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Family-based treatment of eating disorders in adolescents: current insights
Renee d rienecke.
1 Department of Pediatrics
2 Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC
3 Department of Psychiatry, University of Michigan Health System, Ann Arbor, MI, USA
Eating disorders are serious illnesses associated with significant morbidity and mortality. Family-based treatment (FBT) has emerged as an effective intervention for adolescents with anorexia nervosa, and preliminary evidence suggests that it may be efficacious in the treatment of adolescents with bulimia nervosa. Multifamily therapy for anorexia nervosa provides a more intensive experience for families needing additional support. This review outlines the three phases of treatment, key tenets of family-based treatment, and empirical support for FBT. In addition, FBT in higher levels of care is described, as well as challenges in the implementation of FBT and recent adaptations to FBT, including offering additional support to eating-disorder caregivers. Future research is needed to identify families for whom FBT does not work, determine adaptations to FBT that may increase its efficacy, develop ways to improve treatment adherence among clinicians, and find ways to support caregivers better during treatment.
Introduction
Eating disorders are serious psychiatric illnesses that generally develop during adolescence, and are associated with significant medical and psychological sequelae. Anorexia nervosa (AN) is characterized by significantly low body weight, fear of weight gain or behavior that interferes with weight gain, and disturbance in the way one’s body weight or shape is experienced, overvaluation of shape and weight, or lack of recognition of the seriousness of the low body weight. Lifetime prevalence rates of AN and subthreshold AN among adolescents are 0.3%–0.6% and 0.6%–0.8%, respectively. 1 , 2 High rates of comorbidity are found among patients with AN, with approximately 50% meeting criteria for another psychiatric disorder. 2 , 3 AN is associated with impaired quality of life 4 and significantly elevated mortality rates that are among the highest of any psychiatric illness. 5 , 6
Bulimia nervosa (BN) is characterized by recurrent episodes of eating that are accompanied by a sense of loss of control, as well as inappropriate compensatory behavior and overvaluation of shape and weight. 7 Lifetime prevalence rates of BN and subthreshold BN among adolescents are 0.9% and 6.1%, respectively. 1 , 2 Almost 90% of patients with BN meet criteria for another co-occurring psychiatric disorder, 2 and BN is associated with high rates of impairment and suicidality. Binge-eating disorder is characterized by binge-eating episodes that are not accompanied by inappropriate compensatory behavior, but are associated with marked distress. Prevalence rates for binge-eating disorder are 1.6% among adolescents. 2 Avoidant/restrictive food-intake disorder (ARFID), introduced as a new disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 7 is characterized by an eating or feeding disturbance resulting in significant weight loss or failure to achieve expected weight, nutritional deficiencies, dependence on enteral feeding or nutritional supplements, or interference with psychosocial functioning. Prevalence estimates range from 5% 8 to 22.5%, 9 depending on the treatment setting.
A substantial number of individuals experience clinically significant difficulties with eating that do not meet criteria for one of the aforementioned diagnoses. 2 , 10 , 11 A diagnosis of other specified feeding or eating disorder is given in these cases. Despite the subthreshold nature of this diagnosis, patients who do not meet full criteria for an eating disorder are still medically compromised 11 and often do not differ in clinically significant ways from their full-threshold counterparts. 12 , 13 Approximately 13% of adolescents will develop an eating disorder by the age of 20. 14 Eating disorders have been reported to be the third-most common chronic condition among adolescents, behind obesity and asthma. 15
Family-based treatment for AN
Research on the treatment of eating disorders in adolescents has lagged behind that of adults, but family-based treatment (FBT), also sometimes known as the Maudsley method or Maudsley approach, has emerged as an effective intervention and is considered by some to be the treatment of choice for adolescents with AN who are medically stable and fit for outpatient treatment. FBT is a manualized outpatient therapy designed to restore adolescents to health with the support of their parents. 16 The treatment for AN consists of three phases. Phase 1 focuses on the rapid restoration of physical health, orchestrated by parents. It is explained to families that because of the ego-syntonic nature of the disorder, the patient on his or her own will have difficulty making healthy decisions about food and eating. In an effort to keep patients out of higher levels of care, decisions about eating are temporarily taken out of their hands and given to parents. Parents are given responsibility for deciding what their child eats, how much is eaten, when it is eaten, monitoring all food intake, and generally curtailing physical activity, much like the treatment team would do on an inpatient unit. The goal of FBT, however, is to allow patients to recover in their day-to-day environment with their support system around them, rather than separating them from their parents by sending them to an inpatient or residential treatment program. Siblings are given a supportive role in treatment, and are not included in the parents’ job of weight restoration.
The second session of FBT consists of a family meal, in which the family brings a meal into the therapist’s office and the therapist begins to instruct the family in ways to be more effective with both the eating disorder and their child. The purpose of the family meal is to give parents, who at this point are often feeling quite defeated by the eating disorder, a taste of success in encouraging their child to eat more than he or she had originally intended.
Phase 1 continues until there is steady weight gain, the eating disorder has begun to recede, and the child is eating without much resistance to parental involvement. Phase 2 involves gradually giving responsibility over eating back to the adolescent, to whatever extent is age-appropriate and normal for a particular family. This phase is conducted gradually, in order to minimize the chances of backsliding, which can be disheartening to families and therapists alike. For example, rather than having parents serve a child at dinner as they would during phase 1, the child may begin to serve himself or herself, with parental oversight in place and the understanding that parents will add food if they deem what the child chose to be inadequate.
In Phase 3, there is a review of adolescent development, and the therapist ensures that the family is back on track with normal family life. The family identifies upcoming developmental challenges that the adolescent must face, and identifies how to help the young person navigate these challenges without reverting to the eating disorder as a way to cope.
Family-based treatment for BN
FBT has been adapted for use with patients with BN. 17 Although it shares several similarities with FBT-AN, the main focus of FBT-BN is on interrupting the pattern of binge eating and purging. Although parents are still in charge of recovery, the approach tends to be more collaborative in nature. This is possible in part because of the more ego-dystonic nature of the illness when compared to AN. Care is taken to modify parental criticism, which may be higher in families of a patient with BN than with AN, 18 and to reduce the shame and secrecy commonly surrounding binge-eating and purging behaviors. In addition, there is somewhat more flexibility in the approach, allowing for a shift in focus to address comorbid illnesses or behavioral problems that may present themselves more often than is usually the case in the treatment of AN.
Family-based treatment for other eating and weight disorders
FBT has also been adapted for use with prodromal presentations of AN, 19 pediatric obesity (PO), 20 and ARFID. 21 In comparison to FBT-AN, the emphasis in FBT for prodromal AN shifts from rigorous weight restoration to normalization of eating habits and efforts to prevent the development of full-blown AN. 19 There is also a focus on implementation of regular family meals and modeling of healthy eating by parents.
In FBT-PO, treatment approaches are modified according to the age of the patient. 20 Parents are involved at the beginning of treatment to varying degrees, depending on whether the patient is a child, preadolescent, or adolescent, and parental control over eating and exercise lessens over the course of treatment. For children in FBT-PO, parental involvement at the beginning of treatment may look very similar to FBT-AN, in that parents take full responsibility for all eating-related decisions and monitor all meals and snacks. However, in FBT-PO, parents would also initiate physical activity.
In FBT-ARFID, the focus of treatment is on helping parents increase the types and variety of food consumed by the patient. 21 There is an emphasis on educating the parents about the factors unique to ARFID, such as the mechanisms that keep children from trying new foods and the frequency with which new foods need to be presented. These adaptations to FBT appear promising, but data are needed to determine the efficacy of FBT for different populations.
Key tenets of family-based treatment
There are several key tenets of FBT that are important to keep in mind when working with families. These tenets set FBT apart from many other schools of thought when it comes to treating eating disorders. First, FBT takes an agnostic view of the cause of the illness, ie, no assumptions are made about the potential causes of eating disorders. 16 Instead, they are viewed as complex and multifactorial illnesses, with many different critical factors needing to “fall into place” for an eating disorder to develop. The focus of FBT is not on identifying these various factors, but on identifying what needs to be done to help the adolescent move forward with recovery as quickly as possible. The adolescent is not blamed for developing the illness, while it is also made clear to families that parents are not to blame for causing the illness.
Second, there is a focus on externalizing the illness from the patient. It is emphasized that the eating disorder and the child are not one and the same. The eating disorder has “taken over” the child when it comes to issues of food, eating, shape, and weight, and in those instances it is driving the child’s thoughts, feelings, and behaviors. Parents must know that their child is not in control of the disorder, and just as they did not choose to develop the disorder, they cannot choose to stop the eating-disordered behavior. Externalization serves several purposes, one of which is to reduce parental criticism, which has been shown to have a negative impact on treatment outcome. 22 – 26
A third tenet is that the therapist takes a nonauthoritarian therapeutic stance when working with the family. The therapist takes an active role in guiding the family through the recovery process, but does not tell the family exactly how to go about helping their child recover. Rather, the therapist joins the family in helping them figure out for themselves the best way to refeed their child. There is no one-size-fits-all approach in FBT. Families are told that they are in charge of weight restoration, but they are not given an exact plan for how to accomplish this. While the therapist is seen as an expert consultant, the parents are seen as the experts on their family, with knowledge about the family’s likes, dislikes, habits and routines, preferences, and ethnic, religious, and cultural backgrounds, all things that can impact a family’s eating patterns. Therefore, they are in the best position to come up with a plan for helping their child recover.
Empowerment of the parents is another tenet of the treatment approach. In FBT, parents are in no way thought to be responsible for causing the eating disorder. 27 Rather, FBT views parents as their child’s best resource for recovery and the main agents of change in the therapeutic process. To be successful in overcoming the eating disorder, parents must feel confident in their interactions with their child and with the eating disorder. The therapist works to empower parents by putting them in charge of the process and communicating to them that the therapist has confidence in their ability to beat the eating disorder. Parents are reminded that they do know how to feed their child, but that the eating disorder has caused them to doubt themselves. By not providing the parents with specific meal plans or explicit instructions on how to bring about recovery, the parents must figure out what will work best for them. This in turn allows them to rely largely on themselves more than the therapist or treatment team, thus building confidence.
Finally, FBT is a very pragmatic approach with an unwavering initial focus on symptom reduction. In an effort to reduce any potential long-term damage that can be done by the state of malnutrition, there is an emphasis on interrupting the pattern of restricting and quickly restoring the patient to physical health. Problems associated with the eating disorder, such as depressed mood, anxiety, irritability, difficulty concentrating, or social withdrawal, are not addressed directly in the first phase of FBT. This is in part to ensure that the focus remains on weight restoration, and in part because many of these secondary problems will resolve themselves with the return to physical health. 28
Empirical evidence for family-based treatment for AN
The first randomized controlled trial (RCT) for adolescent AN was conducted by Russell et al at Maudsley Hospital in London. 29 Eighty female patients with eating disorders between the ages of 14 and 55 years were admitted to an inpatient unit for weight restoration, and upon discharge were randomized to 1 year of family therapy or individual therapy. Due to the heterogeneity in age and diagnosis, participants were divided into four subgroups. One group consisted of adolescents with AN who had a short duration of illness, defined as less than 3 years, and an early age of onset, defined as on or before the age of 18 years. Patients in this subgroup responded better to family therapy, with 90% of patients falling into “good” or “intermediate” Morgan–Russell outcome categories (based on body weight, menstruation, and presence/absence of bulimic symptoms), whereas only 18% of patients receiving individual therapy fell into these categories. Furthermore, these gains were maintained at 5-year follow-up. 30
The first studies outside Maudsley Hospital were conducted by Robin et al. 31 , 32 They randomized 37 adolescents with AN to either behavioral family systems therapy (BFST) or ego-oriented individual therapy (EOIT). BFST was similar to FBT, but also incorporated nutritional counseling and cognitive restructuring. In EOIT, the therapist met with the adolescent weekly and had bimonthly collateral sessions with the parents. The focus of treatment was on building the adolescent’s ego strength, developing coping skills, helping to individuate from his or her family of origin, and exploring other interpersonal issues and how they relate to eating. Both groups gained weight, although the BFST group gained more than the EOIT group at the end of treatment and 1-year follow-up. At the end of treatment, more patients in BFST than in EOIT had resumed menstruation. Few differences were found between the two groups on measures of eating attitudes, depression, ego functioning, and family relations.
