Family-based Therapy Research Articles

Attachment‐Based Family Therapy as an Adjunct to Family‐Based Treatment for Adolescent Anorexia Nervosa

Adolescent anorexia nervosa (AN) has a significant and long‐standing impact for the health and well being of young people and their families. The determinants of illness are multi‐factorial, however, adolescent AN has been consistently associated with parental distress (e.g., depression, anxiety, alcoholism), family conflict, and low parental warmth toward the adolescent. Whilst Family Based Therapy (FBT) for adolescent AN is the recommended first line of treatment, a substantial proportion of patients do not experience remission by the end of therapy or may relapse following remission. Although a range of adjuncts to FBT have been proposed, no preferred model has emerged. In this paper, we compare and contrast Attachment‐Based Family Therapy (ABFT) with FBT, and argue that ABFT's focus on relationships, rather than behaviours, could make a substantive contribution to the practice of FBT. We present a case study to demonstrate how ABFT may help to alleviate some of the maintaining factors of adolescent AN through the repair of parent–child relational ruptures.

Intensive Family-Based Therapy During an Acute Medical Admission for Anorexia Nervosa

Family-based therapy (FBT) is the evidence-based treatment of choice for anorexia nervosa (AN) in adolescents, with numerous studies providing support for its efficacy in the outpatient realm. This case report describes the application of a brief FBT intervention during an inpatient medical admission for an adolescent presenting with medical instability secondary to new onset AN. The intensive, four-session FBT-guided intervention included (a) psychoeducation and illness externalization, (b) parent skills training, (c) meal coaching, and (d) behavioral contracting. Self-report assessment and anthropometric data collected at pre-, post-, and 5 months following the intervention suggest increase in body mass index (BMI) and percent ideal body weight, increased parental understanding of AN and parental self-efficacy in managing the illness, decreased parent emotional burden of the illness, and decreases in overall adolescent Eating Disorder Examination Questionnaire (EDE-Q) scores. This case report provides preliminary evidence for the acceptability and effectiveness of a brief FBT-based intervention during medical stabilization for adolescents with AN and their families before proceeding to outpatient FBT.

Family-Based Therapy for Young Adults with Anorexia Nervosa Restores Weight.

We examined the preliminary acceptability and efficacy of family-based therapy (FBT) for weight restoration in young adults (FBTY) with Anorexia Nervosa (AN). Twenty-two primarily female participants ranging from age 18 to 26, with AN or atypical AN (ICD-10) and their support adults were enrolled in a 6-month open trial of FBTY. Participants were assessed at baseline, after treatment, and at six and 12 month follow-up visits. The primary outcome was BMI and secondary outcomes included eating disorder psychopathology, current eating disorder obsessions, and compulsions, number of other Axis I disorders and global assessment of functioning. Although FBTY was rated as suitable by participants and their support adults, during FBTY, 9/22 participants dropped out and 3/22 dropped out at follow-up assessments. Despite being offered 18-20 sessions over six months, a mean of 12 FBTY sessions (SD = 6) were attended. After FBTY, 15 of the intent-to-treat sample of 22 were no longer underweight (BMIs ≥ 19 kg/m(2) ) and 12 months after treatment, 13/22 were no longer underweight. The magnitude of the BMI increase during FBTY (Hedges g = 1.20, 95th percentile CI = 0.55-1.85) was comparable to findings for adolescent FBT for AN. Secondary outcomes also improved. FBTY for young adults with AN and atypical AN, which involves support adults participants have chosen, results in weight restoration that is sustained up to a year after treatment. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:701-707).

Family-based music therapy: from dissonance to harmony

ABSTRACTThis study is unique in that it expands the use of family music therapy to a broader range of families. It moves beyond the prevailing tendency to employ family music therapy with families of children with special needs to nonclinical families seeking therapy. Joining Alvin’s free improvisation model and Satir’s experiential family therapy, the study engages family members in mutual musical improvisation. It explores the clinical application and therapeutic value of short-term family-based music therapy with three families in a community setting. Each family received six pre-structured interventions from the dual-expertise music and family therapist. Results reveal family-based improvisations accurately accentuated family dynamics as musical representations. They provoked heightened awareness of family difficulties, which were explored using process questions and verbal reflections. Evidence suggests that family-based music therapy can serve as an effective and accurate family clinical assessment, and an intervention addressing an array of family objectives. Family-based music interventions tapped into family resources for the sake of promoting family and individual congruence and well-being. The study informs music therapists of the clinical value of adding a family-systems perspective to their professional toolbox, and family therapists and other clinicians of the potential of family-based musical interventions in family therapy.

