Families Helping Families Helping Families Fight the Families Fight the

Beast Beast

Roxanne E. Rockwell M.A. Roxanne E. Rockwell M.A. University of California, San DiegoUniversity of California, San Diego

Department of PsychiatryDepartment of Psychiatry858 212-1831 858 212-1831

rrockwell@ucsd.edurrockwell@ucsd.edu

OverviewOverview

Finding the right treatmentFinding the right treatment Standard levels of careStandard levels of care Overview of innovative treatment Overview of innovative treatment

modelsmodels Intensive Family Therapy (IFT)Intensive Family Therapy (IFT) Multi-Family Intensive Therapy (MIFT)Multi-Family Intensive Therapy (MIFT) Multi-Family Day TreatmentMulti-Family Day Treatment

Clinical ReflectionsClinical Reflections

Where to Start Where to Start ______________________________________________________________

Making a planMaking a plan Evaluation: Evaluation:

pediatrician/family doctor: r/o medical issuespediatrician/family doctor: r/o medical issues ED expert for a formal diagnosis: AN, BN, ED expert for a formal diagnosis: AN, BN,

EDNOSEDNOS Diagnostic limitationsDiagnostic limitations

Education:Education: Reputable websites and books (see references)Reputable websites and books (see references) Medical journalsMedical journals Long standing debate on treatment: i.e Long standing debate on treatment: i.e

parentectomyparentectomy Familiarize yourself with different treatment Familiarize yourself with different treatment

philosophiesphilosophies

Standard Levels of CareStandard Levels of Care______________________________________________________________

Outpatient (OP): Outpatient (OP): The patient lives at home The patient lives at home 1-2 hour long sessions 1-2 hour long sessions

weeklyweekly

Intensive Outpatient Intensive Outpatient Program (IOP):Program (IOP):

The patient lives at home The patient lives at home Attends sessions for 3-5 hrs Attends sessions for 3-5 hrs

per day per day May eat 1-2 meals at the May eat 1-2 meals at the

clinicclinic

Day Treatment (DT): Day Treatment (DT): The patient may spend 6-10 The patient may spend 6-10

hours at a treatment facility hours at a treatment facility May have most or all meals May have most or all meals

at the clinic (5-7 days)at the clinic (5-7 days)

Partial Hospitalization (PHP): Partial Hospitalization (PHP): The patient lives part of the The patient lives part of the

time at the hospital and part time at the hospital and part of the time at homeof the time at home

Inpatient (IP): Inpatient (IP): The patient is hospitalized, The patient is hospitalized,

usually for medical usually for medical stabilizationstabilization

May or may not include May or may not include therapytherapy

Residential: Residential: Full timeFull time Long-term residence at a Long-term residence at a

specialized treatment facility specialized treatment facility Few weeks to several Few weeks to several

monthsmonths

New Treatment ModelsNew Treatment Models______________________________________________________________

A WHOLE family approach to the A WHOLE family approach to the treatment of EDstreatment of EDs ParentsParents SiblingsSiblings Friends/RelativesFriends/Relatives

Incorporating “treatment” for family Incorporating “treatment” for family members is essential for strength members is essential for strength against the EDagainst the ED

New Models of Family New Models of Family Based CareBased Care

______________________________________________________________Intensive Family Therapy (IFT): Intensive Family Therapy (IFT): The entire family attends a 5 day intensive The entire family attends a 5 day intensive

program for education, treatment planning and a program for education, treatment planning and a family based treatment “jumpstart.”family based treatment “jumpstart.”

Multi-Family Intensive Week (MIFT):Multi-Family Intensive Week (MIFT): Child or adolescent attend day treatment Child or adolescent attend day treatment

program with separate parent and child tracksprogram with separate parent and child tracks Including some or all meals/snacks on site with Including some or all meals/snacks on site with

parent and coachparent and coach

Multi Family Day Treatment Multi Family Day Treatment Standard day treatment with 10 +hrs per week Standard day treatment with 10 +hrs per week

of multi-family sessions.of multi-family sessions.

Intensive Family TherapyIntensive Family Therapy

IFT was first started in November IFT was first started in November 2006 at UCSD2006 at UCSD

Rather than a controlled manualized Rather than a controlled manualized protocol it was an evolving concept protocol it was an evolving concept with variations tailored for individual with variations tailored for individual familiesfamilies

30+ families completed the program 30+ families completed the program through Dec 2010through Dec 2010

Of the first 19 families, a follow up Of the first 19 families, a follow up study was conducted.study was conducted.

