Development of a Manual for Bulimia Nervosa
Based on our manual for AN, family-based therapy for adolescent BN also proceeds through three clearly defined phases. Whereas in AN the initial and main focus of treatment is the empowerment of the parents in order to succeed in refeeding their starving adolescent offspring, the focus in treatment for adolescents with BN is for the parents to assist their adolescent offspring to regain control over her/his eating and to prevent her/him from engaging in binge eating and purging. As is the case in the treatment of AN, it is only after the eating disorder has been successfully addressed that the parents will hand control over eating back to the adolescent. It is also at this point that the family will begin to discuss regular adolescent issues. Below is a brief outline of the three phases of treatment for BN.
Phase I: Regulating the Patient’s Food Intake (Sessions 1-10)
In Phase I, treatment is almost entirely focused on the eating disorder in an attempt to mobilize the parents to help the adolescent regulate eating and prevent purging. A family meal early on in treatment usually serves to start the process of parental involvement. This provides the therapist with an opportunity for direct observation of the familial interaction patterns around eating. The therapist reviews with the family the medical and psychiatric dangers of the illness to increase their anxiety in order to encourage the parents to take action, rather than be critical and angry. Also, the therapist externalizes the illness from the adolescent to relieve parental guilt in the service of empowerment. This permits the therapist to disclaim the notion that the parents have caused the eating problem and instead to express sympathy for the parents' plight. The therapist makes careful and persistent requests for united parental action directed toward assisting the adolescent to reestablish healthy eating which is the primary concern at this point of the treatment. In addition, the therapist directs the discussion in such a way as to create and reinforce a strong parental alliance around their efforts at reinforcing healthy eating in their offspring, on the one hand, and align the patient with the sibling sub-system, on the other. This phase is characterized by attempts to absolve the parents from the responsibility of causing the illness, and by complimenting them as much as possible on the positive aspects of their parenting of their children. The attitude of the therapist should reflect something like the following sentiment: "You have been successful with raising your children to this point in your personal lives. We hope to encourage the application of the skills acquired in these earlier successes in helping you resolve the current eating problem with your daughter." This emphasizes the therapist's role as a caring and concerned expert, rather than an authoritarian force. Finally, families are encouraged to work out for themselves how best to stabilize their bulimic child's eating.
Phase II: Negotiating for a New Pattern of Relationships (Sessions 11-17)
The patient's surrender to the demands of the parents to normalize food intake, abstinence from binge eating and purging, and a change in the mood of the family (i.e., relief after having taken charge of the eating disorder), signal the start of the second phase of treatment. Although symptoms remain central in the discussions, regular meals with minimum tension are encouraged. The second phase also marks the return of control over eating back to the adolescent. In this phase, the parents monitor eating, but they allow the adolescent to make his/her own food choices so as these choices are not influenced by the eating disorder. In addition, all other issues that the family has had to postpone can now be brought forward for review. This, however, occurs only in relationship to the effect these issues have on the parents in their task of assuring regular eating in the absence of bulimic symptoms.
Phase III: Adolescent Issues and Termination (Sessions 18-20)
Phase III is initiated when the patient maintains a stable weight and binge/purge symptoms have abated. The central theme here is the establishment of a healthy adolescent or young adult relationship with the parents in which the illness does not constitute the basis of interaction. This entails, among other, working towards increased personal autonomy for the adolescent, more appropriate family boundaries, and the need for the parents to reorganize their life together as parents of a more autonomous adolescent.
Clinical Issues and Summary
Despite its prevalence, BN in adolescents has received little attention in the literature. Consequently, our knowledge of the clinical presentation of BN in this population is in its infancy, and the systematic evaluation of effective treatments is nonexistent. In this report, we argue that a manualized family-based treatment with proven efficacy for adolescent AN might similarly benefit adolescents with BN. We provided a rationale for family-based treatment for BN and described the outline of this treatment approach. Albeit tentative at this stage, but similar to our family-based treatment of AN, we found that a manualized version of family-based therapy for BN can be developed in a way to provide a consistent, focused and directed intervention in both a clinical and research environment. Our BN manual was developed having followed several stages: 1. We reviewed the few existing descriptions of family treatment for BN; 2. reviewed the literature comparing AN and BN; 3. reviewed and adapted our AN manual given the former steps; and 4. piloted this revised manual with several cases prior to its implementation in a controlled treatment study. This manualized version of family-based therapy is currently being evaluated in a randomized NIMH clinical trial at The University of Chicago where we are comparing family-based treatment with a manualized individual therapy.
At this early stage of our work with the families of bulimic adolescents, it is quite clear that the parental involvement in BN should be somewhat different from that for AN. BN poses a unique challenge to the adolescent and her parents, and greater flexibility around addressing the eating disorder symptoms appears to be necessary. This, and some other significant differences between these two eating disorders such as secrecy and shame in BN vs. resilience and even pride in AN, as well as the developmental stage of the adolescent have all been accommodated in the manualized treatment described in this paper. It is clear though, that this new treatment has promise in alleviating bulimic symptoms in adolescents and that parents can be a helpful resource in therapy.
In summary, family therapy for adolescent BN might enable recovery without protracted outpatient treatment or hospital admission. Successful restoration of an adolescent bulimic's health, through the return to healthy eating habits and the absence of binge eating and purging, depends in large part on the parents' ability to assist their child in much the same way as the parents would have in the case of AN. However, controlled treatment studies are required to evaluate the efficacy of this treatment before we can comment more definitively about the role of the parents in the recovery of BN.
- Le Grange, Danieal, Lock, James, & Maureen Dymek; Family-based therapy for adolescents with bulimia nervosa; American Journal of Psychotherapy; 2003; Vol. 57; Issue 2.
Reflection Exercise #8
The preceding section contained information
about family-based therapy for adolescents with bulimia nervosa. Write three case study examples regarding how you might use the content of this section
in your practice.
Peer-Reviewed Journal Article References:
Fitzpatrick, S., MacDonald, D. E., McFarlane, T., & Trottier, K. (2019). An experimental comparison of emotion regulation strategies for reducing acute distress in individuals with eating disorders. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 51(2), 90–99.
Lowe, M. R., Marmorstein, N., Iacono, W., Rosenbaum, D., Espel-Huynh, H., Muratore, A. F., Lantz, E. L., & Zhang, F. (2019). Body concerns and BMI as predictors of disordered eating and body mass in girls: An 18-year longitudinal investigation. Journal of Abnormal Psychology, 128(1), 32–43.
Luo, X., Nuttall, A. K., Locke, K. D., & Hopwood, C. J. (2018). Dynamic longitudinal relations between binge eating symptoms and severity and style of interpersonal problems. Journal of Abnormal Psychology, 127(1), 30–42.
Online Continuing Education QUESTION 22
According to Le Grange et al., what should be the focus of Phase II of treatment for a bulimic client? Record the letter of the correct answer