Families Helping Families Fight the Beast  Roxanne E. Rockwell M.A.  University of California, San Diego Department of Psy...
Overview <ul><li>Finding the right treatment </li></ul><ul><li>Standard levels of care </li></ul><ul><li>Overview of innov...
Where to Start _______________________________ <ul><li>Making a plan </li></ul><ul><li>Evaluation:  </li></ul><ul><ul><li>...
Standard Levels of Care _______________________________ <ul><li>Outpatient (OP):  </li></ul><ul><li>The patient lives at h...
New Treatment Models _______________________________ <ul><li>A WHOLE family approach to the treatment of EDs </li></ul><ul...
New Models of Family Based Care _______________________________ <ul><li>Intensive Family Therapy (IFT):  </li></ul><ul><li...
Intensive Family Therapy <ul><li>IFT was first started in November 2006 at UCSD </li></ul><ul><li>Rather than a controlled...
5 Day Intensive Family Therapy _______________________________ <ul><ul><li>One family at a time </li></ul></ul><ul><ul><li...
Discharge Planning Contracting  4:00 -  5:00  Final Contracting  Carers Individual Therapy  Family Therapy: Systemic Indiv...
IFT Follow Up Study <ul><li>For the first 19 families, a follow up study was conducted. </li></ul><ul><ul><li>An Innovativ...
IFT Follow Up Study <ul><li>Self report data were obtained on all patients and families between 52 days and 738 days (mean...
  14.5 11.8 193.8   8.7 2.1 2.1 2.0 SD     15.0 99.3 278.4   84.3 15.0 1.1 12.3 Mean   NO 4.7 103.8 486 Fluoxetine 40 mg/d...
Multi-Family Based Treatment _______________________________ <ul><li>Dare and Eisler (2000) adapted FBT to use as part of ...
UCSD Multi Family IFT (MIFT) <ul><li>UCSD began a MIFT in December 2009 </li></ul><ul><li>To date approx 25 families have ...
MIFT Program Components <ul><li>Individualized Psychiatric evaluations </li></ul><ul><li>Group based family therapy </li><...
Multi-Family IFT (MIFT) Schedule         4:00-5:00 Combined Multi  Family Groups  3:30-4:00 Final Discharge Planning and P...
Multi-Family Week:  A Closer Look at Day 1 <ul><li>Prior to families arriving for the program we conduct a clinical interv...
Multi-Family Week:  A Closer Look at Day 1 <ul><li>Parents are instructed to leave and bring back an appropriate meal for ...
Multi-Family Week:  A Closer Look at Day 1 <ul><li>Multi-Family Meal </li></ul><ul><ul><li>Families are given free choice ...
IFT vs. MIFT: pros for one family may be cons for another <ul><li>One family  </li></ul><ul><li>Individual Services </li><...
Conceptual Framework of Multi-Family Interventions <ul><ul><ul><li>Seeing things in multiple perspectives </li></ul></ul><...
Advantageous Therapeutic Processes in Multi-family Groups <ul><li>Coping improvement </li></ul><ul><li>Stigma reversal  </...
Multi-Family Day Treatment <ul><li>Multi-family day treatment at UCSD evolved during August 2010 when several local MIFT f...
Multi Family Day Treatment 4:30-5:00 4:00-4:30 Multi Family Group 3:30-4:00 Family Skills Training Break  3:00-3:30 Goals/...
Clinical Reflections: What works and what doesn’t with multi-family groups <ul><li>Works </li></ul><ul><li>Parental agreem...
Whether or Not to Mix  Groups and Ages? <ul><li>Pros of mixing </li></ul><ul><li>Cons of mixing </li></ul>
Summary <ul><li>Each family with a loved one suffering from an eating disorder must find their own unique path to recovery...
References _______________________________ <ul><li>Lock, James and Le Grange, Daniel. (2005)  Help Your Teenager Beat an E...
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Maudsley Parents San Diego Conference, Roxie Rockwell.

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Maudsley Parents San Diego Conference, Roxie Rockwell.