5 Day Intensive Family 5 Day Intensive Family TherapyTherapy

______________________________________________________________ One family at a timeOne family at a time All family members All family members

attend including attend including siblingssiblings

Emphasis on family Emphasis on family involvement in involvement in treatmenttreatment

Aimed at limiting or Aimed at limiting or preventing inpatient preventing inpatient and/or residential and/or residential treatment for treatment for children and children and adolescents when adolescents when possiblepossible

Numerous Numerous treatment treatment components components including:including:

family based therapyfamily based therapy systemic family systemic family

therapy therapy ContractingContracting psychoeducationpsychoeducation parent coachingparent coaching carers sessionscarers sessions individual individual

psychotherapypsychotherapy cognitive behavioral cognitive behavioral

therapies. therapies.

TIME MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

Adol Parent Adol Parent Adol Parent Adol Parent Adol Parent

9:00 -10:00 Peds appt off site

Treatment Planning:Clinical Team Meeting

Family Therapy: Psychoeducation

Family Therapy: CBT III

10:00 -

11:00

Family Therapy: Behavioral

Family Therapy: Psychoeducation: Family Therapy: CBT II Family Therapy: Behavioral

Family Therapy: Systemic

11:00 -

12:00

Family Therapy: Cognitive Behavioral Therapy I Family Therapy: Meal

Family Therapy: PsychoeducationArt

Parentgettin

g lunch Medication Follow up

12:00 - 1:00

Family Therapy: Meal

Lunch on Own

Individual: Meditation/ Relaxation

Couples Therapy:Parent

Coaching Lunch on Own

Finish

ArtParents leave to get lunch

1:00 - 2:00 Family Therapy: Communication Skills Break

Family Psychotherapy: Contracting

Family TherapyFamily Meal

2:00 - 3:00

Individual Therapy: patient

Parent Coaching

patient DBT Carers Family Therapy: Contracting

Family TherapySystemic Art

Parent Coaching

3:00 - 4:00

Psychiatric Evaluation

Individual therapy: patient

Individual Therapy: Father

Individual

Therapy: Mother Family Therapy: Systemic

Individual Therapy

Carers

Final Contracting

4:00 - 5:00 Contracting

Discharge Planning

IFT Follow Up StudyIFT Follow Up Study

For the first 19 families, a follow up study For the first 19 families, a follow up study was conducted.was conducted. An Innovative Short-Term, Intensive, Family-Based

Treatment for Adolescent Anorexia Nervosa: Case Series (Rockwell, R.., et al, European Eating Disorders Review, In Press 2011).

Patients 68% (n=13) were diagnosed with AN-restricting

type, 11% (n=2) were diagnosed with AN purging type, 11% (n=2) with ED NOS. bulimia nervosa (n=1) feeding-disorder not otherwise specified (n=1).

IFT Follow Up StudyIFT Follow Up Study Self report data were obtained on all

patients and families between 52 days and 738 days (mean=278) post treatment.

Admission IBW ranged from 69.3% to 99.1% (mean = 84.3%, SD = 8.7).

Follow-up IBW ranged from 84.4% to 134.6% (mean = 99.3%, SD = 11.8).

All but one patient reported a sustained gain in IBW post treatment (mean =15.0, SD = 14.5).

