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.