  1. 1. Families Helping Families Fight the Beast Roxanne E. Rockwell M.A. University of California, San Diego Department of Psychiatry 858 212-1831 [email_address]
  2. 2. Overview <ul><li>Finding the right treatment </li></ul><ul><li>Standard levels of care </li></ul><ul><li>Overview of innovative treatment models </li></ul><ul><ul><li>Intensive Family Therapy (IFT) </li></ul></ul><ul><ul><li>Multi-Family Intensive Therapy (MIFT) </li></ul></ul><ul><ul><li>Multi-Family Day Treatment </li></ul></ul><ul><li>Clinical Reflections </li></ul>
  3. 3. Where to Start _______________________________ <ul><li>Making a plan </li></ul><ul><li>Evaluation: </li></ul><ul><ul><li>pediatrician/family doctor: r/o medical issues </li></ul></ul><ul><ul><li>ED expert for a formal diagnosis: AN, BN, EDNOS </li></ul></ul><ul><ul><ul><li>Diagnostic limitations </li></ul></ul></ul><ul><li>Education: </li></ul><ul><ul><li>Reputable websites and books (see references) </li></ul></ul><ul><ul><li>Medical journals </li></ul></ul><ul><ul><li>Long standing debate on treatment: i.e parentectomy </li></ul></ul><ul><ul><li>Familiarize yourself with different treatment philosophies </li></ul></ul>
  4. 4. Standard Levels of Care _______________________________ <ul><li>Outpatient (OP): </li></ul><ul><li>The patient lives at home </li></ul><ul><li>1-2 hour long sessions weekly </li></ul><ul><li>Intensive Outpatient Program (IOP): </li></ul><ul><li>The patient lives at home </li></ul><ul><li>Attends sessions for 3-5 hrs per day </li></ul><ul><li>May eat 1-2 meals at the clinic </li></ul><ul><li>Day Treatment (DT): </li></ul><ul><li>The patient may spend 6-10 hours at a treatment facility </li></ul><ul><li>May have most or all meals at the clinic (5-7 days) </li></ul><ul><li>Partial Hospitalization (PHP): </li></ul><ul><li>The patient lives part of the time at the hospital and part of the time at home </li></ul><ul><li>Inpatient (IP): </li></ul><ul><li>The patient is hospitalized, usually for medical stabilization </li></ul><ul><li>May or may not include therapy </li></ul><ul><li>Residential: </li></ul><ul><li>Full time </li></ul><ul><li>Long-term residence at a specialized treatment facility </li></ul><ul><li>Few weeks to several months </li></ul>
  5. 5. New Treatment Models _______________________________ <ul><li>A WHOLE family approach to the treatment of EDs </li></ul><ul><ul><li>Parents </li></ul></ul><ul><ul><li>Siblings </li></ul></ul><ul><ul><li>Friends/Relatives </li></ul></ul><ul><li>Incorporating “treatment” for family members is essential for strength against the ED </li></ul>
  6. 6. New Models of Family Based Care _______________________________ <ul><li>Intensive Family Therapy (IFT): </li></ul><ul><li>The entire family attends a 5 day intensive program for education, treatment planning and a family based treatment “jumpstart.” </li></ul><ul><li>Multi-Family Intensive Week (MIFT): </li></ul><ul><li>Child or adolescent attend day treatment program with separate parent and child tracks </li></ul><ul><li>Including some or all meals/snacks on site with parent and coach </li></ul><ul><li>Multi Family Day Treatment </li></ul><ul><li>Standard day treatment with 10 +hrs per week of multi-family sessions. </li></ul>
  7. 7. Intensive Family Therapy <ul><li>IFT was first started in November 2006 at UCSD </li></ul><ul><li>Rather than a controlled manualized protocol it was an evolving concept with variations tailored for individual families </li></ul><ul><li>30+ families completed the program through Dec 2010 </li></ul><ul><li>Of the first 19 families, a follow up study was conducted. </li></ul>
