Family Therapy for the Teen with Bulimia Nervosa

A three-phase approach using family-based treatment may be a helpful option for adolescents with bulimia nervosa (BN), according to an ongoing study at the University of Chicago (Am J Psychotherapy 2003;57:237).

Still uncharted territory

Although much information is available about the causes and treatment options for adults with BN, much less is known about effective treatment for adolescents diagnosed with BN. For example, although cognitive behavioral therapy (CBT) and interpersonal therapy (ITP) have been helpful for adults, no clinical trials of CBT or IPT have yet been designed for teens.

Dr. Daniel LeGrange and colleagues at the University of Chicago have had good preliminary results with a family therapy approach for adolescents with BN.

There are several strong arguments for including the family in treatment of teens with BN, according to the researchers. For example, information about BN can be shared with the parents and their child, and issues about meals and the impact of the eating disorder on family relationships can be addressed. Additionally, the intrinsic denial of the alarming nature of bulimic symptoms makes many teens incapable of appreciating how serious the disorder may be. This makes it necessary for the parents to become involved to make certain that the teen gets adequate treatment.

A manualized approach for BN

Based on an earlier manual developed for family treatment for anorexia nervosa (AN), the researchers developed a manual for BN that reflects three clearly defined phases of treatment. Whereas in AN the first and main focus of treatment is empowering the parents to succeed in refeeding their starving daughter or son, the treatment focus for adolescents with BN is helping parents help their son or daughter regain control over eating and preventing the child from turning to binge-eating and purging. Just as in AN, it is only after the eating disorder has been successfully addressed that parents can hand control over eating back to their child.

Phase 1. Regulating food intake (sessions 1-10). In the first phase, treatment is almost entirely focused on the eating disorder, in order to enable parents to help their child to regulate eating and stop purging. A family meal with the therapist early in treatment starts the process of parental involvement, and lets the therapist directly observe the family’s interactions to eating. The therapist helps parents relieve their guilt, so they stop thinking that they caused the eating problem. The emphasis is on the positive aspects of parenting. Families are encouraged to work out for themselves how best to stabilize the bulimic child’s eating. The initial session also helps educate the family about the nature and challenge of treating bulimia, especially the secretiveness and shame associated with binge eating and purging.

Phase 2. Negotiating a new pattern of relationships (sessions 11-17). The second phase can begin once the patient has agreed to her parents’ demands that she normalize food intake and abstain from binge eating and purging, and when the therapist detects a change in the mood of the family (e.g., relief after taking charge of the problem). Although symptoms are the center of discussions, regular, stress-free meals are now encouraged. This second phase also marks the return of control over eating to the adolescent. Parents monitor eating but allow the teen to make her own food choices. Other family issues can now be brought forward for review.

Phase 3. Adolescent issues and termination (sessions 18-20). Once the patient maintains a stable weight and binge/purge symptoms have disappeared, the therapist and family work to establish a healthy adolescent or young adult relationship with the parents. In this relationship, the illness is not the center of attention. This stage also involves working toward increased personal autonomy for the adolescent, more appropriate family boundaries, and addressing the need for independence.

According to the authors, their manualized treatment approach is still in the preliminary stages, but family therapy for adolescents with BN may enable patients to recover without protracted outpatient treatment or hospital admission.