Externalization Part 2 - The Analogy of the Solar Eclipse

During FBT treatment, it is important to consider the child’s capacity to make decisions. There are many analogies to help the parents understand that the eating disorder has made the child incompetent to have the age appropriate food control, and that they need to take responsibility. A classic analogy, which also illustrates the concept of externalization of the illness is a solar eclipse – refer to figure 1.


Figure 1 depicts the analogy of the solar eclipse. Whereby light blue refers to the adolescent that the family has known and loved; and bright blue refers to anorexia (the eating disorder) that tends to compare, negotiate, and manipulate

Here you would ask parents which of these scenarios resonates with them. It is not unusual for parents not to have the same perspective, and so it would be about having a conversation around this.

Accelerating Change: Part 2 "Using the Change Curve"

Author: Anna Oliver BSc, BPhEd, PGDipDiet, RD

With knowledge of the Change Curve, you can plan how you'll minimize the negative impact of the change and help your clients adapt more quickly to it. Your aim is to make the curve shallower and narrower, as you can see in figure 2.


Figure 2 – Using the Change Curve

You can use your knowledge of the Change Curve to give individuals the information and help they need, depending on where they are on the curve. This will help you accelerate change, and increase its likelihood of success.

Actions at each stage are:

Stage 1
At this stage, people may be in shock or in denial. This is when reality of the change hits. They need time to adjust. Here, people need information, need to understand what is happening, and need to know how to get help.

So effective communication is crucial. Make sure you communicate often, but also ensure that you don't overwhelm the individual / family. They'll only be able to take in a limited amount of information at a time. But make sure that people know where to go for more information if they need it, and ensure that you take the time to answer any questions that crop up so that people feel secure.

Stage 2
Stage two is the ‘danger zone’ - as people start to react to the change, they may start to feel concern, anger, resentment or fear. They may resist the change actively or passively. They may feel the need to express their feelings and concerns, and vent their anger. Make sure that you, and in the case of child – their parents, are prepared for this stage; so you can make it as short lived as possible. But be aware: you can't anticipate exactly how each person will react, so watch, listen and support as necessary.

Stage 3
This is the turning point for individuals – they are starting to accept what’s happening. As people's acceptance grows, they'll need to test and explore what the change means. They will do this more easily if they are helped and supported to do so, even if this is a simple matter of allowing enough time for them to do so.

Be aware that this stage is vital for learning and acceptance, and that it takes time. Build in contingencies so that people can learn and explore without too much pressure.

Stage 4
This stage is the one you have been waiting for! This is where the changes start to become second nature, and people start to commit to the new way of doing things.

Now’s the time to celebrate with them. This is important! The journey is likely to have been rocky. What's more, they will find it much easier to cope with a major change next time if they can remember this sense of satisfaction and reward.

Help Us Help You: Needs Assessment

The 5 C's for Caregivers and Clinicians

Accelerating Change, and Increasing Its Likelihood of Success

Author: Anna Oliver BSc, BPhEd, PGDipDiet, RD

For all of us, implementing change is rarely easy, and it is particularly intense for someone with an eating disorder. The Change Curve is a popular and powerful model used to understand the 4 stages most people go through as they adjust to change; which are similar to the stages of dealing with grief. You can see this in figure 1, below. It’s partly based on the work of psychiatrist Elisabeth Kubler-Ross.


Figure 1 – The Change Curve

When a change is first introduced, people's initial reaction may be shock or denial. They might even convince themselves that there won’t really be any change. This is stage 1 of the Change Curve.

Once the reality of the change starts to hit, people tend to react negatively and move to stage 2 of the Change Curve. They may fear the impact; feel angry; and actively resist or protest against the changes. Some will wrongly fear the negative consequences of change. Others will correctly identify real threats to their world. For those struggling with an eating disorder, as a result of this – their life can quickly spiral into chaos if they don’t get support.

For as long as people resist the change and remain at stage 2 of the Change Curve, the change will be unsuccessful. This is a stressful and unpleasant stage. For everyone, it is much healthier to move to stage 3 of the Change Curve, where pessimism and resistance give way to some optimism and acceptance.

At stage 3 of the Change Curve, people stop focusing on what they have lost. They start to let go, and accept the changes. They begin testing and exploring what the changes mean, and so learn the reality of what's good and not so good, and how they must adapt.

By stage 4, they not only accept the changes but also start to embrace them: they rebuild their ways of working. Only when people get to this stage can they really start to reap the benefits of change.

Continued in Part II.

What does it mean to 'Maintain an Agnostic Stance?'

In FBT the provider takes an agnostic view of the cause of the illness. 

Instead of identifying these various factors, energy is directed at what needs to be done to help the adolescent move forward towards recovery ASAP. Where there's blame, inevitably there's shame, inaction, or worse yet, avoidance. So no blaming the adolescent or the parents. Maintaining an agnostic view means making no assumptions about the potential cause of the illness. Especially if it distracts from the task at hand, re-nourishment.

I think of it like a sinking ship. We would waste precious time deliberating about why it is sinking or who is to blame. The more immediate task at hand is get everyone to safety!

What are the Tenets of Family Based Treatment (FBT)?

The following are the five tenets of Family Based Treatment (FBT):

Maintain agnostic stance

Externalize the illness

Maintain a non-authoritarian/consultative stance

Empower parents/caregivers

Prioritize weight restoration/symptom remission


Infographic

FBT is intended to be provided by qualified mental health providers experienced in the assessment and treatment of eating disorders (ED). They can access consultants, such as pediatricians, psychiatrist, dietitian/nutritionists (RDNs), etc. But if FBT trainings don't include RDNs, then how should RDNs address the need in their practices, where access to FBT therapists are limited? How do they collaborate with FBT therapists? Moreover, if they are tapped as consultants, are they practicing in a way that is consistent with the tenets of FBT? More to come! 

References:
Rienecke, R.D., Family-based treatment of eating disorders in adolescents: current insights. Adolesc Health Med Ther. 2017 Jun 1;8:69-79.
Lock, J., Le Grange, D. (2013). Treatment manual for anorexia nervosa: A family-based approach, 2nd ed.