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A NEW FAMILY-BASED TREATMENT FOR ANOREXIA AND BULIMIA

VIEWS: 41 PAGES: 72

									  A NEW FAMILY-BASED
    TREATMENT FOR
ANOREXIA AND BULIMIA IN
     ADOLESCENTS

   Cris Haltom, Ph.D.
  Eating Disorder Recovery
   Center of Western NY
        Oct. 5, 2007
The trouble with parentectomies:
          old thinking revised
 Minuchin and colleagues (1975) found
  family involvement helped patients with
  anorexia
 Dare and Eisler at the Maudsley
  Hospital in London built on Minuchin et
  al‟s work: families recruited as necessary
  for recovery
 Radical change and new paradigm:
  parents supervise eating
Research support for FBT
   Randomized controlled trials indicate 70-80%
    of adolescents with anorexia do well, when
    treated early, with weight restoration,
    normalization of eating-related thoughts and
    behaviors, and psychosocial functioning
    (LeGrange et al, 1992; Eisler et al, 2000; Lock et
    al, 2005)
   Two large controlled trials of FBT for adolescents
    with bulimia support using FBT (LeGrange and
    Lock, 2007, LeGrange and Schmidt, 2005)
                  Overview
   Who, why, where, what and when of the
    Maudsley approach or FBT
   Review three phases of Family-Based
    Treatment (FBT)
   Comparison with traditional family treatment
    model
   Harnessing parents‟ anxiety
   Facilitating positive parent characteristics
   When not to use FBT
   Important differences between AN and BN
   Description of Phases I and II
   Transitioning to adolescent autonomy
   What patients and parents have to say
     Parents are necessary
   Included: family is the best resource
   Empowered: parents challenge/disrupt
    disordered eating behaviors
   Informed: parents given information about
    ED‟s as part of therapy, e.g., medical/psych.
    problems
   Prepared: join with the therapist to persistently
    deal with the illness and figure out how to take
    it away
   Equipped: therapist guides, doesn‟t give
    specific solutions – parents figure out their own
    mutually agreeable solutions
Parent                Parent
         Parents
          united
         against ED
      Who is Family-Based
    Treatment intended for?
Efficacy of the program has been demonstrated
  with adolescents with anorexia under the age of 18
  years old and living at home with their families.

Daniel Le Grange and James Lock have recently published
  a new treatment manual, Treating Bulimia in
  Adolescents: A Family-Based Approach (2007): a family-
  based treatment adapted for adolescents with
  bulimia 19 years of age or younger, at home.

Can be used with weight-restored patients
  who need balanced eating: Prevent weight
  loss/normalize eating/curtail purging
           Why Family-Based
             Treatment?
   Avoid separation of parents from children
    during a hospitalization
   Outpatient: child stays in usual surroundings
   Less need for hospitalization and specialty
    care
   Better use of easily available resources
   Less costly
   Not worried about “Why?”
   Helps parents not blame themselves: no one to
    blame
   Helps parents overcome helplessness
    Where does the work take
            place?
   Mostly at home: Newer research by LeGrange,
    Lock and others looking at applications in IP,
    IOP, PHP settings including multi-family groups
   Whole family attends therapist-led family
    meetings in initial phases in outpatient setting
   Other consultations in other outpatient or
    clinic settings will likely take place
   Other safe, therapeutic settings like partial
    hospitalization or inpatient may be needed
 Multi-family group applications
-Dare and Eisler (2000) have adapted FBT to use as part
 of a multiple family day treatment program

- Meet with 4-6 families over several long weekends or
 sessions

- aim to help families share, develop skills and become
 motivated together, united against the eating disorder:
 especially helpful with unskilled, reluctant, or defeated
 parents (15-20% poor outcome rates w/ single families)

-therapist does not have the answer as to what any
 individual family will need

-Dr. Tantillo will introduce a related MFG method
WHAT is FBT? FIVE BASIC
      PRINCIPLES
   1. Agnostic
   2. Parent-empowered
   3. Focus on restoring healthy
      eating
   4. Separate illness from child
   5. Therapist as consultant
             1. Agnostic


-Agnostic with regard to causes: for
 example, “no „anorexegenic‟ family” and
 causes are multiple and complex

-Family seen as resource rather than the
 source of the problem: little evidence that
 families cause ED‟s
     2. Parent-empowerment
•   Adolescent is out-of-control of eating
    disorder