 ID DX Onset # Mo IP Age IBW% Discharge Medication Days FU FU IBW% change IP @ FU

1 AN 12 0 15 69.3 escitalopram 10mg/day 297 84.4 15.2 NO

2 AN 12 0.5 13 72.0 Olanzapine 3.75mg/day, Citalopram 10mg/day 285 112.1 40.1 NO

3 AN 13 8 17 74.2 Citalopram 40mg/day, olanzapine 5mg/day 255 91.4 17.3 NO

4 AN   0 17 77.2 None  393 107.1 29.9 NO

5 AN 12 2.5 13 77.4 Risperidone 0.25mg bid 182 107.6 30.2 NO

6 AN/BN 12 4 15 80.2Sertaline 100 mg/day, olanzapine 5mg/day,

trazodone 25mg qhs prn 66 89.1 8.9 NO

7 AN 14 0 16 80.9 None 190 89.6 8.7 NO

8 AN 11 1 15 82.3 Olanzapine 2.5mg/day 451 90.2 7.9 NO

9 AN 14 0 16 82.6 Aripiprazole 2.5mg/day 738 134.6 52.0 NO

10 NOS 9 0 10 83.5 olanzapine 1.25mg/day 87 98.2 14.7 NO

11 AN 11 0 12 86.7 None 52 99.5 12.8 NO

12 AN 11 2.5 16 87.9 None 157 92.6 4.7 NO

13 AN 11 0 12 88.9 Fluoxetine 30mg/day 129 100.2 11.3 NO

14 AN 13 0.75 15 89.0 None 591 102.6 13.6 YES

15 AN/BN 9 0.2 17 93.2 None 241 86.6 -6.6 NO

16 AN 15 0 16 94.9 None 353 97.2 2.2 NO

17 NOS 17 0 18 98.0 Fluoxetine 10mg/day 58 101.0 3.0 NO

18 NOS 13 0 16 99.1 Fluoxetine 40 mg/day 486 103.8 4.7 NO

  Mean 12.3 1.1 15.0 84.3   278.4 99.3 15.0  

  SD 2.0 2.1 2.1 8.7   193.8 11.8 14.5  

Multi-Family Based Multi-Family Based TreatmentTreatment

______________________________________________________________ Dare and Eisler (2000) adapted FBT to Dare and Eisler (2000) adapted FBT to

use as part of a multiple family day use as part of a multiple family day treatment programtreatment program

Eisler trained the UCSD staff on his multi Eisler trained the UCSD staff on his multi family methods which were then family methods which were then integrated with IFT methods to develop integrated with IFT methods to develop Multi-Family IFT.Multi-Family IFT.

Aim to help families share, develop skills Aim to help families share, develop skills and become motivated together, united and become motivated together, united against the eating disorder.against the eating disorder. especially helpful with unskilled, reluctant, or especially helpful with unskilled, reluctant, or

defeated parentsdefeated parents

UCSD Multi Family IFT UCSD Multi Family IFT (MIFT)(MIFT)

UCSD began a MIFT in December 2009UCSD began a MIFT in December 2009 To date approx 25 families have participatedTo date approx 25 families have participated Groups range from 2-4 families per week.Groups range from 2-4 families per week.

Program runs 1x per month on averageProgram runs 1x per month on average Children, adolescents and young adults have Children, adolescents and young adults have

participated.participated. Ages 9-21 yrs. with their families. Ages 9-21 yrs. with their families.

Diagnoses include AN, BN, OCD, MDD, EDNOSDiagnoses include AN, BN, OCD, MDD, EDNOS Families attend during all of the Maudsley Families attend during all of the Maudsley

phasesphases Tailored to meet the family where they are at in the Tailored to meet the family where they are at in the

processprocess

MIFT Program MIFT Program ComponentsComponents

Individualized Psychiatric evaluationsIndividualized Psychiatric evaluations Group based family therapyGroup based family therapy Adolescent only groupsAdolescent only groups Parent only groupsParent only groups Live parent coaching during mealsLive parent coaching during meals

Lunch 5 days plus daily snack(s)Lunch 5 days plus daily snack(s) ContractingContracting PsychoeducationPsychoeducation Discharge planningDischarge planning

Multi-Family IFT (MIFT) Multi-Family IFT (MIFT) ScheduleSchedule

  MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

9:00-9:30Orientation

Family Based Therapy SNACK at 10:15

Family Based Therapy Family Based Therapy

SNACK at

10:15

Family Based Therapy

SNACK at 10:15

9:30-10:00

10:00-10:30

Family Based Therapy

Physiological Effects of Starvation and

Medical Consequences of

ED

10:30-11:00 Contracting Introduction Contracting Contracting

11:00-11:30

11:30-12:00Parents get food and

Teens join adol DT for Vitals

Parents get food at 11:30 Teens Body

Image with adol DT

Parents get food at 11:30 Teens join

DT for Vitals

Med Checks if needed

Parents get food at 11:30

Body Image with DT

Parents get food at 11:30

Teens join DT for Vitals

12:00-12:30Multi Family Meal Multi Family Meal Multi Family Meal Multi Family Meal Multi Family Meal

