socw 6446

Article

Family-Based Therapy for Pediatric Anorexia Nervosa: Highlighting the Implementation Challenges

Jennifer Scarborough 1

Abstract Family-based therapy is a recommended treatment for children and adolescents diagnosed with an eating disorder. Despite the promising results, this model is not without its challenges. Through literature review and treatment exemplars, this article provides a brief overview of family-based therapy and highlights the many challenges for clinicians and parents implementing this therapy. Noted challenges are barriers to clinical supervision, inadequate treatment options, time and finances, relationships, and parental adjustment. This article concludes with implications for research and clinical practice.

Keywords eating disorders, family based therapy, pediatric, maudsley, anorexia nervosa

Eating disorders have the highest mortality rate of any mental

illness, with 10–20% of individuals succumbing either to the medical complications of the disorder or to suicide (Crow et al.,

2009; Fisher, 2006; Harris & Barraclough, 1998; Nielsen,

2001). The illness generally presents between the ages of 13

and 19; a time when an adolescent is still usually dependent on

their parents but is also experiencing greater autonomy (Scott,

Biskman, Woolgar, Humayun, & O’Connor, 2011; Smick, van

Hoeken, & Hoek, 2012; Weaver & Liebman, 2011).

Eating disorders can be difficult to treat. This is partly due

to the diagnosed individual’s inability to understand the

severity of their illness (Fisher, Schneider, Burns, Symons,

& Mandel, 2001). Thus, the involvement of parents can

greatly increase the chances of successful recovery (Golan

& Crow, 2004). Family-based therapy is currently a fre-

quently recommended treatment for children and adolescents

diagnosed with an eating disorder (American Psychiatric

Association, 2006; Findlay, Pinzon, Taddeo, & Katzman,

2010; Mitchum, 2010).

Although family-based therapy is a highly recommended

treatment, this intervention is not without its challenges. Pre-

sently, family-based therapy does not explicitly acknowledge

the additional pressures that parents face when engaged in

treatment. Everyday family demands (e.g., finances, relation-

ships) become more challenging with the added demands and

expectations of treatment.

The aim of this article is to highlight the many challenges

that are encountered when attempting to implement family-

based therapy. Understanding these issues is vital for success-

ful implementation. Exploring the potential barriers for parents

and clinicians is necessary in order to improve the chances of

successful implementation of family-based therapy as well as

longevity in treatment. This article is intended to help clini-

cians gain a better understanding of these pressures on parents

and to support their discussions with parents as well as open a

dialogue on the challenges faced in family-based therapy. In

addition, this article will help researchers develop a better

understanding of the parental experience when caring for an

adolescent diagnosed with an eating disorder as well as the

challenges of implementing family-based therapy.

This article begins with a brief overview of family-based

therapy to provide context and a general understanding of

manualized family-based therapy and its expected outcomes.

This is followed by an explanation of the procedures used in

identifying issues such as (1) training and adherence to family-

based therapy, (2) inadequate treatment options, (3) time and

finances, (4) relationship maintenance, and (5) parenting

adjustment and eating disorder resistance. Each discussion of

an issue is supported by literature and illustrated by an exem-

plar from family-based therapy practice. The article concludes

with a discussion of implications and suggestions for

improvement.

1 Faculty of Social Work, Wilfrid Laurier University, Kitchener, Ontario,

Canada

Corresponding Author:

Jennifer Scarborough, Faculty of Social Work, Wilfrid Laurier University, 120

Duke St. W., Kitchener, Ontario, Canada N2H3W8.

Email: jscarborough@wlu.ca

The Family Journal: Counseling and Therapy for Couples and Families 2018, Vol. 26(1) 90-98 ª The Author(s) 2018 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066480717754280 journals.sagepub.com/home/tfj

Overview of Family-Based Therapy

This overview section is provided to inform readers of family-

based therapy and the role parents play in this treatment.

Family-based therapy is a treatment that encourages and moti-

vates parents to facilitate their child’s recovery by preparing

and supervising meals. Family-based therapy is a weekly out-

patient treatment that is nondirective in nature. The therapist is

more of a consultant asking parents questions to empower them

to arrive at decisions to fight the eating disorder. The purpose

of family-based therapy is to intervene to decrease the chances

for hospitalization.