•   Parents take charge of nutrition
    restoration: manage meals, disrupt extreme
    dieting, exercise, and purging

•   In the case of bulimia, parents seek
    collaboration with their child to promote
    healthy eating and disrupt pathological eating
    and purging behaviors

•   Parents respect need for adolescent control
    and autonomy in areas other than weight/food
     2. Parent-empowerment
•   Parents in authority: Siblings play patient-
    supportive (not parent-supportive) role
•   Parents‟ supervision and involvement in
    adolescent‟s eating and weight-related
    behaviors is temporary: once ED hold is
    released control is returned to adolescent
•   Parents return control of eating and
    weight-related behaviors to adolescent after
    eating patterns normalized and purging
    discontinued
FBT can be demanding …it
takes time and focused effort.
    3. Focus on restoring healthy
            eating habits
   Initial task is focus on healthy eating
    habits and normalizing eating at home:
    parents manage the eating disorder
   Family encouraged to work out for
    themselves how to best manage eating
    disorder symptoms: restore healthy eating
    and curtail purging
    4. Separate illness from child
   Adolescent is ill rather than obstinate:
    prevent criticism of patient

   Illness is externalized: symptoms don’t
    belong to child, illness overtakes child

   Parents sympathize with the plight the
    illness has created for their offspring

   Therapist models sympathy and
    understanding
    5. Therapist as consultant
•   Outpatient family therapist acts as
    consultant and coach
•   Therapist asks, “What will it take to
    restore your child’s health?”
•   Therapist guides, assists, encourages
    parents to take an active role
•   Reminds parents of their skills
•   Reinvigorates when parents
    discouraged
Other professionals on the team:
   biopsychosocial approach
   The family therapist leads the treatment
    philosophy – make regular team contacts
   Co-therapist in family therapy, if available
   Nutritionists, physicians,
    psychopharmacologists act as consultants
   Close medical management is important:
    weights usually taken by therapist, objective
    weights occur in physician‟s office
   Everybody on the same page: team
    members need to be familiar with the treatment
    philosophy and allow it to guide their contact
    with the patient and family
Three phases of treatment with
 Maudsley approach or FBT
•   Phase I: Establish healthy eating and
    curtail purge behavior (1-10 sessions or as
    needed)
•   Phase II: Return control of eating and
    weight management to the adolescent
    (Sessions 11-16 or as needed)
•   Phase III: Address family and normal
    adolescent developmental issues (Sessions
    17-20 or as needed)
Phase I:
The eating
disorder
rules
Phase III:
Adolescent has
mastered the
symptoms
                 Phase III
•   Attention to other family and
    developmental problems deferred until
    later in therapy when illness no longer
    basis for interaction unless there is
    obvious interference with therapy

•   Phase III already familiar to
    experienced therapists
             Duration of FBT
   Studies (Lock et al, 2005) and others studying
    FBT show treatment of AN lasts from 6 to 18
    months with anywhere from 9 to 47
    sessions.
   Study by Lock, Agras, Bryson, and Kraemer
    (2005) shows short-term course of family
    therapy for AN as effective as long term,
    regardless of intensity and duration, except in
    case of non-intact family and more severe
    eating-related obsessive-compulsive features
   Length of each phase can vary, especially with
    BN: be flexible, maintain integrity of protocol
    (example: comorbidities with BN)
                               Weight gain over time: 14 y/o Height: 67 in.
                                            FBT Approach

                 150


                 145


                 140
Weight in lbs.




                 135


                 130


                 125


                 120
                       0   5           10        15           20       25     30   35
                                                      Weeks
Traditional family treatment
    model: similarities
   Family support recruited

   Family-based guidelines commonly given
    to parents during nutrition restoration

   Like Maudsley or FBT, unity/coordination
    of treatment professionals across
    disciplines required
        Key differences between
        traditional family and FBT
                approaches
Traditional approaches:
 A combination of individual and family
  sessions are included from the beginning.