A large RCT randomized 121 adolescents with AN to either FBT or individual adolescent-focused therapy (AFT; previously referred to as EOIT). 31 – 33 The primary outcome variable in this study was full remission, defined as reaching at least 95% of expected body weight and achieving a mean global score on the Eating Disorder Examination within one standard deviation of community norms. The authors found no differences between the two groups at the end of treatment, but significantly more patients receiving FBT had achieved full remission at 6-month (FBT 40%, AFT 18%) and 12-month (FBT 49%, AFT 23%) follow-up.
Various forms of FBT have also been studied. Because patients in the Russell et al study 29 were hospitalized for weight restoration prior to beginning treatment, the study can be conceptualized as a relapse-prevention study. Therefore, efforts were made to examine the efficacy of FBT without prior hospitalization of patients. Le Grange et al 34 and Eisler et al 35 each compared two forms of family treatment among adolescents with AN. In conjoint family therapy, the adolescent and parents are seen together with the therapist. In separated family therapy, the adolescent is seen alone by the therapist and the parents are then seen separately. Le Grange et al found no differences between the two treatment groups. In a separate study of 40 adolescents with AN, Eisler et al found that approximately 60% of patients fell into the Morgan–Russell good- or intermediate-outcome categories, with no significant differences between conjoint family therapy and separated family therapy. Patients continued to improve after treatment ended, with 90% of patients in the good or intermediate categories at 5-year follow-up. 24
Lock et al 36 examined short- and long-term versions of FBT. Eighty-six adolescents with AN were randomized to short-term FBT (ten sessions over 6 months) or long-term FBT (20 sessions over 12 months). No significant differences were found at the end of treatment between the two groups. However, nonintact families and patients with higher levels of eating-related obsessive–compulsive symptoms did better in the long-term version. Specifically, patients with high levels of eating-related obsessive–compulsive symptoms gained more weight in the long-term treatment, and patients from nonintact families had lower global scores on the Eating Disorder Examination if they participated in the long-term treatment. Four years later, 83% of the 86 patients were followed up, and no significant differences were found between those receiving short- and long-term treatment; 89% of patients had an expected body weight above 90%, and 90% were menstruating. No moderators of maintenance of treatment effects were found. 37
Recently, Le Grange et al compared FBT to an adaptation of FBT called parent-focused treatment (PFT). 38 In PFT, the adolescent is seen at the beginning of the session by a nurse who weighs the patient, assesses medical stability, and provides brief supportive counseling. This information is then shared with the therapist, who spends the rest of the session meeting alone with the parents. A total of 107 patients with AN were randomized to FBT or PFT. The primary outcome variable was full remission, as defined in Lock et al. 33 Remission rates were higher in PFT (43%) than in FBT (22%) at the end of treatment, but the treatment groups did not differ at 6- or 12-month follow-up.
A question arising at this point is: does FBT work because of the involvement of the parents, or is it the specific way in which parents are involved that leads to the treatment’s efficacy? This was assessed by Agras et al 39 in a study comparing FBT to systemic family therapy (SFT). In SFT, the focus of treatment is on the family system and on the relationships and interactions that develop among family members. Normalization of eating and weight is not a specific focus of treatment, but is addressed if the family raises the issue. The authors found no significant differences between treatment groups in percentage expected body weight at the end of treatment or 1-year follow-up. However, participants in FBT gained weight significantly faster than participants in SFT, and significantly fewer participants in FBT were hospitalized.
There is preliminary evidence to suggest that FBT is effective for older populations in addition to adolescents. 40 , 41 In a small study, 22 patients with AN between the ages of 18 and 26 years participated in a 6-month open trial of FBT for young adults (FBT-Y). 41 Patients started treatment at a mean body mass index (BMI) of 17.84. At end of treatment and 6-month follow-up, 68% had a BMI ≥19, and 59% had a BMI ≥19 at 12-month follow-up. FBT-Y also resulted in improvements in eating-disorder psychopathology, eating-related obsessions and compulsions, other Axis I disorders, and global functioning. However, dropout rates were 41%.
Empirical evidence for family-based treatment for BN
Although BN generally develops during adolescence, only three RCTs for adolescent BN have been published to date. Le Grange et al 42 randomized 80 adolescents to either FBT-BN or individual supportive psychotherapy (SPT). The primary outcome variable was abstinence from binge eating and purging over the previous 28 days. At the end of treatment, more patients in FBT were abstinent (39%) than in SPT (18%), and this difference remained significant at 6-month follow-up (FBT 29%, SPT 10%). In addition, reduction in symptoms occurred more rapidly for patients receiving FBT.
Schmidt et al 43 compared family therapy to cognitive behavioral therapy guided self-care (CBT-GSC) for 85 adolescents. The family therapy in this study was similar to FBT-BN, but differed in that adolescents were allowed to choose “close others” other than parents in their treatment, and a quarter of patients chose this option. The primary outcome variable was abstinence from binge eating and purging over the previous 28 days. At 6 months, more patients in CBT-GSC (42%) were abstinent from binge eating compared to patients in the family-therapy group (25%). However, this difference was no longer significant at 12 months, and there were no differences between the groups in frequency of vomiting at either assessment point. The cost of treatment was lower for those assigned to CBT-GSC than to family therapy.
A recent RCT compared FBT-BN with CBT adapted for adolescents (CBT-A). 44 Abstinence rates were significantly higher for FBT-BN (39.4%) than for CBT-A (19.7%) at end of treatment and 6-month follow-up (FBT-BN 44%, CBT-A 25.4%), but the difference was no longer significant at 12-month follow-up (FBT-BN 48.5%, CBT-A 32%). More participants were hospitalized in CBT-A (21%) than in FBT-BN (2%).
Multifamily therapy for AN
Despite evidence that FBT is an effective form of treatment for adolescents with eating disorders, 45 not all families respond to treatment, and some need a different or more intensive level of intervention. Multifamily treatment (MFT) for eating disorders has been developed in Dresden, Germany 46 and London, UK, 47 and provides a promising alternative for some families. MFT shares a conceptual focus with FBT, in that the family is mobilized to draw on their strengths to help the adolescent recover from the eating disorder. However, MFT offers a more intensive experience, with five to seven families learning from and supporting one another during an introductory evening where families meet a “graduate family” who shares their experience of participating in MFT. This is followed by a 4-day intensive workshop with five to eight follow-up sessions over the next 6–9 months, with separate FBT sessions between follow-up visits as needed. 48
Thus far, much of the data supporting the use of MFT has consisted of uncontrolled studies. 49 – 51 One RCT randomized 169 adolescents to either MFT (MFT-AN) or single-family therapy, although participants randomized to MFT-AN also received individual family meetings as needed. 52 At the end of treatment, significantly more people in the MFT-AN group fell into good- or intermediate-outcome categories, although this difference was no longer statistically significant at 6-month follow-up. At the end of treatment, there were no differences between the groups in mean percentage BMI, eating-disorder psychopathology, depression, or self-esteem. However, at 6-month follow-up, mean percentage BMI was higher in the MFT-AN group.
Family-based treatment in higher levels of care
The efficacy of FBT has led to efforts to incorporate FBT principles into higher levels of care, such as partial hospitalization programs (PHPs). While it is important to note that FBT is an outpatient form of treatment that cannot be replicated in higher levels of care, it is possible to remain true to the basic tenets of the treatment approach in different treatment settings. Hoste 53 described the development of a family-based PHP, outlining various considerations that should be taken into account when incorporating FBT principles, such as how to involve parents in treatment and the role that the treatment team should take in supporting the family. Preliminary outcome data for this program show improvements in eating-disorder psychopathology and parental self-efficacy. Other descriptions of family-based PHPs show promising preliminary outcomes. 54 , 55 Although from a clinical perspective, some patients seem to require higher levels of care, further studies are needed to determine whether higher levels of care are as effective as empirically supported forms of outpatient therapy, such as FBT or CBT.
Implementation of family-based treatment
Despite evidence supporting the efficacy of FBT and manualization of the treatment for both AN and BN, 16 , 17 in clinical practice the treatment is often not carried out in accordance with the manual. 56 Couturier et al 56 interviewed 40 therapists regarding their treatment of AN, their perspectives on evidence-based practice, and barriers and facilitating factors related to their adoption of FBT. Although over 80% felt that manualized FBT was well scripted and used it with their own patients, not one therapist practiced the treatment approach with fidelity to the manual.
Themes raised during these interviews were divided into six categories. Interventional barriers to the use of FBT included the time commitment required of therapists and families, the lack of a dietitian on the treatment team, the requirement that the therapist weighs the patient at each session, and the family meal. Organizational factors related to the implementation of FBT included support for the treatment approach on the part of the organization’s clinical director or administrator. Interpersonal factors related to reluctance to provide evidence-based practice involved a belief that one approach does not fit all families, and that it is not desirable to commit to a particular form of treatment without considering each family individually. Parental reluctance to engage in FBT and therapist reluctance to use FBT when a parent has an active eating disorder were listed as patient/family barriers to implementing FBT. Systemic barriers to treatment included a lack of awareness in the community about eating disorders and treatment options. Illness factors were also mentioned, as 68% of therapists reported that the complexity of AN prohibits them from committing to one form of treatment with full fidelity to the model. There was also a belief that patients participating in treatment studies have fewer comorbidities and are not representative of the general population; therefore, using just one form of treatment would not be desirable for more complex patients.
In another study of FBT fidelity, Kosmerly et al 57 assessed 117 clinicians who reported using FBT for eating disorders. Cluster analysis revealed that one third of clinicians used techniques not recommended by the FBT manuals, including individual therapy, mindfulness techniques, and motivational work.
Three components of FBT that caused some of the most significant discomfort for therapists in the Couturier et al study 56 were weighing the patient, the lack of a dietitian, and the family meal. PFT 38 may be a good alternative for these clinicians, as there is no family meal and a nurse is responsible for weighing the patient. It would also be useful to determine whether these components of FBT are critical to good treatment outcome. Although dismantling studies have not been conducted, Ellison et al 58 examined some of the core objectives of FBT, including parents taking control of eating, parents being united against the eating disorder, parents not criticizing the patient, externalizing the illness, and sibling support of the patient, and assessed how they were related to treatment outcome. All objectives except for sibling support predicted greater weight gain. A review of the family meal in three different models of family therapy found that firm conclusions cannot yet be drawn about the usefulness of the family meal in treatment. 59 Questions proposed for future research include: 1) is the family meal a necessary component of treatment?; 2) do all patients (eg, adolescents versus young adults) benefit similarly from the family meal?; 3) what are the components that make up an effective family meal?; 4) how does the therapeutic context influence the potential benefits of the family meal?; and 5) if it is not feasible to have a family meal in session, can other meal-oriented techniques serve the same purpose?
Without dismantling studies to identify the critical components of FBT, it is difficult to state the consequences of nonadherence to the treatment manual. What can be said is that nonadherence to the treatment manual will result in the delivery of a non-empirically supported form of treatment. Couturier et al 56 point out that it is important to determine in these situations whether one should prescribe following the treatment manual as written and risk rejection of the manual by therapists who do not feel qualified or equipped to implement it, or whether there is room for some flexibility to allow clinicians who are uncertain about components of the treatment to administer it according to their comfort level.
