F.E.A.S.T's Around The Dinner Table forum

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JangledUSA
This popped up tangentially in another thread and I didn't want to hijack that thread so I started this one.

What I want to know:

By the book, FBT is 20 sessions.    

Who here has had FBT that stuck with the script 100% through 20 sessions and were discharged.

Has it ever happened outside the laboratory?
A dad.
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Christopher
The FBT manual explicitly states that it's not a script to be followed slavishly.
It leaves a lot of room for variation. In fact, the key feature of FBT -- that families are encouraged to work out for themselves how best to help restore the weight of their child with AN -- necessarily implies that each course of treatment will be unique.
Having said that, in the large clinical trial published in 2010, involving 60 patients and their families, each family was given exactly 20 sessions. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038846/?tool-pmcentrez 

The treatment was conducted generally on an out-patient basis, not in a laboratory.

In an earlier experiment with FBT, Lock found that many families reached full recovery with only 10 sessions.
 
There is a large body of research literature comparing manualized forms of treating psychological disorders with approaches that rely on flexibility and the intuition of professionals. Generally, manualized forms of treatment tend to be more effective. When therapists are free to rely on their intuition, rather than on empirically-supported manuals, the therapists tend to endorse erroneous ideas and outcomes tend to be worse, on average.
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JangledUSA
Thanks Christopher.

Mark Warren, in his talk asked everyone who had only 20 sessions of FBT to raise their hand. Not a single hand went up.

we've had between 25 and 30 sessions so far. and we are dealing with a case that was caught early and treated aggressively with FBT and without any cormorbid conditions. I don't know where we would be in the official manual - but I don't think we are following that protocol.

However. I would not mess with success.
A dad.
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breathingmomUSA
I've been curious about this too. I'm not questioning the the importance of manualization,  but anecdotally I don't know of a single family who has emerged "successful" from 20 FBT sessions or less.

On the other hand, I am not sure how success is defined. My daughter has been weight restored for many months, so I wonder if we would be counted as a success in terms of the criteria used for the large clinical trial. She is definitely a success in weight restoration, but in terms of being free from ED thinking and eating independently, she is not there yet. 
Daughter (16) diagnosed with AN at age 12 1/2. She's weight restored and eating freely.

Every worthwhile accomplishment, big or little, has its stages of drudgery and triumph; a beginning, a struggle and a victory. -Gandhi
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JangledUSA
I need to get a copy of the manual.

Does the 20 session model get you through phase 3? How can that be?

Another question I have.   Let's say I'm a data driven parent and after doing my research I decide that the way to go is the manualized version of FBT. Outside of a trial is there even a clinician that offers it?
A dad.
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Christopher
People, of course, have been debating endlessly what it means to be "recovered" from anorexia nervosa. In the FBT v. AFT randomised
clinical trial, the researchers used as their outcome measure 95% of expected weight for gender, age, and height, and an Eating
Disorder Examination (EDE) global score within one standard deviation of community norms. The EDE is a questionnaire that essentially asks the
person about eating-related thoughts and behaviors.

No outcome measure is perfect. But when the objective is to compare two treatment methods head-to-head (AFT versus FBT for example) it is necessary, as Lock and LeGrange did, to use the same standard when measuring outcomes in two groups. The experiment will only show which of two treatments is relatively more effective than the other, on average, using the particular standard involved.

It's not clear to me that if a young person is at 95% or 100% of expected weight, eating normally in such a way that weight is maintained, if an adult, or
increasing along the normal growth curve, if an adolescent, and has eating-related thoughts and behaviors within normal range, (even with some remaining issues), more meetings with an eating disorder professional would be either necessary or desirable. After all, it may be that at that point, the parents are able to continue helping the young person recover without the need for professional intervention, thereby minimizing financial cost and the disruption to the adolescent's and family's return to normal life that would be involved if there continued to be scheduled appointments with a professional.
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MarcellaUK
I heard Ivan Eisler, the grandfather of FBT, make a similar argument to that just made by Christopher about the dangers of prolonging treatment unnecessarily. As he pointed out, families need to be able to rely on their own strengths and not become dependent on a therapist.

That said I do think that it should be the family, gently guided by a reputable therapist if necessary, who decide when to stop treatment, when to step it up, when to tail off, not some insurance company or health board wedded to the idea of paying for as few sessions as possible.
Fiona Marcella UK
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JangledUSA
Where, outside of a Lock and LeGrange trial, could a parent find a clinician that follows the manual closely enough to replicate their results?

