Parental Involvement in Cognitive Behavior Therapy for Eating Disorders

Eating disorders have a profound impact on psychosocial functioning and physical health. Therefore, they must be treated early and effectively to avoid long-lasting negative and, sometimes, devastating effects.

Enhanced cognitive behavior therapy (CBT-E) is one of the most effective treatments for eating disorders. The treatment is based on the observation that the main features and maintaining processes are essentially the same across eating disorder diagnoses (i.e., anorexia nervosa, bulimia nervosa, binge-eating disorder, and other similar states). Therefore, if these maintaining processes can be disrupted in one eating disorder, it is possible to disrupt them in other eating disorders. This is known as a “transdiagnostic approach."

CBT-E was initially developed at the Centre for Research on Eating Disorders at Oxford (CREDO) for adults with eating disorders. The treatment has been evaluated in numerous and rigorous clinical trials and is now recommended by the most important international guidelines for all clinical forms of adult eating disorders.

The idea of adapting CBT-E for the treatment of young persons was raised about 10 years ago at the Department of Eating and Weight Disorders of Villa Garda Hospital in Italy, stemming from the observation that young patients with eating disorders display the same specific eating-disorder features as adults. This led to the hypothesis that adolescents could also benefit from CBT-E, which is designed to address eating disorders' features and maintaining mechanisms.

CBT-E has many key features that make it well-suited to younger patients with eating disorders. First, it adopts a flexible and individualized approach, which is easily adaptable to the needs of young patients at different stages of physical and cognitive development in their lives. Second, it is both comprehensible and easy to receive and adopts a collaborative approach to improve the patient’s general sense of control—this is well-suited for younger patients who value the pursuit of control, autonomy, and independence. Last but not least, CBT-E includes several strategies for supporting patients to agree to and engage with treatment. This feature is vital for the management of adolescents who, by nature, are often ambivalent about their treatment.

CBT-E for young persons is the subject of ongoing scientific and clinical research to ensure continuous improvement of the treatment and its procedures. It has been evaluated across several studies of patients aged 12 to 19 years. The results of these studies indicate that about two-thirds of young patients completing CBT-E achieve lasting remission of their eating disorder. The promising results obtained from these studies have influenced international health policy and the 2017 National Institute for Health and Care and Clinical Excellence (NICE) guidelines for eating disorders to recommend CBT for adolescents as an alternative to family therapy for the treatment of eating disorders.

Parental involvement in CBT-E for adolescents

One of the main differences between CBT-E for young persons compared to the standard adult protocol is that parents are always involved in the adolescent’s treatment, while in the treatment of adults, significant others are only involved with the consent of adult patients and if they are in a position to facilitate treatment or if they are hindering it.

Involving parents in the treatment of young persons with eating disorders is recommended for several reasons. Firstly, parents have the right and responsibility to make important decisions regarding the treatment of their teenage children. This means that the treatment cannot be started without the parent’s informed consent. Secondly, research consistently shows that the parent’s reaction to an adolescent’s eating disorder symptoms can influence treatment outcomes. Thus, it is important to ensure this impact is positive and that the parents do not unknowingly or unintentionally hinder or prevent positive changes in their child. Thirdly, research has shown that parents play an important role in helping their child recover from an eating disorder. This sentiment was officially reflected in 2009 when the Academy for Eating Disorders (AED) published a position statement asserting that parents are not responsible for their children’s eating disorders but that they can be important allies in care and recovery. The CBT-E conceptualization of eating disorders and its strategy to involve parents as a “helper” of their child during the treatment and the change is in line with the AED recommendation.

The following sections give an overview of the nature of parental involvement in CBT-E for adolescents with eating disorders. Readers interested in having a detailed description of the CBT-E strategies and procedures suggested to parents for supporting their adolescent’s recovery journey should refer to the recently published book, Cognitive Behaviour Therapy for Eating Disorders in Young People: A Parent’s Guide.

Family-based treatment and CBT-E

Parents’ involvement in family-based treatment (FBT) is vitally important for the ultimate success of the treatment. Moreover, in FBT, parents must defer working on other family conflicts or disagreements until the eating-disorder behaviors are resolved. In CBT-E, parents’ involvement is considered very useful but not essential. The role of parents is to support the implementation of the one-to-one treatment, not to drive it.

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Both treatments pay attention to adolescent development and encourage peer social interactions. However, in FBT, the adolescent is not viewed as being in control of their behavior (it is believed that the eating disorder is controlling the adolescent). This is the reason why, in FBT, parents are initially empowered to take control of their child’s eating. On the contrary, the main objective of CBT-E is to help the adolescent take control over their behavior and for the parents to be involved in helping in this task. In FBT, the adolescent is not actively involved and plays a passive role, while in CBT-E, they are encouraged to become actively involved in the treatment.

CBT-E sessions with parents

Parental involvement includes one parent-alone session in the first week of treatment, and then several joint sessions with the adolescent and the therapist at the end of the individual patient’s session (Figure 1). The joint sessions typically last about 15 minutes. Additional joint sessions can be scheduled under unusual circumstances, such as family crises, extreme difficulties during meals, or parental criticism towards the adolescent.

Figure 1. The CBT-E map for adolescents with the involvement of parents.

Source: Riccardo Dalle Grave, M.D.

Improving knowledge about eating disorders

Parents are educated, with the help of the book and five specific videos, about the following main topics:

• The role of parents in CBT-E.
• The causes (still unknown) and the maintaining factors of eating disorders.
• The psychological, cognitive-behavioral model of eating disorders.
• The goals, organization, strategies, and procedures of CBT-E.
• How to create an optimal family environment.
• How to support the young person to implement the procedures of the treatment.

Creating an optimal family environment

Parents are helped to create an optimal family environment with the implementation of the following main strategies:

• Adopting a warm and functional communication style.
• Spending stress-free time with your child.
• Taking time for yourself and asking for support from others.
• Changing the home environment (e.g., avoiding dieting, conversations that emphasize thinness, engaging in reassurance-seeking behaviors; instilling hope; creating a physical and digital environment that does not encourage concerns about shape and weight; creating a “new” home environment, etc.).
• Managing crises using the problem-solving procedure.
• Addressing some barriers to change.

Supporting the young person

CBT-E addresses the features of eating disorders with specific strategies and procedures. Parents’ involvement in helping the young person use these tools varies from case to case as appropriate. However, the strategy involves three steps:

1. The therapist discusses the procedure first with the patient (e.g., evaluating the pros and cons to change, adopting regular eating, managing the meals, addressing dietary restriction and weight regain, coping with events, moods, and setbacks, etc.).
2. Then assist the patients in evaluating the pros and cons of involving their parents to help them implement it.
3. Finally, if the patient agrees, parents are invited to join parents and patient sessions to discuss the type of help required to implement the procedure.

To find a therapist, please visit the Psychology Today Therapy Directory.