However, it could be argued that discomfort with certain elements of FBT could prove detrimental to treatment outcome. For example, despite the manual clearly stating that the patient should be weighed by the therapist prior to every session, and that weight loss or weight gain sets the tone for the session, over one third of therapists in the Couturier et al 56 study said that they did not weigh their FBT patients. Although the reasons for this were not detailed in the study, Waller and Mountford 60 outlined several reasons given by therapists for not weighing their patients in the context of CBT. These included concerns that it will ruin the therapeutic relationship, a belief that weighing is unnecessary because the patient weighs him/herself or is already weighed by another professional, concern that the patient will be too upset if weighed, stating that there is not enough time in the session to weigh the patient, or believing that the therapist can judge weight gain or weight loss by looking at the patient. FBT therapists in training have also reported being fearful of the reaction of the eating disorder. Not weighing the patient is often done to alleviate either the patient’s anxiety or the therapist’s anxiety. Either one can be problematic. Although patients may become anxious when being weighed, the FBT therapist is there to support patients and help them process their reaction to being weighed, thereby building therapeutic alliance and rapport. 16 If the therapist avoids weighing the patient in order to avoid making the patient anxious, this could send a message that the therapist is not equipped to handle the patient’s anxiety, thus creating less of a safe and containing therapeutic environment.
Likewise, avoiding therapist anxiety could be equally problematic. Much of an FBT therapist’s job is modeling for parents how to interact with the eating disorder and with their child. The therapist models an uncritical, supportive, and compassionate stance toward the patient, along with taking a firm, zero-tolerance approach toward eating-disordered behavior. It will be difficult for therapists to model this firm stance toward the eating disorder if the therapist is scared of it. If the therapist avoids weighing the patient because of fear of the wrath of the eating disorder, this therapist will not be as effective in treatment.
The issue of treatment implementation is an important one. Effective therapies do not help patients if they are not effectively implemented. The majority of therapists in Couturier et al 56 requested additional training in FBT. Additional studies are needed to assess whether the level of training in FBT improves treatment adherence.
Adaptations to family-based treatment
Even when practiced with full adherence to the manual, FBT is not effective for all families. Now that the efficacy of the treatment has been established, research can turn to the question of what to do with families for whom FBT does not work. In a study of early response to treatment, it was found that 2.88% weight gain (approximately 2.2 kg) by session 4 was the strongest predictor of posttreatment remission. 61 Lock et al 62 examined the feasibility of an adaptive treatment intended to enhance parental self-efficacy in families of patients who were early nonresponders to therapy. Forty-five patients with AN were randomized to either FBT (n=10) or FBT with intensive parental coaching (IPC; n=35) if patients did not gain 2.2 kg by session 4. In addition to standard FBT, IPC included three additional sessions that focused on mealtime coaching. In the first of these three additional sessions, the failure to achieve adequate weight gain is presented to the family as a crisis situation, and the family is reinvigorated to make the behavioral changes necessary to result in weight restoration. In the second IPC session, the therapist meets the parents alone to identify barriers to successful weight restoration. The third session consists of a second family meal, after which point manualized FBT resumes.
There were no differences in attrition rates, number of sessions, treatment suitability and expectancy ratings, or clinical outcomes between the two treatment groups, indicating the feasibility and acceptability of IPC. Mothers of patients who responded early to treatment had higher levels of self-efficacy than nonresponders at session 2, but after the additional IPC sessions, parental self-efficacy scores no longer differed between the two groups. The weight trajectories of the IPC arm were also compared to a group of FBT nonresponders from a different RCT (n=38). 39 At baseline, the two groups’ average weight was similar. After session 4, when IPC was introduced in the Lock et al study, 62 the weight trajectories begin to differ, and at the end of treatment patients in the IPC arm were significantly higher in terms of weight than patients from the Agras et al RCT. Data must be interpreted with caution, given the small sample size, but these preliminary results suggest that adaptive FBT is feasible and may be effective in bringing about weight restoration for early treatment nonresponders.
Eating-disorder caregivers
Additional parental coaching may be particularly welcome, given the stress that can accompany caring for an individual with an eating disorder. Caregivers of people with eating disorders experience high levels of caregiving burden and psychological distress. 63 – 67 Although FBT can be an intense and challenging process for parents, parents’ experience of FBT has not been well documented. Anecdotal accounts suggest that it can be quite difficult. 68 , 69 An exploration of blogs of mothers engaged in FBT found two main themes: the importance of social support and shifts in parenting. 70 Mothers described formal support from members of their treatment team, as well as informal support, such as support from online forum members or significant others, as being key to their caregiving experiences. They also discussed the shift in parenting that is often required by FBT, in the sense that they became much more involved in their child’s life than they were prior to the onset of the eating disorder.
Given the importance of support from others, it is worthwhile to consider ways to offer assistance to parents going through FBT. Rhodes et al 71 evaluated parent-to-parent consultation for 20 families going through FBT. Ten families received standard treatment, and ten received additional parent-to-parent consultation. The consultation involved a joint interview with parents new to FBT and parents who had successfully completed treatment. Graduate parents were asked to share their experiences of treatment and of the weight-restoration process, and to discuss how they facilitated the recovery of their children. Parents in parent-to-parent consultation felt that the experience made them feel less alone, enabled them to reflect more on family roles and interactions, and gave them confidence that they may be similarly successful in treatment. The consultation did not lead to differences in percentage of ideal body weight at the end of treatment, but it did lead to a small increase in the rate of weight restoration. 72
Online support has also been offered to parents going through FBT. 73 Thirteen caregivers participated in 15 weekly online therapist-guided chat sessions. Participants reported a high degree of satisfaction with the group (91.7%), and the majority said it helped them cope with their child’s eating disorder and they would recommend the chat group to another caregiver.
Caregiving burden has been found to be associated with high expressed emotion (EE). 74 EE is a measure of a relative’s attitudes and behaviors toward an ill family member across five domains: critical comments, hostility, emotional overinvolvement, positive remarks, and warmth. 75 Relatives who score high on critical comments, hostility, or emotional overinvolvement are considered high on EE. High parental EE is associated with poor treatment outcome in families of patients with AN, 76 , 77 whereas parental warmth is associated with good treatment outcome. 78 Several caregiver interventions have been developed that result in a reduction in EE. 74 , 79 , 80 It would be worthwhile to determine whether these interventions can be used to improve treatment outcome in FBT specifically.
FBT is considered by some to be the first-line treatment for adolescents with AN, and evidence is accumulating for its use with adolescents with BN. FBT has been expanded upon such that its principles are now included in multifamily therapy, as well as in higher levels of care. The development of FBT and its reliance on families as the primary agents of change in the recovery process has significantly changed the landscape of treatment for adolescents with eating disorders. FBT, however, does not work for all families. Future research is needed to identify better the families for whom FBT does not work, determine adaptations to FBT that may increase its efficacy for treatment nonresponders, develop ways to improve treatment adherence among clinicians offering FBT, and find ways to support parents during treatment better.
Acknowledgments
The author would like to thank Daniel Le Grange, PhD for his comments on an earlier version of this manuscript.
Dr Rienecke receives consulting fees from the Training Institute for Child and Adolescent Eating Disorders, LLC, and reports no other conflicts of interest in this work.
- Correspondence
- Open Access
- Published: 03 May 2022
The five tenets of family-based treatment for adolescent eating disorders
- Renee D. Rienecke ORCID: orcid.org/0000-0003-0423-7403 1 , 2 &
- Daniel Le Grange 3 , 4
Journal of Eating Disorders volume 10 , Article number: 60 ( 2022 ) Cite this article
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Family-based treatment (FBT) is the leading treatment for adolescent eating disorders and is based on five tenets, or fundamental assumptions: (1) the therapist holds an agnostic view of the cause of the illness; (2) the therapist takes a non-authoritarian stance in treatment; (3) parents are empowered to bring about the recovery of their child; (4) the eating disorder is separated from the patient and externalized; and (5) FBT utilizes a pragmatic approach to treatment. Learning these tenets is crucial to the correct practice and implementation of manualized FBT. The purpose of the current paper is to provide an in-depth overview of these five tenets and to illustrate how they are used in clinical practice. This overview will aid clinicians who are learning FBT.
Introduction
Family-based treatment (FBT) has emerged as the leading evidence-based treatment for adolescents with eating disorders (EDs) and is recommended as the first-line treatment for patients who are medically stable for outpatient care [c.f., 1 , 2 ]. The earliest studies of family therapy for anorexia nervosa (AN) were conducted at the Maudsley Hospital in London [ 3 , 4 , 5 ], with this approach subsequently adjusted somewhat in the United States, given a more behavioral focus, and called FBT [c.f., 6 , for a description of FBT and the process of manualization]. These initial developments of FBT, building on the seminal work done at the Maudsley Hospital, occurred at The University of Chicago and Stanford University, leading to the clinician manuals for adolescents with AN, now in its second edition [ 7 ], and for adolescents with bulimia nervosa (BN) [ 8 ]. The early description of the manualization of FBT [ 6 ] briefly alludes to the fundamental assumptions of this treatment approach, that is, in FBT:
the therapist holds an agnostic view of the cause of the illness;
the therapist takes a non-authoritarian stance in treatment;
parents are empowered to bring about the recovery of their child;
the eating disorder is separated from the patient and externalized; and
FBT utilizes a pragmatic approach to treatment, with the focus on the here and now.
The purpose of the current paper is first to provide a more detailed overview of these five fundamental assumptions or key tenets of FBT, and second, to illustrate how they are used in clinical practice. As mentioned, although these tenets are briefly alluded to elsewhere [ 6 ], the current paper will provide an in-depth description of these tenets to aid in the training of therapists in the implementation of FBT and to improve dissemination of this important treatment approach.
Overview of FBT
FBT consists of three phases: in Phase 1, parents are given the responsibility for bringing about weight restoration in the case of AN [ 7 ] or eliminating binge eating and purging and establishing a regular pattern of eating in the case of BN [ 8 ]. Parents are asked to make all eating-related decisions for their child, and usually curtail physical activity, until the ED has loosened its grip and is no longer influencing the child’s behaviors and thoughts about issues related to food, eating, shape, and weight. Due to the egosyntonic nature of AN, adolescent agency related to food is not a focus in the early stages of treatment, whereas Phase 1 for BN may allow for more of a collaborative approach between parents and children, due to the more egodystonic nature of BN. In Phase 2 of treatment, responsibility over eating is gradually handed back to the adolescent to whatever extent is age-appropriate and typical for that particular family. Phase 3 involves a review of healthy adolescence and an assessment of where the adolescent is developmentally once the ED has receded.
FBT is meant to be practiced by trained mental health providers experienced in the treatment of adolescents with EDs [ 7 ] and skilled in working with families. Given the medical complications and prevalent psychiatric comorbidities of these patients, a multidisciplinary team is essential. Other providers, such as physicians (pediatricians or general practitioners) and child and adolescent psychiatrists, can provide FBT-informed care and support the messages that the FBT therapist is giving, but the FBT therapist is the “leader of this clinical group” [ 7 ], p. 28].
Tenets of FBT
The tenets of FBT are fundamental to the conduct and implementation of the treatment approach, but not all are described in detail in the treatment manual [ 7 ]. The following review is intended to serve as a guide for therapists learning FBT.
