Abstract
Family-based treatment (FBT) has become well established as the first-line evidence-based treatment for adolescents with anorexia nervosa. However, fidelity to the FBT model can be poor, and treatment is often augmented or modified in various untested forms in the hope of increasing its effectiveness and acceptability. The New Zealand Eating Disorders Clinic, a private specialist outpatient clinic in New Zealand, has been seeing increasing numbers of families presenting for treatment reporting an experience of “failed FBT”. All of the families who presented with a child under the age 19 living at home agreed to restart FBT with the author when re-engaging in treatment. This essay summarizes the experience of the author in repeating FBT with previously “failed” FBT cases over 20 months between 2017 and 2019. Common themes of the first course of FBT were identified that raised questions for the author as to whether FBT had been implemented with sufficient fidelity and proficiency the first time around. This clinical perspective essay describes how these identified issues were addressed when FBT was administered again. It does not intend to make broad claims, but instead is intended to be helpful to clinicians who are implementing FBT, to assist them in carefully examining and assessing whether key FBT principles and procedures have been exhausted before evaluating the need for modification or augmentation. Furthermore, this perspective provides suggestions as to how the identified common themes can be addressed if families re-present for FBT treatment after having had a course of “failed FBT”.
Highlights
Manualized family-based treatment (FBT) is an empirically supported treatment for adolescents with anorexia nervosa with outcomes of full and sustained remission in 35–45% of cases [1,2,3]
The most critical one might be that it was possible to achieve full recovery using FBT treatment even after a course of previously “failed” FBT. It might be re-assuring to know for FBT therapists faced with similar cases that revisiting FBT is a valid treatment option
The themes discussed were present in all cases and, while comprehensive conclusions about the families’ previous treatment cannot be drawn, they were common and clear enough to question whether important key principles of FBT treatment had not been attended to with sufficient fidelity and proficiency the first time the families had engaged in FBT treatment
Summary
Manualized family-based treatment (FBT) is an empirically supported treatment for adolescents with anorexia nervosa with outcomes of full and sustained remission in 35–45% of cases [1,2,3]. Discussions among colleagues and presentations at conferences, it seems that a “modified” approach entails some or all of the following: additional individual treatment for the adolescent, the use of a dietitian to provide dietary advice or meal plans, the use of adjunct groups (e.g., self-compassion, distress tolerance), or a planned hospital admission or residential stay to assist with weight restoration or management of eating disorder behaviors Incorporating these kinds of interventions deviates from the empirically tested manualized version and is not informed by any research. A study of therapist adherence to manualized FBT showed that adherence to the model decreased over time, and that adherence was strong only on behavioral interventions focused on meals and eating but weaker on other elements of the treatment such as modification of parental criticism and attending to general family process issues [14] This perspective essay summarizes the author’s learning and reflections of providing FBT a second time around for cases with a reported history of “failed” FBT.
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