Current Thinking about Family Therapy and Systemic Interventions with Eating Disorders

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Current Thinking about Family Therapy and
Systemic Interventions with Eating Disorders

• Facilitator Lesley Novelle

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Workshop format

• explore common themes across current research
  studies and any gaps
• explore facets of multi-disciplinary working
  within a systemic frame
• Consider from a family perspective

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What it is not?

• The answer!
• Comprehensive , looking at what families might
  say within the literature and the approach ,
  Method, Technique of current studies, not looking
  any further afield than systemic texts (at this
  point)

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Context

• Year one of a four year taught Doctorate, produce
  a comprehensive literature review before
  development of a research proposal
• Family Therapy team as part of MDT approach
• Providing justification for further study (or
  changing the focus)
• Why am I interested?
• Please share what interested you in coming today

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NICE Guidance and Junior Marsipan

• Systemic invitation not just in terms of family
  interventions but also working together as
  systems of concern.

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Search Strategy

• Key words
• Eating (disorder), Anorexia, Bulimia (very tight)
  EBSCO, Psychinfo
• Only systemic journals, results from
• Journal of Family Therapy
• Family Process
• Australian and New Zealand Journal of Family
  Therapy
• Journal of Marital and Family Therapy
• Journal of Feminist Family Therapy
• American Journal of Family Therapy
• Contemporary Family Therapy

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Systemic Literature

• Some key ideas emerging from the texts
• Using families as a resource
• Considering both conjoint family work and
  separating out different sub systems.
• Multi-modal, multi-family groups
• Strengthening parental position and decision
  making
• Externalising the Eating problem
• Long term and tricky 3-4 years duration

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Some statistics

• USA (Hudson et al , 2007) Downs and Blow (2013)
• 1.2 individuals experience Anorexia Nervosa
• 2 experience Bulimia Nervosa
• 5.5 Binge Eating Disorder
• Little evidence to suggest that families cause
  eating disorders, some evidence to suggest family
  patterns can maintain. Eating disorders can
  dominate family functioning and intensify
  previous patterns.

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Quote

• The impact of the illness on the family is
  immediately evident through the influence that
  the symptoms hold within the household. Just as
  issues around food, eating and weight dominate
  the sufferers thoughts and behaviours, food may
  also take a predominant role within family life
  and interactions
• Whitney and Eisler (2005, p,577) in Downs and
  Blow (2013)

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Which Models?

• Emerging from the development of the last 18
  years in particular

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Maudsley model

• Inspired by the work of Salvador Minuchin
• (1975, 1978), Palazzoli et al (1978), in Downs
  and Blow (2013) Primarily focused on Anorexia
  Nervosa
• Three tasks
• Gaining and maintaining family co-operation by
  intensifying the need to treat the disorder.
  (removing blame and shame)
• Assess the organisation of the family, what
  alliances, boundary and control techniques are
  used
• Establish interventions to help the family in the
  creation of change
• Three Phases
• Getting parents to work together, empowering to
  gain control over weight gain and weight
  restoration
• Focus on helping adolescent to begin to eat on
  own
• Family work to help young person to gain back
  control of thier eating (life)

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Multi-family groups

• No quantitative studies but a number of case
  study write ups.
• Multiple family groups, four families in one
  study Colahan and Robinson (2002)
• Multiple interventions with all four families,
  using roles in family, treatment modalities and
  shared mealtimes.
• Adaptation of Maudsley model looking at parent to
  parent support as adjunct.
• Downs and Blow (2013) suggest this as an area for
  further study.

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Family Based Treatment

• Girz et al (2013)
• Adolescent day treatment (Canada)
• Parents check in with FT after weekend
• FT holds conversation with parents after weekly
  team rounds
• Re-entry meeting if extra support needed
• Parents and children weekly FT sessions
• Parents and children attend MFT evening
• Parents involved in setting family transition
  plans (food and non-food related)

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Conjoint or Separated Family Therapy

• Discussion in the literature about family based
  interventions and their delivery. Eisler et al
  (2000) (not published in FT literature)
• Links to some of the earlier work with a
  psychoanalytic/systemic theory base.
• 40 adolescent patients assigned to either
• Conjoint Family and young person
• Separated Parent (and siblings?), young person
  separate.
• Outcomes
• High levels of maternal criticism- Separated
  Family Therapy, better outcomes
• Symptomatic change was more evident in the
  Separated Family Therapy whereas emotional change
  was more highly reported in the Conjoint Family
  Therapy.
• Also significant changes in family measure of
  expressed emotion and critical comments between
  parents and young people were significantly
  reduced as was so between parents. Warmth
  between parents increased.

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Family members voices

• Weak or quiet with some exceptions
• Located in questionnaires and outcome measures
• What is their narrative?
• Downs and Blow (2013) , lack of literature about
  the role or support of siblings

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Exercise

• This may be quite a challenging and emotional
  exercise, please look after yourself and one
  another and only share what you feel you would
  like to share.
• There will be people in the room who have
  experienced eating problems, please be mindful.
• Purpose of exercise is to
• Allow room to hear a family perspective
• To consider any incoherence
• To consider the best next steps from a family
  based intervention perspective.

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Vignette

• Family White British, Young woman aged 14,
  Mother aged 41, Father aged 45 , younger brother
  aged 12
• Primary care group Practice nurse, GP , Health
  Visitor, School
• Camhs team Care co-ordinator, family therapist,
  Psychiatrist, MAT practitioner, 3rd sector
  support organisation.