Agnostic view of the illness
The central idea of this tenet is that treatment in the FBT model does not focus on exploring causes of the illness, but rather aims to engage the family as a resource to bring about early behavioral change. Eating disorders are complex illnesses, with genetic, sociocultural, personality/temperamental, and metabolic factors involved in their development [ 9 , 10 ]. While family factors, such as weight-related teasing or maternal dieting, may increase the chances of developing unhealthy weight control behaviors or restrictive eating [ 11 , 12 ] in those individuals who are vulnerable to developing an ED, the field has decisively moved away from blaming families for causing EDs, as there is no research to demonstrate that this is true [ 13 ]. Although there is evidence that families of patients with an ED report worse family functioning than healthy controls [ 14 ], this could very well be because of the negative impact of the ED on the family [ 15 ]. Thus, parents should not be viewed as a causal factor in the development of the illness, so no blame is assigned to parents in FBT.
Parents often feel to blame despite the FBT therapist assuring them that this is not the case. Although anecdotal, it is often the case that parents note that they must have ‘done something’ to cause the disorder, or they feel that they should have caught it earlier, which is easy to do given the often-insidious onset of the ED. It is important for the FBT therapist to address parental guilt, even if the parents do not bring it up themselves. Guilt can cause parents to second-guess themselves and doubt their ability to take appropriate action to solve the crisis of the ED. In addition, it can cause parents to lose confidence in their own ability to weight restore their child. Parents’ sense of self-efficacy in this domain has been shown to be a mediator of weight gain in FBT [ 16 ], and greater increases in parental self-efficacy during treatment predict greater adolescent weight gain [ 17 ]. Thus, parental confidence in FBT is very important. Anxiety, on the other hand, can be mobilizing provided it is not overwhelming. EDs are serious illnesses and parents should be at an optimal level of anxiety. The FBT therapist works to contain families who may be overly anxious, while raising the level of anxiety for those who are not “anxious enough” and thus may not be properly motivated to take on the task of weight restoration. However, it is important that the FBT therapist assures parents that there is no reason to feel guilty and, in fact, it is not a useful emotion in the context of this treatment.
Relatedly, FBT therapists do not pathologize the family. It is not helpful to think, for example, that one parent is somewhat controlling and that is why the adolescent developed AN. The FBT therapist keeps in mind that as a field we do not always know conclusively why EDs develop, and perhaps less so for any given individual. Furthermore, even if we did know why a particular person developed an ED, this knowledge does not necessarily translate to symptomatic improvement. Rather than spending time attempting to uncover the cause of the illness, FBT focuses on rapid symptom reduction. It is important to note that FBT is effective, not because it resolves a hypothetical family etiology, but rather because it changes the way a family responds to and manages their child’s ED.
Maintaining an agnostic view in clinical practice . One way to keep the focus of FBT agnostic is to appropriately address parents’ inevitable questions about why the ED developed. An FBT therapist might respond:
It is natural to want to know what caused the ED. EDs are complex illnesses with several factors that come into play: genetic, environmental, personality, etc. Unfortunately, we may never know for sure what caused the ED in your child’s case. The good news is that we do not need to know what caused it in order to fix it. One thing we do know is that parents are not to blame for the development of the ED. Rather, you will be an important resource – the most important resource - in your child’s recovery.
At times, parents have difficulty not pursuing this line of questioning, particularly if they firmly believe that the underlying cause of the ED needs to be identified for their child to recover. The “cancer analogy” [ 7 ] can be useful here:
I understand your desire to know what caused this illness. It feels like if you know what caused it, you can keep it from coming back. However, we are in a crisis situation and cannot afford to spend time hypothesizing about why the disorder might have developed. If your son developed cancer, you would have it treated quickly and aggressively, without waiting to find out what caused it. We are in a similar situation here. Spending time speculating about the cause of the eating disorder takes the focus off the hard work of behavioral change, which is what will help your son recover. Once the crisis is out of the way, we might be able to attend to the question of possible causes of your child’s eating disorder.
For the therapist, focusing on the family’s strengths rather than their weaknesses can be helpful in reducing any temptation to pathologize the family. Anecdotally, FBT therapists are often pleasantly surprised by the strength and creativity that families bring to the therapeutic process. Although the treatment is problem-focused, encouraging and acknowledging family strengths, while simultaneously working on ways that they can interact more effectively with their child and with the ED, will aid the therapist in keeping an agnostic perspective and not inadvertently blaming the family. Perhaps particularly important for new FBT therapists, supervision can also be useful in addressing any difficulties the therapist might be having in maintaining an agnostic view. Maintaining agnosticism is particularly important as it has been shown to be associated with recovery at the end of treatment. Lock et al. (2020) [ 18 ] found that fidelity to maintaining agnosticism at session 1 predicted recovery with 58% accuracy.
It is important to note that although the FBT therapist does not blame or pathologize the family, the FBT therapist should intervene when unhelpful or illness-maintaining family dynamics are observed. There is a great deal of research showing that high levels of parental expressed emotion, characterized by criticism, hostility, and emotional overinvolvement, result in poor treatment outcome [ 19 ]. When parents exhibit high expressed emotion, it can be useful to explore the reasons behind this. Are parents having difficulty externalizing the illness (reviewed below), resulting in attributing unwanted illness behavior to their child? Are parents burned out, and need assistance to problem-solve around utilizing additional resources in the weight restoration process, such as extended family members? It may be useful for an FBT therapist to say the following:
It is understandable that you may get angry when you see your child hides food or seems unable to complete a meal. Watching your daughter waste away is frightening for parents, and this can sometimes come out as anger. However, we know that therapy suffers when parents get angry at their children. How can we help you manage this anger and help you express the feelings that are actually behind it: concern and love?
If it is well-established in Phase 1, the agnostic view of the illness will generally carry over into Phases 2 and 3. If families are successful with FBT, their sense of self-efficacy grows, their feelings of guilt diminish, and they see that the ED is improving without the need to discuss the possible reasons behind its development.
Non-authoritarian therapeutic stance
In FBT, the therapist is seen as an expert consultant. The therapist is the expert on EDs and on treatment, and the parents are seen as the experts on their child and their family. The therapist is active in treatment, providing psychoeducation and guidance, but generally does not tell the parents what to do. Or rather, parents are told what to do: “feed your child” but are not told exactly how to do this. In other words, therapists “give parents the frame, but the parents paint the picture”. Many of the decisions about how to implement treatment are left up to the parents. In addition to empowering parents, which will be reviewed shortly, it sends an important message to the child and to the ED that the parents are the primary agents of change in this treatment.
Many FBT therapists, even experienced ones, struggle with this concept. Taking a non-authoritarian therapeutic stance does not mean that parents are encouraged to do whatever they would like to do in treatment, or that the therapist can never take a more directive approach. Some of this decision-making may be based on how severe the adolescent’s situation is. For example, if an adolescent is at 78% expected body weight (EBW), actively restricting, and in Phase 1 of treatment, and parents want to send their child away to camp for several weeks, the therapist may start the conversation reviewing the pros and cons of such an action. If parents persist in this intended direction, the therapist may more firmly state that this is not in the best interest of the adolescent. However, ultimately the decision belongs to the parents. If they decide to send their child to camp, the therapist can then work with them to minimize the chances of a poor outcome, such as arranging regular weigh-ins at camp and having a camp nurse or counselor eat meals with the adolescent. On the other hand, if their child is near the end of Phase 2 and generally weight restored, the therapist can leave decision-making much more in the hands of the parents, with appropriate guidance. A similar approach is taken when discussing physical activity. For an adolescent who needs to weight restore, physical activity during Phase 1 is usually contraindicated and may even be medically unsafe. However, if a patient is medically stable and needs to gain weight, and the parents express their desire to continue physical activity for their child, a discussion of the pros and cons is warranted. The FBT therapist might point out that as it is, even without any physical activity, a substantial number of calories is needed to gain weight, and that this number will need to be increased even further if the child is exercising. Many patients are not willing to eat more to be allowed to exercise. However, if they are, and parents feel strongly about continuing physical activity, it can be useful to problem-solve with the parents in detail around how to increase caloric intake and ask them to consider discontinuing exercise if the patient loses weight or fails to gain at the expected tempo.
It is important for the FBT therapist to remember that there is no one-size-fits-all approach to this treatment. Therapists do not know all the family’s likes, dislikes, routines, habits, preferences, or details of their cultural, ethnic, or religious backgrounds—all of which can impact eating behavior. The therapist must believe that with his or her guidance, families will find their own answers that may be more effective than anything the therapist could prescribe.
Maintaining a non-authoritarian stance in clinical practice . To establish an FBT therapist’s role as an expert consultant, is it important that the therapist be knowledgeable about EDs and about the way in which adolescents with EDs think. Parents are often in a state of crisis when starting treatment, and they can be put at ease by seeing that their therapist is an expert on EDs, is up to date on the most recent research, has received training in FBT, and understands the mindset of an adolescent with an ED. Communicating to families that you understand the fear that their son or daughter experiences when faced with a plate of food, for example, can not only normalize their experience but may also aid in the development of rapport with the patient. An FBT therapist might say:
My role in treatment is to guide you through this process with the knowledge I have about EDs and about this treatment approach. I will rely on you as the experts on your child and your family as we work together to restore your child’s health. It is important to note that AN is what’s sometimes called an ego-syntonic illness, in contrast to an ego-dystonic illness. Anxiety and depression, for example, are ego-dystonic illnesses. If you are anxious or depressed, you don’t want to feel that way. However, having an ego-syntonic illness means that part of you wants that illness. Your daughter is ambivalent about treatment, so we cannot leave decisions about recovery in her hands. Therefore, you will be playing a large role in treatment.
Maintaining this collaborative stance is an ongoing process. FBT therapists should reassure the family that although the primary responsibility for recovery is in the hands of the parents, the therapist will support them through this challenging journey until it is over.
Viewing parents as the experts on their family and their children, and giving them the responsibility for weight restoration, enables the family to reorganize itself to enhance parental effectiveness. Prior to presenting for treatment and over time, the family of a child with an ED tends to organize around and accommodate the illness [ 15 ] and the illness becomes the center of family life. Structural family therapy, one of the therapeutic approaches that FBT draws on [ 7 ], seeks to strengthen the parental subsystem and displace the ED from the central position it has come to occupy [c.f., 20 . Although the ED may resist being “demoted”, the healthy part of the child often feels a sense of safety knowing that his or her parents are fighting the ED and making food-related decisions on behalf of their child, particularly given how difficult it is to fight the ED alone. This issue often presents in therapy when explaining why adolescents are not given choices about what to eat in Phase 1:
It makes sense that you would want to give your daughter choices about what to eat. She is 16 years old and up until now she has had input into what she wants to eat. However, when someone has an eating disorder, asking them to make a food-related decision puts them in an internal battle – the healthy part of her versus the eating disorder. This is an agonizing place to be, particularly when the eating disorder is very strong. It is much kinder to temporarily take that decision away from her and shoulder that burden yourself. Your thinking is not clouded by the eating disorder and you know what is best for her right now.
The non-authoritarian therapeutic stance continues throughout Phases 2 and 3. It is often easier for FBT therapists to maintain this stance later in treatment as parents become more confident in their role and need less direct guidance from the therapist.
Parental empowerment
Parental empowerment involves building confidence in parents to take on their role as the primary agents of change in the recovery process. To take on the challenging task of ensuring that an adolescent with AN eats an appropriate amount of food, parents have to have confidence that they can accomplish this task. Confidence enables parents to stand firm in the face of resistance from the ED, and to avoid second-guessing themselves when in difficult situations. If parents do not have confidence in themselves, the ED will realize this quickly and use it to its advantage, often in the form of negotiation around meals and snacks, to “poke holes in their parents’ armor”. Thus, it is vital that therapists communicate to the parents that they have confidence in the parents’ ability to take on this role. The therapist should remember that parents are the most important resource in therapy, as they are the ones who are with their child day in and day out and will be doing most of the work. It is also helpful for the therapist to remember that parents have valuable skills and strengths that they bring to treatment, that most parents can help their children renourish, and to never underestimate the love and concern that parents have for their children, which FBT harnesses so well. Like agnosticism, fidelity to establishing and maintaining externalization at session 3 has been found to predict recovery at end of treatment with 67% accuracy [ 18 ].