  8. 8. 5 Day Intensive Family Therapy _______________________________ <ul><ul><li>One family at a time </li></ul></ul><ul><ul><li>All family members attend including siblings </li></ul></ul><ul><ul><li>Emphasis on family involvement in treatment </li></ul></ul><ul><ul><li>Aimed at limiting or preventing inpatient and/or residential treatment for children and adolescents when possible </li></ul></ul><ul><ul><li>Numerous treatment components including: </li></ul></ul><ul><ul><ul><li>family based therapy </li></ul></ul></ul><ul><ul><ul><li>systemic family therapy </li></ul></ul></ul><ul><ul><ul><li>Contracting </li></ul></ul></ul><ul><ul><ul><li>psychoeducation </li></ul></ul></ul><ul><ul><ul><li>parent coaching </li></ul></ul></ul><ul><ul><ul><li>carers sessions </li></ul></ul></ul><ul><ul><ul><li>individual psychotherapy </li></ul></ul></ul><ul><ul><ul><li>cognitive behavioral therapies. </li></ul></ul></ul>
  9. 9. Discharge Planning Contracting 4:00 - 5:00 Final Contracting Carers Individual Therapy Family Therapy: Systemic Individual Therapy: Mother Individual Therapy: Father Individual therapy: patient Psychiatric Evaluation 3:00 - 4:00 Parent Coaching Art Family Therapy Systemic Family Therapy: Contracting Carers patient DBT Parent Coaching Individual Therapy: patient 2:00 - 3:00 Family Therapy Family Meal Family Psychotherapy: Contracting Break Family Therapy: Communication Skills 1:00 - 2:00 Parents leave to get lunch Finish Art Lunch on Own Couples Therapy: Parent Coaching Individual: Meditation/ Relaxation Lunch on Own Family Therapy: Meal 12:00 - 1:00 Medication Follow up Parentgetting lunch Art Family Therapy: Psychoeducation Family Therapy: Meal Family Therapy: Cognitive Behavioral Therapy I 11:00 -12:00 Family Therapy: Systemic Family Therapy: Behavioral Family Therapy: CBT II Family Therapy: Psychoeducation: Family Therapy: Behavioral 10:00 -11:00 Family Therapy: CBT III Family Therapy: Psychoeducation Treatment Planning: Clinical Team Meeting Peds appt off site 9:00 -10:00 Parent Adol Parent Adol Parent Adol Parent Adol Parent Adol FRIDAY THURSDAY WEDNESDAY TUESDAY MONDAY TIME
  10. 10. IFT Follow Up Study <ul><li>For the first 19 families, a follow up study was conducted. </li></ul><ul><ul><li>An Innovative Short-Term, Intensive, Family-Based Treatment for Adolescent Anorexia Nervosa: Case Series (Rockwell, R.., et al, European Eating Disorders Review, In Press 2011). </li></ul></ul><ul><li>Patients </li></ul><ul><ul><li>68% (n=13) were diagnosed with AN-restricting type, </li></ul></ul><ul><ul><li>11% (n=2) were diagnosed with AN purging type, </li></ul></ul><ul><ul><li>11% (n=2) with ED NOS. </li></ul></ul><ul><ul><li>bulimia nervosa (n=1) </li></ul></ul><ul><ul><li>feeding-disorder not otherwise specified (n=1). </li></ul></ul>
  11. 11. IFT Follow Up Study <ul><li>Self report data were obtained on all patients and families between 52 days and 738 days (mean=278) post treatment. </li></ul><ul><li>Admission IBW ranged from 69.3% to 99.1% (mean = 84.3%, SD = 8.7). </li></ul><ul><li>Follow-up IBW ranged from 84.4% to 134.6% (mean = 99.3%, SD = 11.8). </li></ul><ul><li>All but one patient reported a sustained gain in IBW post treatment (mean =15.0, SD = 14.5). </li></ul>