Or are most FBT therapist just winging it?

Not that that's necessarily a bad thing but if the results of their trials are not available to the masses then what is the use of pointing to those results when talking about FBT in general?
A dad.
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Minx67
We will be done in 20 sessions. Nearly there YEH!
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JangledUSA
Wow, that is really great, congratulations!   

You are seeing a private clinician, right?   (that is, you're not in a trial?)
A dad.
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Goingtobeatthis_AUS
We were in a trial but only had i think 14 sessions but did not stick to the script in that we did not complete stage 3 or even stage 2 by the time we got the visit 14. Our schedule was supposed to be weekly for 8 weeks, fortnightly for 8 weeks the monthly for last two months.
Having finished nowhere near the end has not necessarily been a bad thing as we feel pretty confident about finishing it ourselves and is nice not to have a definite timeline

Belinda Caldwell FEAST Executive Director. D 21 now well into recovery after developing AN in 2011. Inpatient 5 weeks, FBT and then just lots of time, love and vigilance.
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Christopher
Surveys in the U.S. and Canada indicate that fewer than 5% of eating disorder therapists offer what they describe as FBT, while
95% of providers use only treatments with little, if any, similarity to FBT. This is true even though FBT has the strongest base of evidence.
Part of the problem is that it generally takes several years for any new model for treating any illness to be accepted among the community of
clincians. There's a natural resistance to change; professionals feel most comfortable doing things they way they were taught in school, and
are often reluctant to accept different models of care, particularly those that are radically different from the status quo.  On top of that, FBT challenges many of the assumptions that many professionals hold dear about the nature of AN, of sufferers, and their families. This makes dissemination of FBT even more difficult.

 If you want a therapist who has been trained in the use of the FBT manual, there's a list of certified providers available at
http://www.train2treat4ed.com 
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JangledUSA
One thing that concerns me is that you can get "Certified" and listed on http://www.train2treat4ed.com  by taking a 1.5 day training and completing 25 hours of consultation.

I would be skeptical of replicating the results of a trial actually conducted by Dr Lock and Dr LeGrange using a therapist with a day and half of training and 25 hours of instruction.

Note that I'm not being dismissive or even mildly critical of ANY therapist who makes an attempt to offer FBT - I think it is outstanding that a therapist would get certified.


A dad.
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Christopher
Actually, Lock and LeGrange did not personally treat the patients who were involved in the study. Rather, they trained the therapists who
conducted the treatment. You can read the procedure at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038846/?tool=pmcentrez  (See section of
the paper entitled Patients and Methods/ Design) 
The reason for doing it this way was to see if FBT could effectively be disseminated. In other words, they took therapists with no
previous training in FBT, gave them a total of only 6 days of training in both AFT and FBT (presumably about 3 days of each, although the paper
doesn't say specifically how the six days was allocated between the two methods) Then those newly-trained therapists conducted the treatment. The success of the FBT group demonstrated that FBT can effectively be implemented by therapists who receive relatively minimal training, only about 3 days' worth.
This shows that the results easily can be replicated in the "real world."

As shown on the FBT website, http://www.train2treat4ed.com , the first 1.5 days is only the initial training period. After that, the therapist must receive additional supervision if he or she wishes to become fully certified.

FBT is not rocket science. I recommend reading the manual; it's really more a matter of simplifying our conception of anorexia nervosa, freeing the mind of
preconceptions, going about
treatment in a staged, or phased, approach, targeting eating behavior directly rather than hypothesized underlying causes, not getting distracted or discouraged, and being reasonably patient.
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JangledUSA
Very interesting, thank you - I did not know that.  

I still wonder where you could find a therapist who follows the 20 session guideline as outlined in the manual  - I would bet you lunch that few do.


A dad.
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Christopher
Certified FBT therapists probably offer 20 sessions. Thier names and addresses are at
http://www.train2treat4ed.com  Other than that, it all depends on how well-informed and
assertive you are in letting your provider know what you want, if you are in the U.S. and
have choice.
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LauraCollins_US
I think it is important to keep in mind that the manualized scenario is important just like dosages of medicine are important. It isn't that the dosage is meant to be magic and the only way to give the medicine but that one must compare apples with apples when testing a treatment. They have to test it out in a regulated way in order to see how it works. 

But just like any medicine, the clinician has to decide how much to prescribe, to what people, and in combination with what other treatments.