Families were first included in the treatment of eating dis-

orders by Minuchin and his colleagues (Minuchin, Rosman, &

Baker, 1978). Due to their relative success with the inclusion of

families in treatment, Minuchin developed the model of the

psychosomatic family, which believed that familial dysfunc-

tions or enmeshments lead to disordered eating behaviors. In

addition to Minuchin’s structural family therapy, both the

Milan group and strategic family therapy influenced the devel-

opment of family-based therapy, which led to controlled stud-

ies conducted at Maudsley hospital in London (Loeb & Le

Grange, 2009).

Family-based therapy was eventually manualized by James

Lock, Daniel Le Grange, and colleagues in 2001. They have

since published a manual for bulimia nervosa and a second

edition of the original manual for anorexia nervosa. Family-

based therapy has specific components. These components are

that the therapist take an agnostic view of the illness, which

means that there are no assumptions as to what may have led

to the eating disorder onset. Since family-based therapy focuses

on what needs to be done in the present to quickly move forward

in recovery, the exploration of potential causes is not examined.

Another component of family-based therapy is externalization

of the illness. Additionally, parental empowerment is a key

feature, whereby the therapist is nonauthoritative and acts more

of a consultant to parents to guide and support them in aiding

their child to recovery (Lock & Le Grange, 2013).

Family-based therapy has a recovery rate of about 50–60% at 6 and 12 months follow-ups, with recovery defined as reach-

ing >95% ideal body weight and within 1 standard deviation of community norms on the Eating Disorder Examination Ques-

tionnaire (Lock et al., 2010). In family-based therapy, parents

are seen as “functioning similar to an effective inpatient nur-

sing staff—at least during the first phase of treatment—albeit

in the home setting” and are tasked with this role as they “love

their children, know them well, and are highly invested in their

[child’s] survival” (Le Grange & Lock, 2011, p. 230).

Family-based therapy consists of three phases with 15–20

sessions in total over 12 months. These three phases are (1)

weight restoration, (2) returning control to the adolescent, and

(3) establishing healthy adolescent identity (Lock & Le

Grange, 2013).

In Phase 1, weight restoration, the therapist supports parents

in the renourishing of their ill child. The second session in this

first phase involves a supervised meal session where the

therapist can view and assist parents in encouraging their child

to eat a meal the parents bring. Throughout Phase 1, the thera-

pist models a noncritical stance toward the ill child and con-

tinues to support the parents in the refeeding process.

Phase 2, returning control to the adolescent, takes place

when the child has begun to show signs of acceptance of

increased food intake from the parent as well as weight gain

and an overall positive change in mood. In Phase 2, the parents

begin to encourage and support their child to regain control

over their eating as developmentally appropriate. Weight gain

remains a focus in this phase.

Phase 3, establishing healthy adolescent identity, is indi-

cated by the adolescent reaching and maintaining a minimum

of 95% ideal body weight. This phase focuses on adolescent autonomy and establishing developmentally appropriate

boundaries for parents.

While family-based therapy is considered by some the first

line of treatment for eating disorders, there are certain instances

where this treatment may not be appropriate. Firstly, children

who are medically unstable, or suicidal, should be hospitalized

and not begin treatment until stable. Parents with severe psy-

chopathology may also be contraindicated for the uptake of

family-based therapy (Le Grange, Lock, Loeb, & Nicholls,

2010). Despite this, Le Grange, Lock, Loeb, and Nicholls

(2010) mention the importance of family involvement even

in difficult circumstances:

the assessment of families requires close attention to the parents’

competencies, motivation, and history of adverse or traumatizing

events. But even when such adverse circumstances are present, the

development of a play to help and support sufferers and how to

ease family burdens should take precedence over accusation and

blame. Thus, it is our position that families should be involved

routinely in the treatment of most young people with an eating

disorder. Exactly how such involvement should be structured, and

how it will be most helpful will vary from family to family. (p. 4)