  12. 12.   14.5 11.8 193.8   8.7 2.1 2.1 2.0 SD     15.0 99.3 278.4   84.3 15.0 1.1 12.3 Mean   NO 4.7 103.8 486 Fluoxetine 40 mg/day 99.1 16 0 13 NOS 18 NO 3.0 101.0 58 Fluoxetine 10mg/day 98.0 18 0 17 NOS 17 NO 2.2 97.2 353 None 94.9 16 0 15 AN 16 NO -6.6 86.6 241 None 93.2 17 0.2 9 AN/BN 15 YES 13.6 102.6 591 None 89.0 15 0.75 13 AN 14 NO 11.3 100.2 129 Fluoxetine 30mg/day 88.9 12 0 11 AN 13 NO 4.7 92.6 157 None 87.9 16 2.5 11 AN 12 NO 12.8 99.5 52 None 86.7 12 0 11 AN 11 NO 14.7 98.2 87 olanzapine 1.25mg/day 83.5 10 0 9 NOS 10 NO 52.0 134.6 738 Aripiprazole 2.5mg/day 82.6 16 0 14 AN 9 NO 7.9 90.2 451 Olanzapine 2.5mg/day 82.3 15 1 11 AN 8 NO 8.7 89.6 190 None 80.9 16 0 14 AN 7 NO 8.9 89.1 66 Sertaline 100 mg/day, olanzapine 5mg/day, trazodone 25mg qhs prn 80.2 15 4 12 AN/BN 6 NO 30.2 107.6 182 Risperidone 0.25mg bid 77.4 13 2.5 12 AN 5 NO 29.9 107.1 393 None  77.2 17 0   AN 4 NO 17.3 91.4 255 Citalopram 40mg/day, olanzapine 5mg/day 74.2 17 8 13 AN 3 NO 40.1 112.1 285 Olanzapine 3.75mg/day, Citalopram 10mg/day 72.0 13 0.5 12 AN 2 NO 15.2 84.4 297 escitalopram 10mg/day 69.3 15 0 12 AN 1 IP @ FU change FU IBW% Days FU Discharge Medication IBW% Age # Mo IP Onset DX   ID
  13. 13. Multi-Family Based Treatment _______________________________ <ul><li>Dare and Eisler (2000) adapted FBT to use as part of a multiple family day treatment program </li></ul><ul><li>Eisler trained the UCSD staff on his multi family methods which were then integrated with IFT methods to develop Multi-Family IFT. </li></ul><ul><li>Aim to help families share, develop skills and become motivated together, united against the eating disorder. </li></ul><ul><ul><li>especially helpful with unskilled, reluctant, or defeated parents </li></ul></ul>
  14. 14. UCSD Multi Family IFT (MIFT) <ul><li>UCSD began a MIFT in December 2009 </li></ul><ul><li>To date approx 25 families have participated </li></ul><ul><li>Groups range from 2-4 families per week. </li></ul><ul><ul><li>Program runs 1x per month on average </li></ul></ul><ul><li>Children, adolescents and young adults have participated. </li></ul><ul><ul><li>Ages 9-21 yrs. with their families. </li></ul></ul><ul><li>Diagnoses include AN, BN, OCD, MDD, EDNOS </li></ul><ul><li>Families attend during all of the Maudsley phases </li></ul><ul><ul><li>Tailored to meet the family where they are at in the process </li></ul></ul>
  15. 15. MIFT Program Components <ul><li>Individualized Psychiatric evaluations </li></ul><ul><li>Group based family therapy </li></ul><ul><li>Adolescent only groups </li></ul><ul><li>Parent only groups </li></ul><ul><li>Live parent coaching during meals </li></ul><ul><ul><li>Lunch 5 days plus daily snack(s) </li></ul></ul><ul><li>Contracting </li></ul><ul><li>Psychoeducation </li></ul><ul><li>Discharge planning </li></ul>
  16. 16. Multi-Family IFT (MIFT) Schedule         4:00-5:00 Combined Multi Family Groups 3:30-4:00 Final Discharge Planning and Process Family Based Process, Activity and Goals Contracting Family Based Process, Activity and Goals Review and Goals 3:00-3:30 2:30-3:00 2:00-2:30 Parent Coaching Teen Expressive Arts with DT SNACK at 2:00ish Parent Coaching Teens Anxiety Reduction with DT SNACK at 2:00ish Psychoeducation SNACK 2:00ish Parent Coaching Teen Self Esteem and Acceptance with DT SNACK at 2:00ish Parent Coaching Teens Anxiety Reduction with adol DT SNACK at 2:00ish 1:30-2:00 BREAK BREAK BREAK BREAK BREAK 1:00-1:30 12:30-1:00 Multi Family Meal Multi Family Meal Multi Family Meal Multi Family Meal Multi Family Meal 12:00-12:30 Parents get food at 11:30 Teens join DT for Vitals Parents get food at 11:30 Body Image with DT Parents get food at 11:30 Teens join DT for Vitals Med Checks if needed Parents get food at 11:30 Teens Body Image with adol DT Parents get food and Teens join adol DT for Vitals 11:30-12:00 11:00-11:30 Contracting Contracting Contracting Introduction 10:30-11:00 Physiological Effects of Starvation and Medical Consequences of ED Family Based Therapy 10:00-10:30 9:30-10:00 Family Based Therapy SNACK at 10:15 Family Based Therapy SNACK at 10:15 Family Based Therapy Family Based Therapy SNACK at 10:15 Orientation 9:00-9:30 FRIDAY THURSDAY WEDNESDAY TUESDAY MONDAY  
