An Integrated Approach for 'Hard-to-Treat' Eating Disorders

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The majority of young people presenting with moderate to severe eating disorder symptoms can be expected to benefit from first-line outpatient treatments like family-based treatment and enhanced cognitive behavioral therapy. Early intervention and compliance with these treatment protocols can lead to strong outcomes in younger patients.

When first-line treatments are not the best fit

There is a subset of adolescent patients, however, for whom first-line treatments in their pure form are not indicated.

In these cases, specific adaptations to the treatments may be necessary to best address the full scope of the patient’s condition. An adapted treatment course should be considered when teens present to care with eating disorders and suicidal or self-injurious behaviors. Young people with other challenging co-occurring conditions like severe emotion dysregulation or oppositional behavior may also fall into this category of patients who will require a skillfully rendered, integrated treatment.

Research on dialectical behavior therapy (DBT) and family-based treatment (FBT) has produced an abundance of support for these interventions to address emotion dysregulation, self-injurious behavior, suicidality (DBT), and eating disorders (FBT) respectively. But when multiple complicating features occur together and alongside an eating disorder, these treatments on their own often prove inadequate. Patients with this combination of an eating disorder, emotion dysregulation, and/or self-injurious or suicidal behaviors have traditionally been considered “hard to treat.” They may cycle through multiple treatments, providers, and facilities with only aspects of their conditions addressed at any given time.

The integration of FBT and DBT

Innovation in the field of eating disorders has led to some highly specialized providers meeting the needs of these patients by integrating FBT and DBT. FBT strategies are used to effect normalization of eating/weight, while DBT brings in the necessary patient and parent skills for emotion regulation. Additionally—and very importantly—DBT is structured to both monitor and manage serious, potentially life-threatening factors like self-harm and suicidality; FBT is not.

Feedback on the implementation of this integration of FBT and DBT is encouraging. Although there’s been minimal formal research to date, a 2015 study on FBT/DBT integration for adolescent bulimia nervosa reinforced efficacy. Robust controlled research trials are both needed and essential since mental health challenges among young people have proliferated with both eating disorders and suicide rates increasing in incidence at alarming rates. There is great promise in bringing together two potent and well-supported treatments to address the full scope of these complex ED cases.

The defining features of an FBT/DBT integrated treatment

Important parent/caregiver role. True to family-based treatment, there is a critical and defined role for parents/caregivers who are tasked with the responsibility of feeding/supervising the nourishment for their teen. DBT for adolescents also involves parents in treatment, both learning skills and supporting the child in practicing them in real-time. But standard DBT does not have a prescribed role for parents in the realm of food/nourishment, which is wholly needed when the teen is “under the influence” of an eating disorder and cannot reliably feed themselves.

Emotion dysregulation. In standard FBT, the provider will support parents in adapting a non-judgmental, blame-free stance, supporting the teen wholly while separating them from the illness (the problem is anorexia, not the child). Often in FBT, parents will experience pushback from the child—resistance that can escalate at times into food refusal, shouting, and even physical violence from the child. This escalation is seen as the ED’s reaction to the imposition of the treatment; the loss of control and the requirement to eat can trigger strong reactions from the child. Further, we understand that weight suppression and chronic inadequate nutrition—the cornerstones of anorexia—can lead to increased emotionality, irritability, and even aggression. In FBT, parents are given strategies to de-escalate, maintain safety in the home, and forge ahead with feeding.

In DBT, the understanding of emotional lability and “acting out behaviors” is quite different; emotion dysregulation is seen as a pervasive issue for the individual—likely pre-dating the onset of the ED and also likely a major factor in the vulnerability to developing the ED in the first place. From the DBT perspective, ED behaviors are part of a repertory of coping measures to manage emotion. With this understanding, the patient needs to build up skills for self-regulating. DBT is focused on this skill-building and uses parents as aids and allies; parents learn, practice, and reinforce skills right alongside their teens.