There is almost NO history of randomized controlled trials in eating disorders AT ALL. FBT is an exception. Eating disorder research is difficult in general mostly because of the problem of dropouts: very few eating disorder patients stay in trials (treatment is very difficult and as you get better you feel worse). Treatment that involves parents has fewer dropouts because it isn't just up to the patient's motivation and insight: parents will keep treatment going!
Laura (Collins) Lyster-Mensh
F.E.A.S.T. Executive Director
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Christopher
Laura and I have different perspectives on this issue. While she writes that the "clinician has to decide how much [treatment] to prescribe," my view is that parents generally should not defer to clinicians to make that decision. I think that ultimately parents need to decide for themselves, where possible, what kind of treatment is sought, evaluate whether it is helpful, and then observe for themselves what "dosage" seems to be correct, based on unique knowledge of their child and family.

Treating anorexia nervosa is not like treating some illnesses, where professionals have a wealth of scientific data to rely on when making treatment recommendations. With most illnesses, it is reasonable, therefore, for parents to defer to professional judgment, and in fact usually unreasonable not to defer. By contrast, other than manualized FBT, professionals are generally improvising when they treat anorexia nervosa in adolescent patients, with each professional tending to be operating using individual prejudices and biases, with very little empirical evidence for guidance. There isn't any reason to believe, however, that professional improvisation is superior to parental improvisation; in fact the best available evidence, including the data from the FBT studies, tends to suggest the opposite.

If the judgment of eating disorder professionals is so good, then why are so few using FBT? 

And if the clincians who do not use FBT, or routinely modify it, are so confident that what they are doing is good for their patients, why are they not coming forward and publishing data showing that they are able to achieve outcomes that are superior? I would think that if someone has developed a treatment model that is consistently supeior to FBT, we would have seen the data by now. 


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YogurtParfait_US
It is so important to always remember that "recovered" as a measure in some kind of study and what we, here, mean by the word recovered are two very different things.

I have been thinking back over our FBT, and probably we have had a dozen sessions between May and now ... so not at 20 yet ...

And, I have no problem with therapists modifying FBT to fit the patient. My daughter is 7. She doesn't need to do adolescent development at this point!!!

YP
"Hope is a wonderful thing ... but hope by itself is not enough. Hope is the reason to take action, to make a plan and then to change the plan when it isn’t working - over and over and over again if necessary." Hannah Joseph (Let's Feast Friday Reflection, "Just Keep Going," Friday, March 3rd, 2015)
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Colleen
Jangled, if I'm understanding your question, you're asking, "Why 20 sessions?"

Twenty sessions is some kind of benchmark in the insurance world.

And L&L are researchers.  They have to establish an exact protocol that can be replicated.  So they have to say, "Session 1 looks like this--scare the parents.  Session 2 is a meal in the office.  Sessions 3-X deal with refeeding.  Sessions X-Y hand over control.  And then we're done by Session 20."

I can tell you that having written a quilting book, I had to be exact on sizes.  I had to decide that everyone who makes that pattern from my book is going to cut their strips 2-1/4" no matter what the scale of the fabric or the intended purpose of the quilt.  That's the manual.  However, I don't teach that way in person.  I make it individual for each student in the class.  They'll all end up with successful quilts in the end, and if you saw them you'd say, "Oh, they are all the same pattern--but they are each one unique too."

I think of the '20 sessions' rule the same as a 2-1/4" fabric strip.  One choice of many right choices.  But when you are writing a pattern, you have to make just one choice.

Hopefully, in the end, you have a recovered kid, and the world can step back and look at all these kids and say, "Oh, I see.  They all recovered with the active help of their parents/families/spouses/partners. I see what they have in common (full nutrition, adequate weight gain, supervision, careful monitoring, gradual return of control, etc) and I can see that each situation is unique (16 sessions, 35 sessions, blended families, extended families, etc)."
Colleen in the great Pacific Northwest, USA

"What some call health, if purchased by perpetual anxiety about diet, isn't much better than tedious disease."
Alexander Pope, 1688-1744
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Emily
A very interesting discussion.  Jangled, I read the clinician's handbook while we were going through FBT treatment with our FBT-qualified therapist.  My reasons for doing this were that I like to be really informed when taking on something this important, and that it gave me an insight into what our FBT therapist was trying to achieve in our sessions - you know, sort of,"oh, that's why the FBT is asking/saying/doing that."  