Using a brief family-based DBT adjunct with standard FBT in the treatment of Anorexia Nervosa

The outpatient program at The Children's Hospital at Westmead (CHW) Eating Disorder Service uses Maudsley family-based therapy (FBT) as the main therapeutic model. For families that experience a high level of distress, avoidance of conflict or emotional expression, or if the young person is engaging in high risk behaviour like self-harm or suicide attempts, the parents ability and confidence to persist with refeeding is often severely undermined. In practice this reduces the efficacy of standard FBT, leading to poor engagement, multiple inpatient admissions, longer treatment and drop-out. The team at CHW are trialling a brief 6 session adjunct based on the core principles of Dialectical Behaviour Therapy (DBT), teaching the young person, their parents and siblings basic skills to engage in mindfulness, distress tolerance, emotion regulation and effective interpersonal relationships. These DBT skills have been adapted to a framework that maintains the core principles and structure of FBT. This oral presentation will discuss the family-based DBT adjunct and its implementation, including session outlines and a case example. Initial data on its effectiveness for patient and parent experience may also be discussed.

Research round-up

Research round-up

Outcome Evaluation of a Family-Based Jail Reentry Program for Substance Abusing Offenders

Offender reentry programs have proliferated since the passage of the Second Chance Act in 2008. This study examines the effectiveness of one such jail-based reentry program for male inmates diagnosed with substance dependency and who have minor children, the Delaware County (OH) Jail Substance Abuse Treatment program. This program served 34 offenders and their families over 2 years and was based on the Community Reinforcement and Family Training model, a treatment modality for substance abuse involving both operant conditioning and family-based therapy for behavioral modification. Results from a quasi-experimental design indicate that program participants were significantly less likely to be rearrested within 1 year after release relative to a comparison group of similarly situated offenders and more likely to comply with child support orders following release. Findings also revealed the treatment group had significantly more days to failure for those who did recidivate.

Can adaptive treatment improve outcomes in family-based therapy for adolescents with anorexia nervosa? Feasibility and treatment effects of a multi-site treatment study

ObjectiveAdolescents with Anorexia Nervosa (AN), treated with family-based treatment (FBT) who fail to gain 2.3 kg by the fourth week of treatment have a 40–50% lower chance of recovery than those who do. Because of the high risk of developing enduring AN, improving outcomes in this group of poor responders is essential. This study examines the feasibility and effects of a novel adaptive treatment (i.e., Intensive Parental Coaching-IPC) aimed at enhancing parental self-efficacy related to re-feeding skills in poor early responders to FBT. Method45 adolescents (12–18 years of age) meeting DSM TR IV criteria for AN were randomized in an unbalanced design (10 to standard FBT; 35 to the adaptive arm). Attrition, suitability, expectancy rates, weight change, and psychopathology were compared between groups. OutcomesThere were no differences in rates of attrition, suitability, expectancy ratings, or most clinical outcomes between randomized groups. However, the group of poor early responders that received IPC achieved full weight restoration (>95% of expected mean BMI) by EOT at similar rates as those who had responded early. ConclusionsThe results of this study suggest that it is feasible to use an adaptive design to study the treatment effect of IPC for those who do not gain adequate weight by session 4 of FBT. The results also suggest that using IPC for poor early responders significantly improves weight recovery rates to levels comparable to those who respond early. A sufficiently powered study is needed to confirm these promising findings.

A review of adolescent adherence in type 1 diabetes and the untapped potential of diabetes providers to improve outcomes.

Only 21% of adolescents with type 1 diabetes (T1D) meet glycemic goals set forth by the American Diabetes Association. Adherence to therapy is a particular concern in this population, and the association between poor adherence and worsening glycemic control indicates that there is a critical need to improve adherence to therapy in adolescents with T1D. In this article, we review barriers to adherence in adolescents with T1D and discuss interventions aimed at improving adherence to therapy and glycemic control. Interventions include technology-based applications, family-based therapies, motivational interviewing, and others. Notably, less than 10% of the interventions reviewed are provider-led, clinic-based interventions, and few have focused on regimen-related aspects of adherence. This article also outlines the importance of provider communication and the role of providers in facilitating adherence behaviors in adolescents with T1D. Finally, we suggest future directions of research to improve adherence to therapy in adolescents with T1D.