   Strong emphasis placed on developing
    assertiveness, autonomy, and self-control
    in adolescents from early stage.
   May involve child meal planning
Traditional approaches:
 Buy and keep around the house a wide
  variety of nutritionally balanced foods for
    child to chose from
•   Family meals: encourage parents not to
    comment on child’s eating behavior
    at meals: neutral discussion topics
•   If patient does not want meal prepared by
    parent, child prepares an alternative
    meal to be eaten at family meal
Traditional approaches:

   Parents avoid responding to requests from
    child for reassurance about food choices

   Binge/purging patients need to clean up any
    messes and replace binge foods

   Parents do not disrupt dieting, exercise, or
    purging: child typically reports symptoms to team
                                  Weight change over time 14 y/o 64 in.
                                      Traditional family approach

                   130




                   125




                   120
Weight in pounds




                   115




                   110




                   105




                   100
                         0   10       20              30                  40   50   60
                                                    Weeks
Harnessing parents’ anxiety
         with FBT
   Families are highly anxious when they
    present for treatment
   Families are often preoccupied with
    food, weight, and purging and eating
    behavior
   Families are often feeling helpless and
    despairing
   Families are often frozen with fear because
    of the life-threatening nature of the illness:
    rigid about change
   Families may be avoiding any stress or
    conflict that they think will aggravate
    their child’s symptoms
   If conflict does ensue or there is failure at
    pre-treatment attempts to restore healthy
    eating, guilt and blame result
     Therapist harnesses the
             anxiety
   Therapist validates, joins, and enhances anxiety
    in early phase of treatment: use anxiety as
    motivational tool
   Families are relieved from their
    helplessness: therapist gives direction, control
    and clear responsibility to parents under
    watchful eye of therapist.
   Get family organized, consistent, persistent
   Families are relieved to have therapist join their
    primary focus on managing and
    eliminating eating disorder
   Enhance therapeutic alliance by
    searching for and identifying family
    strengths that may surface in the midst of
    family helplessness and anxiety,
    e.g., find positives in enmeshment, “This is
    close knit family with lots of caring and
    support.”
What family characteristics
need to be facilitated with
           FBT?
   Parental unity: parental agreement needs to
    be present
   Willingness to take control or supervise:
    starvation, pathological eating, purging not
    an option, parents may be reluctant
   Patience and empathy: parents try to
    understand the patient’s internal landscape
   Organized, persistent and consistent:
    available daily, routinely
   Willingness to see the therapist as
    collaborator: de-mystify therapy as having all
    the answers
   Non-blaming of child for eating
    disorder: parental criticism found to be
    associated with poor outcomes
    (LeGrange et al, 1992): Separated
    family therapy may be necessary
   Willingness to let go of parental self-
    blame
   Tolerance of child’s anger and
    resistance to change
   Knowledgeable of ED’s and Tx goals
   Flexible, e.g., let go of “why?”, put
    recovery first, be experimental
       When not to use FBT
   Excessive marital discord, parental disunity
   Parent(s) too disabled
   Lack of understanding child‟s eating disorder
   Excessive, chronic parental self-blame: often
    results in excessive parental frustration, anger,
    defensiveness, lack of therapeutic alliance
   Child too ill with other mental health or medical
    problems
   Too few resources or opportunities
   Unable to attend initial sessions at least 3x per
    month
                               Weight gain over time: 14 y/o Height: 67 in.
                                     FBT Approach with anorexia

                 150


                 145


                 140
Weight in lbs.




                 135


                 130


                 125


                 120
                       0   5           10        15           20       25     30   35
                                                      Weeks
Important differences in AN
          and BN
 (LeGrange and Lock, 2007)
   More adolescents with BN – 2-5% of
    adolescent girls with BN (Walsh and Wilson,
    1997). Some have progressed from AN.
   Broader specturm of co-morbid illnesses
    with BN, e.g., self-harm behaviors common:
    can derail the therapy
   AN often arouses more fear making it easier
    to stay focused on ED symptoms
   BN more secretive, less obvious: patient
    may appear well, detracting from parental
    motivation
Important differences in AN and BN
   BN usually ego-dystonic: more shame,
    embarrassment, & motivation to get rid of
    binge/purge symptoms – child unable to stop or
    interrupt symptoms
   BN adolescents often appear more
    independent: have more active life experiences
    - parents de-motivated to interfere with
    adolescent freedoms and emerging independence
    by supervising eating and purging behaviors
   BN often more connected to peer group,
    reactive to others: higher peer exposure and
    motivation to yield and conform to ideal to be
    thin or perfect (AN more self-willed)
            FBT in phase I

1.   Take weights with patient individually,
      then join family in session

2.   Harness anxiety to motivate family
3.   Take a history from each family member
      about the impact of ED

4.   Give parents permission to involve
      themselves actively with adolescent‟ s
      eating
                            Weight chart
Weight
In
Lbs. or
kg.