Strategies for empowering parents in clinical practice . As with taking a non-authoritarian stance, empowering the parents involves not telling them exactly how to go about the process of weight restoration. Therapists can give guidance and advice but encourage the family to come up with their own plan. This is one reason that prescribed meal plans are not used in FBT. By the time parents get to treatment, they have tried to battle the ED, either on their own or with other treatment attempts. They are often feeling quite helpless and defeated. To restore parents’ confidence in themselves, the FBT therapist might say the following:
Until the ED came along, you had a healthy child. You know how to feed your child, but the ED has made you second guess yourself. Now you may feel that you don’t know what to do, but you do. You have two other healthy children at home, so you have the knowledge to do this. We are going to tap into that knowledge so that you can restore your child to health.
Parental confidence can not only help parents stand firm in the face of resistance from the ED, but it also enables parents to handle difficult situations without feeling the need to ask for advice or support from their treatment team every time. Allowing parents to struggle at times through this process and come up with their own answers seems to be invaluable in increasing their confidence [ 21 ]. Giving parents too much guidance, including meal plans, would be in contradiction to the message that FBT therapists are trying to communicate. That is, FBT clinicians should be mindful not to tell parents that they know what to do and simultaneously give the message that they need to rely on an expert to get it done.
Parents sometimes genuinely feel that they do not have the nutritional knowledge necessary to bring about weight restoration. It is important for the FBT therapist to determine whether this is true, or whether the ED is making the parents doubt themselves in this domain. The following question can be extremely helpful in elucidating this:
You often hear about actors needing to bulk up for a movie role. If I asked you to gain 30 pounds, would you be able to do it?
Parents almost inevitably answer yes, indicating that they are doubting their ability to refeed their child but do not lack the necessary nutritional information to do so. Parents are often concerned about what their child is willing to eat, rather than what he or she should eat. Pointing this out to parents can be helpful; when they no longer have to worry about buying the right low-calorie dressing for their child and they can instead focus on adequate nutrition, this can feel freeing and empowering. However, if parents are truly struggling with finding appropriately caloric foods, the therapist can provide examples of approaches that other families have found helpful or direct them to websites with high-calorie recipes.
Parents remain empowered through the latter phases of FBT. In Phase 2, parents retain oversight of eating behaviors while their child is developing more independence. For example, children may start to serve themselves dinner, but parents are there to add more if the child chooses an insufficient amount. In Phase 3, parents stay empowered in part by the reorganization of the family and the strengthening of the parental subsystem. Parents are the leaders of their own family and are no longer supplanted by the ED.
Externalization of the illness
Separating the illness and the adolescent is a crucially important part of FBT. Anecdotally, when parents are struggling with treatment, it is often because they are having difficulty with this concept, so it is vital to ensure that parents understand it and successfully incorporate it into their conceptualization of the ED. Watching their child waste away due to eating too little evokes many emotions on the part of parents, including frustration, fear, worry, and anger. These are understandable reactions, but frustration and anger, especially when directed at the child, can be unhelpful. When their child sits at the dinner table and does not eat, parents must remember that their child is not being difficult, immature, or stubborn, and is not doing it on purpose. They must remember that the child is in the grip of a powerful disorder that is influencing his or her thoughts, feelings, and behaviors. The parents’ task is to battle the ED, not their healthy child, who is still there but may be overshadowed by the ED. Truly understanding this concept seems to be very effective in reducing parental criticism and hostility, which have been shown to have a negative impact on treatment retention and outcome [ 22 , 23 ].
Strategies for externalizing the illness in clinical practice . There are several ways to explain this concept to families. One that is often used in FBT is to compare the ED to cancer or another serious medical illness. Like cancer, individuals with EDs do not choose to develop their illness, and once they have it, they cannot just decide to get better. Much as one cannot will away a tumor, their child cannot “just eat”. Their child has a serious illness and needs help to recover. Similarly, a caregiver would not become angry at their child or blame them for developing cancer. Likewise, children should not be blamed for developing the ED. Parents may still feel frustrated and angry by the circumstances, but these feelings should be directed toward the ED and not their ill child. FBT therapists may explain this in the following way:
At mealtimes it may seem that you are no longer interacting with your healthy, loving child, and, in fact, you are not. You are dealing with a powerful disorder that has over- taken your child, and she needs your help to overcome it. It is important to remain compassionate with your daughter and remember how frightened she is to eat and gain weight, while remaining firm with the ED and ensuring that she gets the healthy amount of food that she needs. Parents sometimes find it helpful to name the ED, often “Ed”, to remind themselves that they are not fighting their daughter, but rather this terrible illness.
FBT therapists may also say to families that at mealtimes it may seem that they are interacting with an alien, or a being that has “possessed” their son or daughter. This often resonates with parents, particularly if resistance to eating is very strong and involves behaviors that are uncharacteristic of their healthy child, such as swearing or throwing food. This may also resonate with patients, who have described the ED as having “complete power over me” [ 24 ], p. 5]. Another helpful example comes from a television show seen by the second author, in which giant spiders jumped from trees, feeding on small birds foraging on the forest floor. The small birds struggled and fought as hard as they could but were unable to remove the spider from their backs. The only way to rescue these birds from such predatory spiders was for someone else to come along and take them off the birds. This is an apt metaphor for an ED. The child may struggle and fight against the disorder, but EDs are too strong for them to cast off themselves. They need their parents to come along and remove the ‘monster’. This example of externalization also seems to resonate well with parents.
However, there are times when despite repeated metaphors and examples, parents struggle to believe that their child needs their help, instead insisting that the child must want to get better for recovery to occur, and that they must fight the illness on their own. This is quite problematic; not only does it keep parents from assuming their necessary role in treatment, but, as mentioned above, it can cause parents to be angry and critical toward their child, thus having a negative impact on treatment outcome. FBT therapists may need to put in extra effort to help such families, moving forward with FBT only when externalization has been achieved. There are no clear guidelines as to when to abandon this treatment approach if parents are not in agreement with externalization or the other tenets of FBT. Early weight gain (approximately 4–5 pounds/2–2.5 kg by session 4) has been shown to predict good outcome in FBT [ 25 , 26 , 27 , 28 ]. If early weight gain does not occur, the therapist may consider another treatment modality, but clinical judgment is needed to determine whether the family simply needs more guidance and time, or whether they are not “buying into” FBT tenets and switching to another treatment is indicated. Research is needed to determine whether early weight gain is associated with parental agreement of FBT tenets.
Although externalization is a critical component of FBT, it should be used carefully, as patients can experience it as dismissive [ 24 ], and as if all their behaviors are being blamed on the ED. Engaging the healthy part of the adolescent in treatment as much as possible can aid in the family not losing sight of their healthy child’s identity.
Externalization often continues throughout the rest of FBT, although the need to continue to emphasize it with families perhaps becomes less pressing as they naturally incorporate this way of thinking into their language and behavior. It continues to be important during Phases 2 and 3 in part because externalization serves to de-pathologize the child and allows for the child to return to regular adolescent development. That is, the child does not need continued age-inappropriate supervision in the eating domain because he or she was just ill and is now recovering.
Pragmatic approach to treatment
The main idea of this tenet is for the therapist to stay focused on the task at hand, which is symptom reduction. FBT is present- and symptom-focused with a strong behavioral approach. EDs are dangerous illnesses with high mortality rates [ 29 ] and potentially long-term medical consequences [ 30 ], even for adolescents, who presumably have shorter durations of illness than adults. Early, effective intervention is crucial to minimize any long-term damage that may occur and to prevent the ED from becoming more entrenched in the ill child’s personality, identity, and way of thinking. Because time is of the essence, and the goals of treatment are to help the child recover as quickly as possible and reduce the chances of developing a chronic disorder, FBT maintains a laser like focus on symptom reduction, particularly in the early phases of treatment.
Parents often ask that the therapist address issues that are secondary to the ED, including increased irritability, depression, anxiety, difficulty concentrating, or social withdrawal. Focusing on these other issues, which are likely to resolve with the resolution of the ED, takes the focus away from behavioral change, which is what will bring about weight restoration. It can be helpful to review the Minnesota Starvation Study [ 31 ] with families to educate them about the physical and psychological sequelae of EDs and the urgent need for rapid weight restoration to facilitate full recovery. So that parents do not feel ignored when expressing their concerns, it can be useful for the therapist to make note of the areas that the parents are worried about and assure them that these issues can be revisited in Phase 3, that is, when the crisis is over, and the child is well again. Often, when the issues are brought up again in Phase 3, it turns out they have been resolved and no longer need to be discussed.
Maintaining a pragmatic approach in clinical practice . In FBT, the therapist weighs the adolescent at the beginning of every session. The weight is then plotted on a chart, which is shared with the family. Starting sessions in this way sends a strong message to the family that weight is the focus of treatment, and indeed, weight loss or weight gain over the previous week sets the tone for each session. Similarly, in Phase 1, the therapist reviews meals and snacks in detail at every session, again reminding families that this is the focus of treatment for the time being. Parents may ask about other distressing issues or may wonder why their child is not receiving individual therapy to address, for example, poor body image or distorted thinking. The FBT therapist might respond:
While the ED has such a strong grip on your daughter, it is unlikely that she will benefit from individual treatment. Furthermore, the ED is potentially deadly, whereas poor body image is not. Our goal is to maintain our focus on adequate eating and weight restoration. Research has shown us that these other symptoms you are seeing, such as increased irritability and difficulty concentrating on schoolwork, will improve as your daughter becomes more physically healthy. We must restore her physical health first, and her emotional, mental, and psychological well-being will follow.
Remaining focused on the ED can be more challenging in Phases 2 and 3 of treatment, when the patient is out of immediate danger and may be progressing well. However, although the crisis has passed, there is still much work left to do in the process of recovery. Keeping the focus on eating behaviors allows the family to gradually navigate the return to normalcy while maintaining the gains they have made in Phase 1. Although it may be tempting to drift and move the focus of treatment to something more “interesting”, such as exploring possible underlying causes of the ED, this is not dictated by the manual, and there is no evidence that this will bring about speedier recovery for patients in FBT. Possible maintaining factors, such as overvaluation of shape and weight, are not addressed in FBT in the same way they are addressed in, for example, cognitive-behavioral therapy. FBT views family accommodation of the illness as a maintaining factor, which is disrupted with psychoeducation and reorganization of the family structure in their effort to address the ED. If FBT therapists feel that they are running out of topics or concerns to discuss when meeting with the family in latter phases, sessions may be scheduled less frequently.
Particularly for new FBT therapists, following the manual is another way to maintain the pragmatic approach to treatment. Anecdotally, therapists who are new to FBT often bemoan the fact that FBT can feel somewhat repetitive, especially in Phase 1, because of the firm focus on food and weight gain. However, the persistent focus on behavioral change in FBT may be one reason that it is so effective.
The purpose of this review of the FBT tenets is to provide guidance to those learning FBT and to aid in dissemination of this manualized treatment approach. Therapists learning FBT, as well as those who have been practicing FBT for some time, will find that the tenets serve as a “road map” to guide them in their clinical practice.
