No More Secrets
Shame, secrecy, and isolation are some of the most challenging aspects of battling Bulimia Nervosa (BN). People with bulimia nervosa may be able to eat normally around their family and friends, but experience out-of-control episodes of binge eating and purging while they are alone. Unlike those with Anorexia Nervosa (AN), teens with bulimia nervosa are often of average weight, so they may appear to be healthy and normal despite being very medically and psychologically ill. For these reasons, many people suffer from bulimia nervosa for months or years before anyone else finds out that they are ill. The hidden nature of bulimia nervosa exacerbates the guilt and shame that the sufferer feels and perpetuates the binge-purge cycle.
Leaving Guilt Behind
A relatively new form of treatment for adolescent bulimia nervosa called Family-Based Treatment (FBT-BN) helps to alleviate the shame, secrecy, and isolation that so often afflict sufferers by encouraging families to discuss and address the illness openly. From the very first session, the clinician emphasizes that parents are not to blame for their teenager’s illness, nor is the teenager herself to blame for having it. This simple but powerful intervention absolves all members of the family of the guilt they have likely been carrying. Once they are freed from their guilt and self-blame, parents and teens can begin working together to overcome bulimia nervosa.
A Brief History of FBT
Family-Based Treatment (FBT), also known as the Maudsley Approach, was first developed to treat adolescent Anorexia Nervosa (AN), and was later adapted for patients with bulimia nervosa. FBT for bulimia nervosa shares many of the same principles and strategies that make FBT for anorexia nervosa so innovative and effective. For example:
- It is a directive, practical, solution-focused approach.
- Parents are considered the experts on their child and are viewed as their child’s greatest resource in recovery.
- The clinician works as a consultant to the parents and empowers them to create a united front against the eating disorder.
- Stopping life-threatening eating disordered behaviors is the first priority of treatment, while other issues are put aside until later in treatment.
While FBT-BN is rooted in the same fundamental assumptions as FBT-AN, there are some key differences in the two treatment approaches which reflect the different symptoms and experiences of teens with BN vs. those with AN. For example, AN is an ego-syntonic illness, which means that the patient is often unable to recognize that she is ill and may perceive food restriction and weight loss as positive things. Thus, FBT-AN empowers parents to take charge of their teen’s food intake and require her to gain weight, given that she cannot make these decisions on her own. In contrast, teens with BN are usually well aware that they have a problem with eating, and they typically present with at least some motivation to stop bingeing and purging. For this reason, FBT-BN empowers parents to work collaboratively with their teenager to interrupt her binge eating and purging.
This article explains Family-Based Treatment for Adolescent Anorexia Nervosa.
A Three-Phased Approach
FBT- Bulimia Nervosa involves the entire family and progresses through three distinct phases, with a total of approximately 20 sessions over the course of 12 months.
In Phase I, the therapist empowers the parents to work collaboratively with their teenager to help her establish regular eating patterns and stop bingeing and purging. Re-establishing normal eating typically involves prioritizing balanced, nutritious family meals and supporting the adolescent in eating appropriate portions. The patient’s siblings are encouraged to provide support to their ill sister or brother during and after meals. During this phase, many families find it helpful to engage in family activities, such as walks outside or playing board games, immediately after meals in order to distract the patient from her compulsion to purge.
Phase II begins once the patient is eating normally and is no longer engaging in binge/purge symptoms. At this point, the therapist assists the parents in helping their adolescent eat on her own in an age-appropriate way. This is accomplished gradually, with the teen earning independence little by little as she gains mastery over her eating and demonstrates the ability to refrain from binge eating and purging.
Once the teenager is able to eat normally on her own without bingeing and no longer requires post-meal support, Phase III begins. The goal of Phase III is to help the patient establish a healthy identity and get back on track with typical adolescent development. At this point, any problems that are interfering with normal adolescent development are identified and addressed. For example, if the teenager is experiencing body dissatisfaction, depression, anxiety, or problems with her peers, these issues may be brought to the family’s attention and treated.
Better Outcomes for Patients
Clinical research has demonstrated that FBT-Bulimia Nervosa is significantly more effective than individual therapy at helping patients recover from bulimia nervosa. It has an edge over CBT-A (cognitive behavioral therapy for adolescents with bulimia) because improvements come sooner. Keeping families fully informed and actively involved in their teenager’s treatment helps to create a full circle of safety around the patient, ensuring that she has the practical and emotional support she needs for every meal, every day. In addition, keeping the first phase of treatment focused on stopping eating disorder behaviors, and putting other problems aside until the last phase of treatment, appears to be more effective than doing the reverse. Given that extreme dieting, binge eating, and purging pose serious medical risks, it makes intuitive sense to halt these behaviors as soon as possible.
Many patients are surprised to learn that their psychological problems, such as depression or anxiety, often improve or even disappear once their eating patterns have normalized. In fact, a recent study demonstrated that adolescents receiving FBT for bulimia nervosa experienced improvements in both depression and self-esteem, comparable to the improvements made by adolescents receiving CBT. However, for some patients, other disorders or mental health concerns persist even after their bulimia has been resolved. In these cases, continued therapy targeting the other condition may be recommended. Fortunately, teens often feel better equipped to deal with their other mental health problems once they have successfully overcome bulimia.
To learn more about an adolescent’s experience of FBT, listen to this podcast.
Le Grange, D. & Lock, J. (2009). Treating Bulimia in Adolescents: A Family-Based Approach.
Le Grange, D., Crosby, R.D., Rathouz, P.J., Leventhal, B.L. (2007). A Randomized Controlled Comparison of Family-Based Treatment and Supportive Psychotherapy for Adolescent Bulimia Nervosa. Archives of General Psychiatry, 64(9): 1049-1056.
About the Author:
Dr. Sarah Ravin is a licensed psychologist in private practice near Miami specializing in Family-Based Treatment for adolescent eating disorders. Dr. Ravin writes an award-winning blog on eating disorders and related topics in psychology and serves as a professional advisor for FEAST: Families Empowered and Supporting Treatment for Eating Disorders.
Updated – 10/2019