12:30-1:00

1:00-1:30 BREAK BREAK BREAK BREAK BREAK

1:30-2:00 Parent Coaching

Teens Anxiety Reduction with

adol DT

SNACK at 2:00ish

Parent Coaching

Teen Self Esteem and Acceptance with DTSNACK at 2:00ish

PsychoeducationSNACK 2:00ish

Parent Coaching

Teens Anxiety Reduction with DT SNACK at

2:00ish

Parent Coaching

Teen Expressive Arts

with DT SNACK at

2:00ish

2:00-2:30

2:30-3:00

3:00-3:30 Review and GoalsFamily Based Process,

Activity and Goals Contracting

Family Based Process,

Activity and Goals

Final Discharge Planning and

Process 3:30-4:00 Combined Multi Family Groups

4:00-5:00        

Multi-Family Week: A Closer Look at Day 1

Prior to families arriving for the program we conduct a clinical interview by phone and obtain previous medical and psychological records.

To the best of our ability we provide families with ages of other families attending their week.

Monday morning follows FBT guidelines for session 1

Individual introductions Family perceptions of the problem and its

development Exploration of the effect of anorexia on the family

Multi-Family Advantage: Families in attendance will have varying levels of education

Multi-Family Week: Multi-Family Week: A Closer Look at Day 1A Closer Look at Day 1

Parents are instructed to leave and Parents are instructed to leave and bring back an appropriate meal for bring back an appropriate meal for their loved one. their loved one.

Multi-family advantage: some parents some parents decide on introducing “feared foods” day 1 decide on introducing “feared foods” day 1 and others rely on “safe foods.” No and others rely on “safe foods.” No recommendation is made either way. recommendation is made either way.

In my experience, the multi-family meals In my experience, the multi-family meals may have the most weight in terms of may have the most weight in terms of parent learning.parent learning.

Multi-Family Week: Multi-Family Week: A Closer Look at Day 1A Closer Look at Day 1

Multi-Family MealMulti-Family Meal Families are given free choice to position Families are given free choice to position

themselves however they like during the themselves however they like during the first meal. first meal.

They tend to lean towards sitting in They tend to lean towards sitting in individual family clusters. individual family clusters. At times it seams that they want to be At times it seams that they want to be

isolated in case “the beast” comes outisolated in case “the beast” comes out However, by the end of the week it is typical However, by the end of the week it is typical

that families sit together and feel comfortable that families sit together and feel comfortable amongst each other whether the beast shows amongst each other whether the beast shows itself or not. itself or not.

IFT vs. MIFT:IFT vs. MIFT:pros for one family may be cons pros for one family may be cons

for anotherfor another One family One family Individual ServicesIndividual Services Undivided family Undivided family

attentionattention Exposure to a variety Exposure to a variety

of treatmentsof treatments CBT, DBT, etcCBT, DBT, etc

Adolescents may feel Adolescents may feel alone in the processalone in the process

Low risk of Low risk of adolescents “picking adolescents “picking up ED tricks”up ED tricks” Parents of younger kids Parents of younger kids

often concerned with often concerned with thisthis

Several familiesSeveral families Limited individual timeLimited individual time Exposure to different Exposure to different

forms of the illness forms of the illness Exposure to different Exposure to different

stages of the illnessstages of the illness Adolescents don’t feel Adolescents don’t feel

alone in the processalone in the process Families may be Families may be

exposed to symptoms exposed to symptoms that they may not have that they may not have otherwiseotherwise Self harm, SI, Self harm, SI,

drugs/alcohol abusedrugs/alcohol abuse

Conceptual Framework of Conceptual Framework of Multi-Family InterventionsMulti-Family Interventions Seeing things in multiple perspectivesSeeing things in multiple perspectives Seeing things from different perspectives Seeing things from different perspectives

through the multiple family group through the multiple family group activitiesactivities

Connecting families together to fight Connecting families together to fight against social isolation and against social isolation and stigmatizationstigmatization

Generate more resources of the families Generate more resources of the families through the expansion of social support through the expansion of social support networknetwork

Advantageous Therapeutic Advantageous Therapeutic Processes in Multi-family Processes in Multi-family

GroupsGroups Coping improvementCoping improvement Stigma reversal Stigma reversal Social network constructionSocial network construction Communication improvementCommunication improvement Crisis preventionCrisis prevention Treatment adherenceTreatment adherence Anxiety and arousal reductionAnxiety and arousal reduction

Multi-Family Day Multi-Family Day TreatmentTreatment

Multi-family day treatment at UCSD Multi-family day treatment at UCSD evolved during August 2010 when evolved during August 2010 when several local MIFT families several local MIFT families requested extended care following requested extended care following their 5 day program. their 5 day program.

