Category: Adolescent

United we stand, divided we drop out.

4/12/2013

In my recent talk for ANZAED, I spoke about the need for clinicians to study what they do. To measure our clinical outcomes to see if what we do, whatever that is, is helpful.

A recent paper published in IJED did a little bit of that and more. The paper by The Redleaf Practice's Director of Family Therapy, Dr Stuart Murray, and The Redleaf Practice's Research Fellow, Scott Griffiths (and some other guy named le Grange) looked at the importance of collegial alliance when working in FBT. This is something that we have written about before in a somewhat provocative way.
In looking at the article a few things jump out at me. One of the most important things to me is that
1) patients gained weight significantly in the 15 sessions the study covered
2) patients achieved significant thinking change in 15 sessions.
As Director of The Redleaf Practice, I am really pleased of these results (that were not really the point of the study).
3) Most change was achieved early. Those early sessions need to focus on behaviour change.
4) Neither Body Weight or EDE-Q score (which measures the thinking component of the eating disorder) predicted drop out. To me this indicates that "severity" of the eating disorder should not be a factor in offering FBT or not.
5) The alliance between clinicians was pretty stable. Either the team members were collaborating at the beginning or they never did. FBT still polarises.
6)Collegial alliance was correlated with drop out. If you want families to stay in a treatment program you need a unified team from the get go.
7)Collegial alliance was correlated with cognitive change (but not weight change). That is an interesting finding. The paper hypothesises that having a united therapy team, as well as united parenting team may help the patient feel more secure and this is helpful in changing cognitions. The teams, parenting and clinical need to be seen to be bigger than the eating disorder.
Why is alliance not correlated to weight change. Maybe because parents are not distracted by ideology that can divides teams (my way is the right way etc) because they simply focus on getting their child well. Maybe clinicians should just focus on that.
CT

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The model or the CLINICIAN: Who comes first?

18/11/2013

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Last week I was asked by the Australian and New Zealand Academy of eating Disorders and by the National Eating Disorders Collaboration lead a discussion on what are the core competencies for someone working in the field of eating disoders. As part of that I gave a presentation entitiled "The Model or The Clinician - Who comes first?" I have attached a link to a PDF of the slides here.

I thought I might just provide some context for some of the slides so it makes some sense.

We start with a brief review of the evidence base in the eating disorders (along with one of my favourite quotes from Christopher Hitchens "What can be asserted without evidence can also be dismissed without evidence".

Slide 3 reminds us we do have Clinical Practice Guidelines to direct us, as well as a more recent Cochrane review and also (slide 4) great review by Bulik (up to 2005) and then Hay (2005-20013). Both published in International Journal of Eating Disorders.

Slide 5 suggests there is the strongest evidence for FBT in the treatment of adolescents with anorexia nervosa, but Slide 6 reminds us that that data (for full recovery - which is the standard to which I hold myself) indicates full remission for 50% of patients. (i.e. it's good but 50% ain't great).

Slide 7 & 8 makes similar point for CBT for BN. Good data suggesting good outcome for most, but again about 50% of patients remain symptomatic at end of treatment. There are also other treatments that are helpful for BN and BED, such as Interpersonal Therapy or DBT. The weight of evidence suggests however a first line treatment for BN should be CBT.

Slide 9 covers adult AN, where our results are poor. Most treatments get about 20% of patients to full remission, and get a substantially higher number to partial remission. 10,11, 12 summarise the latest study from Germany - the ANTOP study. This study again found that the type of treatment (a manualised psychotherapy or CBTE) didn't really matter in terms of outcome. Our treatment manuals aren't guiding us to what we should specifically do with adult patients in AN. I would point out however that the majority of the manuals focus on improving nutrition.

So we have some data to guide us on what may be helpful in the treatment of eating disorders. However, the question is how many practitioners are using the evidence base which suggests some empirically supported treatments exist.

Slide 15 was chosen not because the Tobin study is the best one indicating the Research Practice Gap, but because it has the coolest name (I know what you did last summer ... and it wasn't CBT) and it allowed me to put up a poster of SMG. There is a concerning "What Manual" with 21% of clinicians asked do they use a manual in the treatment of BN. I am more interested in the "flexible" user group, as this is where manual and clinician come together (maybe).

16 is on who uses manuals. Well when I here CBT, research focused and young I tend to think of my Doctor of Clinical Psychology and Master of Clinical Psychology students (some of who are pictured in the slide). When the first graduate the don't have the clinical experience, so should be sticking close to the manualised treatment where ever possible.

