In this podcast Tabitha Farrar talks to Dr Adele LaFrance about Emotion Focused Family Therapy in eating disorder treatment.
Links to resources:
Hello there welcome to this weeks podcast. This week I am delighted to have a conversation with Doctor Adele LaFrance who is a psychologist and she’s based in Denver. She is also the co-founder of something called Emotion Focused Family Therapy which is a pretty interesting concept and I think maybe a helpful addition for anybody who is struggling with the refeeding process themselves or who is refeeding a loved one or just knows somebody that is going through that. Cause it’s pretty emotional isn’t it? Refeeding. Food. Weight gain. All of those things. So I’m super excited to talk to her about this, we are going to get on with it without further ado. Here is Doctor Adele LaFrance:
Dr Adele LaFrance: I’m a psychologist and an Associate Professor at Laurentian University. I’m co-developer of Emotion Focused Family Therapy which is a new treatment model that was developed for eating disorders. So I do a lot of research as well.
T: Great, so tell us a little bit about the Emotion Focused Family Therapy.
Dr A: So Emotion Focused Family Therapy kind of was developed in response to treatment failures actually. So I was doing family based treatment which is a well know first line approach for treating family based eating disorders in children and adolescents. But I was working in a day treatment program and family based treatment was developed for an Outpatient. So we were adapting the model because we really wanted to harness the power of caregivers. But there were times where parents wouldn’t engage in the treatment or would refuse to engage in certain interventions. Or would accommodate or enable their loved ones symptoms.
And for a while I fell into the trap of blaming parents for not doing the right thing, or not caring enough, or not getting it. So those were the kind of three tag lines that used to come out of my mouth unfortunately. Then I started to get really curious about why, why is this? Why is it that this mum doesn’t want to support her daughter to finish her milk? Why is it that this dad doesn’t want to support his son in finishing this meal? Through clinical exploration, through asking lots of questions of caregivers, and doing some research, what I found was, what we just talked about when parents struggle to support their loved ones recovery in these ways, it had nothing to do with motivation, it had nothing to do with whether or not they got it, and it had way more to do with how afraid they were that something worse would happen.
So that was one element, the other element was, I was coaching parents and caregivers to support their loved one to eat more and to have fewer symptoms but aside from encouraging them to eat more or not to engage in symptoms, I wasn’t really teaching them any strategies to actually increase the effectiveness of their efforts. I write often about this one particular scenario but there was this time when parents came in and said, yeah we got her to eat more but plates went flying in the kitchen. I was like what? Plates went flying? I couldn’t believe it! And there had been many many stories to come of similar outbursts and I thought, oh my gosh we need to support these parents and caregivers with skills so that there doesn’t have to be this level of conflict and in some cases, trauma. You know? When we are supporting children and adolescence to eat more.
So from those two observations, two conundrums actually in which I found myself and I felt helpless as a clinician. I started working with others to find ways to make it more likely that mealtimes could be successful but also less conflictual. So part of the Emotion Focused Family Therapy model is teaching parents and caregivers emotion coaching skills so it’s a very structured form of support to increase compliance, to decrease outbursts but also to strengthen the relationship. So instead of going through this difficult phase of battling it out with the eating disorder, using these skills can actually improve the relationship between the parent or caregiver and their child.
So that was one element. The other element though was that we found in doing so, in using these emotion coaching strategies, what would happen over time is that the child or adolescent would actually internalise the ability to process their emotions in healthy and adaptive ways. Which meant that they no longer needed symptoms to cope with stress or emotional distress.
I was really interested in that part, I spoke to neuroscientists and asked them, how does this happen? And they explained to me that when parents engaged with their loved ones using these techniques even if it doesn’t, quote unquote, work in the moment, the process stimulates building blocks of the brain that facilitates some neural rewiring between the frontal lobe and the limbic system which means that these individuals who are on the receiving end of the emotion coaching whether it’s around meal times or eating disorder thoughts, they are actually benefiting from the creation of new pathways that serve to regulate emotional experiences.
T: So can you give me an example of how this could play out, say in a family scenario or in a real life meal time. What the difference might be?
Dr A: Absolutely, so lets say, I’ll use a teenager but Emotion Focused Family Therapy is applicable across the lifespan, so it is a lifespan but lets use a teenager, parents are supporting her to eat, they put a plate of food down in front of her and she says, I don’t want to eat that. A very common response would be, well you have to, you’re not well, so using logic for example to try to convince their loved one to eat more.
