Erin was terrified when her 13-year-old daughter was diagnosed with anorexia. She spent a few months just trying to get her feet under her as she navigated the care system and tried to figure out what she was supposed to do to help her daughter get better.
“I felt like I was running through quicksand,” she says. “It was awful. Professional advice ranged from ‘wait and see’ to residential treatment, and neither option felt like the right one for us.”
Eventually, she was relieved when she was referred to a practice providing family-based treatment (FBT) for anorexia. “When I found FBT I just knew that was what we needed,” she says. “Our therapist helped us get our arms around the disorder and treat our child with respect and firmness. It made a world of difference, and she started to get better faster than I thought was possible.”
Erin’s experience with FBT is what every parent who has a child with an eating disorder wishes for: efficient recovery at home. And while FBT isn’t a fit for every child who has an eating disorder, it has been very effective for a subset of families facing anorexia in particular.
Eating disorder recovery
Approximately 13% of adolescents will develop an eating disorder by the age of 20. Eating disorders have been reported to be the third-most common chronic condition among adolescents. Despite this, research into the best treatment for eating disorders has been chronically underfunded. Therefore, evidence-based treatment trials for adolescents with anorexia nervosa are few, and study sizes tend to be small. As a result, many parents facing an eating disorder feel isolated and frustrated with the system of care.
Because it is one of the few anorexia treatments with scientific validation, FBT is considered by some to be the first-line treatment for adolescents with anorexia. There is also some evidence for its use with adolescents with bulimia. In this article, I’ll review:
- The evidence for FBT for eating disorders
- How FBT can be used to treat eating disorders
- What you should know if you’re thinking about FBT for your child’s eating disorder
What is FBT?
Family-based treatment (FBT) is also sometimes known as the Maudsley method or Maudsley approach. It is considered by some to be the “gold standard” treatment of choice for adolescents with anorexia. FBT is a manualized outpatient therapy designed to restore adolescents to health with the support of their parents.
Who does FBT work best for?
Family-based treatment (FBT) is an effective intervention for some adolescents with anorexia nervosa. Also, preliminary evidence suggests that it may be efficacious in treating adolescents with bulimia nervosa.
Qualified therapists use FBT with all sorts of eating disorder populations. So far, eight scientific studies have evaluated FBT in 657 patients with anorexia. And while it has been tested in multiple demographics, the majority of scientific evidence so far indicates positive outcomes for people who fit these criteria:
- Adolescents <18
- Illness duration <3 years
- Medically stable and fit for outpatient treatment
FBT has also been evaluated for bulimia. Three randomized controlled studies have evaluated 295 patients. These studies have indicated positive outcomes compared to individual therapy, though the results are less dramatic than those for anorexia.
How to provide Family-Based Treatment
Many parents will cobble together an FBT-like treatment for their child with an eating disorder. However, true FBT is a detailed program based on a manual. Therefore, it contains specific elements in an outpatient setting and requires sessions with a trained therapist. Studies have evaluated short-term FBT (10 sessions over 6 months) and long-term FBT (20 sessions over 12 months). These have found no significant difference between the two approaches.
The first session typically includes a family meal. During this the therapist can observe the child’s eating patterns and family behaviors. At each session, the therapist will weigh the person who has an eating disorder. Following that, they meet with the family to discuss progress. These meetings may begin on a weekly schedule and decrease over time.
The central premise of FBT is that families can be central to eating disorder recovery. And while it does not work for every family, many find it very helpful.
FBT is designed to replace inpatient treatment for an eating disorder. Meals at home are the priority, similar to how they form the foundation of inpatient treatment. This enables the person with the eating disorder to continue attending school and participating in activities as long as they are eating enough.
Principles of FBT
Family-based treatment for eating disorders is organized around a few basic principles:
1. Agnostic view of the illness
FBT makes no assumptions about the cause of the illness. Previously, families were blamed for eating disorders. To counteract this, FBT takes a strong position that families are not to blame. Rather, FBT focuses entirely on resolving the primary symptom of not eating. FBT is not concerned with identifying the underlying factors. Instead, it aims to get adolescents to stop using their eating disorder behaviors.
