A recent, and important article has just been published in the Journal of the American Academy of Child and Adolescent Psychiatry by Le Grange et al. The paper is the results of a Randomised Controlled Trial of Family Based Treatment (FBT) and Parent Focused Treatment (PFT) done at Royal Childrens’ Hospital in Melbourne.
FBT is probably well known to most in the field. PFT is a variant of FBT which is very interesting. There is a manual available and an outline in the book Family Therapy for Adolescent Eating and Weight Disorders edited by Loeb, le Grange & Lock. In PFT the adolescent only has a brief session with a clinic nurse who weighs the patient, assesses behaviours and medical stability, and provides “brief supportive counseling”. The weight and other information is then communicated to the therapist and parents who then have a 50 minute session. That is, the adolescent is not in the room with the therapist and parents for the treatment. That of course also means that ‘the eating disorder’ is not in the room either. Given the level of distress that is often experienced in FBT, I can see advantages of this. I do however wonder about the poor adolescent who has received just 15 minutes of supportive counseling in a time of acute distress.
The content of the PFT sessions is described as similar to an FBT session, just without the distraction of anorexia in the room (or the opinion of the adolescent). Siblings are not involved at all. The patient only meets the therapist briefly in the initial and final sessions. There is no family meal in PFT – anxious and conflict avoidant therapists I can hear you cheering.
The sample was aged about 15, mean BMI was 82% (weight restored being 100%). Illness duration was less than a year. About 85% of patients completed treatment in both groups.
At the end of treatment – remission rates were higher in the PET group (43.1% v 21.8%). Note that both rates seem low and the FBT rate seem particularly low, but in line with another Australian study Madden et al (2015). At 6 month follow up the results still favoured PFT. Interestingly FBT remission stayed steady whilst PFT had decreased slightly to 39%. At 12 month follow up there was no difference in remission as PFT had dropped further to 37% and FBT increased to 29%. It is interesting that PFT results declined slightly and FBT increased over the 12 months. Patients with more obsessive compulsive symptoms did better with FBT. Interestingly, patients with a shorter duration of illness did better in FBT, those with a longer duration in PFT.
Not surprisingly given the outcomes, 61% of adolescence had treatment during follow up and 18 percent needed hospitalisation during treatment. It is not clear if these patients were excluded from the analysis as this skews the impact of the active treatments (i.e. weight gained in hospital can not be attributed to the outpatient therapy).
I am interested in why the remission data for FBT in two Australian studies (this study was in Melbourne and the other from Westmead in NSW (Madden et al 2015) have similar, but low, remission rates (22% and 25% respectively) when compared to the one US based study which also had stringent criteria for remission (Lock et al 2010) which achieved a 42% remission rate. The results from our private practice trial (Goldstein et al 2016) only had weight data as an outcome, so comparison is difficult, but 46% of our patients made the 95% weight restored criterion.
The authors correctly point out the benefit of the result for dissemination of evidence based treatment for adolescent anorexia. I can think of a number of therapist who are reluctant to provide FBT because of the conflict in the therapy room, particularly in the family meal. There is also a less “family therapy” feel to PFT as you do not have to engage as a therapist with the complexity of having more than two people in the room. PFT may have advantage in terms of therapist training as it may lack complexity that is involved in FBT.
The results do raise questions as to the role of the family meal in FBT. I can see that the meal has really important assessment, teaching and modeling benefits from a clinical perspective. In PFT this is achieved by having parents describe a successful and unsuccessful meal in great detail. I think you may lose the ability to model and reinforce to the parents the externalisation of the illness and the stance of empathic firmness that we are trying to help parents achieve. I’m not sure that discussion of a meal would the same effect.
I think that the study does further bring into question whether every single sibling needs to attend every single session. I think there is growing evidence that this is not a necessary part of FBT. However, not having them in therapy prevents siblings from talking of how they feel about the anorexia and in developing greater empathy and ability to support the sufferer.
Another interesting study that has got me thinking about the best practice of treating adolescents with anorexia nervosa.
As always comments welcome. Im particularly interested in how studies like this might change a clinicians practice.