   115

   110

   105

   100



Date of session 1   2   3    4   5   6   7   8   9   10   11   12
       Phase I: Family picnic

5. Family picnic: forbidden foods +
  healthy amounts of food




            Role play
               Phase I
6. Re-emphasize goal is to normalize
   eating and eliminate binge eating
   and purging.
7. Congratulate any progress,
   sympathize with lack of progress,
   reinforce vigilant stance against ED
                  Phase I
8.   Regularize, organize family meals: parents
     supervise eating

9. Sibling support defined

10. Therapist helps parents eliminate criticism
    and judgment as well as avoid arguments with
    patient: will improve patient‟s honesty, reduce
    shame and guilt common with BN
   Differences between AN & BN
 treatment interventions in Phase I
Take more firm control with AN:

With AN review weight charts each session. Look
 for progress in the form of an upward
 trajectory as sessions progress

With BN, keep binge and purge charts, take
 weights with patient individually, then join family
 in session. Report B/P progress to family, not
 weight with BN, unless extreme weight loss
    Patient binge/purge log
(LeGrange and Lock, 2007, p. 29)
 Day        Binge       Purge
 1
 2
 3
 4
 5
 6
 7
#      Therapist binge/purge charts
O    (LeGrange and Lock, 2007, p. 30-31)
F
     8
P
U
     7
R
G
     6
E
S
     5
Or   4
B    3
I
N    2
G
E    1 2     3     4      5     6     7        8   9   10
S
           Date of session or session number
Show respect for the adolescent’s point of
  view and experience: adolescents with AN more
  regressed than adolescents with BN - help
  shape eating behavior of adolescent with BN
  while carefully keeping some distance from
  adolescent‟s other life activities:
 Say to parents: “Your role is to help your child
  get better with your daughter‟s (or son‟s) help.”
With BN parents negotiate with adolescent
 to help disrupt binge eating and purge
 episodes:
    examples:
    (1) negotiate planned distractions
    (2) adolescent fills out B/P chart with parent
        reminders
    (3) parents and child agree to work on one
        problem at a time
Dealing with parental hostility

The Effective Meal Support for Family and
Friends video: British Columbia Children‟s
Hospital
    How to deal with parents’
            hostility
   Model non-critical acceptance of patient and symptoms
   Help parents blame the illness, not the child
   Carefully identify ways instance of
    criticism/hostility got in the way of progress – look
    at pain underneath hostility, e.g., parents overburdened,
    exhausted, frustrated
   Find alternative ways to handle hostile interaction:
    “The eating disorder (rather than child) is a very selfish
      illness right now – it is trying to stop you from eating.”
   Call on less critical parent/caretaker to support and
    assist in decreasing critical comments, finding
    alternatives
       Returning autonomy to
            adolescent:
              phase II
   In Phase II, use treatment to begin introducing
    return to normal adolescent development:
    foster autonomy
   Parents’ anxiety reduced and confidence in
    managing illness is high
   In case of AN, patient has surrendered to the
    parents‟ demands in Phase I
   In case of BN, begin to return control of
    eating and related purge behaviors to
    adolescent under parental supervision.
             Phase II: When?
 Patient able to eat without cajoling by
  parents

   The hold of the AN or BN over excessive weight
    preoccupation, diet strategies, and binge and
    purge behaviors broken by collaborative efforts
    in Phase 1: Binge/purges less than 1-2
    times per month.

   Family ready for increased independence
    from therapist

   Healthy weight is restored/weight stable
                 Phase II
   Use of diet supplement drinks or bars
    discouraged heading into phase II
   Sessions more spread apart: every 2-3
    weeks OK
   Examine relationship between adolescent
    issues and development of ED
   Therapist introduces previously set aside
    non-eating-disorder-related issues
   Continue to monitor and modify criticism
    of adolescent by parents or sibling
   Weights and binge/purge behaviors
    continue to be monitored until Phase III
   Continued reinforcing of the difference
    between illness-driven thinking and
    healthy thinking
   Monitor parents‟ increased temptation to
    criticize patient as she or he takes over:
    support best efforts of patient.
   Healthy eating habits and absence of
    purging behavior remain the focus of
    treatment even as parent supervision
    is phased out
 Ways to decrease parental
        supervision
1. Adolescent gradually makes more food
  choices as long as choices are healthy and in
  adequate volume: e.g., allow some healthy
  substitutions
 2. Reduce supervision of snacks
 3. Reduce supervision of one meal at a time
 4. Increase food shopping responsibility and
    meal preparation
      Decreasing parental
         involvement
5. Eat alone sometimes versus with
  family
6. Adolescent able to report urges to
  purge/restrict/binge to parents and ask for
  support, when needed
7. Adolescent dishes out own portions
  under watchful eye of parents
Role play