While not contraindicated, there are several factors that are

worth mentioning that need to be kept in mind when implement-

ing family-based therapy. Children over the age of 18 or who

have had the eating disorder for longer than 3 years may not fare

as well compared to younger and less chronic children (Le

Grange, 2005; Lock & Le Grange, 2013; Loeb & Le Grange,

2009; Rienecke, 2017). Adolescents with comorbid psychiatric

disorders have higher rates of treatment dropout and lower

remission rates (Lock, Couturier, Bryson, & Agras, 2006). Par-

ents who present as hostile or overly critical may be better suited

for a separated form of family-based therapy, whereby the thera-

pist meets with the child and parents separate from each other

(Dare, Hodes, Russell Dodge, & Le Grange, 2000).

Procedures

The origin of this article emerged from observations of family-

based therapy through clinical practice, supervision of other

clinicians implementing family-based therapy, and agency-

Scarborough 91

based challenges. Through these observations, a number of

implementation issues have been identified.

In addition to clinical practice observations, and conversa-

tions with parents, clinicians working in the field of pediatric

eating disorders have echoed these difficulties when applying

family-based therapy. Once themes had been identified, a com-

prehensive literature search and review was completed focused

on these issues.

Using Primo, a library catalog search procedure, the key

words “parents, caregivers, family-based therapy, Maudsley,

eating disorders, children” were used to find appropriate liter-

ature about family-based therapy implementation challenges.

Once this literature was reviewed, pertinent material was then

combined with the author’s practice experiences, leading to

the identification and discussion of issues and challenges

within the family-based therapy model as presented in this

article. To effectively convey family-based therapy chal-

lenges, the article is organized into sections containing a

review of literature pertinent to the issues identified, followed

with an exemplar from practice, supervision, or agency admin-

istrative experiences.

Family-Based Therapy Demands on Clinicians

Clinicians who are trained in family-based therapy are fortu-

nate to have the ability to implement the most up to date,

evidence-based treatment for families who have a child diag-

nosed with an eating disorder. Despite having formal training

in this therapy, there remain several challenges that have con-

sequences for clinicians and clients.

Family-based therapy training and adherence for clinicians. Current evidence in the treatment of eating disorders for adolescents

shows that outpatient treatment using a family-based approach

is effective in returning adolescents to health (Lock et al.,

2010). For this reason, a training institute to ensure quality of

care and proper training in the use of family-based therapy in

practice has been developed (see Training Institute for Child

and Adolescent Eating Disorders, 2017).

In order to be considered a certified family-based therapy

therapist, 2 days of training and 25 hr of individual supervision,

with tape recordings of sessions and in-person or phone meet-

ings, must be completed. In Canada, there are only five fully

certified family-based therapy therapists listed on the Training

Institute for Child and Adolescent Eating Disorders website.

This lack of fully certified family-based therapy therapists is

not surprising, as many agencies are unable to fund their clin-

icians in the full course of certification. What often happens is

just the 2-day workshop (Level 1) is completed. Due to this,

clinicians are often attempting to implement family-based ther-

apy without supervision.

A study by Couturier et al. (2013) found that several of the

key aspects of family-based therapy were not being adhered to

in agencies, such as weighing the adolescent at the start of all

sessions as well as the family meal which takes place in the

second session of Phase 1. Reasons for not implementing

certain key aspects of family-based therapy were due to various

factors such as the clinician’s scope in practice (e.g., weighing

of the patient is viewed as a medical role) or by organizational

barriers such as a lack of space to complete family meals within

the agency. For these reasons, parents are provided with more

of an informed family-based therapy rather than the manualized

model. In some cases, many therapists are using therapeutic

techniques that are not suggested or recommended by the

family-based therapy manual (Kosmerly, Waller, & Lafrance

Robinson, 2015).

Parents are led to believe that they may be receiving the

recommended treatment; however, in order to confidently

expect outcomes similar to those indicated in research, the

manualized treatment protocol must be followed. One of the

major issues with this informed family-based therapy is that

there is a lack of data on mixing therapeutic techniques. This

informed family-based therapy may mislead parents into

believing that they are receiving the evidence-based treat-

ment. Should the therapy fail, these parents may end up

believing that the best treatment to date was not enough to

help them, when in fact they never received the manualized

treatment in the first place.