  17. 17. Multi-Family Week: A Closer Look at Day 1 <ul><li>Prior to families arriving for the program we conduct a clinical interview by phone and obtain previous medical and psychological records. </li></ul><ul><li>To the best of our ability we provide families with ages of other families attending their week. </li></ul><ul><li>Monday morning follows FBT guidelines for session 1 </li></ul><ul><ul><li>Individual introductions </li></ul></ul><ul><ul><li>Family perceptions of the problem and its development </li></ul></ul><ul><ul><li>Exploration of the effect of anorexia on the family </li></ul></ul><ul><ul><ul><li>Multi-Family Advantage: Families in attendance will have varying levels of education </li></ul></ul></ul>
  18. 18. Multi-Family Week: A Closer Look at Day 1 <ul><li>Parents are instructed to leave and bring back an appropriate meal for their loved one. </li></ul><ul><ul><li>Multi-family advantage: some parents decide on introducing “feared foods” day 1 and others rely on “safe foods.” No recommendation is made either way. </li></ul></ul><ul><ul><li>In my experience, the multi-family meals may have the most weight in terms of parent learning. </li></ul></ul>
  19. 19. Multi-Family Week: A Closer Look at Day 1 <ul><li>Multi-Family Meal </li></ul><ul><ul><li>Families are given free choice to position themselves however they like during the first meal. </li></ul></ul><ul><ul><li>They tend to lean towards sitting in individual family clusters. </li></ul></ul><ul><ul><ul><li>At times it seams that they want to be isolated in case “the beast” comes out </li></ul></ul></ul><ul><ul><ul><li>However, by the end of the week it is typical that families sit together and feel comfortable amongst each other whether the beast shows itself or not. </li></ul></ul></ul>
  20. 20. IFT vs. MIFT: pros for one family may be cons for another <ul><li>One family </li></ul><ul><li>Individual Services </li></ul><ul><li>Undivided family attention </li></ul><ul><li>Exposure to a variety of treatments </li></ul><ul><ul><li>CBT, DBT, etc </li></ul></ul><ul><li>Adolescents may feel alone in the process </li></ul><ul><li>Low risk of adolescents “picking up ED tricks” </li></ul><ul><ul><li>Parents of younger kids often concerned with this </li></ul></ul><ul><li>Several families </li></ul><ul><li>Limited individual time </li></ul><ul><li>Exposure to different forms of the illness </li></ul><ul><li>Exposure to different stages of the illness </li></ul><ul><li>Adolescents don’t feel alone in the process </li></ul><ul><li>Families may be exposed to symptoms that they may not have otherwise </li></ul><ul><ul><li>Self harm, SI, drugs/alcohol abuse </li></ul></ul>
  21. 21. Conceptual Framework of Multi-Family Interventions <ul><ul><ul><li>Seeing things in multiple perspectives </li></ul></ul></ul><ul><ul><ul><li>Seeing things from different perspectives through the multiple family group activities </li></ul></ul></ul><ul><ul><ul><li>Connecting families together to fight against social isolation and stigmatization </li></ul></ul></ul><ul><ul><ul><li>Generate more resources of the families through the expansion of social support network </li></ul></ul></ul>
  22. 22. Advantageous Therapeutic Processes in Multi-family Groups <ul><li>Coping improvement </li></ul><ul><li>Stigma reversal </li></ul><ul><li>Social network construction </li></ul><ul><li>Communication improvement </li></ul><ul><li>Crisis prevention </li></ul><ul><li>Treatment adherence </li></ul><ul><li>Anxiety and arousal reduction </li></ul>
