A surprising treatment approach for adolescents with anorexia nervosa
By Linda Castor
Imagine you and your family just sat down together and are enjoying a lively conversation over a delicious meal. Laughing, you look up and notice that your teenager is slowly pushing food around on her plate.
After several minutes of observing her behavior, you conclude she has not been eating at all. You think back to other times when she would not eat in front of you and how truly thin she appears. Despite her unwillingness to eat, you recall that she has developed a strange, new preoccupation with food and weighs herself several times a day. A sinking feeling overwhelms you as you realize: Your daughter may have an eating disorder.
This scenario demonstrates the confusion, worry, anxiety, fear - and even denial - that most parents experience when dealing with anorexia nervosa. The adolescent will also experience intolerance to cold, dry and brittle hair and nails, fatigue, loss of menses and the need for excessive exercise. According to the National Eating Disorders Association, anorexia nervosa has one of the highest mortality rates of all mental disorders. I'm already annoyed that she makes it seem like AN is the only eating disorder out there, but hey, let's roll with it.) So, it is quite understandable when parents who have tried to resolve the problem and don't see any progress become desperate for answers. "What do we do now?" they ask. "Send her to a hospital? Our daughter reacts with hostility and refuses to eat when we encourage her. Individual therapy isn't helping. What are we doing wrong?" If the adolescent is medically stable, there is an option for parents: family-based treatment.
At a recent training I attended at the University of Chicago, I heard something profound that actually made sense.
"One of the worst things you can do to a teenager is take away her parents," said Dr. James Lock, one of the proponents and authors of the treatment manual for anorexia nervosa. Family-based treatment has been around for several years, and it is beginning to emerge in practices all over the country.
Ding ding! Congratulations Dr. Lock, you just completely disregarded the very important role families and childhood usually play in the development of eating disorders. Sure, I'm not denying that there are some families out there who took good care of their kids and they still ended up with EDs, but "One of the worst things you can do to a teenager is to take away her parents"? Really? All the time? To all teenagers?
Often referred to as the Maudsley Method, this insightful and research-based approach continues to show that parental involvement is an effective catalyst in helping the adolescent recover from anorexia nervosa. Parents become the primary treatment management team, and the therapist acts as the consultant who oversees the entire process. Siblings also are included, but the parents retain all the decision-making power until the adolescent overcomes the eating disorder. Of course, the adolescent doesn't like this one bit in the beginning, but as long as anorexia nervosa is in the picture, the teenager is unable to overcome it on her own. She needs the help of her family to fight this sneaky disorder. (Or maybe she needs to get out of there as fast as she can. Again with the generalisations!)
If you think about it, this is a sound approach. Having your child sit with a rotation of hospital nurses 24-7 in a strange environment, with tubes ready for feeding, is probably not quite the nurturing she was looking for. Yes, because that is what all IP treatment looks like. In fact, your adolescent may eat just enough to be discharged from the hospital, only to go home and repeat the eating-disordered behavior. One of my patients tearfully admitted that she decided to get smaller and smaller until someone said, "Are you okay?" She was really hoping a family member would "save" her. Having parents and siblings involved at the beginning of treatment, with the therapist acting as the coach, can encourage opportunities for healing within the family.
After all, home is where the child will return, so why not have the intervention be based there as well?
Lock and his colleague, Dr. Daniel le Grange, cite the following encouraging results from multiple studies in determining the efficacy of the family-based approach:
There is no evidence to date that shows parents cause anorexia nervosa. (Pffft. There is not enough evidence to prove ANY eating disorder theory right now. Sure, new discoveries are made every day - one's about brain chemistry, one's about the media, there are plenty of options to choose from.)
Hospital care is not superior to outpatient treatment. (Again, it depends on the individual.)
Focus on treatment should ultimately be on individual adolescent control. (Control? I'm sorry, WHAT?)
Individual therapy has not demonstrated superiority over family treatments. (Because family treatment has demonstrated superiority. Right.)
Family treatments have been found to be effective for adolescents with bulimia nervosa. (W-what? You mean AN isn't the only eating disorder? Oh my!)
The authors note that a crucial window of opportunity exists for intervention in the childhood and adolescent years. Like any other treatment, family-based approach has its challenges, but it has been shown to be effective in ways that give parents an opportunity to heal their adolescent while improving relationships within the family. (I'm not touching the "heal their adolescent" thing with a five-foot pole. I'm just... not. ETA: Make that a ten-foot pole, five doesn't seem enough.)
Linda Castor, RN, LCPC, is a nurse and psychotherapist at Clocktower Therapy Center who treats children and adolescents with eating disorders. Sources cited can be viewed on her blog at www.lindacastor.com.