Rocky Terrain: Challenging Ideas About How Professionals Look at Families

2. Rocky Terrain: Challenging Ideas About How Professionals Look at Families James Lock, MD, Ph.D Professor of Child Psychiatry Stanford University

3. Outline • How did we get here? Historical Context • Training Biases: How did therapists get here? • Family Biases: What do families expect? • How can we move forward? Challenges to changing attitudes and practices

4. Historical Context

5. “The child is exposed from "the beginning to parental coldness, obsessiveness, and a mechanical type of attention to material needs only.... They were left neatly in refrigerators which did not defrost. Their withdrawal seems to be an act of turning away from such a situation to seek comfort in solitude.” Leo Kanner, 1943

6. "The difference between the plight of prisoners in a concentration camp and the conditions which lead to autism and schizophrenia in children is, of course, that the child has never had a previous chance to develop much of a personality.“ Bruno Bettelheim

7. “we suggest, the double-bind nature of schizophrenia results in place a child in a position where if he responds to his mother’s simulated affection her anxiety will be aroused and she will punish him…to defend herself from closeness with him.” Bateson, et al, 1956

8. “The patients should be fed at regular intervals, and surrounded by persons who would have moral control over them; relatives and friends being generally the worst attendants.” Sir William Gull (1816-1890)

9. “It is necessary to separate both children and adults from their father and mother, whose influence, as experience teaches, is particularly pernicious” Jean Martin Charcot (1825-1893)

10. “excessive concern with the body and its size, and the rigid control over eating, are late symptoms in the development of youngsters who have been engaged in a desperate fight against feeling enslaved and exploited, not competent to lead a life of their own.” Hilda Bruck

11. Psychosomatic Families: enmeshed, rigid, anxious, over involved

12. Training

13. Training in Psychology and Psychiatry • Based in theoretical models • Many of these models are untested • Psychodynamic models are untested but strongly held • Focus on causation/etiology, but little data support suppositions • Treatment based on putative causes often biased against families • Instructors/time to change

14. Psychiatrists • Psychiatrist may be particularly challenged to work with eating disorders (fewer opportunities to work with this population) • Lack of clear effectiveness of medications • Lack of family therapy training • Turning it over to psychologists/family therapists • Few child psychiatrist and these disorders mostly onset in adolescence

15. Psychologists • Concern/anxiety of co-morbid medical problems • Insufficient training in specific therapies for eating disorders • Lack of exposure/experience with the eating disorder patients • Preference for individual approaches?

16. My experience • Developmental disorder • Parents over controlling • Professionals better than parents • Institutions better than parents • Losing/finding my way • Prophet in his own land • Re-institutionalization

17. Dissemination • Limited data for evidence-based practice • Clinician’s resist “manualization” as “cookie-cutter” and not “real world” • System problems—diagnosis, reimbursement, administrative/clinical/physical structures • Limited training/methods for dissemination of EVP • Specialists/Guild issues/accessibility

18. Interpersonal Factors (Couturier et al) • 65% (26/40) discussed their reluctance to commit to an evidence-based practice, stating “one size does not fit all” • 75% (30/40) felt it was imperative to involve parents

19. Results - Organizational Factors (Couturier et al) Administrative Buy-In I think that’s where the individual organizations have to make a commitment to supporting their staff because if they’re working in eating disorders then they need to actually provide their staff with the training so that they can deliver the best treatment possible Team Buy-In Definitely our treatment team …if they’re not on board then that makes it a little bit difficult to formulate a treatment plan that they don’t believe in.

20. Family Concerns • Want to know “cause” • Guilt and blame—overt and covert • Feel unprepared/unable to take on problem at home • Non-responders—what next? • Realistic expectations?

21. Moving Forward

23. Agnostic view of cause of illness (Parents nor adolescent are not to blame) Non authoritarian therapeutic stance (Joining with family) Parents are responsible (Empowerment) Externalization (Separation of child and illness) Initial focus on symptoms (Pragmatic) Fundamental Assumptions of FBT—Possibly applicable for therapists too?

24. What’s a therapist to do? • Embrace agnosticism/humility (non-authoritarian stance) • Empower oneself to learn • Accept consultation • Externalize the problem (separate the disorder from the treatment) • Focus on symptom change

25. Practice Forgetting What You Think You Know • ” I do not consider it an insult, but rather a compliment to be called an agnostic. I do not pretend to know where many ignorant men are sure -- that is all that agnosticism means.” Clarence Darrow • "Extraordinary claims require extraordinary evidence."- Carl Sagan • “In all affairs it’s a healthy thing now and then to hang a question mark on the things you have long taken for granted.” Bertrand Russell • “If you see a man approaching you with the obvious intent of doing you good, you should run for your life.” Henry David Thoreau • “When I told the people of Northern Ireland that I was an atheist, a woman in the audience stood up and said, "Yes, but is it the God of the Catholics or the God of the Protestants in whom you don't believe?“ Quentin Crisp

26. Possession Model

27. Treatment Process

29. Moving Forward—For Families • Empowering Families—with knowledge • Parental Advocacy—overcoming stigma (perhaps our biggest obstacle • Research in EBP (demand therapist practice it—depand research to develop new treatments) • Research in dissemination • Targeting professional education—Professional meetings, graduate schools, post-doc training programs