  23. 23. Multi-Family Day Treatment <ul><li>Multi-family day treatment at UCSD evolved during August 2010 when several local MIFT families requested extended care following their 5 day program. </li></ul><ul><li>The program incorporates a variety of therapeutic approaches (CBT, DBT, individual) with a solid family based core. </li></ul>
  24. 24. Multi Family Day Treatment 4:30-5:00 4:00-4:30 Multi Family Group 3:30-4:00 Family Skills Training Break 3:00-3:30 Goals/Snack Goals/Snack Goals/Snack Goals/Snack Goals/Snack 2:30-3:00 Weekend Planning 2:00-2:30 Anxiety Reduction/ Mindfulness Chain Analysis Family Skills Review/ DBT hmwk Body Image/ Anxiety Reduction/ Mindfulness 1:30-2:00 Activity and Weekend Planning Exp. Arts/Movie Process Group Process Group Process Group Process Group 1:00-1:30 Family Lunch Lunch Lunch Lunch Lunch Lunch 12:00-1:00 Homework /Vitals 11:30-12:00 Nutrition Group 11:00-11:30 Diary Card Homework/ Vitals Diary Card Homework/ Vitals Diary Card Homework/ Vitals Diary Card Homework/ Vitals 10:30-11:00 Multi--Family Process Process Group Process Group Process Group Process Group Process Group 10:00-10:30 Family Breakfast Breakfast Family Breakfast Breakfast Breakfast Breakfast 9:00-10:00 Saturday Friday Thursday Wednesday Tuesday Monday  
  25. 25. Clinical Reflections: What works and what doesn’t with multi-family groups <ul><li>Works </li></ul><ul><li>Parental agreement on the method or at least both parents open to trying something new. </li></ul><ul><li>Adolescents that react with tears, silence or yelling. </li></ul><ul><li>Loving yet firm parents </li></ul><ul><li>Parents willing to reflect on boundaries. </li></ul><ul><li>Parents who research treatments, read and ask questions. </li></ul><ul><li>Parents who take care of themselves. </li></ul><ul><li>Parents willing to move out of their comfort zone. </li></ul><ul><li>Doesn’t </li></ul><ul><li>Dragging a co-parent that does not want to participate. </li></ul><ul><li>A violent adolescent/young adult. </li></ul><ul><li>Co-occurring substance abuse </li></ul><ul><li>Young adults no longer supported financially or otherwise by parents. </li></ul><ul><ul><li>Contracting </li></ul></ul><ul><li>Siblings who support the ED rather than their sibling. </li></ul><ul><li>Abusive relationships in the family. </li></ul><ul><li>Belief that the problem is the individuals and that they need the treatment. </li></ul><ul><li>When one or both parents have disordered eating that they are unwilling to confront. </li></ul>
  26. 26. Whether or Not to Mix Groups and Ages? <ul><li>Pros of mixing </li></ul><ul><li>Cons of mixing </li></ul>
  27. 27. Summary <ul><li>Each family with a loved one suffering from an eating disorder must find their own unique path to recovery </li></ul><ul><li>A WHOLE family based approach is essential for treatment of children and adolescents </li></ul><ul><li>New treatment models can offer families education and strategies to fight the illness through unity </li></ul>
  28. 28. References _______________________________ <ul><li>Lock, James and Le Grange, Daniel. (2005) Help Your Teenager Beat an Eating Disorder . NY: Guilford Press. </li></ul><ul><li>Lock et al. (2001) Treatment Manual for Anorexia Nervosa: A Family-based Approach . NY: Guilford Press. </li></ul><ul><li>Maudsley Parents http://www.maudsleyparents.org/ </li></ul><ul><li>UCSD http://eatingdisorders.ucsd.edu/ </li></ul><ul><li>F.E.A.S.T. http://www.feast-ed.org / </li></ul>

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