Monday, December 2, 2013

UCED's Treatment Approach for Adolescents with Eating Disorders

For the past couple years, there has been a lot of research going into, and professional debate regarding, the appropriate treatment of adolescents with eating disorders. Eating disorder treatment, and the mental health field in general, is a hard field when it comes to finding concrete answers as to what is the best approach for treatment. In general, the focus is on identifying empirically/research supported treatments, and then using clinical judgement and skill to identify what will work best for a particular individual.

Recently, most of the focus in treatment of adolescents has been on Family Based Treatment (FBT), which is also known as Maudsley Method. Lock and LeGrange are the main forces behind FBT here in the US, and there are ongoing trials continuing to assess this treatment approach. The mindset behind the approach is keeping adolescents at home, rather than sending them to inpatient/residential treatment centers. Treatment centers certainly have their benefits and are needed in some cases, but our stance here at UCED is that every adolescent (and adult) should first be able to try outpatient treatment at home, prior to being sent to an inpatient/residential program.

One of the major tenets of FBT is the idea that parents know how to feed their children. If you go back in the history of the understanding of EDs, unfortunately, you will find a lot of blame on parents and families. The field as a whole no longer has this attitude towards families, but some long-held beliefs are hard to get past. Fortunately, FBT has shown that many adolescents can get better at home, with their families. However, as with any therapeutic approach, one size does not fit all.

Our approach with adolescents is to first give the teenager a chance to show they have the motivation to get better on their own. So, first we give them the opportunity to make healthy choices regarding food, with the support of their parents. A surprising number of teenagers actually will choose to get better without invasive intervention--a testament to the maturity of these young men and women, and their awareness that the ED is not serving them well. Because adolescents live at home and are supported primarily by their parents, in addition to friends, we involve parents in therapy frequently; typically every other session, although some teenagers choose to have their parents involved in every session. This approach, which teenagers typically are not thrilled to hear about initially, allows us to avoid the risk of the ED "splitting" the treatment team and the parents. Fortunately, most teenagers quickly realize family therapy isn't THAT BAD and come to accept it pretty quickly. (Sometimes parents end up disliking it more than the teenagers!)

If, with this structure, the teen remains unable to do what he/she needs to do in terms of food and activity, we transition to more of an FBT approach, which provides the parents with much more say in what the child is eating and doing. This is a tough transition for some teenagers, as the last thing they want is for parents to tell them what to do! However, on the flip side, this can provide motivation to do what they need to with food, so they can regain some control. This approach is often difficult for parents because they find themselves feeling pulled to "go easy" on their teen, which unintentionally ends up as negotiating with the eating disorder and allowing it to get away with ED behaviors. Therefore, parents need a lot of support in supporting their teens during this phase of treatment. Fortunately, there are a number of resources for parents in this situation; some include:

Finally, there are some teenagers whose ED is so deeply entrenched that inpatient/residential treatment is what is needed. Fortunately, there are very solid adolescent treatment programs in the US, many of which use the FBT approach. At that point, we will help facilitate the teen's admission to a treatment program, and provide ongoing support for the family, as there is still work to be done to make for a successful transition back home.

It is terrifying to have a teenager with an eating disorder. Parents spend a lot of time blaming themselves and trying to figure out what they did wrong. Eating disorders are not so simple as to be caused by one thing, including parents and families. But, by working together, the teen and parents can rid the family of the eating disorder, and strengthen their bonds. 


  1. I wish I would have gotten better outpatient treatment as a teen. I think it could have possibly saved me several hospital and inpatient/residential stays. Of course that was 15 years ago. I was pretty stubborn as a teen, as I would assume many teens are. I'm curious to know how you help teenagers get to a place where they are willing to let their parents have some of the control over food.

  2. Krista, it comes down to a couple things, I think. One is helping the parents identify what matters to the teenager. Although EDs make it seem like teens no longer care, and they certainly will say that directly, reality is they do still care about something. I find myself frequently saying to parents, "Where's your power? Use your power." For some, the power is that the teen doesn't want to go to treatment, and so they will accept the parent's support. For others, it is other things in their life that they want but can't have if they are sick. For a small subset of teens, they simply will not accept the parental support, and they fight tooth and nail. In my experience, that is where the need for a higher level of care comes in. Second, I fight to find the healthy part of the teenager (or adult). I'm pretty sure almost everyone with an ED, if not everyone, has some part that wants to get better. I seek to talk to that part of the person, and to have that part respond to me. Even if only 1% of the person wants to get better, it is still 1% and that is something to grab onto.