Addressing the Needs of Military Children Through Family-Based Play Therapy

Ongoing foreign conflicts have exposed military-connected children to stressors not generally faced by the general child population. Although many children of service members and veterans are resilient and successfully adapt to these changes, frequent relocation, fluid family structure, and ambiguous loss can become too overwhelming for many children of military families and lead to pathological symptoms that require them to receive treatment. This paper discusses the use of family-based play therapy interventions with military children. It will focus on the following areas: (1) risks to the psychological and emotional health of children of service members, (2) adverse effects of combat stress reactions of military parents on their children, (3) traumatic grief of children whose family member has died or been grievously wounded, (4) family-based therapies currently in the treatment of childhood grief and trauma, and (5) play therapy as a means of treating bereavement and traumatization of military-connected children and their families. A case example demonstrating a couple and family therapist’s use of family-based play therapy to deal with traumatic grief of a military child is provided. Recommendations for future research are presented.

A Brief, Intensive Application of Multi-Family-Based Treatment for Eating Disorders

There is a continued need to improve upon the efficacy and availability of treatments for anorexia nervosa. Family-based therapy for anorexia nervosa demonstrates strong empirical evidence; however, trained treatment providers are limited and a subsample of participants receiving the treatment fail to respond. The intensive family treatment program is a brief, time-limited, multi-family program that trains families of adolescents with eating disorders to oversee their adolescents’ recovery at home by providing psychoeducation, skills training, and immersive practice over the course of a 5-day period. This article provide a description of the program by summarizing underlying theoretical principles and key therapeutic components.

Short-term intensive family therapy for adolescent eating disorders: 30-month outcome.

Family therapy approaches have generated impressive empirical evidence in the treatment of adolescent eating disorders (EDs). However, the paucity of specialist treatment providers limits treatment uptake; therefore, our group developed the intensive family therapy (IFT)-a 5-day treatment based on the principles of family-based therapy for EDs. We retrospectively examined the long-term efficacy of IFT in both single-family (S-IFT) and multi-family (M-IFT) settings evaluating 74 eating disordered adolescents who underwent IFT at the University of California, San Diego, between 2006 and 2013. Full remission was defined as normal weight (≥ 95% of expected for sex, age, and height), Eating Disorder Examination Questionnaire (EDE-Q) global score within 1 SD of norms, and absence of binge-purging behaviours. Partial remission was defined as weight ≥ 85% of expected or ≥ 95% but with elevated EDE-Q global score and presence of binge-purging symptoms (<1/week). Over a mean follow-up period of 30 months, 87.8% of participants achieved either full (60.8%) or partial remission (27%), while 12.2% reported a poor outcome, with both S-IFT and M-IFT showing comparable outcomes. Short-term, intensive treatments may be cost-effective and clinically useful where access to regular specialist treatment is limited.

Relatives' emotional involvement moderates the effects of family therapy for bipolar disorder.

The "critical comments" dimension of the expressed emotion (EE) construct has been found to predict the illness course of patients with bipolar disorder, but less is known about the "emotional overinvolvement" component. The goal of this study was to evaluate whether relatives' observed appropriate and inappropriate emotional involvement (intrusiveness, self-sacrifice, and distress about patients' well-being) moderated the effectiveness of a family-based intervention for bipolar disorder. 108 patients with bipolar disorder (mean age = 35.61 years, SD = 10.07; 57% female) and their relatives (62% spouses) from 2 clinical trials completed 10-min problem-solving interactions prior to being treated with pharmacotherapy plus family-based therapy (FBT) or brief psychoeducation (crisis management [CM]). Patients were interviewed every 3-6 months over 2 years to assess mood symptoms. When relatives showed low levels of inappropriate self-sacrifice, CM and FBT were both associated with improvements in patients' manic symptoms over 2 years. When relatives showed high levels, patients in CM became more manic over time, whereas patients in FBT became less manic. Group differences in mania trajectories were also observed at high levels of inappropriate emotional response but not at low. When relatives showed high levels of appropriate self-sacrifice, patients in both groups became less depressed. At low levels of appropriate self-sacrifice, patients in CM did not improve, whereas patients in FBT became less depressed. Future studies of bipolar disorder should consider the prognostic value of the amount and appropriateness of relatives' emotional involvement with patients in addition to their critical behaviors.