Well the problem is if emotion is high, the individual loses access to rational thought. They lose access to logical reasoning, they lose access to problem solving. So using a rational approach when the person is in the emotion brain doesn’t work. So instead we would coach the parents to say something like this, I don’t blame you for not wanting to eat that, you haven’t eaten pasta in a really long time and pasta is a food that you have some fears around and I could imagine that you might actually be scared of feeling really bloated afterwards or that you might gain too much weight this week. So it makes sense to me that you wouldn’t want to eat that pasta.
Now that’s the paradox! When the external the environment can mirror the internal experience. The alarm bells of the brain go down, they lessen in their volume. But this is not a typical way of responding to someone who has a life threatening eating disorder. So we really using the latest of what we are learning in the context of neuroscience to increase engagement so once a parent responds that way, their loved ones brain will be more flexible. It will be more likely to follow through with the meal and so when the parent says, OK sweetie you have to eat this pasta and we’re going to stay with you until you’re able to do that. The engagement is going to be a lot higher.
So that’s one of the things that we do, we coach parents to use these strategies to increase compliance, increase treatment engagement and then also increase the extent to which the sufferer feels heard and feels understood which then strengthens that relationship.
Another example is when people say, I feel fat. So if you kind of think, what’s your gut response? When someone says, I feel fat? It’s probably like, oh no you look beautiful, or you look great. And now imagine, someone who’s severely malnourished, says I feel fat. Again, when we respond with the oh my gosh, you’re not fat, you’re underweight, really underweight, you’re really ill, we need to something more and that’s not how we see you. So all of that type of responding, which is very normal, very normal. Unfortunately it increases the stuckness in the other because they don’t feel felt.
Instead we validate what it must feel like to feel fat in an emaciated body. If anyone has ever felt fat for a second in their life, they know what it feels like. The scales haven’t changed but when you have a day when you feel fat, it feels gross, you feel like hiding, you feel embarrassed, you feel afraid of judgement and so that’s how you can actually validate somebody’s experience of feeling fat even if they are really underweight. Again, doing so will decrease the rigidity of the brain when it comes to that feeling.
T: How do you then, do you then work with parents and caregivers to help them understand these things?
Dr A: Yes, so we can work with the whole family. But to be honest I actually find it more efficient to work with the caregivers on their own. So that we can teach them these skills but then they can also practice them. They can practice them in a way that’s uncensored. So they can let us know what their fears are, let us know what their concerns are as part of the EFFT model I developed a measurement tool and it has to do with treatment engagement fears. So that’s also part of the work so we will ask parents straight up, if you engage in this work with your loved one, if you support them in the behavioural management of their symptoms, with their emotional support, what are you afraid might happen that would be worse?
And there is a whole list of items, one of them is, I’m afraid if I do this I’ll burn out, or I’ll break down. Or I’m afraid if I do this, if I push her too hard the distress will cause her to commit suicide. I think that those are really really important conversations to have on the front end. And better to have those conversations one on one with the caregivers so that they can really reveal the extent to which they are suffering with those fears. Doing so helps to reframe and better understand when parents and caregivers engage in behaviours that are unhelpful or even obstructive.
I’ve learnt this from caregivers, oh my gosh, they have been my greatest teachers. I remember this one woman, and I was very critical of her so I’m just going to be honest about that, I was very critical, very frustrated. I couldn’t understand why she wouldn’t follow through on the treatment recommendations to support her daughter. After some head butting in session, I finally got a clue and realised what was going on, it turns out mum’s sister in law had attempted suicide when she was a teenager, had an eating disorder and looked a lot like her daughter. So whenever mum and dad would encourage her to eat more, or increase the pressure on her to eat more and daughter would start to feel sad, withdrawn, depressed, they would back right off because they were terrified that she could be pushed so far as to try to kill herself.
So it was like, no wonder they are pushing back! Which parent wouldn’t? It made so much sense. So we were able to figure out how to extricate the parents from the rock and the hard place, sick kid or dead one. That became a huge component of Emotion Focused Family Therapy where there is a whole module of tools and techniques including psychotherapeutic ones to help parents move through what we call emotional blocks. Really an emotional block is just any time when someone’s emotion robs them of access to their instincts or leads to inflexible patterns of behaviour. That usually comes from fear.
T: So when that emotion is really getting in the way of them being able to see what the answer is or what needs to be done.