17 is some of the reasons people don't use manuals. I am most worried about those who don't know the manual. Slide 18 is an interesting study that indicated that even of those for whom CBT was their treatment of choice, few had formally being trained in the manual. ANZAED and the various state based training organisations must roll out training in evidence based treatment. I know Victoria have done this with FBT, as has NZ, but NSW is far behind.

RCT's dont exclude most patients - its an excuse we use when our results aren't as good as RCT. I have never met an eating disordered clinician who doesn't think they have the toughest patients that have all been excluded from RCT. The evidence generally suggests that treatments do disseminate if you use them.

Maybe our treatment models are "ignorant". I am thinking here of adult anorexia nervosa. Maybe drive for thinness or drive for control just doesn't cut it. I look forward to looking at the data coming out of neuropsychiatry labs like Walter Kaye's and the emerging research on Cognitive Remediation Training that may increase the outcomes for CBT.

The most common reason proffered for not using the Empirically Supported Treatment is that therapy is an art that should not be restrained by a cookbook. Surprisingly I agree with this to some extent. Mainly in the restraints that an RCT puts on the length of treatment. Maybe 40 sessions is not enough for adult anorexia (see the ANTOP studies weight graph that shows people keep getting better after treatment). Sometimes patients may need 30 sessions of FBT rather than stopping at 20 as the manual and RCT protocols suggest.

However, there are ideas in the manuals that help our patients. Our therapies need to reflect this.

As clinicians we need to remember that Evidence Based Practice is a three legged stool. Yes, one leg is Empirically Supported Treatments (our manuals). The other legs are clinical experience and also patients values and preferences.
Each of our camps tend to grab onto on leg of the stool and pull. The stool then looks a bit like a "hitting stick" (Slide 20) to beat people over the head with. Or as Phillipa Hay once wrote in response to our article "tyrannise" people with THE EVIDENCE.

However, as clinicians we need to however be aware of our own humanity and vulnerability to thinking errors - most importantly the confirmation bias (slide 21). This is when we do what we think works and collect evidence that it works and discount evidence it doesn't. This bias can lead us to do things that don't work continually, because we assume they do. It is this that, in my opinion, using manuals grounded in science helps us with.

You know I'm using a boring quote when I use a picture of a cute baby to keep the audience interested. I prefer the quote (from the book "Mistakes were made .... but not by me - which btw is going on my tombstone) about science being 'arrogance control'. Clinicians, and unfortunately I can't exclude myself here, can be some of the most arrogant people I now. We think we know that what we do is right and, if unchecked, our confirmation bias keeps it going.

Im not just bashing clinicians who wont use the evidence base. We need to be aware that as science evolves the evidence base will keep changing and we need to be ready to integrate new evidence into our formulations. For example the evidence for the cognitive behavioural model of BN is not as strong as I thought. I had selectively neglected a body of literature that indicates that dietary restraint may not lead to binge eating - although my clinical experience tells me it does. We all need to keep changing and adapting.

So, Im not bashing flexible manual users (which surprised some in the audience). Indeed I think I am one. The manual keeps me "anchored" to principles that are helpful. I try to integrate the concepts in the manual using my clinical experience - sometimes this is not the order the manual tells me. As clinicians we need to be aware of our tendency to drift into the latest clinical 'fad' or basing out therapy on the latest book we have read or workshop we have attended unless they have data to support them (ACT show me your data please).

Slides 24 & 25 are about the idea that maybe what we do is better than the manualised treatment. I feel all practitioners need to be accountable and to measure (and publish) their outcomes - this is the cornerstone of the generation of Practice Based Evidence. Be able to show what you do works. If it does - teach me what you do (make it disseminate-able).

We finish with the photo's of me cooking a BBQ, Jamie Oliver and Heston Blumenthal. I suggest manuals are a bit like cookbooks (which some take as a criticism). I can't cook. For me to cook chicken pizza - you need to give me a McCain's frozen Pizza that has all the ingredients included with strict instructions on what to do (including remove the plastic, turn on the oven to 180 degrees, place on a tray in the oven, leave in for 25 mins etc. Detailed step by step instructions. Heston may prepare a chicken pizza for you. It wont have chicken, pizza base and may be served as a gas - it is art, but it is not chicken pizza. Jamie however, has some instructions for chicken pizza, He includes a chicken and a pizza base. He can add to that base whatever he likes that might make it better. He doesn't need to be told when to remove the pizza from the oven - he just knows (he could tell you when to though). He uses the key ingredients in an understandable manner. He adds to the recipe in a way as guided by his experience, but his chicken pizza can be replicated by those who want to. When it comes to the treatment of our patients, I think Jamie serves as a model that integrates clinician and model.