Phase II
        Pitfalls of negotiating
                Phase II
   Patient sees the lull coming out of Phase I
    as a long-awaited opportunity to resume
    unhealthy eating and purge behavior and
    therapist/parents fail to renew supervision
   With AN, family and/or therapist mistake a
    suboptimal plateau in weight as adequate for
    moving to Phase II: encourage appropriate
    anxiety about relapse
   Therapist influenced by other team
    members
                 Other pitfalls
   Parents/therapist too exhausted to move on and
    wish to stop treatment once health restored: make sure
    adolescent well on the way to normal adolescence before
    moving on, e.g., adolescent realigned with peers while
    parents refocused on normal adult lives
   Failure to see connections between adolescent issues
    and development of ED: must understand ways in which
    ED is a form of communication, currency in family
   Therapist takes too much responsibility for family
    problem solving: therapist must advocate family arriving
    at their own solutions, assist the family process
   Parents too traumatized/anxious to let go of
    control: become critical
   An artificial deadline for “getting finished” looms: e.g.,
    college
                               Weight change over time: 17 y/o Height: 70 in.

                 140


                 135


                 130


                 125
Weight in lbs.




                 120


                 115


                 110


                 105


                 100
                       0   5      10     15     20      25     30     35        40   45   50
                                                      Weeks
    What parents have to say
   Helpful: Laura Collins, “Olympia‟s mind came back
    incrementally. It was one bite at a time.” (p. 142)
   Anxiety-provoking to have so much responsibility
   In beginning difficult to let go of pursuing “why” ED
    occurred.
   Parents say they second-guess themselves about letting
    go of supervision, e.g., give adolescent a choice then act
    disappointed
   Parents sometimes say they didn‟t know what their child
    was eating before FBT: chaotic meal times
   Parents find occasional nutrition consultation important
   Parents usually need consultation about restricting
    exercise: how much? how often?
What patients have to say
   Two studies (Krautter and Lock, 2004 and le
    Grange and Gelman, 1998) have found both
    patients and parents find FBT helpful and
    successful, although many adolescents reported
    a need for more individual therapy.
   Observations of patients:
    - Adolescents appreciate seeing their parents
    relieved from their anxiety. Many tend to
    worry about their parents‟ distress.
    - If given a choice between a more traditional
    model and FBT, many choose FBT because
    they felt out-of control of ED
 Adolescents’ reactions to FBT
Adolescents generally form a good
 therapeutic alliance even though therapist
 supporting their parents‟ supervising their
 eating and weight management behavior:

 they know you know and know they
 need help
“Yelling at my mother about food was the first
   time I ever yelled at her since I was little.”
“I hate this even though I understand why my
   parents had to do it.”
“I can tell my father when I feel like purging and
   he helps me think about it and not vomit.”
“I have learned the best way to eat things I am
   afraid of is just do it.”
“Later on when I went to college I had trouble
   eating enough consistently but I never lost my
   ability to eat all kinds of foods I learned to eat
   with my parents. That did not change.”
“I might as well gain weight because my parents
   won‟t give up.”
“Don’t give up too soon, as the family is
 the best resource for recovery.”