2. Externalize the illness from the patient
FBT emphasizes that the eating disorder and the child are not one and the same. The idea is that the eating disorder has “taken over” the child and is driving their thoughts, feelings, and behaviors. Parents are asked not to blame their child or believe that the eating disorder is the child’s choice. The goal of externalizing the illness is to reduce parental criticism, which has been shown to harm treatment outcomes.
3. The therapist takes a nonauthoritarian stance
The role of the FBT therapist is to take an active role in guiding the family through the recovery process. However, an FBT therapist does not tell the family exactly how to go about helping their child recover. The therapist partners with the family to help them figure out how best to refeed their child. The therapist models an uncritical, supportive, and compassionate stance toward the patient. Meanwhile, they take a firm, zero-tolerance approach toward eating disorder behaviors.
4. Parents are empowered
In FBT, parents are empowered as the best resource for their child’s recovery. Essentially, they are seen as the main agents of change in their child’s therapeutic process. Therefore, FBT success rests in the parents’ confidence that they can handle the eating disorder. The therapist works to put the parents in charge and communicate confidence in their ability to beat the eating disorder.
5. Unwavering focus
FBT has a pragmatic, unwavering focus on symptom reduction. It is designed to quickly and single-mindedly focus on weight gain. Or, in the case of bulimia, ending binging and purging. Therefore, problems associated with the eating disorder like depression, anxiety, irritability, body image issues, trauma, loneliness, and more are not addressed in the first phase of FBT. The belief is that many of these secondary problems will lessen with the return to physical health.
What are the three phases of family-based treatment?
The FBT treatment for anorexia consists of three phases.
Phase 1 focuses on rapid weight gain. In cases of bulimia, the focus is on ending binge and purge behaviors. Parents are told that the disorder makes it hard for the child to make healthy decisions about food and eating. They are empowered to take over decisions about eating, much as would be done in inpatient care. Parents are responsible for deciding what their child eats, when, and how much is eaten. They typically also curtail any physical activity, much as would take place in residential treatment.
In the first or second session of FBT, the therapist will coordinate a family meal. During this meal, they will instruct the family on how to be more effective with the eating disorder. The goal of this meal is to give parents the confidence that they can encourage their child to eat more than they intended.
Phase 1 continues until the following conditions are met:
- Steady weight gain
- Eating disorder symptoms have begun to recede
- The child is eating without significant resistance
During the second phase, parents will gradually give eating decisions back to the adolescent based on what is age-appropriate. This phase is introduced gradually and managed carefully.
During the third phase, the therapist reviews the adolescent’s progress and ensures the family is on track to get back to normal family life. The therapist offers skills to support ongoing development. Additionally, they will help the child navigate change without reverting to eating disorder behaviors to cope.
Is FBT right for your family?
Family-based treatment can be more effective than individual treatment for anorexia, especially in cases where it’s caught early. If you are considering FBT, it’s best to engage a qualified therapist who can follow the manualized process and guide your family through the steps.
However, if it’s not a good fit for you, you should know quickly. If that is the case, don’t hesitate to try other treatment options. It’s not a failure on your part, it just means FBT is not the right treatment for your family. Please don’t listen to anyone who says that FBT is 100% effective for everyone. It’s not. There are alternatives, and you should not feel ashamed if FBT is not the right fit for you.
What do parents say about FBT?
When it is a good fit, FBT is very effective, and parents rave about it. Parents who succeed with FBT say recovery is faster and more effective than alternative treatments. But even parents who found FBT efficacious say it is time-consuming and emotionally challenging. Implementing Phase 1 of FBT can be a full-time job for parents. Therefore, in some families, one partner will take a leave of absence from work to administer the treatment.
The risk of parental burnout with FBT is high. Burnout is a major risk for any parent who has a child with an eating disorder. Also, it’s serious because parental burnout has negative consequences for eating disorder treatment outcomes, whatever the modality. Therefore, parents report that having a qualified therapist and support community makes the job easier. Additionally, parent coaching can help prevent burnout.
That’s what Erin found helpful. “We had a great therapist, and I was active on parent message boards,” she says. “But I found that parent coaching was the real game-changer for me personally. Having a coach helped me work on my side of the equation and learn better communication skills. It made me much more influential over the eating disorder.”
Ginny Jones is on a mission to empower parents to raise kids who are free from eating disorders and body hate.
She’s the founder of More-Love.org and a Parent Coach who helps parents who have kids with eating disorders and other struggles.