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A Discharge Letter to Anorexia

25/3/2012

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A Discharge Letter to Anorexia

MFBT can be challenging for many families, who in implementing the required interventions to guide their child to recovery, may experience distress at how the necessary firmness of interventions may impact upon familial relationships. A family I recently worked with repeatedly raised concerns over whether the course of treatment would damage their relationship with their daughter. In this particular instance, the anorexia coerced their daughter Mary to repeatedly threaten their relationship, stating that if her parents didn’t back off she would forever hate them and never speak with them again. This understandably caused considerable distress for Mary’s parents, who decided to make some tough decisions which their daughter might not like, but which ultimately would save her life.

At the end of treatment, this is the discharge letter Mary wrote to the anorexia.

Dear Anorexia

GOODBYE! All you did to me was push away my loved ones and loose my true self. I was beautiful inside and out, but with you in my life I had doubt. You were one of the worst things that have ever happened to me. I know to never be your friend again. I lost myself, I just wasn’t me. But now that you are no longer a part of my fantastic life, and I realize the strength of love and life, and how anorexia tears people apart and love brings them together.

The pain I experienced is indescribable, I had no control and it was scary. I have been so unlucky to experience anorexia, but there have also been some of life’s lessons learned. I have learned to always look at the positive side of things. I have learnt that you only live once, so live life to the full. I have learnt family is what will save you any day and every day. I have learnt that sometimes you may feel like giving up, but giving up is never an option. I have learnt that in life you should try smile every minute of the day, laugh until you wet yourself, and love like there’s no tomorrow. I have learnt that life’s journey is tough but with friends and family beside you it is possible to pull through it. Having YOU ANOREXIA RUIN MY LIFE has made me realise how important it to live everyday.

I have learned that nobody is perfect, everyone is individual and beautiful in their own way so don’t judge yourself against others, because you’re as perfect as it gets. I’d like to say I hate you for everything you damaged! I don’t ever want to see your ugly face again. I suggest you NEVER EVER come back to visit me or my beautiful family, because it is bloody proven that my family can beat anything in life no matter how difficult, we just put our hearts and minds to it. So I ban you from coming anywhere near me, my family or friends. Life without you is worth living. You made me hurt so so much that I am scarred. Although the memories are painful, I don’t mind looking back on them to say I will never go there again! GOODBYE ANOREXIA you are ugly, selfish, hurtful, painful, and damaging and you make me feel sick! I am Mary and I am cured, I choose to love my family, friends and myself. You’re no longer present in my life. You do not exist! That’s right I said you do no longer fucking exist!

I am now stronger more beautiful and happy. I love my life! I love my family. Without my family I would also not exist. You kept me going. You kept my heart beating. You are irreplaceable. I cannot thank you enough for understanding. I know I have hurt you but I am deeply sorry. Because when you hurt, I hurt. When you cry, I cry. When you laugh, I laugh. When you smile, I smile. So I say lets smile because life is a treasure, but the biggest gift of all is that we have each other. Thank you for being my family!

To finish this letter my last statement will be GOODBYE, GOODBYE Anorexia! YOU ARE NO LONGER A PART OF ME.

From Mary (Officially cured from Anofuckingrexia)

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Is Maudsley Family Based Therapy the right treatment for you?

16/2/2012

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By Chris Thornton - Clinical Director of The Redleaf Practice
and Dr. Stuart Murray - Director of Family Therapy at The Redleaf Practice
The learned doctor says to the family of the young girl suffering from anorexia nervosa, "I'm not sure if Maudsley is the right treatment for you. I think individual therapy would be much better for you".

There may be many reasons that said learned doctor may say this to this patients family. Some of the most common ones will be; “we know that Maudsley doesn't work for everyone (and you are one of those)”; “you/your daughter is too old or to psychologically mature”; “anorexia is a chronic illness and is resistant to treatment so it is not logical that a family could renourish a starving child in the long term ( as hospital has often failed to do)”; “your daughter is not motivated to change”; “your daughter's eating disorder is too severe to be treated with family therapy”; “your daughter needs to be helped to separate for you and learn to make her own decisions”; and the less often expressed but implied - “your daughter has an eating disorder which means you have caused it by over enmeshment with your child; as it was your fault you can not be involved in fixing it.”