Effectiveness of pilot trial of family meal support prior inpatient discharge

The North Western Mental Health Eating Disorder Program at The Royal Melbourne Hospital provides treatment for adults 18 years and over since 1994. The eating disorder program provides an in-patient and day-patient treatment program and comprehensive out-patient services. Family members have been an effective and vital support for clients with eating disorders in their treatment and recovery in our day patient program. This pilot trial is to explore the family dynamics and confidence of family members in supporting in-patient clients with anorexia nervosa during a meal. Family members would be empowered with evidence based knowledge and strategies to support their loved ones through a meal prior to discharge as part of the discharge planning. The theoretical framework for this trial is based on a modification of the Family-Based Therapy (FBT). In several controlled studies, it has proven that Family-Based Treatment to be successful in an out-patient setting especially for adolescent in helping individual in weight restoration.

Alcohol and drug use among adolescents: an educational overview.

Alcohol and drug use continues to be a significant global problem with many health and economic consequences. Multiple studies have shown that the majority of adults who end up with an alcohol/drug use disorder have their first contact with these substances as adolescents. This article aims to briefly summarize current prevalence and impact on society, as well as its etiology, comorbid psychiatric disorders, and treatment and prevention of adolescent drug and alcohol use. Alcohol and substance use impacts both the user and society at large, from health risks to the user to increased early pregnancies, car accidents, financial cost, and productivity cost. Substance use and abuse results from intricate interactions between genetic and environmental influences. Also, substance abuse along with a comorbid psychiatric disorder is more common than a solitary substance use disorder in adolescents. Current options for the treatment of substance abuse disorders range from various therapy-based strategies, including behavioral and family-based therapies, to the use of medications. More attention must be placed on the importance of prevention of use, as well as progression of use to dependence. Successful prevention requires a comprehensive plan that needs to include, but should not be limited to, increasing education of all gatekeepers and limiting access of substances and alcohol through policy and reinforcement of those policies. Education of parents, pediatricians, school nurses, teachers, and mental health workers is essential to ensure that children at risk are identified in time to provide appropriate interventions.

Assessment of Obsessive Compulsive Disorder in Young Children: Psychometric Properties of the Children’s Yale-Brown Obsessive Compulsive Scale

The Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) is the most commonly used instrument to assess the symptoms and severity of pediatric obsessive compulsive disorder (OCD). However, only one prior study has evaluated the psychometric properties of the CY-BOCS for assessing young children, ages 5 to 8 years. The limited available evidence suggests that psychometric properties are less favorable with younger children. Thus, the present study aimed to re-examine the technical qualities of the CY-BOCS in a sample of 5 to 8 year olds with early-onset OCD. The sample consisted of 127 younger children, enrolled in a multi-site randomized controlled trial comparing the efficacy of family-based cognitive behavioral therapy to relaxation therapy. The CY-BOCS Total score demonstrated adequate internal consistency, although at a lower level than is typically reported in studies of older children. Internal consistency of the Obsessions and Compulsions subscales was poor. The Total and subscale scores demonstrated good temporal stability over 5 weeks. Agreement between clinician and parent versions was poor at baseline but improved substantially throughout the course of the trial. Results also indicated that the CY-BOCS had good convergent and discriminant validity. Further, certain CY-BOCS items appear more reliable indicators of OCD severity in younger children than others. Limitations, implications, and future directions are discussed, including the potential for further developmentally sensitive refinement of the CY-BOCS for this age group.

Treating Nonsuicidal Self-Injury

Nonsuicidal self-injury (NSSI) evaluation and treatment are critical for comprehensive patient care. A thorough assessment of nonsuicidal self-injury(NSSI) following DSM-5-proposed criteria is critical in understanding and treating NSSI and should be informed based upon past and current self-harm behaviors, including self-injury methods, frequency, severity, and intent, along with a comprehensive suicide risk assessment. After NSSI is diagnosed, patients should be offered proper management of co-occurring psychiatric illnesses, if applicable, enhanced by an 8 – 12 week trial of cognitive behavior therapy (CBT) focusing on NSSI. Cognitive strategies to be used include Socratic questioning, keeping thought records, and addressing self-derogatory and distorted beliefs about NSSI. Behavioral strategies include contingency management, behavioral activation, and addressing environmental factors maintaining NSSI. In adolescents, individual CBT work might be supplemented with family-based therapy. Dialectical strategies (acceptance and distress tolerance) and skills training (focus on improving emotion regulation, problem-solving, interpersonal, and communication skills) can be used to enhance CBT, but in some cases DBT can be cost prohibitive. If adequate psychotherapy trials are ineffective, a pharmacotherapy trial of emerging drug therapies for NSSI, e.g. naltrexone, N-acetylcysteine, or topiramate to enhance supportive psychotherapy would be recommended. We would encourage patients to continue effective treatment for at least 6 months and would continuously assess for self-harm urges and behaviors. Psychoeducation and adequate treatment of comorbid conditions should be provided on an ongoing basis along with attention to physical self-care and regular exercise.