Maintaining safety. FBT was developed as a focused and potent treatment for adolescent anorexia (and later adapted for adolescent bulimia, too). Given the seriousness and urgency of the condition[s], FBT is designed to move swiftly and aggressively in service of getting the child renourished and weight restored. Typically, we’re looking for two to three pounds of weight gain each week. Parents remain wholly focused on managing feeding and supervising their child to be sure that all of the food/“medicine” is completed—and kept down (in the case of bulimia, additional supervision is in place to prevent purging).

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FBT’s power is its intensity and “laser focus,” so it is not a treatment designed to address problematic behaviors outside of the eating disorder. Behaviors like self-harm, suicidal gestures, severe emotional outbursts, etc. can threaten the success of FBT as they interfere with the critical re-feeding that needs to take place. This is where DBT comes in. In the context of re-feeding, skilled DBT/FBT providers can also support parents in managing behaviors like self-harm, tantrums, defiance, physical aggression, and more.

Core to the DBT/FBT treatment is a risk management plan. Parents are guided in creating a hospital at home; not only are they overseeing their child’s nourishment, but they’re also securing the environment so their child does not have access to anything that they could use to harm themselves or others. Parents are given strategies to de-escalate when things at home get heated. They learn how to support their child when in distress, using skills and strategies learned all together within the structure of treatment.

Family relations and communication. Among the strengths of DBT treatment is a concrete and robust focus on interpersonal communication. Within the context of a crisis—a family facing an eating disorder and potential co-occurring difficulties—communication can easily break down. FBT addresses communication specifically by creating an accepting, blame-free setting to conquer the eating disorder. DBT takes communication work further; the therapist guides the family members in integrating scripts, skills, and strategies grounded in validation, cooperation, mindfulness, and flexibility.

If there is volatility, criticism, conflict, and/or frequent breakdowns within a family system, ED symptom management can be disrupted, and FBT can get off course. DBT expertise in this regard can be a game-changer, supporting the continuation of important family work and ED recovery.

Avoiding hospitalization. Both FBT and DBT are treatments that are designed to keep teens out of the hospital. FBT is appropriate for even the more severe cases of anorexia or bulimia as long as the patient is medically stable and followed regularly by an M.D. with eating disorder expertise. DBT is structured to closely monitor and address potentially life-threatening behaviors in teens via the use of behavioral contracts, skill provision, safety planning, and parent management training. Between-session coaching may also be used in DBT to support teens in the moments when they are in the highest distress and most triggered to engage in self-destructive behavior.

Challenge of the starved brain. DBT-Informed FBT is a potent treatment with the notable potential to support recovery at home. That said, it’s important to acknowledge the inherent challenge in using a therapy intervention like DBT with patients who are malnourished. We know that when the brain has been starved, it is not most receptive to talk therapy. Additionally, depression, anxiety, irritability, and compulsivity—big emotions, essentially—are expected side effects of starvation. Coping and self-soothing skills can help, but the vast repertory of DBT skills available may not be helpful until the brain is properly nourished.

These realities must be taken into account when implementing the FBT/DBT combined treatment. Until there has been some physical stabilization, the treatment is mostly reliant on parents to follow protocols and create an environment that is as safe, validating, and consistent as possible.

Filling in the gaps. While philosophically and technically distinct, FBT and DBT are both compatible and complementary. Integrating these treatments fills in gaps that, if not addressed, invariably force patients into more restrictive and disruptive settings like residential and inpatient facilities. Used in tandem, FBT and DBT support changes in environment and relations with the family system that bode well for both a strong outcome and sustained recovery.

The importance of provider confidence and expertise

Unfortunately, it takes extensive training and years of practice to gain competency in either FBT or DBT—so strength in delivering the treatments in tandem will be found in experienced practitioners who have trained in evidence-based settings. Given the risk associated with treating multi-diagnostic young people, provider confidence and expertise are a must.

We are in need of more attention and resources directed to research, training, and dissemination of outpatient evidence-based treatments—particularly robust interventions like FBT/DBT. These treatments keep families together, empowered, and free from the disruption of hospitalization. With further study, there’s potential for the development of specific and practical guidelines—a roadmap that could simplify and standardize treatment delivery, thus making FBT/DBT integration more accessible to providers and the patients they treat.

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