The result of these five tenets of FBT is a focused treatment that emphasizes behavioral change rather than insight. Moreover, there is no direct focus on cognitive change through such cognitive-behavioral therapy techniques as cognitive restructuring, although cognitive improvement does occur because of treatment [ 32 ]. Although there is evidence that FBT therapists may “drift” from the manual and incorporate techniques or interventions from other treatment modalities, such as cognitive-behavioral therapy or dialectical behavior therapy [ 33 ], this is not recommended by the manual. FBT also results in improvements in family functioning [ 34 ]. These changes might perhaps be due to the way in which the family is ‘reorganized’ to support their unwell offspring, a process aided by psychoeducation and giving the parents responsibility for weight restoration, among other interventions.
The FBT manuals [ 7 , 8 ] are valuable tools to guide clinicians in learning and implementing FBT. However, they cannot cover all possible situations that may arise in clinical practice. When faced with a clinical situation in which FBT therapists are unsure of which course to take, adhering to these five tenets will guide them to make the decision that will be most beneficial to the patients and their families. These tenets are inherent to the practice of FBT, and without following them, an FBT therapist is not practicing fidelity to the model.
Guidance such as that provided in the current paper may also aid in the dissemination of this important treatment approach. There is a limited number of FBT-trained therapists, thus, creative solutions are required to expand the availability of FBT to those who need it, such as delivering FBT via telehealth [ 35 ] or online training in FBT [ 18 ]. There is evidence that FBT can be successfully disseminated outside of the original treatment development sites [ 36 , 37 , 38 ], but much work remains to make FBT available to all families in need of support for their child with an ED.
In addition to access, the issue of manual adherence is an important one. Adherence to treatment manuals has been shown to improve patient outcomes in cognitive-behavioral therapy for BN [ 39 ]. However, research has found that many therapists do not practice FBT with fidelity. In a study of 117 clinicians who reported using FBT, Kosmerly et al. [ 40 ] found that one-third used techniques not recommended in the manual, such as individual therapy, mindfulness techniques, and motivational work. Another study of 40 therapists providing treatment for youth with AN found that the majority did not practice FBT with adherence, citing barriers such as discomfort with the family meal in the second session and lack of administrative support [ 41 ]. Although practicing a treatment with fidelity inherently seems a worthwhile goal, further research is needed on the relationship between treatment fidelity and treatment outcome. One study found that adherence to FBT was not related to weight gain, although treatment fidelity decreased over the course of therapy [ 42 ]. No other studies have examined adherence to FBT and patient outcomes; future research should further explore this topic using measures that have been developed to assess fidelity to this treatment approach [ 43 ]. Further, although taking a non-authoritarian therapeutic stance and taking a pragmatic approach to the illness are steeped in a rich history of family therapy approaches, they have not yet been shown to act as mediators of FBT and warrant future research attention.
Availability of data and materials
Not applicable.
Abbreviations
Anorexia nervosa
Bulimia nervosa
Expected body weight
- Eating disorders
- Family-based treatment
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Eating Recovery Center and Pathlight Mood and Anxiety Centers, 333 N. Michigan Avenue, Ste. 1900, Chicago, IL, 60601, USA
Renee D. Rienecke
Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL, USA
Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
Daniel Le Grange
Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, IL (Emeritus), USA
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Rienecke, R.D., Le Grange, D. The five tenets of family-based treatment for adolescent eating disorders. J Eat Disord 10 , 60 (2022). https://doi.org/10.1186/s40337-022-00585-y
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Everything You Need to Know About Family-Based Treatment (FBT)
Family-based treatment (FBT) is one of the most successful treatments for eating disorders in children and teens with anorexia nervosa, bulimia nervosa, and other specified feeding or eating disorder (OSFED). To distinguish it from other forms of family therapy, parents sometimes call it “Maudsley Family Therapy,” a reference to its initial development at the Maudsley Hospital in London. Our owner and clinical director, Dr. Muhlheim wrote one of the leading books for parents about this treatment . Dr. Muhlheim and several other of our therapists provide expert-led FBT therapy for families in California and some other locations. We also deliver FBT in the context of a full team including a medical doctor and dietitian.
FBT is a specific treatment that follows a manual . Parents—supervised by trained professionals—deliver FBT in an outpatient setting. Some residential and partial hospitalization programs incorporate principles of FBT in their programs.
Centers the Family
FBT differs significantly from traditional treatments for adolescent eating disorders. Earlier approaches to eating disorders suggested that parents caused eating disorders in their children—as far back as 1873 William Gull wrote that “relations and friends” were “generally the worst attendants” for patients with anorexia nervosa. During the 1960s and 1970s leading treatment models for eating disorders continued to blame parents, especially mothers. Through the twentieth century, many professionals continued to view eating disorders as a struggle for independence from a dysfunctional family system. Professionals as a standard practice removed patients from their families and sent them to treatment facilities.
Today this myth persists. Some providers continue to focus on unearthing a family problem that needs solving and helping a teen to individuate in order to recover. However, more recent research clarifies that families do not cause eating disorders. We now understand eating disorders to be complex illnesses caused by a complicated interplay of biological, psychological, and environmental factors. FBT is at the forefront of the research that demonstrates that families are not a detriment, but often an integral part of the solution to their teen’s or child’s eating disorder.
The Problem with Traditional Treatments
Traditional treatments that wait for a teen to develop insight and the motivation to get better pose risks. They waste precious time trying to find an underlying problem that likely doesn’t exist . In the meantime, the eating disorder’s physical consequences continue to ravish the young person’s health. FBT works faster than other treatments and is often more cost-effective.
Teens and children with eating disorders often lack the motivation to eat and get better. FBT recognizes this and can work around it. Your child will likely reject treatment. That is okay. FBT can work in spite of their resistance . Until your child is ready to want their own recovery, you can want it on their behalf. No one loves your child more than you do; this uniquely positions you to help them recover.
What Exactly IS FBT?
FBT involves the whole family in solving their child’s eating disorder. Unlike traditional family therapy, it does not blame the family. FBT prescribes family sessions with a therapist at first once a week, decreasing over the course of treatment. But because the parents are empowered to be a part of the treatment team, the treatment is much more intensive than is typically possible in outpatient treatment. FBT often provides a level of care that is similar to residential or partial hospitalization programs (PHP).
Typically, our therapist meets with the entire family—or, at a minimum, the person with the eating disorder and one parent—for one hour per week, either in our office or by telehealth. We prioritize the meal above everything else, much like a treatment center would do. However, instead of attending treatment all day, your teen participates in as much of their life as possible. As long as they are eating enough, they may be able to attend school and other activities.
FBT typically includes at least one family meal at the beginning of treatment in the therapist’s office. This gives the therapist a chance to observe the behaviors of different family members during the meal and to assist the parents in helping their child eat.
FBT requires active participation by parents and leverages parents as agents of change. In FBT, family meals form the core of the treatment: parents take charge of nourishing their teens with eating disorders by providing energy-dense meals. Parents plan, prepare, serve, and supervise all meals. A typical recovery meal plan includes three meals plus two to three snacks per day . If purging is an issue they provide supervision after meals. They implement strategies to prevent purging, excessive exercise, and other eating disorder behaviors. I liken FBT to providing a residential treatment center in your house for a single patient—your child.
FBT centralizes the role of food in recovery. Your teen may fear eating but the cruel irony is that recovery cannot happen without regular energy-dense meals. We often say in FBT that “ Food is medicine .”
Principles of FBT
FBT has five core principles:
- Agnostic view of illness: FBT takes an agnostic view of the eating disorder, meaning we do not waste time trying to analyze why the eating disorder developed.
- Initial symptom focus: FBT prioritizes full nutrition and prevention of eating disorder behaviors.
- Family responsible for refeeding/addressing behaviors: Parents provide full nutrition by taking charge of meals for their child.
- Non-authoritarian stance: The therapist actively collaborates with parents who are full members of their child’s treatment team. Parents are the experts on their child.
- Externalization of illness : The illness is an external force that has possessed the child and is attacking their health. Parents and providers join forces with the healthy part of the teen to fight off the eating disorder.
Focusing on Symptoms Versus Underlying Issues
FBT focuses on achieving recovery by treating the symptoms directly. Some parents and even some treatment providers worry that this approach is superficial and ignores the underlying issues. I can understand this. Focusing on food, regular eating, and regulation of weight and health may seem mundane. But it works!
We also prioritize returning a teen to their unique weight curve as we believe this improves chances for a full recovery. We also believe the family can become a treatment ally by standing up to diet culture .
Who is On an FBT Treatment Team?
An FBT treatment team can be small compared to those encountered in other types of eating disorder treatment. The team requires a therapist to guide the parents and a medical doctor to manage their medical needs. While FBT does not require a dietitian, we have found that a dietitian who works primarily with the parents can provide valuable guidance. We believe a dietitian should not meet alone with the teen or child during the early part of treatment because FBT places parents in charge of food decisions.
Of course, additional providers can be added as needed. If there are multiple providers, it is important that all team members are aligned about treatment philosophy and goals. Otherwise, a nonaligned team may be detrimental. We can provide referrals to dietitians, pediatricians, adolescent medicine doctors, and psychiatrists.
Who Is FBT For?
FBT is supported by research for children and adolescents with anorexia nervosa and bulimia nervosa. FBT can also be effectively applied to young adults and other adults with anorexia nervosa and other eating disorders including other specified feeding or eating disorder (OSFED). Finally, FBT can also be effective with ARFID in children and teens. FBT works in all kinds of family configurations including separated and divorced families .
Three Phases of FBT
FBT has three distinct phases:
- Phase 1: Full parental control. Parents are fully in charge of meals helping their child to reestablish regular patterns of eating and interrupting eating disorder behaviors including purging and overexercise. If weight gain is needed, we set a goal of 1 to 2 pounds per week. Parents help their teens to reincorporate foods they have dropped from their repertoire.
- Phase 2: A gradual return of control to the adolescent. This phase usually begins once most weight has been restored, when meals are going more smoothly, and when behaviors are mostly under control. We gradually give the teen more independence over their own eating in an age-appropriate manner. For instance, they may begin to have some meals or snacks independently from the parent. Families continue to focus on building flexibility in their teen’s eating. The teen begins to eat with different people and in different settings and incorporates all fear foods. This phase can be characterized by some backsliding and parents may have to reclaim control until the adolescent is fully ready; this is part of the process.
- Phase 3: Establishing autonomy. Once the adolescent has resumed an age-appropriate level of independence and no longer exhibits eating disorder behaviors, treatment shifts in focus to helping them develop a healthy balanced life and catch up on other developmental issues. Other co-occurring mental health problems can be addressed. Relapse prevention is incorporated.
Feed, Love, Heal
Feeding and helping your child recover is a loving act. However, love is not always easy or gentle. The strength and resolve you show will nurse your teen back to full health. our FBT therapist will support you in managing the stress and challenge of the process. We will teach you how to tolerate your own distress as well as your child’s and how to teach your child to tolerate distress . This will not be easy, but it can be one of the most important things you will do as a parent.
Common Questions About FBT:
Will it work for our family.
We’ve heard it all: “My teen is too old.” “My child is too independent.” I’m not strong enough.” “We are too busy.” None of these factors has proven to be a deal-breaker for successful execution of FBT. We support you in doing this with love and compassion and we believe that most parents can successfully implement FBT. FBT appears to be most effective for families in which the length of illness is less than three years.
What if My Teen Doesn’t Want to Do FBT?
No problem! FBT does not require your teen to agree . In fact, we expect your teen will not want to do FBT because we will be confronting the eating disorder head-on. This will cause discomfort for your teen (and you) in the short run, but it will bring about change more quickly and completely.
How Long Will It Take?
It varies! Treatment may take a year, but can also take longer. Speedy diagnosis and early intervention can drive a faster result. But eating disorders are difficult illnesses. If weight gain is slower than desired it can take longer. Some teens also struggle with independent eating and so benefit from a longer period of supervised eating. Early behavior change is key! If the teen’s condition requires weight gain, we want to see 4 pounds of weight gain by week 4; otherwise, the research shows that FBT is unlikely to be successful. If we do not see the progress we will encourage intensifying treatment or a higher level of care.
