Parents of children with eating disorders face an extraordinarily difficult challenge; the work that they put into caring for their loved ones cannot be discounted. This can be especially challenging in the face of a social environment that tends toward parent-blaming for disorders. Further, the kinds of behaviors caregivers are obliged to encourage in the individual with an eating disorder (for example, eating calorically-dense foods in order to gain weight) are frowned upon, to say the least, in our “anti-obesity” oriented society.
There is a rich body of literature exploring caregiver well-being, including studies suggesting that increasing the availability of support in various forms from social to practical may help caregivers to navigate a complicated path toward supporting a loved one with an eating disorder. Researchers are asking key questions around what we can do to better support parents and other caregivers.
Along these lines, Goodier et al. (2014) talked to parents who had participated in a skills-based training intervention. They were interested in finding out more about whether this intervention helped to bolster against the potential negative impacts of providing care for an individual with an eating disorder.
By all accounts, giving care in general is no easy task. A number of studies (e.g. Haigh & Treasure, 2003; Zabala, Macdonald & Treasure, 2009; Perkins et al., 2009 and many others) highlight the challenges that providing care for an individual with an eating disorder can pose. This experience can lead to negative mental and physical health outcomes, including anxiety, hopelessness, role confusion, and stress, among other impacts.
Family-based treatment (FBT) is one popular choice for treating children and adolescents with eating disorders. This form of treatment has a high degree of parent involvement, leveraging parents’ support in guiding the child or adolescent through recovery (to read more about FBT, see this, from F.E.A.S.T., and Tetyana’s post here). Though not without controversy (there was a lively debate at ICED about FBT), many parents have embraced this approach, which allows for deep family involvement in the process of eating disorder treatment.
In the family-involved treatment vein, the New Maudsley Method (based on Schmidt & Treasure’s “cognitive-interpersonal model”) focuses on how family processes, including but not limited to carer distress and expressed emotion, can impact the course of anorexia nervosa, and accordingly includes an element of caregiver training.
PARENT SKILLS TRAINING TREATMENT (PSTT)
The PSTT was designed by Treasure et al. (2007) and is delivered in workshop format. As Goodier et al. describe, parents prepare by reading 2 chapters from the “Skills Based Training for Carers of People with Eating Disorders” manual; these chapters focus on interpersonal relationships and communication. The workshop itself is two days long, adapted from a 14-hour group treatment designed for caregivers. It is designed to build skills, such as:
- Open questions
- Reflective listening
- Change talk
- “Rolling with resistance”
- Functional analysis
- Behaviour modification
- Boundary setting
- Problem solving
(These skills are listed on page 370 in the article, and I would imagine they are described in greater detail in the book, though I have not read the book)
These skills are taught through a combination of more traditional information-provision style teaching and interactive exercises, such as reflection and discussion, therapist skill modeling, and role-playing.
To find out how participants responded to the treatment, Goodier et al. conducted semi-structured interviews with parents two weeks after the workshop.
11 caregivers participated:
- 6 mothers
- 1 step-mother
- 4 fathers
Caregivers ranged in age from 41-51, with a mean age of 44.5. Their children ranged in age from 11-14, with an average age of 13.3. 3 children had been diagnosed with AN-R, 3 with EDNOS (“AN-like”) and 2 EDNOS (unspecified). They had a relatively short illness duration, with an average of 5.8 months.
The researchers analyzed the interview data using thematic analysis, and two researchers coded the data separately and then compared results to bolster the rigour of the analysis.
THE MAIN RESULTS
Goodier et al. present their results around 3 main thematic areas:
- Intervention effectiveness and acceptability
- Interpersonal experience
- Feedback on content of intervention
Effectiveness and Acceptability
The parents in this study noted feelings of support and increased confidence stemming from the intervention; the authors note that parents used words like useful, helpful, beneficial, positive, and encouraging to describe their experiences in the workshop. Though some parents reported continuing difficulties following the workshop, parents also found that the intervention:
- Improved communication with their child
- Improved family dynamics
- Increased their feelings of efficacy (i.e. their sense of being able to manage the illness)
- Increased feelings of being able to cope
- Improved boundary-setting abilities
- Increased ability to externalize the eating disorder
The authors present quotes to illustrate each of these outcomes; I found this quote, relating to communication improvements, to be among the most compelling, as it speaks to a specific skill taught in the workshop and how a parent is using this in interaction with their child:
I find myself, particularly with the open-ended questioning…‘how do you feel about that etcetera’, that I’m using those sorts of statements more often right now and I think about my response before I say anything. So I’ve found it really helpful.
In speaking about the workshop itself, participants reported feeling supported within the group and so were able to discuss experiences that they had in common. Though the authors note that this was not a universal sentiment amongst group members, in general the workshop environment provided a safe space in which parents could openly share:
I think everyone was really open and frank. I think that really fostered that kind of atmosphere of sharing and caring for each other.
Feedback on Content of Intervention
Feedback on the actual content of the workshop was somewhat mixed. For example, while some parents perceived interactive activities to be enjoyable, others found that activities like role-plays provoked anxiety or uncertainty. Some suggested that there was too much theory and not enough about how to put theory into practice.
Parents were mixed in how they experienced the amount of content: some desired more detail, while others thought there was too much information. The following quote illustrates how the workshop might be experienced as partially helpful, particularly because what most parents are likely hoping for (what this parent described as “a miracle cure”) is not possible:
You’re still hoping you’re going to get a miracle cure, but yeah, it met expectations. It made me realise that education and understanding is everything you need, and it’s a long slow process of love and caring.
This study offers a first look at the use of a parent skills training program adapted from the New Maudsely Method. I’m always an advocate of talking to the people you are trying to reach, so I found it very encouraging that the researchers used a qualitative approach to get parents’ perspectives on the workshop.
Keeping in mind that you can’t please everyone (unfortunately!) it did seem as though parents were satisfied with the workshop. Encouragingly, the authors look to parents’ suggestions to modify future iterations of the workshop, for example by offering more opportunities to practice skills and integrating other members of the family, such as siblings. Parents also suggested that the workshop would be most effective early on in the child’s eating disorder, and that further developing the “safe space” for the workshop would enhance their ability to share openly and honestly.
I’m hopeful that this type of study also indicates movement toward increased engagement of parent perspectives in guiding family-based treatment, whether that is Maudsley or “New Maudsley”; if there was one thing that stood out to me in the debates around FBT at ICED, it was that parents want their voices heard and their opinions counted, especially in guiding forms of treatment that explicitly involve the family.
That being said, I think it is also important that, as both I and Tetyana have mentioned in prior posts, FBT/Maudsley/New Maudsley be presented as one treatment option among several… it bears repeating, as always that one size definitely does not fit all in eating disorder treatment! It might also be interesting to see whether a similar training workshop could help “chosen families” and other caregivers of individuals with eating disorders, or whether it could be adapted to fit the needs of those giving care to individuals with longer course disorders or to older individuals (i.e. beyond adolescence).
Goodier, G.H., McCormack, J., Egan, S.J., Watson, H.J., Hoiles, K.J., Todd, G., & Treasure, J.L. (2014). Parent skills training treatment for parents of children and adolescents with eating disorders: a qualitative study. The International Journal of Eating Disorders, 47 (4), 368-75 PMID: 24843891