Dr A: Exactly and there is a module for clinicians as well because I’ve done some research among clinicians working with eating disorders and I found that it turns out we really are all human and clinicians get blocked by their own emotions, their fear, their fear of being to blame. They are also engaged in behaviours that can be treatment interfering that can exclude parents/spouses from treatment if they are scared that involving them could make it worse.
We are all human so whether you’re the person with the eating disorder, their parents or their clinicians, every person in the system is going to be faced with situation at one time or another where their fears are going to interfere with treatment.
T: Right. And you are able to give an example to illustrate that sort of scenario?
Dr A: Absolutely. So I do clinician training in EFFT regularly and one of the common questions is, if a parent has an eating disorder, shouldn’t we exclude them from the treatment? Wouldn’t it make it worse if we included them? And so their fear of the parents influence will make it more likely that they will exclude that parent from the treatment process. Whereas we found that parents who have eating disorders that are active can actually be very good supports to their loved ones. There are some special considerations for how to frame that involvement but they don’t need to be excluded and they can be quite helpful.
So that’s one example. Another example is that, and I just did a clinician training this weekend. Part of the training as clinicians is to stand up and admit to their fears and the way that their fears interfere with treatment. So it’s such a beautiful thing actually. It’s really quite nice, a number of clinicians are scared of being to blame. So when treatment starts to get rocky, I’ll seek out multiple second opinions from my colleagues to reassure myself that it’s not my fault or that it’s the systems fault, or that well this family is just a really difficult family. So clinicians blame family members or point to their low motivation as a way of defusing their own fears of being to blame.
Another clinician shared with me that sometimes they wouldn’t bring cases to supervision if they were feeling particularly triggered by a family. This is not to criticise clinicians at all. This is going to happen to you no matter what. It happens to me all the time. Even though I do research in the area, this is just part of being human. Like it can happen with parents and caregivers, it happens with clinicians as well. So I say it’s not about it happening, it’s about, what do you do to increase your awareness of the process and to deal with the process, either individually or as a team.
T: I like the recognition that it’s not just caregivers and it’s not just the actual people in recovery themselves, that often have emotional blocks that they need to process in order to help a person through recovery in the best way that they can. I don’t know, sometimes I have the impression that sometimes that sort of thing doesn’t go over well with all the clinicians.
Dr A: What do you mean?
T: The idea that the clinician might be part of the block.
Dr A: You know I’ve been really lucky that I’ve been able to work with the clinicians who are quite open to that possibility. I think that like anything if a clinician is afraid of being judged or being blamed then they will be less revealing of themselves and they might be more resistant to that framework and so it might speak to the need for some TLC around the culture in that workplace.
But on the whole I have had quite positive experience with clinicians who are open to talking about it, exploring it but there needs to be some element of safety with vulnerability. But we do have a ways to go because one of the studies that I did, your observations as astute, one of the studies that I did among eating disorder clinicians, I asked them about the influence of emotions on clinical decisions and they were randomly assigned to either answer about their own emotions, or the emotions of their colleges. What we found was that there was a huge difference in the response rates. The clinicians that were answering about themselves said it was happening a certain amount of times, but when the clinicians were answering about their colleagues they reported it happening about twice as often. So there is definitely some evidence of a blind spot.
T: Right, that’s so interesting. Actually that has surprised me, maybe I shouldn’t be surprised by that but it’s quite interesting that’s why we do research isn’t it? Because it brings up things that might not be obvious. How then do you use that information to work with clinicians? Do you think that just telling people that research will make people think and wonder about themselves?
Dr A: Absolutely, I use the research to say, hey this is normal, lets talk about it. I really want to increase the frequency of these conversations so they can be normal, so we can see these responses as normal, to be expected and part of being human. So my goal in doing the research was not to out clinicians to being blinded by their biases. My goal was to normalise the process so that as a field we can talk about this without pointing fingers.
T: That’s really cool. I love this. Do you think that this sort of research and these sort of I guess trainings and discussions. Do you think that they are something that’s happening quite a lot in the field? Or do you think it’s something that needs to be developed a lot more?
Dr A: Well I think that we have a ways to go to make it so that eating disorder treatment involves caregivers in a more systematic way, especially with adult sufferers. I do think that we have a ways to go in terms of creating a culture among clinicians where it’s absolutely normal to talk about our biases and our blind spots. So yes I would encourage more of these conversations.
T: Say clinicians are operating independently do you think that when they are not in an environment where these sort of discussions are happening a lot, do you think that leads to being a little bit more insular and not really reflecting on their own practice?