I'm sure that the learned doctor is not trying to practice in an uninformed or unethical way. They mean no malintent. It is just by behaving in an uninformed way, they are potentially depriving their patient of the leading treatment available for adolescents with anorexia. This is a potentially lethal mistake. In my humble opinion it is also unethical

“MFBT does not work for everyone”

Numerous reviews of the scientific literature have reported six Randomised Control Trials involving MFBT. These have indicated the clinical effectiveness of the treatment approach. The outcome data for this therapy is strong with around 70-80% of patients undertaking MFBT achieving a good recovery after 12 months and 90% recovery after 5 years (Lock et al. 2006).

Previously, one fair criticism was that MFBT had not been compared to an individual therapy that would be suitable for adolescents. This was rectified in 2010 when Lock et al (2010) published data that indicated that MFBT was superior to Adolescent Focused Therapy in terms of weight gain and change on the Eating Disorders Examination (a measure of eating disorder behaviour and cognitions) at end of treatment. MFBT was also superior in terms of full remission rates at both 6 and 12 month follow up.

That is between 70 - 90% of patients do well with MFBT, and MFBT seems superior to when the adolescent was treated in individual therapy. It is correct to say that MFBT won't work for everyone, it will however assist 70-90% of patients gets well. This compares favourably with the natural history of Anorexia Nervosa which shows a recovery rate of less than 50% at 5 years.

MFBT is, without question, the first line treatment of choice for an adolescent or child with anorexia nervosa. Any practitioner that recommends against it is giving you bad advice.

“MBFT will not work for your child because the Anorexia is too severe”

It is important to work out which families may do well with MFBT. We now have some data, based on one study, done by the originators of MFBT, that might help use science to answer some of the learned (but paradoxically, uninformed) doctors other criticisms.

The paper I'm looking at today is by Daniel le Grange et al (2112). This paper tries to break down the data and see if we can be guided in looking at which families MFBT may work best for. Previous studies have indicated that for greater weight change, patients with HIGH levels of eating related obsessionality did better with a longer, rather than a shorter course of MFBT. This makes sense as it is typically thought that the higher levels of obsessionality the more severe the patients anorexia. Single parent or non intact families also did better ( in terms of eating disorder psychopathology) with a shorter rather than longer course. This again makes sense as MFBT is difficult enough for "intact families" and single parent families are likely to need support over a longer period.

The most recent study found the following :

Again, patients with the MORE SEVERE ILLNESS DID BETTER WITH MFBT than AOT. Both patients with higher level of obsessionality and higher global EDE scores did better when treated with MFBT than in individual therapy at the end of treatment. In addition the presence of the binge-purge subtype of anorexia seemed also to do better at follow up when treated with FBT over individual therapy. This was not a significant result but is interesting because the presence of binge-purge behaviour is also an indication of the drivenness of the patient to lose weight (ie higher anorexic severity).

It did not matter as to how depressed you were, what your level of self esteem was, your level of self efficacy (of patient or parent), or BMI at beginning of treatment (although patients weights were above 75% of ideal body weight at the beginning of the study). There was no difference between treatment here.

This means that these variables, including markers of severity such as weight and depression, do not help us determine if MFBT or individual therapy would be better. MFBT should not be denied on these markers of “severity”.

Outcome in both treatment was worse if you had required an inpatient admission. Notably it did not mean that MFBT was less helpful if you had this marker of severity and is hence not a reason to note use MBFT as your first line treatment. Again in BOTH conditions older adolescents had a poorer level of remission of illness irrespective of the type of treatment. The same can be said for duration of illness. What these point to is the need for early and active treatment of the illness with the most effective treatment.

A common ‘learned Doctor” reason to not use MFBT is that the older adolescent, with their assumed greater maturity and insight may be more suitable to an individual approach (actually the studies authors of the current study predicted this). This data says that this is not the case. Age is not a factor in not choosing MFBT.

“You shouldn’t use MFBT because you can’t trust the research”

I have heard this said often as an argument to not use Evidence Based Treatments. It is tantamount to saying the data supporting MBFT is scientific fraud. Clinicians will often claim that the patients selected in the research studies are “not like my patients”. They usually sound very convincing, but I’m not sure how they know. What may not be openly discussed, is that in such cases the learned doctor may be (unintentionally) overlooking many years of international scientific and rigorous research, on the basis of an opinion with no scientific support. This advice may jeopardize your child’s well being.

The only way to work this out is to look at the exclusion criteria used in studies. In the study discussed above the exclusion criteria were: currently psychotic, dependent on drugs or alcohol, had diabetes or were pregnant, or had previously had MFBT or AFT. Patients were not excluded for common comorbid diagnosis such as anxiety, OCD, or depression. In my practice I would not engage in an active treatment for an eating disorder patients with psychosis or active substance issue. I would treat patients with diabetes and who are pregnant. Patients also had to be seen to be medically fit for outpatient treatment, which is entirely reasonable.