The program incorporates a variety The program incorporates a variety of therapeutic approaches (CBT, of therapeutic approaches (CBT, DBT, individual) with a solid family DBT, individual) with a solid family based core. based core.

  Monday Tuesday Wednesday Thursday Friday Saturday

9:00-10:00Breakfast Breakfast Breakfast Family Breakfast Breakfast Family Breakfast

10:00-10:30

Process Group

Process Group Process Group Process Group Process GroupMulti--Family

Process10:30-11:00

Diary Card

Homework/ Vitals

Diary Card

Homework/ Vitals

Diary Card

Homework/ Vitals

Diary Card

Homework/ Vitals 11:00-11:30

Nutrition Group11:30-12:00 Homework /Vitals

12:00-1:00 Lunch Lunch

Lunch

Lunch

Lunch

Family Lunch

1:00-1:30 Process Group Process Group Process Group Process Group

Exp. Arts/Movie Activity and

Weekend Planning 1:30-2:00

Body Image/Anxiety Reduction/

Mindfulness

Family Skills Review/ DBT hmwk

Chain AnalysisAnxiety Reduction/

Mindfulness2:00-2:30

Weekend Planning

2:30-3:00 Goals/Snack Goals/Snack Goals/Snack Goals/Snack Goals/Snack

3:00-3:30 Break

Family Skills Training3:30-4:00

Multi Family Group4:00-4:30

4:30-5:00

Multi Family Day Multi Family Day TreatmentTreatment

Clinical Reflections:Clinical Reflections:What works and what What works and what

doesn’t with multi-family doesn’t with multi-family groupsgroups

Works Parental agreement on the Parental agreement on the

method or at least both method or at least both parents open to trying parents open to trying something new.something new.

Adolescents that react with Adolescents that react with tears, silence or yelling.tears, silence or yelling.

Loving yet firm parentsLoving yet firm parents Parents willing to reflect on Parents willing to reflect on

boundaries.boundaries. Parents who research Parents who research

treatments, read and ask treatments, read and ask questions.questions.

Parents who take care of Parents who take care of themselves.themselves.

Parents willing to move out Parents willing to move out of their comfort zone.of their comfort zone.

Doesn’t Dragging a co-parent that does

not want to participate. A violent adolescent/young

adult. Co-occurring substance abuse Young adults no longer

supported financially or otherwise by parents.

Contracting Siblings who support the ED

rather than their sibling. Abusive relationships in the

family. Belief that the problem is the

individuals and that they need the treatment.

When one or both parents have disordered eating that they are unwilling to confront.

Whether or Not to MixWhether or Not to Mix Groups and Ages? Groups and Ages?

Pros of mixingPros of mixing Cons of mixingCons of mixing

SummarySummary

Each family with a loved one Each family with a loved one suffering from an eating disorder suffering from an eating disorder must find their own unique path to must find their own unique path to recoveryrecovery

A WHOLE family based approach is A WHOLE family based approach is essential for treatment of children essential for treatment of children and adolescentsand adolescents

New treatment models can offer New treatment models can offer families education and strategies to families education and strategies to fight the illness through unityfight the illness through unity

ReferencesReferences______________________________________________________________

Lock, James and Le Grange, Daniel. Lock, James and Le Grange, Daniel. (2005) (2005) Help Your Teenager Beat an Help Your Teenager Beat an EatingEating DisorderDisorder. NY: Guilford Press.. NY: Guilford Press.

Lock et al. (2001) Lock et al. (2001) Treatment Manual for Treatment Manual for Anorexia Nervosa: A Family-based Anorexia Nervosa: A Family-based ApproachApproach. NY: Guilford Press.. NY: Guilford Press.

Maudsley Parents Maudsley Parents http://www.maudsleyparents.org/http://www.maudsleyparents.org/

UCSD UCSD http://eatingdisorders.ucsd.edu/http://eatingdisorders.ucsd.edu/ F.E.A.S.T. F.E.A.S.T. http://www.feast-ed.orghttp://www.feast-ed.org//