Guideline Watch (August 2012): Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd Edition

This guideline watch reviews new evidence and highlights salient developments since the 2006 publication of APA’s Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd Edition. The authors of this watch constituted the work group that developed the 2006 guideline. We find the guideline to remain substantially correct and current in its recommendations. The sole exception is a recommendation (with moderate-level confidence) for sibutramine for binge-eating disorder. In 2010, the U.S. Food and Drug Administration (FDA) withdrew approval for sibutramine because clinical trials showed increased risk of heart attack and stroke, and the manufacturer, Abbott Laboratories, subsequently withdrew this medication from the U.S. market. Noteworthy recent publications about the treatment of eating disorders include systematic reviews by the Agency for Healthcare Research and Quality (Berkman et al. 2006; Bulik et al. 2007); practice guidelines from international groups, including the Catalan Agency for Health Information, Assessment and Quality (Working Group of the Clinical Practice Guideline for Eating Disorders 2009), the World Federation of Societies of Biological Psychiatry (Aigner et al. 2011), and the German Society of Psychosomatic Medicine and Psychotherapy and the German College for Psychosomatic Medicine (Herpertz et al. 2011); and a 2011 guidance statement by the Academy for Eating Disorders, which was written by some of the authors of this

Transitions to Systemic Practice for a Clinical Psychology Trainee

This article provides an individual perspective on encounters with systemic and family therapy ideas during the transition from university training to professional practice as a Clinical Psychology Registrar. Clinical psychology training provides a solid grounding in individually focussed, cognitive and behavioural models of psychotherapy. What may be less developed on entry to practice are the knowledge, procedural skills and reflective competencies needed to understand and respond to challenges in family-based therapy and in working within complex caregiving systems. Systemic ideas can provide important resources for facilitating these transitions. Trainees may need support not only in gaining knowledge of family therapy models, but also in making a challenging ‘epistemological shift’ (Cullin, 2014) from internalised models of psychopathology to systemic ways of thinking about problems and change. Systemic concepts and support in developing a position of ‘hospitality’ (Larner, 2003) towards competing therapeutic models can also help the trainee be more effective in complex caregiving environments. This article provides examples from my learning as well as reflections on what may help trainees make the transition to professional practice and make use of systemic ideas.

Relapse From Remission at Two- to Four-Year Follow-Up in Two Treatments for Adolescent Anorexia Nervosa

Long-term follow-up studies documenting maintenance of treatment effects are fewin adolescent anorexia nervosa (AN). This exploratory study reports relapse from full remission and attainment of remission during a 4-year open follow-up period using a convenience sample of a subgroup of 65% (n= 79) from an original cohort of 121 participants who completed a randomized clinical trial comparing family-based therapy (FBT) and adolescent-focused individual therapy (AFT). Follow-up assessments were completed up to 4years posttreatment (average, 3.26 years). Available participants completed the Eating Disorder Examination as well as self-report measures of self-esteem and depression at 2 to 4 years posttreatment. Two participants (6.1%) relapsed (FBT: n= 1, 4.5%; AFT: n= 1, 9.1%), on average 1.98 years (SD= 0.14 years) after remission was achieved at 1-year follow-up. Ten new participants (22.7%) achieved remission (FBT: n= 1, 5.9%; AFT: n= 9, 33.3%). Mean time to remission for this group was 2.01 years (SD= 0.82 years) from 1-year follow-up. There were no differences based on treatment group assignment in either relapse from full remission or new remission during long-term follow-up. Other psychopathology was stable over time. There were few changes in the clinical presentation of participants who were assessed at long-term follow-up. These data suggest that outcomes are generally stable posttreatment regardless of treatment type once remission is achieved. Clinical trial registration information-Effectiveness of Family-Based Versus Individual Psychotherapy in Treating Adolescents With Anorexia Nervosa; http://www.clinicaltrials.gov/; NCT00149786.