I agree that 'recovered' may mean different things to different people - researchers, ED-educated parents and non-ED educated parents.  Then there's good old biological variation.  So, for a start some patients need to put on more kgs to get to WR than other patients.  Some parents take longer to 'get on the same page' as other parents, or they may take longer to learn to separate the ED from their child, or others take longer to have the courage to stand up to ED rages.  All of these things mean that weight will go on more slowly, hence recovery takes longer.  Then there's whether the patient's behaviour starts to change around WR, or does it take 3-6 months or longer after WR for positive behavioural changes to occur?  

Jangled, we were fortunate that in our city there were FBT-trained therapists working in the public health system.  We were fortunate because a) there were FBT therapists in our city, and b) the service was free.  They also happened to be the only FBT therapists in our city.  They used the 20 sessions as the basis for their treatment, but also allowed leeway for those patients and families who needed more sessions.  Also, as Christopher said, the properly accredited FBT therapists also participate in ongoing supervision.  The FBT therapists in our city were supervised by Kate Fitzpatrick from Stanford University.

Emily   xox
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nevermorED
Great thread! I would add that the FBT studies also showed good long term recovery (5 years out) after the 20 sessions. I think like with all illnesses the treatment is not the only ingredient for restoration to health- time and healing (dont forget maturation) happen too.
Perhaps the main reason people on this forum need more time is that the co-morbids are more common here. The silent ones are doing well and have no reason to post, or attend feast conferences?

Mom to recovered RAN daughter, now age 18
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LauraCollins_US
Well, Christopher, we agree and we disagree. As usual.

I believe clinicians have to make their best judgements on when and how to apply an approach. I also believe parents must decide how and when they will work with clinicians! FBT is not just a recipe in a book. It takes clinical skill in empowering parents and employing ALL the skills of a psychotherapist. They may stray from the manual for good reasons, or for bad ones.

Most families don't actually have a choice of clinicians and don't have unlimited latitude in how they work with any particular clinician. Most families are constrained in their choices by insurance, geography, money, national health system, or other issues. Those who are in a position to make choices can't design their clinician either: they have to work with that clinician in their particular set of skills and practices.

Some clinicians CHOOSE to work right out of the book because they believe that works best. Others stick to the book because they don't know what else to do - and do a poor job of it. It may be manualized but training and experience and supervision are also part of the approach.

Other clinicians stray from the book because they do not, essentially, believe in empowering parents or know how. Many clinicians adopt little pieces of various fashions in treatment but don't understand them. This sort of straying is the problem.

But painting ALL ED clinicians as somehow the same is just as silly as painting all parents with the same brush. Clinicians range from highly skilled and effective to completely incompetent and so do parents. I don't want parents to defer to clinicians just based on their title but I also don't want parents to treat clinical support as a dispensing machine. Families need and deserve good clinical help.

What we do best here in this community is empower and educate both parents and clinicians in how to work together and build our toolbox of skills. One of our failings, however, is a tendency to prescribe what worked for us as the only path, and what harmed us as the greatest hazard. My advice to all parents is to read widely, listen broadly, and make what will always be their own unique plan for success.
Laura (Collins) Lyster-Mensh
F.E.A.S.T. Executive Director
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WeNWinning
Excellent points Laura.  One added piece is that although a clinician works well with one family and situation, doesn't mean that they are skilled to work with all families/situations.  A lot of this has to do with comorbid conditions and other variables that the clinician might not have the training, experience or skill to treat.
WenWinning (formerly wenlow) - a Mom who has learned patience, determination, empathy, and inner strength to help her young adult daughter gain full remission after over a decade of illness and clinician set inaccurate weights
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Christopher
I'm not sure the standard number of FBT sessions (20) is merely for the convenience of researchers or the financial advantage of insurance companies. Instead, I think there is an important principle embedded there. Refeeding a loved one who is suffering from anorexia nervosa is a very unpleasant task. It is easy to want to delay the process, even procrastinate. Having a fixed number of sessions with a professional, determined in advance, helps to impose a sense of urgency and even a deadline. On the other hand, having no endpoint in sight makes it too easy to delay the process, while the anorexia only gets worse over time if not addressed as promptly as possible.

It's true that Phase 3 of FBT  involves issues of adolescent development, and is probably therefore not appropriate for younger patients. However, Phase 3  comes at the end, involves only 4 sessions (sessions 17-20), and is described in the manual as essentially optional.

Amoma, I don't know if the list of certified providers on http://www.train2treat4ed.com is complete. However, I do know that there are many eating disorder professionals who advertise that they are trained in FBT who have actually not gone through the training program run by Lock and LeGrange. That doesn't necessarily mean they are unqualified. It seems reasonable for a parent to ask the provider where he or she was trained.
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