveness (Lock, Le Grange, 2018; Treasure, 2010, 2017). This sense of personal ineffectiveness leads the patient to feel vulnerable, to experience uncertainty, anxiety, fear and consequently to implement coping strategies, such as control over weight and body shapes and the consequent food restriction. Control over food would reduce perceived vulnerability, but in fact it is a source of maintenance. For example, says patient G., 15 years old, BMI of 15. “… at school I never feel the real me, there sometimes you have to be someone else to be accepted, I always see the others with a march in more, I struggle and then I get a weight that often becomes stronger like a punch in the stomach. The others are all skinny, made up, dressed in fashion and are ahead, not me … if I eat less and be careful I will be like them … “

Faced with a teenager with a body mass index (BMI) of less than 17, in some very serious cases it even reaches 15, we focus on the medical condition in the first place. Malnutrition interferes with the maturation and frontalization processes of the brain: emotional regulation, self-reflexivity, metacognition are all capacities that are compromised in a growing brain and therefore it becomes very dangerous. Since the research of the 1940s (Minnesota Study, 1944), to date, it has been seen that malnutrition changes the psychological structure of the individual and also has behavioral and physical effects. If with a patient suffering from AD, the therapist works directly on malnutrition, which is a coping strategy, to recover the state of well-being, the patient will feel his perception of control fail, he will feel ineffective, vulnerable, he will increase fear, he will also increase control and rigidity and he will have greater food restriction. With DAs it is therefore important to work primarily not on coping strategies, but on the underlying motivation that pushes that patient to implement the food restriction. Malnutrition in fact creates basic behavioral, physical and psychological maintenance mechanisms with social effects, what patients with AD try to achieve maintains the disorder itself. Change strategies must start from the awareness that if the patient is forced to abandon a pattern that at that moment, albeit dysfunctional, is a source of security, then in parallel, another alternative, more functional way must be built. The intervention is aimed at a systematic desensitization where food (anxiogenic stimulus) is presented gradually and simultaneously with stimuli that elicit emotional responses antagonistic to anxiety and fear. Through the help of the nutritionist we try to re-establish a more natural access to food and at the same time we are taught the skills to move within “difficult” contexts such as pastry shops, supermarkets, restaurants and we work on how to feed ourselves in social contexts. At the same time the attention is placed on the reduction of fixed and pervasive thinking for food and on the increase of self-efficacy and self-esteem. The techniques used are mainly cognitive-behavioral and mindfulness techniques. While working on building healthy parts, healthy desires that emerge in the sessions, such as reading, listening to music, walking in the woods, alternatives to dysfunctional ones, it must be taken into account that emotional regulation needs more time to improve, compared to flexibility and central consistency. In fact, the level of emotional interference is higher in those with pure AN (Kaye et al., 2009; Tchanturia et al., 2004; Fassino et al., 2002; Green et al., 1996).

The ultimate goal of FBT treatment is to promote the autonomy of the patient suffering from AD. When the patient is in a state of danger for his illness, he is considered unable to provide himself temporarily. All the management of containment, the decisions on how, what and how much to eat passes into the hands of the parental figures, who for this onerous task must be greatly supported and validated. The adolescent’s task is to follow the parents’ directions to get out of the disease state and restore body weight. A metacognitive effort must be made to understand the parent who is currently in a combination of emotions such as helplessness, guilt, fear, failure and oscillates between protection and attack at the source of the danger. In these cases the agent and the victim of the perceived threat coincide, the parents tend to see their child as the one who does the “tantrums” not as sick, oscillating between hyperprotection (“come on if you’re not hungry don’t it does nothing … give it a little more try for me … “), on the attack (” and on, but if you do this we won’t finish it anymore, do you realize what you are creating? … “). To make a similarity, it is as if we were faced with a patient suffering from asthma and constantly urged him to breathe well. The FBT protocol helps the parent to support negative emotions, helping him to regulate them to act in a congruous and healthy way towards the care needs of the daughter. swinging precisely between the overprotection (“come on if you’re not hungry it doesn’t do anything … try a little more do it for me …”), attack (“and on from though if you do so we don’t finish it anymore, you make yourself account of what you are creating? … “). To make a similarity, it is as if we were faced with a patient suffering from asthma and constantly urged him to breathe well. The FBT protocol helps the parent to support negative emotions, helping him to regulate them to act in a congruous and healthy way towards the care needs of the daughter. swinging precisely between the overprotection (“come on if you’re not hungry it doesn’t do anything … try a little more do it for me …”), attack (“and on from though if you do so we don’t finish it anymore, you make yourself account of what you are creating? … “). To make a similarity, it is as if we were faced with a patient suffering from asthma and constantly urged him to breathe well. The FBT protocol helps the parent to support negative emotions, helping him to regulate them to act in a congruous and healthy way towards the care needs of the daughter. it is as if we were facing a patient suffering from asthma and constantly exhorting him to breathe well. The FBT protocol helps the parent to support negative emotions, helping him to regulate them to act in a congruous and healthy way towards the care needs of the daughter. it is as if we were facing a patient suffering from asthma and constantly exhorting him to breathe well. The FBT protocol helps the parent to support negative emotions, helping him to regulate them to act in a congruous and healthy way towards the care needs of the daughter.

The training weekend was stimulating and raised many food for thought. I wonder how much and how such a protocol is applicable to the private clinic. Certainly a limit is to be found in the cost that the patient would face as well as in the timing of the meetings with the different team figures, both by the patient himself and by the professionals. Probably with an excellent initial design phase, assuming a general intervention package, these limits could be exceeded. A further reflection is on the involvement of the patient who, in the early stages of treatment, would seem to be zero. In reality, the adolescent brings his emotional states which are always treated from a family perspective and the family itself takes charge of managing the dynamics.