Do We Need A Meal Plan?
No, you don’t need a meal plan. FBT empowers parents to serve foods that will nourish their starving teen back to health rather than feeding them according to what the eating disorder wishes to eat. Your therapist or an FBT-aligned dietitian can help you identify foods and meals from those your teen previously enjoyed and your family has traditionally eaten. In some cases, you may also incorporate the use of nutritional supplements to promote weight gain .
How Do I Supervise All Meals?
This can be daunting, especially for busy families. One or both parents may take a leave of absence from work. Sometimes grandparents and other extended family members can help with supervising meals. You may need to coordinate lunches with your child’s school or keep your child home from school for some time. Many parents bring lunch to school and eat with their teen in the car. We are always amazed by the creativity our parents show in figuring this out.
Doesn’t My Child Need Also Need to See an Individual Therapist?
Not necessarily! As a primarily behavioral treatment, FBT initially focuses on rescuing a malnourished brain, and then on eliminating symptoms. Both medical providers unfamiliar with FBT and treatment centers that insist on having complete teams may pressure families to add an individual therapist. This is not always desirable. In FBT, less can be more; the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT . In one case series of families with “failed FBT ” several families pivoted to individual therapy and the teens later admitted that “they had asked for individual treatment as a deliberate strategy to exclude their parents because they knew it would mean that there would be less pressure for weight gain and more chances of avoiding stress and conflicts around the challenges related to their eating behavior.”
A return to healthier eating behaviors and stabilization of weight often relieves many of the eating disorder-and related symptoms including anxiety and depression. Additionally, research shows that at least in the case of bulimia nervosa, no additional therapy may be needed . If indicated, you can always add it later and you may avoid spending money on unnecessary services and treatment. Sometimes patients may benefit from specific adjunctive therapies .
What About Residential Treatment?
We believe higher levels of care, including residential and partial hospitalization programs, have their place. Sometimes parents cannot make enough headway against the eating disorder, or the child has extreme reactions to relinquishing control to parents or parents just get worn out and need a break. There is no shame in sending your child to a higher level of care if needed. Parents assume a vital role after the child returns home. We can provide referrals to various treatment programs as needed.
How Do I Know The Treatment My Child is Receiving is Really FBT?
Sometimes providers who provide aspects of FBT say they provide FBT, but it’s not true FBT. Read how to distinguish FBT from FBT-informed therapy .
Can You Provide FBT by Teleconference?
Yes! Providers in our practice hold licenses in the states of California, Indiana, Florida, New York, and South Carolina . For families that cannot travel to our office but reside in one of those states, we can provide FBT by teleconference . In the face of the COVID-19 pandemic, we increased our telehealth capabilities .
Find an FBT Therapist outside of California, Indiana, Florida, New York, and South Carolina
We cannot provide services for patients outside these five states. If we are not in your area and you are looking for an FBT therapist, the Training Institute for Child and Adolescent Eating Disorders trains therapists in this treatment and maintains a list of certified therapists and therapists in training.
Can We Use Insurance for FBT?
We are proud to be one of 3 US-certified FBT clinicians who accept Medicaid and part of the one-third of certified FBT providers who accept any insurance. Check our fees and insurance page to see which insurances we can bill directly.
Learn More About Family-Based Treatment
Check out our other pages to learn more about how to navigate some specific situations in the course of FBT:
- Surviving the First Week of FBT
- The Use of Supplemental Shakes in Eating Disorder Recovery
- When Your Child With an Eating Disorder is Sick….
- This Halloween, Serve Candy to Your Teen in Recovery
- Getting Your Teen with an Eating Disorder Ready for the First Day Back at School
- Traveling With Your Teen in Recovery
- How Do I Parent My Teen When Doing FBT? When to Set Limits
- Is Your Young Adult with an Eating Disorder Ready for College?
- Eating Disorder College Contracts
- Are we Setting Recovery Weights Too Low?
- Supporting your Child or Other Loved One with an Eating Disorder Through the Holidays
- FBT With Separated and Divorced Families
Begin Family-Based Treatment in California
You do not have to continue to struggle to help your teen with their eating disorder alone. Counseling can help your teen gain weight and reestablish a healthy relationship with food and body. Our Los Angeles, California practice has caring therapists who specialize in the treatment of anorexia , bulimia, and other eating disorders in teens . To start your counseling journey, follow these simple steps:
- Contact Eating Disorder Therapy LA
- Speak to our practice manager who will match you to an FBT therapist
- Start your teen on the path to full recovery.
Other Counseling Services at Eating Disorder Therapy LA
At Eating Disorder Therapy LA, we specialize in evidence-based treatments for all eating disorders and related issues. We provide therapy for Anorexia Nervos a, Atypical Anorexia , Bulimia Nervosa, Avoidant/Restrictive Food Intake Disorder , and Body Image.
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Family-Based Treatment (FBT) for Eating Disorders
Will it work for my family member?
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Alternative Approach
Fbt vs. family therapy, principles of fbt, three phases of fbt, advantages of fbt, research on fbt.
- FBT Is Not for Every Family
Family-based treatment (FBT, also sometimes referred to as the Maudsley method) is a leading treatment for adolescent eating disorders including anorexia nervosa , bulimia nervosa , and other specified feeding or eating disorder (OSFED ).
It is a manualized treatment delivered by trained professionals. It is primarily delivered in outpatient settings , although there are some residential and partial hospitalization (PHP) programs that incorporate FBT.
While FBT may not be for every family, research shows that it is highly effective and faster to act than many other treatments.
It should therefore usually be considered as a first-line approach to treatment for children , adolescents, and some young adults with eating disorders.
FBT represents a radical departure from more traditional treatments. Older theories about anorexia and eating disorders, advanced by Hilde Bruch and others, ascribed their onset to family enmeshment or other dysfunction within the family. Mothers were believed to be the primary cause of the eating disorders of their children, as they were in the case of schizophrenia and autism.
The typical treatment instructed parents to step aside and turn their children with anorexia over to individual treatment or residential treatment centers—an approach we now know to have been, in many cases, detrimental to both the families and the patients.
Recent research has debunked the theory of parental causation of eating disorders, just as it has for schizophrenia and autism.
Genetic studies indicate that approximately 50% to 80% of a person's risk of an eating disorder is due to genetic factors .
The literature has rediscovered older starvation studies demonstrating that a number of characteristic behaviors of anorexia are actually the result of malnutrition that accompanies anorexia.
It is also believed that many clinicians made a basic selection bias error: observing the dynamics of families as they were seeking treatment, clinicians naturally saw families locked in a life-and-death struggle over food. This struggle is, however, a symptom of the disorder, not a cause—in the years preceding the eating disorder, their dynamics likely looked no different than other families.
Acknowledging that the weight of evidence had shifted, in 2010, the Academy for Eating Disorders published a position paper specifically refuting the idea that family factors are a primary mechanism in the development of an eating disorder. This is a positive shift because it has resulted in the greater inclusion of parents in treatment in general and greater acceptance of and demand for FBT.
FBT should not be confused with the similarly-named but potentially fundamentally different approaches under the umbrella of family therapy. Traditional family therapy often takes the view that the child with an eating disorder is expressing a family problem.
It focuses on identifying and solving that problem in order to cure the eating disorder . This approach has not been supported by research and is challenged by the AED position paper.
In the 1970s and early 1980s, the clinicians at the Maudsley Hospital in London, England, conceived a very different form of family therapy, treating parents as a resource, not a source of harm. The Maudsley team has continued to develop and teach the approach, which they do not refer to as the Maudsley approach, but as anorexia-focused family therapy.
Meanwhile Drs. Daniel Le Grange and James Lock further developed the model in a manual (published in 2002 and updated in 2013), naming their manualized version Family-Based Treatment (FBT).
The FBT approach is rooted in aspects of behavioral therapy, narrative therapy, and structural family therapy. Lock and Le Grange have established the Training Institute for Child and Adolescent Eating Disorders, an organization that trains therapists in this treatment and maintains a list of certified therapists and therapists in training.
FBT takes an agnostic view of the eating disorder, meaning therapists do not try to analyze why the eating disorder developed. FBT does not blame families for the disorder. On the contrary, it presumes the powerful bond between parents and children and empowers the parents to use their love to help their child.
In FBT, parents are viewed as experts on their child, an essential part of the solution, and members of the treatment team.
In FBT, the eating disorder is viewed as an external force that is possessing the child. Parents are asked to join with the healthy part of the child against the eating disorder which is threatening to take their child away. Full nutrition is viewed as a critical first step in recovery; the role of parents is to provide this nutrition by actively feeding their child.
FBT sessions usually involve the entire family and include at least one family meal in the therapist’s office. This gives the therapist an opportunity to observe the behaviors of different family members during a meal and to coach the parents to help their child eat.
Because patients with eating disorders may present with medical complications , they should be monitored by a physician during the course of treatment.
FBT has three phases:
- Phase 1: Full parental control. Parents are usually in complete charge of meals as they help their child to reestablish regular patterns of eating and interrupt problematic eating disorder behaviors such as bingeing, purging, and overexercise. If weight gain is indicated, the goal is 1 to 2 pounds per week. The therapist works to empower the parents to take on these tasks and helps the parents learn to manage the child at mealtimes.
- Phase 2: A gradual return of control to the adolescent. This phase typically begins once weight is mostly restored, when meals are going more smoothly, and when behaviors are more under control. Control is gradually handed back to the adolescent in an age-appropriate manner: for example, the child may start to have some meals or snacks away from the parent. There can be backsliding and parents may have to reassert control from time to time until the adolescent is fully ready; this is part of the process.
- Phase 3: Establishing healthy independence. When the adolescent is able to eat with an age-appropriate level of independence and does not exhibit eating disorder behaviors, the focus of treatment shifts to helping them develop a healthy identity and catch up on other developmental issues. Other comorbid problems may be addressed. The family is helped to reorganize now that the child is healthier.
Brain starvation can cause anosognosia , a lack of awareness that one is ill. As a result, there can be a long time lag before the minds of adolescents in recovery are capable of the motivation or insight to maintain their own recovery.
FBT assigns the work of behavioral change and full nutrition to the parents and gives them skills and coaching to meet these goals. As a result, it helps the child to recover even before they have the capacity to do so on their own.
Because it tends to work faster than other treatments, FBT reduces medical repercussions and increases the chances of a complete recovery. It allows the child to remain at home with their parents and is often more cost-effective than residential treatment .
Research has shown that adolescents who receive FBT recover at higher rates than adolescents who receive individual therapy:
- A study out of the University of Chicago and Stanford shows that at the end of a course of FBT, two-thirds of adolescents with anorexia nervosa have recovered; 75 percent to 90 percent are weight-recovered at a five-year follow-up.
- A recent study compared FBT for bulimia nervosa with CBT for bulimia nervosa. The findings indicated that FBT led to faster and sustained abstinence rates for teens.
- Preliminary research and case studies also indicate that FBT is an acceptable approach for young adults.
FBT appears to be most effective for families in which the length of illness is less than three years. An early positive response to the treatment (commonly by week four) is prognostic of a long-term successful outcome.
FBT Is Not for Every Family
Parents often believe that FBT will not work for them. “My child is too old.” “My child is too independent.” “I’m not strong enough.” “We are too busy.” Yet none of these issues have shown to necessarily be a barrier for a successful FBT treatment execution. Research and clinical experience demonstrate that many diverse families are able to successfully implement FBT.
However, it is not for every family. It is rigorous and requires a strong commitment by the family members. It is not recommended for families in which the parents are physically or sexually abusive or are abusing substances.
FBT may not be recommended for families in which the parents are overly critical.