In addition to this, supervision of clinicians implementing

family-based therapy is vital given that clinician anxiety has

been shown to lead clinicians to stray away from evidence

based the protocol (Waller, Stringer, & Meyer, 2012). In fact,

eating disorder clinicians working with children and adoles-

cents reported that negative emotions impacted clinician deci-

sions (Lafrance Robinson & Kosmerly, 2014, p. 10).

Supervision does exist specifically for the clinical blockages

that may hinder treatment progression (Lafrance Robinson &

Dolhanty, 2013). However, some agencies may be unable to

access this supervision due to financial limitations.

Supervision of treatment implementation is necessary to

help clinicians be aware of judgments they may have when

working with families. Part of family-based therapy is main-

taining a nonjudgmental and nonblaming stance toward par-

ents. Yet Couturier et al. (2013) reported that some clinicians

had “little sympathies for families who do not attend appoint-

ments during normal work hours, because therapists feel fam-

ilies would not hesitate to attend if their child was diagnosed

with a serious physical illness (e.g., cancer)” (p. 182).

Exemplar. In the case of Sam, a 15-year-old female with anorexia nervosa, a referral to an outside, private therapist to

treat her depressive symptoms was made as her parents felt that

these emotions were the precursor to the development of the

eating disorder. Sam’s family-based therapy clinician sup-

ported the parents’ decisions since the child was not engaging

with the family-based therapy clinician and thus was not get-

ting enough emotional support through the process.

In the family-based therapy protocol, it is recommended that

all other forms of counseling be halted while in treatment. The

reason for this is demonstrated in Sam’s case, where contra-

dicting messages were given from the private therapist about

the parents’ role in refeeding. The private therapist

92 The Family Journal: Counseling and Therapy for Couples and Families 26(1)

recommended that Sam’s parents stop preparing and supervis-

ing Sam’s meals as this was contributing to Sam’s depression.

Sam felt that she was being treated like a toddler. The private

therapist assured the parents that Sam had learned skills to cope

with the depressive thoughts, which were similar to the eating

disorder thoughts. The parents then withdrew from family-

based therapy treatment, so Sam could pursue her individual

treatment for depression. A closing letter from the family-

based therapy clinician to the family doctor recommended

medical monitoring.

Sam eventually returned to the eating disorder agency. Her

eating disorder behaviors never ceased and weight loss contin-

ued while in private treatment for depression. The private

therapist eventually discharged Sam from her care as the med-

ical urgency of her weight loss became too pressing. When Sam

and her family returned to the agency, a referral was made to an

inpatient eating disorder program as her weight loss was too

extreme to manage on an outpatient basis.

Inadequate treatment options. For anorexia nervosa, family- based therapy has a nonresponse to treatment rate of 15–30% (Krautter & Lock, 2004; Lock et al., 2010). Some of the mod-

erators identified as having an impact on the outcome are (1)

the eating disorder’s severity at clinical assessment, (2) diag-

nosed comorbidities, (3) being an older adolescent, and (4)

parents with high emotional expression (Dare, Eisler, Russell,

& Szmukler, 1990; Le Grange et al., 1992, 2012; Murray & Le

Grange, 2014).

In terms of nonresponse to family-based therapy, Doyle, Le

Grange, Loeb, Doyle, and Crosby (2010) found that the stron-

gest indicator for remission was a weight gain of 2.88% by the fourth session (approximately 1 month into therapy) of the

manualized treatment. For patients unable to achieve this

weight gain, another treatment model may be required. A key

challenge for clinicians is the lack of treatment options and

training for these treatment models that currently exist. As a

result, clinicians may desperately try to continue to use family-

based therapy and not know when, or how, to switch to another

form of therapy (Steiger, 2017).

Other treatments do exist for adolescents, either as comple-

ments to boost family-based therapy effectiveness or as alter-

native treatments to family-based therapy. They include (1)

adolescent focused psychotherapy (see Fitzpatrick, Moye,

Hoste, Lock, & Le Grange, 2010), (2) cognitive behavioral

therapy (see Dalle Grave, Calugi, Doll, & Fairburn, 2013),

(3) cognitive remediation therapy (see Lask & Roberts,

2013), and (4) emotion focused family therapy (see Robinson,

Dolhanty, & Greenberg, 2013).