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Instructions

• Form in to groups as identified. Do not confer
  until all of boxes completed.
• Using paper with six boxes follow instructions
  read out and make a mark or representation in
  each box which represents the instruction.
• Now share your thoughts and experiences of the
  exercise in the group paying particular attention
  to feelings and then next steps (boxes 4 and 6).
• Agree how you will feedback to the larger group.

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Feedback

• What was it like doing the exercise, is everyone
  ok?
• What next steps emerged, talk from each group to
  the other groups in turn?
• What dilemmas, concerns, exciting ways forward
  emerge?

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Six instructions

• Family -mark the paper to represent relationship
  with your daughter/Sister. Drawing lines, dots
  and squiggles.
• Goal mark the paper to represent your goal with
  this person. Where do you see yourself headed?
• Obstacle marks the paper to represent what is
  getting in the way of achieving the goal.
• Counter transference- mark the paper to
  represent her feeling about young person.
• Theories- mark the paper to represent what you
  know theoretically about this situation. What
  are the possible causes and context of your
  struggle?
• Next steps- mark the paper to represent what
  their next steps will be with this work. What do
  they envisage in the future?

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Early family intervention

• Focus on preventing further weight
  loss/destructive behaviours.
• Support parents work with parental authority and
  responsibility.
• Strike a balance between making it clear that the
  eating problem is unwelcome and acknowledging
  that it is functional
• Use family and individual strengths
• Keep young person linked to their world

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Family Therapy, what we are discovering Approach

• Consider who is the client Dare (1997)
• In involving parents and other family members
  what approach do you have
• Contract ( bearing in mind safety and motivation
  for change)
• Family culture respected
• Current goals
• Life cycle issues
• Privacy and transparency
• What is the impact on siblings, what is the forum
  for them to share
• Both directive and collaborative? (outcome from
  narrative in studies about different experiences
  of treatment)
• Clear and well co-ordinated , regular care plan
  reviews
• Collaborative adaptable engagement with current
  system
• Score- measuring progress across a number of
  domains

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Methods

• How we intervene
• Structured family therapy- reflecting team
• Family input in home-purpose?
• Consultation
• Educational and practical input
• Explore needs of all family members
• Use of a reflecting team approach
• Individual work in the presence of
• Joint team approach to care planning- are we
  stronger than the eating problem

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Techniques

• Collaboration and transparency re goals/contract-
  write
• Engagement- key area and linked to
  approach/careful attention to contract
• Voices to be heard
• Explore resilience and strengths
• Teach, role play, enact, play, toys and tech
• CBT
• Develop rituals for talking, building on family
  strengths
• Develop a genogram as a tool
• Outcome measures
• Timing- when and how to intervene
• Within sessions-
• Sculpting
• Externalising
• directives/coaching
• enactment
• intensification

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Some ideas about ways forward

• Remember that Anorexia is very powerful and can
  organise us all to do things we might otherwise
  not consider e.g. feelings, actions
• Use people close to the person experiencing the
  problem as a resource. System of Concern
• Consider the risk and the dilemmas associated
  with consent- but be open to possibilities

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References

• Journal articles
• Colahan, M. Robinson, P.H., (2002) Multi-family
  groups in the treatment of young adults with
  eating disorders. Journal of Family Therapy, Vol
  24, pp. 17-30
• Downs, K.J. and Blow, A.J., (2013) A substantive
  and Methodological review of the family-based
  treatment for eating disorders the last 25 years
  of research. Journal of Family Therapy.
  Vol.3551p3-28
• Eisler, I., Dare C., (2000) Family Therapy for
  Adolescent Anorexia Nervosa The results of a
  Controlled Comparison of Two Family
  Interventions. Journal of Child Psychiatry,
  Vol.41, pp. 727-736
• Griz, L., Robinson, A.L., Foroughe, M., Jaspewr,
  K., Boachie, A., (2013) Adapting family-based
  therapy to a day hospital programme for
  adolescents with eating disorders preliminary
  outcomes and trajectories of change. Journal of
  Family Therapy, Vol.3551 pp.102-120
• Minuchin, S., Baker, B.L., Rosman, B.L., Milman,
  L., Todd, T.C., (1975) A conceptual model of
  psychosomatic illness in childrenfamily
  organisation and family therapy. Archives of
  General Psychiatry, Vol.32, pp. 1031-1038
• Minuchin, S., Rosman, B.L, Baker, B.L, (1978)
  Psychosomatic Families Anorexia Nervosa in
  Context. Cambridge, M.A. Harvard University
  Press.
• Palazzoli. S.M. (1978), Self-Starvation from
  individual to Family Therapy in the Treatment of
  Anorexia Nervosa. Trans. Pomerans, A. New York
  Jason Aronson.

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References

• Grey literature
• Junior MARSIPAN Management of Really Sick
  Patients under 18 with Anorexia Nervosa. Royal
  College of Psychiatrists, College report, January
  2012 http//www.rcpsych.ac.uk/files/pdfversion/CR1
  68.pdf accessed 28.8.13 
• National Institute for Clinical Excellence
  Eating disorders Core interventions in the
  treatment and management of anorexia nervosa,
  bulimia nervosa and related eating disorders
  Clinical Guideline http//www.nice.org.uk/nicemedi
  a/live/10932/29218/29218.pdf accessed 29.7.13
• Burnham, J. (1992). Approach, Method, Technique
  Making Distinctions and Creating Connections.
  Human Systems The Journal of Systemic
  Consultation and Management. Vol 3, p3-26
• See hand out for references over last 20 years