 (Lock et al. 2001. Treatment Manual for Anorexia Nervosa: A
 Family-based Approach. NY: The Guilford Press. p. 21.)
                REFERENCES Meal
British Columbia Children‟s Hospital (2002) Effective
   Support for Family and Friends (DVD-R and VHS film)
Collins, Laura (2005) Eating with Your Anorexic. NY: McGraw
   Hill.
Eisler, I The empirical and theoretical base of family therapy
   and multiple family day therapy for adolescent anorexia.
   Journal of Family Therapy, 2005; 27:2, 104-131.
Eisler, I., Dare, C., Hodes, M., Russell, G.F. M., Dodge, E. and
   LeGrange, D. “Family therapy for adolescent anorexia
   nervosa: The results of a controlled comparison of two
   family interventions.” Journal of Child Psychology and
   Psychiatry. 2000; 41, 727-736.
Haltom, C. (2004) A Stranger at the Table: Dealing with Your
   Child‟s Eating Disorder. Denton, TX: Ronjon Pub. (in Gurze
   on-line catalog)
Krautter, T. and Lock, James. Is manualized family-based
  treatment for adolescent anorexia nervosa acceptable to
  patients? Patient satisfaction at the end of treatment.
  Journal of Family Therapy. 2004; 26: 65-81.
Le Grange, D., Eisler, I, Dare, C., and Hodes, M. Family
  criticism and self-starvation: A study of expressed
  emotion. Journal of Family Therapy. 1992; 14: 177-192.
Le Grange, D., Eisler, I., Dare, C., Russell, G. Evaluation of
  family treatments in adolescent anorexia nervosa: A pilot
  study. International Journal of Eating Disorders. 1992;
  12:4: 347-357.
Le Grange, D., Gelman, T. The patient‟s perspective of
  treatment in eating disorders: A preliminary study. South
  African Journal of Psychology. 1998;
    28: 182-186.
Le Grange, D. and Lock, J. The dearth of psychological
  treatment studies for anorexia nervosa, International
  Journal of Eating Disorders 2005; 37,79-81
Le Grange, D. and Lock, J. Treating Bulimia in Adolescents:
   A Family-Based Approach (2007) NY: Guilford Press.
Le Grange, D., Lock, J., and Dymek, M. Family-based
  therapy for adolescents with bulimia nervosa. American
  Journal of Psychotherapy. 2003; 67, 237.
Le Grange, D., Loeb, K., Van Orman, S., Jellar, C. Bulimia
  nervosa in adolescents: A disorder of evolution? Archives
  of Pediatrics & Adolescent Medicine. 2004; 158:5, 478-
  482.
LeGrange, D. and Schmidt, U. (2005) The treatment of
  adolescents with bulimia nervosa. Journal of Mental
  Health. 14:6, 587-597.
Lock, J. (2006) The role of family therapy for adolescents
  with anorexia nervosa. Psychiatric Times. Sept 1, 2006.
  CMP Media LLC.
Lock, J., Agras, W.S., Bryson, S., Kraemer, H. A comparison
  of short-and long-term family therapy for adolescent
  anorexia nervosa. Journal of the Academy of Child &
  Adolescent Psychiatry. 2005; 44:7, 632-639.
Lock, J., Courtier, J., Bryson, S., Agras, S. (2006) Predictors
  of dropout and remission in family therapy for adolescent
  anorexia nervosa in a randomized clinical trial.
  International Journal of Eating Disorders.
  39:8, 639-647.
Lock, J. and Gowers, S. (2005) Effective interventions for
  adolescents with anorexia nervosa. Journal of Mental
  Health. 14:6, 599-610.
Lock, James and Le Grange, Daniel. (2005) Help Your
  Teenager Beat an Eating Disorder. NY: Guilford Press.
Lock et al. (2001) Treatment Manual for Anorexia Nervosa:
  A Family-based Approach. NY: Guilford Press.
Lock, J. LeGrange, D., Forsberg, S., and Hewell, K. (2006)
   Is family therapy useful for treating children with
  anorexia nervosa? Results of a case series. Journal of the
  American Academy of Child and Adolescent Psychiatry.
  45:11, 1323-1328.
Minuchin, S. et al (1978) Psyhosomatic Families: Anorexia Nervosa In
   Context. Cambridge, MA: Harvard University Press.
Siegel, M., Brisman, J. and Weinshel, M. (1997) Surviving an Eating
   Disorder: Strategies for Families and Friends. New York: Harper
   Collins Publishers.
Tantillo, M. “Staying afloat in a sea of disconnections: using a
   multifamily therapy group to engage patients, families and providers
   in the treatment of eating disorders,” Presentation at Renfrew
   Center Foundation Conference. Philadelphia, Pa. Nov. 11, 2006.
Treasure, J. Whitaker, W., Whitney, J., and Schmidt, U. Working with
   families of adults with anorexia. Journal of Family Therapy. 2005;
   27:2, 158-170.

								
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