There is a need for clinicians to have a variety of treatment

intervention options when working with families with a child

diagnosed with an eating disorder. However, to have a breadth

of training and knowledge in the various modalities can be

costly for agencies. It can also be confusing to clinicians in

selecting which treatment to implement when there is a non-

response to family-based therapy. Clinicians can also struggle

with how to effectively change and manoeuvre between these

treatments. As a result, the pressure clinicians may place on

parents to adhere to the family-based therapy treatment recom-

mendations may increase frustrations and a sense of hopeless-

ness when the model is proving to be noneffective. Switching

to another treatment can be confusing to parents and may send

mixed or contrasting messages if the course of treatment differs

greatly from family-based therapy.

Many of these alternative treatments do contradict family-

based therapy and focus on the adolescent as an individual. The

parent role is seen as secondary, perhaps having only once-a-

month progress sessions or 15 min at the end of a session for

support. This puts parents in a confusing position of going from

the prime role in the recovery to taking a back seat and becom-

ing a supportive bystander.

There are no clear protocols as to how to end family-based

therapy and transition to alternative treatment, but generally

treatment termination is based upon agency/institutional agree-

ment. Thus, it is recommended that at the outset of family-

based therapy treatment, the explicit limits of the program be

communicated to parents. Should there be an “inability on part

of the family to mobilize weight gain,” it may be beneficial for

teams to meet with parents to discuss progress and to reevaluate

the fit of family-based therapy for the patient and family

(Woodside, Halpert, & Dimitropoulos, 2015, p. 368).

Exemplar. Justin was a 16-year-old male who frequently exercised to burn calories and restricted his caloric intake,

although his weight loss had not yet put him in the diagnostic

criteria for anorexia nervosa. Family-based therapy was imple-

mented for about six sessions, or a month and a half, but his

weight loss continued. After a lengthy discussion during clin-

ical rounds and with Justin’s parents, it was decided that Justin

would try adolescent focused psychotherapy. Justin’s parents

found this helpful and less stressful as sessions were individual

for Justin and collateral sessions for parents were infrequent.

However, over time, Justin’s parents began to struggle with

their lack of knowledge about what Justin was saying in ses-

sions as well as how to deal with Justin continuing to make his

own meals separate from the family. This, in fact, led to con-

flict as his parents would attempt to try to implement aspects of

family-based therapy despite no longer following this treat-

ment model. Justin’s parents struggled to be supportive of Jus-

tin’s “self-directed change” (Fitzpatrick et al., 2010, p. 35).

They felt they could not watch their child struggle in front of

them while they did, in their words, “nothing,” especially after

recalling the importance of parental involvement in family-

based therapy treatment.

Family-Based Therapy Expectations of Parents

Research on adolescent interventions for eating disorders

recognizes that the involvement of parents in treatment

improves the chances of recovery (Godart et al., 2012). Parents

are no longer considered to be part of the cause of eating dis-

orders, instead they are seen as part of the solution. However,

Scarborough 93

family-based therapy can place high demands on already

exhausted parents and the pressure to implement the treatment

and monitor their child may prove to be daunting. There is a

responsibility and pressure for parents to follow the recom-

mended treatment, regardless of how taxing it may be, and

failure may be seen as caused by the parents’ inability to carry

out the treatment. In addition to caring for their ill child, parents

face external pressures when engaging in treatment.

Time and Finances

In family-based therapy, the expectation is that the entire family

will attend treatment sessions. For parents, this may mean tak-

ing time off work every week (Plath, Williams, & Wood, 2016).

A study of caregivers with a loved one above the age of 18

diagnosed with an eating disorder found that 40% of caregivers reported having high (>21 hr per week) face-to-face contact

with their child, most of which was spent giving emotional and

nutritional support (Raenker et al., 2013). Given the recom-

mended family-based therapy model, it can be assumed that the

time demands on caregivers of an adolescent include signifi-

cantly higher face-to-face contact and support with their child.

