Cris Haltom, Ph.D, is a Massachusetts-based therapist specializing in eating disorders. Her recent monthly newsletter for parents presented an overview of the new Family-Based Treatment (FBT) for bulimia. I have been awaiting the publication of Drs. Daniel LeGrange and James Lock's new book, Treating Bulimia in Adolescents (January 2007, Guilford Press) with great anticipation. For parents to have yet one more perspective and approach to the treatment of bulimia is a true gift. There is no “one size fits all” in the treatment of any eating disorder, but I share with you Cris’ overview of this approach so that you, too, are aware:
Like the related, manualized treatment for anorexia, this treatment is empirically supported and depends on parents to be a pivotal resource for assisting young people in their recovery. A separate, unique application of FBT for adolescents with bulimia was developed because LeGrange and Lock found it important to address differences in the symptoms of anorexia and bulimia and in the personalities and families of those with bulimia.
LeGrange and Lock point out young people with bulimia are secretive and shamed by their symptoms. Those with anorexia are more ashamed of eating and pleased with their restriction successes, making motivation to change more difficult to engender in those with anorexia.It is easier for those with bulimia to admit they are ill and need help.
Adolescents with bulimia typically have more peer connections and more adolescent experiences such as romantic relationships than those with anorexia. Parents of a child with more life experiences outside the home may find it difficult to impose order and guidance on their child with bulimia. They may find it difficult to justify parental supervision of a child who seems to be appropriately independent. However, LeGrange and Lock remind us that the appearance of greater independence does not reflect true development of independence skills which are often lacking in young people with
bulimia.
Although there is no typical "anorexic" or "bulimic" family, findings suggest families of those with anorexia tend to be more conflict avoidant, placing importance on a polite presentation. Families of those with bulimia, on the other hand, are more likely to be openly conflicted and more inclined to disorganization. LeGrange and Lock suggest such a family constellation with bulimia invites the therapist to help "establish some order (p. 6)".
A key difference in FBT for adolescents with bulimia is the drafting of adolescents and parents into a combined, collaborative effort toward recovery from bulimia. In FBT
for anorexia, parents take control of weight management and nutrition restoration. They do not expect their child with anorexia to collaborate with them because she or he is not able to see beyond psychological distortions associated with anorexia. The brain is "eclipsed" by anorexia. Individuals with anorexia are more likely to try to protect their symptoms and see them as desirable. Those with bulimia have shame and embarrassment associated with binge and purge symptoms. They are more likely to state they want to be rid of their symptoms but are usually unable to stop or interrupt
their symptoms.
Parental supervision of food and weight management is a common objection to FBT because it occurs at a time in adolescents' lives when they are typically pursuing
autonomy and independence from parents. However, LeGrange and Lock explain that the temporary involvement of parents in their child's life in the arena of eating and weight management is a deliberate intervention to wrest control from the anorexia or bulimia. Parents take charge of the anorexia or bulimia so the illness cannot be "in charge (p. 19)" of the child and cannot inhibit recovery and restoration of healthy and balanced eating. With time and recovery and as treatment progresses, control over eating and weight management is returned to the adolescent. In the case of bulimia, autonomy and control are returned to the adolescent when she or he can refrain from binge and purge behaviors.
For parents engaged in FBT for bulimia in their child, key guidelines, based on LeGrange and Lock's work, include the following:
1. Parents collaborate with their adolescent to develop strategies for healthy eating and interruption of binge and purge behaviors. Parents take away the bulimia with the help
of their adolescent.
2. Parents develop an understanding of the difference between bulimia-related thinking and the adolescent's own life, ideas, and needs apart from the bulimia. They highlight these differences and reinforce them with their adolescent with bulimia.
3. Family members prepare themselves for a collaborative, joining relationship with the psychotherapist. The therapist does not give specific solutions. Rather family members are encouraged to work out solutions for themselves with the help of the therapist.
4. Parents need to be prepared for delaying an exploration of "why"the eating disorder occurred. Underlying issues are addressed later in treatment because it is assumed the adolescent is caught up in preoccupation with bulimia and is not in a position to gain insight into the origins of the eating disorder.
5. All family members are encouraged to regularly attend family meetings. Everyone in the family has a supportive role. Family members, including the adolescent with bulimia, provide a history of the way the bulimia has affected them and their family.
6. Family-Based Treatment engages siblings who are old enough to provide non-critical and sympathetic support for an ill sister or brother.
7. Parents set up a healthy meal regimen at home and set about to close loopholes for bulimia by supervising in non-critical, kind, empathetic ways to prevent binge eating or purging. (Purging includes overexercising.)
8. Parents and family members need to be prepared for the time and energy it will take to plan, make decisions, and carry out their duties as supervisors and collaborators during FBT. Their job is compared to that of the nursing staff in a residential or hospital treatment program.
9. Even though parents may be discouraged by the dire medical consequences of bulimia and the difficulty of recovery, they are encouraged to be hopeful. They are reminded to harness their anxiety about bulimia to tackle the bulimia with focused and sustained energy.
10. Bulimia is an illness and is seen as separate from the adolescent.
SUMMARY
Family-Based Treatment offers parents an empowered way to play a pivotal, positive role in restoring an adolescent with anorexia or bulimia to health. A new application of FBT to bulimia reflects the unique symptoms and personality and family characteristics of those with bulimia. Using FBT, family members come together and agree on a plan to restore healthy eating and disrupt binge and purge behaviors in their adolescent with bulimia.
REFERENCES
LeGrange, D. and Lock, J. (2007) Treating Bulimia in Adolescents. New York: The Gilford Press.
Lock, J. and LeGrange, D. (2005) Help Your Teenager Beat an Eating Disorder. New York: The Guilford Press.
Lock, J., LeGrange, D., Agras, W.S., and Dare, C. (2001) Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: The Guilford Press.
