Part VI UCSD EDC2014 Review

In the afternoon of day one, Drs. Kerri Boutelle and Ivan Eisler provided two seminars on the topic of intensive multi-family treatment of eating disorders and the day was rounded out with a roundtable session with these researchers along with Dr. Jim Lock. 

Ian D. Keating:
Ian D. Keating:

Again, the treatment focus is on adolescents and young adults still primarily residing with their families of origin. But when I asked during various question periods that afternoon, it seems as though they have applied these approaches within adult settings (usually within partner and spouse interactions).

While I believe that group therapy settings for teenagers or young adults with eating disorders often just give wings to competitive restriction within the group, these multi-family settings appear to flip the usual “they just become better at restricting” group dynamic.

Dr. Boutelle laid out why the UCSD Eating Disorders Center has developed this intensive multi-family therapy program (IFT):

  1. Not everyone has access to trained family based treatment (FBT) therapists.
  2. It boosts treatment for non-responders.
  3. It assists with various transition points through the phases of recovery.
  4. It helps the parents develop skills to take home such that they become the change agents for further improvements in their child’s outcomes.

By offering a multi-family program it can broaden the number of patients who get the benefit of FBT and there are some pretty impressive benefits for the patient when families collaborate beyond their nuclear pod.

The program itself is a 5-day intensive process where 35+ hours of treatment are delivered over those five days. From two to six families will be involved and the diagnoses will include eating disorder classifications as the primary condition (AN, BN, ARFID, EDNOS etc.) with secondary conditions that might be present of depression, anxiety, OCD etc.

The program is conducted on a monthly schedule at the University of California, San Diego Eating Disorders Center for Treatment and Research in La Jolla California at present.

IFT is designed to mobilize carers to take action towards recovery. When a patient develops an eating disorder the family interactions tend to veer towards accommodation and avoidance across the entire family. The carers have an opportunity to develop and practice skills that are easily transferred into the home environment. IFT allows for parents to “get on the same page” and develop the ability to function in unison. It also allows for family structure to be modified so that recovery is fully supported. To go from a space of avoidance, delay and accommodation to active advocacy for continued recovery is almost as hard for the family members as it is for the patient.

The current IFT programs are for those ages 8-23 (the adolescent stream) and those ages 18-35 (the adult stream). Of course most of the families within the adult stream are still patients living in their childhood homes and not adults entering the program with their partners or spouses.

In the adolescent stream, the treatment is modeled on FBT. Within the adult stream, the treatment involves both FBT and temperament-based treatment.

The therapist acts as a consultant and coach. The primary goals are to empower the parents to support recovery; to restore healthy eating; and to separate the child from the illness.

IFT also incorporates the parent-to-parent consultation that allows families to share with each other and through that process gain both skills and motivation to encourage further progress towards remission.

Likely the most powerful facet of IFT is removing the isolation that the family experiences. If you look at the forums on this site, you see the relief that patients can experience when they discover that others are experiencing their same struggle and difficulty through recovery. IFT is providing that same de-pressurization for parents. It allows both parents and patients to overcome stigmatization and social isolation. They learn from each other. It stimulates new perspectives and reflectivity. It offers mutual support, feedback, solidarity and raises hope.

Because UCSD Eating Disorder Center is a research and care facility, there is much research discipline that has gone into the development of IFT and it has taken eight years of moving it from single- to multi-family treatment.

There are three phases within the IFT program. The first phase involves observation and assessment. This phase involves the therapist/coaches watching the eating disorder symptoms and behaviors at meals and how the family interactions unfold. From there recovery and interfering behaviors are defined and the plan for applying targeted interventions is drawn up.

The intervention and instruction phase involves facilitating insights as and where they might be applied; providing instruction and skills-training; facilitating the in-vivo (meaning in this case as mealtimes unfold) application of the skills; and identifying the recovery guidelines.

The final phase includes reinforcement and planning: practicing the skills and constructing a discharge and home-recovery plan.