This leaves little time for parental self-care and preservation as

well as time for other children or other aspects of living.

In family-based therapy, parents are expected to take charge

of their child’s weight restoration and interruption of symptoms

(i.e., exercising, vomiting, and restricting). Parents are often

spending more time preparing meals, waiting hours over these

meals for their child to finish, and monitoring their child if there

is compulsive exercise or other harmful behaviors (Findlay

et al., 2010). A recent study by Månsson, Parling, and Swenne

(2016) identified that parent directive tasks for family-based

therapy include having the child stay home from school, having

all meals with a parent, and not allowing the child to exercise or

vomit. While parents who could implement these tasks had

children who gained weight more quickly, the time required

to do these tasks, coupled with the emotional turmoil that par-

ents experience while intervening, is significant.

If parents are to intervene and effectively interrupt eating

disorder symptoms, it may be required that the child be

removed from school and a parent take a leave of absence from

employment (Hillege, Beale, & McMaster, 2006). The finances

lost by taking time off work, gas mileage, and parking, com-

bined with (for some parents) needing to buy additional high

energy items (i.e., homogenized milk, boost-plus drink, and

high-calorie granola bars) can create added stress on parents

during an already challenging time. Single parent families may

need a longer duration in family-based therapy treatment,

meaning a longer duration spent in financial strain with only

one income (Lock, Agras, Bryson, & Kraemer, 2005).

ExemplarMegan was a 14 year old with a diagnosis of anor-

exia nervosa purging subtype. She had purging symptoms via

vomiting and excessive exercising. Her family consisted of her

father who worked as a car mechanic, her mother (Susan) who

worked at a grocery store, and two siblings aged 16 and 12.

Given the severity of Megan’s difficulties, Susan took a leave

of absence from work to be able to prepare all her meals and

provide supervision postmeals. Megan was also removed from

school at the beginning of treatment while her parents

attempted to refeed her.

During a session, Susan was tearful when explaining that

because she was not working, their family budget could not

accommodate soccer for her other two children. The siblings

were reportedly very angry and blamed Megan. The agency

was able to provide funding for the two children to attend

soccer; however, Susan stated that she was not sure whether

she or her husband had the energy or time to drive each child to

their soccer games while also being present for Megan.

Megan’s dinner would often take several hours to complete,

going well into the time when soccer would begin. When dis-

cussing if other parents of the soccer team members would be

able to bring the children to games, or if their father could take

over a meal role, Susan explained feeling guilty that all her

time and her husband’s was spent on Megan and that the other

two children were feeling neglected.

In the end, the siblings did not enrol in soccer. The siblings

were encouraged to continue to attend family-based therapy in

order to express their own frustrations and have their voices

heard; however, they often stated that they did not wish to

attend as they had other activities and homework they would

rather spend their time on than go to therapy.

Relationships

It is well-documented that eating disorders create tension and

challenges in family relationships (Gilbert, Shaw, & Notar,

2000; Highet, Thompson, & King, 2005; Hillege et al., 2006;

Honey & Halse, 2006). The demand family-based therapy has

on parents is exacerbated by potentially neglected relationships

with other family members. Maintaining relationships with

family members and friends is overshadowed by the reality

of the illness as well as the family-based therapy treatment and

its requirements. In family-based therapy, the whole family,

including siblings, are required to attend treatment, and family

vacations are often cancelled while the eating disorder beha-

viors are addressed and weight is restored (Gilbert et al., 2000).

These changes that affect the whole family can lead to resent-

ment, particularly between siblings, which adds another stres-

sor that parents need to manage.

Parents living together report that stress and strain increases

in their marriage (Hillege et al., 2006). This is a particularly

impactful reality of treatment, given that successful family-

based therapy requires parental unity and consistency. The

maintenance of the marital relationship and effective commu-

nication is crucial for successful treatment, yet time spent on

the couple relationship becomes less frequent. Parents are

under pressure to focus on creating consistent parenting proce-

dures and supervision of the child with an eating disorder.