The patients in these studies are the same as the patients who present to an eating disorders clinic. There is no reason not to apply the scientific findings to your child.

“Individual therapy would be better for your child (... because it is your
fault she has it)”

If anyone can show me any data about an etiological role for families in anorexia I would be very happy to see it. Until then, I am going to keep putting it out there that families are not the cause of anorexia. To continue to hold this view restrains the treatment of anorexia. To the contrary, families are the single most effective resource in getting children well from anorexia.

To say that families cause or maintain anorexia is wholly uninformed. The presence of any life threatening illness naturally causes changes within family functioning, and anorexia is no different. Simply put, everybody in the family is effected by the presence of AN, and not just the patient. It can make some family members to feel guilty, others to feel angry, and it can often coerce us away from our normal instincts and relationships through fear of not wanting to elicit an anorexic backlash or exacerbate symptom severity. In a sense, the presence of anorexia, and the fear it sometimes elicits, can result in some families almost becoming used to the anorexic regime. To my mind, this a symptom of the anorexia which impacts the whole family, and does not mean that the family caused or is maintaining their child’s anorexia.

What strikes me is that it is impossible to address such family wide effects of anorexia in individual therapy. In my opinion, one of the reasons why MFBT is so effective is precisely that it relies on parental expertise. Nobody knows children better than their parents, nobody loves them more, and nobody will fight harder to save their life. Also, the changes brought about in MFBT (which include addressing the family wide symptoms) lead to lasting change because children live and exist in the context of their families 24/7. This is most certainly support by scientific research which shows that even after 5 years, 90% of children who undergo MFBT are still symptom free.

MFBT is most certainly a difficult form of treatment, and in many instances is one of the tougher challenges a family will face. However, this alone is not sufficient to dissuade people from commencing a treatment which although difficult, is highly effective in saving their child’s life. In my experience, every single family I have worked with has said during the course of treatment that the sacrifices and challenges involved in getting their child well pale into insignificance when considering the potential thought of their child not getting well.

“MFBT is only about weight gain and will not take into account the underlying psychological factors that have caused the anorexia”

Even if this was true, and MFBT was a only a vehicle for weight gain, this may not be a bad thing as weight gain and full nutrition is needed in recovery from anorexia. However, weight gain is necessary but not sufficient for recovery. Otherwise, hospitalisng patients and refeeding to normal weights would be curative. We know that it is not.

The idea that MFBT does not address adolescent issues that may be involved in maintaining the anorexia simply indicates that the maker of the statement does not have a rudimentary understanding of, and certainly no training in, MBFT. Phase 1 - agreed, it is focused on weight gain. Simply put, the magnitude of the potential medical crisis means that treatment is justifiably focused on weight gain, to reverse the features of starvation which trap many adolescents in long term anorexia. However, to achieve this weight gain there are usually some important changes that occur in the structure of families (such as everyone being present at meal times; health becoming a priority; sibling relationships are strengthened and parent relationships are empowered). Then in Phase 2 - eating is handed back to the adolescent and in Phase 3- adolescent issues are addressed. Repeat in phase 3 (and in practice it probably begins in phase 2) adolescent issues are addressed. It is just that these issues are addressed in an individual without a starved brain rather than prior to refeeding. I have done enough individual therapy with patients with a starved brain to recommend against it whenever possible.

Conclusion.

When we look at the data, there are very few reasons to suggest an individual approach over MFBT approach in the treatment of adolescent anorexia. MFBT needs to be the first line treatment as over 70% of families will have a good outcome with MFBT. Any advice to the contrary is, at best misguided, and is not based on the latest evidence. We do need some more information about extremely low weight patients, but overall, patients with high levels of severity do as well or better with MFBT. There does not seem to be any reason to not offer MBFT based on measures of “family dysfunction”. The initial goals of MFBT are weight gain, as they should be in the treatment of anorexia. The notion that MFBT is only about refeeding is misguided and shows a lack of training in MFBT. Lack of initial and ongoing training in Evidence Based Therapy in the eating disorders is a major problem which needs to be addressed as a priority.

with thanks to www.maudsleyparents.org

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United we stand, divided we drop out.

The model or the CLINICIAN: Who comes first?

A Discharge Letter to Anorexia

Is Maudsley Family Based Therapy the right treatment for you?

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