Dr A: I don’t have the data on that but I can talk about what my research suggests. My research suggests that being on a treatment team increases the extent to which clinicians can become aware of and appreciate the extent to which their emotions may influence their practice. So being on a treatment team is a protective factor. So I would certainly encourage clinicians who are on their own to join peer supervision groups so that they can protect themselves from their biases. On the other hand, I have seen also on teams that clinicians can become polarised in their perspectives depending how things go. So I’ll give you an example, so we used Janet Treasure’s Animal Models but on clinical teams as well.
So everyone on the team identifies as a kangaroo or a rhino for example. So if you’re a kangaroo, you tend to be overprotective, you tend to want to increase length of stay, increase treatment intensity. If you’re a rhino you may look at it more practically, you might push for discharge so that the person can be more independent and so on. Now if you have a rhino or the team and you have a kangaroo on the team and you’re making a decision about discharge, when the kangaroo does their kangaroo thing, it might actually make the rhino even more rhino and then both those clinicians end up polarising in their tendencies. So if the team isn’t aware of these polarising effects then it can increase the potential for problems both in terms of team cohesion but also in decision making. So whether you’re in private practice working on your own, or in a team, we all have to think about how to protect ourselves from ourselves, but it’s going to be slightly different in terms of the focus.
T: That’s a really great example, thank you and so I’m now thinking that there will probably be parents listening to this podcast who after you have given that example, might be, it may be occurring to them that they are seeing that happen in the team that is helping them with their child or something like that. So, how would an outsider of that team, if this team isn’t aware of these things and hasn’t been through such trainings to build awareness. How might an outsider help draw awareness? Are there resources for this?
Dr A: Yes so if you go to emotionfocusedfamilytherapy.org the model is laid out. Mentalhealthfoundations.ca has so many resources available and we’ve just finished the first draft of the clinicians manual for submission through the American Psychological Association and there is going to be a whole section on that. There’s research available out there that I’ve completed, that others have completed.
I’m looked at these aspects but from a very very practical perspective, if I were a parent and I was worried that perhaps some of these dynamics were occurring, I would bring it to the team in a very respectful, validating manner. Because one of the things that I’ve found is that sometimes advocacy depending on how it’s delivered can have a counterproductive effect. If advocacy is done with aggression, criticism or judgement, I mean this is just a human process, the other person will respond with defensiveness and perhaps even counter responses.
So what I say to parents and caregivers and of course when I do these workshops for parents and caregivers, the EFFT caregiver workshop, I tell parents and caregivers that these things happen with clinicians too. So it’s not a secret, it’s very very open, we are all human but I also say to them, remember we are all human and so the best way to approach it is with respect and with validation so that you can have productive conversations which are more likely to be fruitful.
T: Well that was very interesting. I found that interesting especially from the perspective of somebody who had a lot of emotion around food at one time and it’s actually one of the things as a marker for progressing towards full recovery is when food ceases to be emotional. So I noticed that when I had an active eating disorder and I was restricting, food was emotional in two ways. First of all it was emotional from the malnutrition perspective, where my brain was trying to motivate me, my brain was using emotion to motivate me to eat, so it was using these lustful emotions towards food. Thinking about food all the time, fantasising about food.
But then there was also the fear based emotion of weight gain and the other things. Just eating the wrong thing or this idea that I could eat too much. So from there I was also have the emotions of regret, guilt, shame, disgust and feeling threatened by my strong emotions of wanting to eat a lot of food. So for me, one of the key things as I started to mentally recover and I’m talking regardless of your body size, mentally recover, was that food just ceased to be so emotional. You know, I still like food but it’s just not on the pedestal that it used to be, that’s for sure because my brain doesn’t need to do that any more because it’s not in malnutrition so it doesn’t need to put food on a pedestal. And I certainly don’t get any feelings of guilt, regret, shame or any of those things but I also did a lot of rewiring work to teach my brain that those emotions were not required after eating any more.
Thank you so much to Doctor Adele LaFrance for talking to me. I found that a very refreshing point of view and I hope that the resources that she provided there, I will link to those in the show notes, I really help that those help some of you and I love that she’s still doing a lot of ongoing research and I think that I can tell you that she’s going to come back and talk to us about some research that she’s doing into treatment resistant in binge eating disorder and things like that. I really hope she does because it’s such an area that needs more work and more help and more focus so definitely check her out, I’ll also see if I can link to her social media accounts so if you want to you can follow her and get in touch. Thanks for listening cheers and until next time. Cheerio.