Parents also report isolation from others (Treasure et al.,

2001). While relationships outside the home may offer addi-

tional support and respite for parents, making time for outside

relationships is difficult. In addition, parents report that many

94 The Family Journal: Counseling and Therapy for Couples and Families 26(1)

outside individuals, including extended family members, do

not completely understand the illness, and feeling stigmatized

from community members is well-documented (Ebneter, Lat-

ner, & O’Brien, 2011; Griffiths, Mond, Murray, & Touyz,

2015; Mond, Robertson-Smith, & Vetere, 2006; Stewart, Keel,

& Schiavo, 2006; Stewart, Schiavo, Herzog, & Franko, 2008).

This may be particularly difficult for single parent families who

are tasked with refeeding without support from an immediate

partner.

ExemplarIn the case of Megan’s family, there were many

reports of relationship difficulties and struggles beyond the

siblings’ resentment of Megan and the time and attention she

received from her parents. Susan (Megan’s mother) often felt

that she was alone in the refeeding, despite her husband being

available at breakfast and dinners as well as on weekends.

Susan spoke of how her husband was the sole income earner

and was unable to wait for Megan to complete her breakfast as

time spent waiting for her meal to finished would make him

late for work. At dinnertime, Susan’s husband was often

exhausted from his job as a mechanic and would become short

and angry with Megan when she would not comply with her

meal. Susan felt this caused more stress in the family and in

their marital relationship.

When discussing how to create time to connect with her

husband, Susan struggled. Even in the evenings, it was difficult

to connect as Susan was sleeping in her daughter’s room

because Megan would exercise in the middle of the night.

Planning couple evenings out was also a struggle. Extended

family lived out of province and Susan’s friends really did not

understand the seriousness of the illness and how to support

Megan.

Susan continued in isolation refeeding her daughter with

great difficulty. The therapist recommended that Susan call the

agency and speak with a clinician when she was struggling,

feeling isolated, or just needed to vent. Often, after hours,

Susan would leave voice messages explaining the difficulties

she had that day.

Megan did regain weight to a healthy range and later ses-

sions were focused on repairing relationships within the family

with the clinician using emotion focused family therapy tech-

niques. This required additional sessions beyond those outlined

in manualized family-based therapy.

Parenting Adjustment and Eating Disorder Resistance

Family-based therapy requires that parents monitor all meals

for the ill child in order to achieve weight gain. For many

parents, this poses a challenge since adolescence is generally

a time of autonomous exploration, yet treatment requires that

parents put autonomy development on hold for their child’s

health. Parents have to learn a new way to discipline and raise

their adolescent. For some parents, the struggle is how to parent

a child whom they no longer recognize. For example, Treasure

et al. (2001) noted how an introverted and worrisome child had

turned into having a volatile personality with “violent mood

swings” (p. 345).

Many parents find it difficult to differentiate what is normal

adolescent behavior and what is distress caused by the eating

disorder. For this reason, parents struggle to determine how to

discipline their child’s (at times) violent or abusive reactions

(Honey & Halse, 2005). Due to these reactions, parents may not

challenge or set boundaries for their child’s behaviors and are

often described as walking on eggshells around the adolescent

(Gilbert et al., 2000; Highet et al., 2005). Siegel (2010) noted

that when parents experience intense emotions, such as fear,

they may lose their innate caregiving knowledge. For example,

the fear of reintroducing a challenging food item that may

result in severe distress in their child may lead a parent not

to introduce the food at all (Stillar et al., 2016). For parents, the

pressure to push their child to eat resisted foods, or a higher

volume of food, may prove to be too difficult and produce fear

in parents. In family-based therapy where parents are to func-

tion as nursing staff, it is almost impossible for them to do so

without becoming emotional. In fact, this is what makes the

task challenging. It can be particularly hard for parents to

remain focused on refeeding when their child is threatening

self-harm or suicide.

Eating disorder treatment can also be a lengthy process

lasting from 6 to 12 months. Parents are faced with the strug-

gles of mealtimes, often 6 times a day, that are frequently

accompanied by distressing behavioral and mood changes. Par-

ents are the target of the child’s verbal and at times physical

backlash (Treasure, 2010). Kyriacou, Treasure, and Schmidt

(2008) found that comorbid behaviors combined with the

child’s rejection of help contribute to caregiver strains.