The entire IFT program includes two individual family therapy sessions, two psychiatric and medication evaluation sessions, 20 supervised therapeutic meals and snacks and five target therapeutic components.

The therapeutic components involve patient skills training, parent management skills training, behavioral contracting, interceding between patient and parents and psychoeducation for parents and patients.

In the parent-only management training it helps for parents to understand that they all usually apply things that don’t work. Scare tactics don’t work. Rewards also don’t work.

It is at this point I sadly recognize that I must have hit a post-lunch slump because my own notes seem incredibly sparse when I match them to the 67 slides that comprise Dr. Boutelle’s presentation. Apologies to both my readers and to Dr. Boutelle that what follows from this point forward likely does not do the presentation justice.

The therapists within the IFT program wear many hats. They flow between authoritative and collaborative efforts with the patients and their families.

As many here will attest, talking about eating and actually eating are two different activities altogether. IFT is designed to create the crisis of eating as family meals are shared and accomplished in the presence of the IFT treatment team.

In addition, the treatment team facilitates multi-family activities that greatly enhance opportunities for novel ways of acting and interacting. Therapy sessions may involve the therapist in a circle with the teens while the involved parents sit on the outskirts of the session to listen in and learn.

Dialectical behavior therapy is applied for distress tolerance, emotional regulation and interpersonal effectiveness.

Throughout the IFT program there is a cycle of didactic training followed by multi-family group discussion, observation and reflection, culminating with in vivo practice at mealtimes.

The core philosophy of the parent management training is a focus on contingency management as a way to alter behavior. The child’s behavior changes when the parent’s response to the child’s behavior changes. Parent management training aims to extinguish parent responses such as threats, nagging, screaming, yelling, guilt-trips etc. and replace them with reinforcing responses such as validation, consequences, disassembling the task into smaller tasks, remaining calm, creating consistency, and offering up if/when statements.

Mealtimes are where the therapist acts as a coach to help both parents and patients practice behaviors that allow the families to reach the goals they have set.

Those goals are framed within the behavioral contract. The contract is developed and agreed to by the parents and patient, with therapist coaching and guidance.

These contracts are successful for a variety of reasons. Those with eating disorders have a low tolerance of uncertainty and a high aversion to harm along with a lack of internal motivation to recover. The contract includes a detailed relapse prevention plan.

There is an overarching goal defined with 2 to 3 target behaviors identified. The child’s feedback is sought for defining motivation as parents’ beliefs about motivators are often not what the child finds motivating. The behaviors are limited to two or three targets as often parents tend to ruminate on everything and will get mired in the details.

The target behaviors are converted into concrete rules and there are short-, medium-, and long-term rewards and consequences assigned to those behaviors as well.

Here is an example of an overarching goal: “To restore Amy to health so that she can enjoy a healthy, active life and gain independence.” The long-term goal for Amy is “to go to university.” The rules and guidelines for Amy require of her that she eat 100% of the 3 meals and 2 snacks provided to her each day. Contingencies for Amy will allow for her to go outside to play with her dog for 10 minutes a day if she meets her daily goals.

Let’s imagine that Amy refuses to eat one of her meals or snacks. There are consequences assigned to that scenario. Every successful day involves a short-term reward of having her phone back in the evening. A short-term consequence of refusing a meal or snack is that her phone is not returned to her in the evening and she will not leave the home for any reason for 24 hours except to attend school. Should this happen three days in a row, then Amy is no longer able to go to school unless she finishes her breakfast and snack before school that day.

Families enter these programs immobilized and fearful— AN impacts the entire family in this way. The psychoeducation facet of IFT reduces blame and helps parents to work constructively with the temperament and personality traits present in those with AN.

It was patently obvious that those involved in the IFT program are passionate about it and it is not hard to see why: to be part of restoring hope to a patient and her family that have come to believe remission is as likely a possibility as immortality, is a truly life-altering process.