A study by Coomber and King (2013) found individuals

with an eating disorder underestimate the level of burden that

their loved ones experience. While for other illnesses, parents

may receive some response of appreciation for the sacrifices

they have made, in the case of eating disorders this is often not

the norm. This consistent lack of appreciation from the child,

and in fact more of a negative response to parental efforts,

contributes to parents doubting their role in their child’s treat-

ment. This leads to a greater chance of disillusionment with the

recommended treatment and a higher risk of burnout.

ExemplarLeona was a 13-year-old female diagnosed with

anorexia nervosa. Her parents described her as a child

that never yelled and never needed to be disciplined.

However, once the family began family-based therapy,

Leona became extremely violent, hitting her head on the

table and screaming at her parents during mealtimes. Leo-

na’s parents struggled to discipline her. They were unsure

whether disciplining Leona would be viewed as punish-

ing her for a symptom she could not control. Leona’s

parents continued to ignore the violent outbursts, but

when she began to threaten suicide, her parents stated

they could not continue to push her to eat high-calorie

meals. Despite Leona admitting to the clinician that she

was not suicidal and it was a desperate emotional reac-

tion, her parents began to collaborate with Leona around

mealtimes in order to prevent the hostile environment at

Scarborough 95

the dinner table. This collaboration led to continuous

weight loss as Leona took control of her meals, knowing

that her parents were fearful of challenging her.

Discussion

Although family-based therapy is a promising treatment for

adolescents diagnosed with an eating disorder, many factors

still need to be explored in terms of clinician barriers and

parental challenges that make this treatment difficult to imple-

ment. As stated by Rhodes, Baillie, Brown, and Madden

(2005), “given the establishment of the efficacy of the

[Family-Based Therapy], there is now a need for researchers

to turn their efforts to the question of how it can be improved”

(p. 400). By acknowledging these potential difficulties,

researchers and clinicians can create better supports for parents

in the treatment process.

The feasibility of resolving the barriers discussed in this

article is challenging. Additional finances for agencies are dif-

ficult to come by which affects proper training and supervision

for family-based therapy clinicians. For parents, a major issue

is what they can realistically give up without creating excessive

financial hardship. Agencies could potentially implement alter-

native session hours that are more in line with parent work

hours, but this requires agency staff to adjust their personal

lives and family responsibilities.

It would be useful for clinicians to frankly discuss with par-

ents the realities of life while in treatment and what they may

have to give up. As parental motivation is necessary for family-

based therapy, it is of importance to explore with parents what

could be demotivating to adopting this therapy model. Clini-

cians need to acknowledge the pressures and challenges that

parents will face in family-based therapy and have a clear dis-

cussion with parents on how to best support them through these

challenges. Making this a mandatory part of the initial clinical

assessment could be useful in starting the dialogue about chal-

lenges and how to problem solve issues as they arise. It may also

be beneficial for researchers to focus on how clinicians can

discuss these challenges with parents without shame or blame

and while maintaining hopefulness in the treatment.

Clinicians would benefit from supervision during family-

based therapy practice to uncover the ways in which their own

anxieties and judgments may impede them from implementing

the treatment. Supervision may also help with the transitioning

between treatments should there be a nonresponse to family-

based therapy. Agencies may benefit from implementing clin-

ical rounds that are focused specifically on the difficulties with

implementing family-based therapy, discussing specific cases

and problem-solving around these identified barriers. This

would help clinicians to remain true to the manualized model

of family-based therapy and to discuss key aspects of family-

based therapy that they struggle to implement rather than sim-

ply not applying the recommended tasks. This is also a more

cost-effective way to provide supervision.

The impact of the financial, relational, and emotional pres-

sures on parents is important for future research to explore. It is

also important to examine how parental experiences affect the

implementation of family-based therapy and long-term results.

By doing so, the field can better understand the challenges

parents face and how improvements could be made in order

to prevent dropout, parental burnout, and helping to combat the

potential chronicity of the illness.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

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