For families where parents tend to be critical, a variation of FBT, called separated FBT, can be a great option. In this approach, the therapist meets only with the parents while the child's weight is monitored by medical personnel.
A Word From Verywell
The above exceptions represent only a minority of cases. Families who have used this approach are generally very enthusiastic and grateful to have been a part of the solution. Helping to play an active role in your child's recovery can be a very rewarding experience.
Jewell T, Blessitt E, Stewart C, Simic M, Eisler I. Family Therapy for Child and Adolescent Eating Disorders: A Critical Review. Fam Process. 2016;55(3):577-594. doi:10.1111/famp.12242
Treasure J, Cardi V. Anorexia Nervosa, Theory and Treatment: Where Are We 35 Years on from Hilde Bruch's Foundation Lecture?. Eur Eat Disord Rev. 2017;25(3):139-147. doi:10.1002/erv.2511
Le Grange D, Lock J, Loeb K, Nicholls D. Academy for Eating Disorders Position Paper: The role of the family in eating disorders. Int J Eat Disord. 2010;43(1):1-5. doi:10.1002/eat.20751
Lock J, Le Grange D. Can family-based treatment of anorexia nervosa be manualized?. J Psychother Pract Res . 2001;10(4):253–261.
Training Institute for Child and Adolescent Eating Disorders. Mission. Upcoming Workshops. San Francisco: Training Institute for Child and Adolescent Eating Disorders 2020 http://train2treat4ed.com
Epstein LH, Paluch RA, Wrotniak BH, et al. Cost-effectiveness of family-based group treatment for child and parental obesity. Child Obes . 2014;10(2):114-121. doi:1.1089/chi.2013.0123
Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry . 2010;67(10):1025–1032. doi:10.1001/archgenpsychiatry.2010.128
Le Grange DL, Lock J, Agras WS, Bryson SW, Jo B. Randomized Clinical Trial of Family-Based Treatment and Cognitive-Behavioral Therapy for Adolescent Bulimia Nervosa. Journal of the American Academy of Child and Adolescent Psychiatry. 2015;54(11):886–894.e2. doi:10.1016/j.jaac.2015.08.008
Timko CA, Zucker NL, Herbert JD, Rodriguez D, Merwin RM. An open trial of Acceptance-based Separated Family Treatment (ASFT) for adolescents with anorexia nervosa . Behav Res Ther. 2015;69:63-74. doi:10.1016/j.brat.2015.03.011
Dimitropoulos G, Lock J, LeGrange D, Anderson K. Chapter 11. Family therapy for transition youth. In: Loeb KL, ed. Family Therapy for Adolescent Eating and Weight Disorders: New Applications. New York and East Sussex, England: Routledge; 2015:230-256.
Thornton LM, Mazzeo SE, Bulik CM. The Heritability of Eating Disorders: Methods and Current Findings . Current Topics in Behavioral Neurosciences. 2011;6: 141–156. doi:10.1007/7854_2010_91
By Lauren Muhlheim, PsyD, CEDS Lauren Muhlheim, PsyD, is a certified eating disorders expert and clinical psychologist who provides cognitive behavioral psychotherapy.
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The parents’ role in helping children return to a healthy weight
Writer: Hannah Sheldon-Dean
Clinical Expert: Daniel Le Grange, PhD
What You'll Learn
- What is family-based treatment for eating disorders?
- What do parents do in family-based treatment?
- Why does family-based treatment work?
For most young people with anorexia or bulimia, the treatment that experts recommend lets kids get better at home with their families. Research shows that family-based treatment helps kids gain weight faster than any other eating disorder treatment.
In family-based treatment, parents take the lead in helping kids recover. A mental health clinician guides parents in showing their child empathy while also enforcing strict rules about eating. Parents choose, prepare and serve all of the child’s foods. They require the child to eat and offer lots of support. The child and their parents meet with a clinician every week for coaching on this process.
Family-based treatment is a big commitment. It’s helpful to think of the treatment like any other emergency medical treatment. It changes everyone’s routines, but the changes are necessary to save the child’s life. In later phases of treatment, the child slowly takes charge of their own eating again.
The idea behind family-based treatment is that getting the child nourished is the most important thing. That’s because it’s hard for kids to think clearly when they are starving. Once they start eating more, they can get perspective on their eating disorder and start to behave in a healthier way.
As long as your child does not need emergency medical or psychiatric treatment, recovering from an eating disorder at home is usually the best option. A clinician can help you manage the changes in routine and find ways to balance your other responsibilities.
Traditional approaches to treating eating disorders in children and young adults often involve removing kids from their homes — and their parents — for in-patient psychiatric treatment.
In cases where a young person with an eating disorder needs immediate medical or psychiatric care, in-patient treatment is still recommended. But the treatment experts prefer for most kids with anorexia or bulimia lets kids remain at home, with parents taking the lead in helping them recover. Family-based treatment (or FBT) gives parents the job of strictly supervising the patient’s eating, and evidence shows that it is the quickest way for an underweight child to return to a healthy weight.
What is family-based treatment?
The core of family-based treatment is the assumption that parents are capable of helping a child recover from an eating disorder. “FBT relies on that core parental capacity to feed your child,” says Daniel Le Grange, PhD, one of the founders of FBT and director of the Eating Disorders Program at the University of California, San Francisco. “In practice, it coaches parents to do the same job that nurses in an in-patient program would do.”
Because eating disorders are complex and confusing illnesses that severely disrupt family life, parents of a child with anorexia have often come to doubt themselves, and they may have given up asserting parental authority over the child’s eating. In FBT they take back that role. “Clinicians in FBT reinforce the idea that parents can do this,” Dr. Le Grange says. “We slowly but surely coach them to begin to trust their gut once more.”
How does family-based treatment work?
In FBT, a clinician guides parents or caregivers in replicating the two major components of in-patient eating disorder treatment: empathy for the child and, in Dr. Le Grange’s words, “an environment in which not eating is not an option.” Just as a parent would insist on treatment for an illness like cancer, even if it is unpleasant, the parent insists that the child comply with FBT guidance. A child with an eating disorder will almost certainly fight eating food that will enable them to gain weight. “But parents need to understand that the disorder is like a malignant tumor,” Dr. Le Grange explains. “They’re not fighting their kid, they’re not trying to make their child’s life miserable. They’re fighting the illness.”
Right at the start of FBT, parents manage their child’s eating, from choosing foods to preparing and serving them. “Essentially, you say to the child: ‘I know this is tough for you, but I’m going to sit here with you until you eat this,’” Dr. Le Grange says. Repeating that process without any exceptions is the core of the initial phase of FBT.
“It can take time,” says Melissa Gerson, LCSW, the founder and clinical director of Columbus Park, a New York City eating disorder treatment clinic. “We may have a parent sitting at the table with the child for an extended period of time, and just waiting for the child to finish.” The idea, she says, is that there’s no room for negotiation. By calmly and confidently directing their child’s eating under a clinician’s guidance, parents are empowered to enforce the boundaries that kids need in order to recover.
Time commitment for parents
Participating in FBT usually means big changes in the family’s routine. For instance, in a two-parent family, the parents might take turns staying home from work to supervise the child’s eating. In single-parent families, it may be necessary to enlist help from extended family or trusted friends. “The first phase of FBT really requires parents to put their lives on hold,” says Dr. Le Grange. Because the treatment can be so disruptive, he emphasizes to parents that eating disorders are an urgent medical threat. “It’s like having a child who’s in renal failure and needs dialysis three times a week,” he says. The change in routine can be hard to manage, but it’s medically necessary.
Ideally, siblings are involved in FBT as well. “Parents are responsible for weight restoration, and siblings are supposed to be supportive of their ill sibling outside of mealtimes,” Dr. Le Grange says. Because the treatment can be stressful and upsetting for the child with the eating disorder, siblings can give the child space to relax and be a kid, away from the structures that the parents impose at mealtimes. Depending on the family circumstances, it may not be plausible to involve siblings without creating more stress, but when possible, they can be an important support system.
In later phases of FBT, the goal is to return decision-making over food intake back to the child or adolescent, once they’ve regained sufficient nutrition and stabilized their weight and behaviors.
Why is family-based treatment effective?
FBT has been shown to be efficacious for underweight kids (with anorexia nervosa) and kids with binge eating and purging behavior (bulimia nervosa). FBT has also been used for kids with other eating disorders such as atypical anorexia or ARFID, but the evidence is not quite as robust as it is for anorexia and bulimia.
The thinking behind FBT is that focusing on improving nutrition is more helpful than analyzing the underlying causes of the disorder. That’s because, Gerson explains, “with anorexia in particular, much of the distress around food — and the low mood, and the isolation, and the compulsivity — is caused by starvation. The child is behaving this way mainly because the brain is starved.” Once the child is no longer starving, they’re better able to think through what’s happening and maintain healthier behaviors going forward.
Dr. Le Grange notes that it’s crucial for families to avoid getting trapped in what clinicians call “anorexic debate.” When your child is trying to convince you that it’s fine to eat only salad, he says, “you’re not reasoning with your rational, smart adolescent. You’re having a discussion with a psychiatric illness.” FBT gives parents a structure in which they can avoid those dead-end debates and focus instead on getting their kids nourished.
How is family-based treatment structured?
FBT generally involves roughly 20 weekly sessions, divided into three phases. Throughout all three phases, the clinician works primarily with the parents or caregivers, while being supportive of the adolescent who is in distress. At the start of each session, the child has a short check-in with the FBT clinician to check their weight and get basic mental health support. Then, parents or caregivers, along with the child and sometimes their siblings, meet with the clinician for coaching and support around their work to nourish their child.
The first phase usually lasts for 10 to 12 sessions, and it’s where the bulk of the work takes place. “Phase one is all about re-nourishing the adolescent,” Dr. Le Grange says. During phase one, parents focus on all aspects of the child’s eating.
The child usually does not attend school for the first week or two, in part because they need to conserve energy while they gain weight. Then, if the treatment is going well, the parents might supervise the child a bit less as phase one goes on. “For instance,” says Dr. Le Grange, “by week three the child might go back to school after lunch. And if they keep gaining weight, then maybe by week five the child eats lunch at school, but with a parent or school counselor there to supervise.”
In phase two, which lasts for five or six sessions, the child begins to make some limited decisions about their eating again, and to participate in age-appropriate activities outside of the home. It’s important to move slowly and look out for backsliding in phase two. “These are all very tentative moves, because just a month or two earlier they were still pretty unwell,” Dr. Le Grange notes. “We had a case where the adolescent was doing really well, and they were a very good athlete, but the parents reintroduced physical activity too quickly, and too vigorously, and everything came tumbling down.” If problems do arise in phase two, then the family has to largely return to phase one.
Phase three, the final three or four sessions of FBT, focuses on launching the child back into their normal daily life. It also helps parents learn how to interact with their child again now that their relationship is much less focused on the eating disorder.
How do you know if family-based treatment is right for your child?
If a child or young adult is in a life-threatening medical or psychiatric situation, then hospitalization is necessary. In most other cases of anorexia and bulimia — including those where the young person is very underweight but otherwise medically stable — experts recommend FBT.
Dr. Le Grange emphasizes while FBT might sound daunting, most parents do have the capacity to manage it. “All parents come to us with strengths and weaknesses,” he says. FBT involves coping with each family’s unique challenges and building on their strengths. “And the major strength is that families love their kids,” Dr. Le Grange adds. There are other eating disorder treatments (including enhanced cognitive behavioral therapy, called CBT-E, and adolescent-focused therapy, called AFT) available if FBT doesn’t work or isn’t feasible, but they generally don’t help kids regain weight as fast as FBT does.
Accordingly, Dr. Le Grange urges parents not to rule out FBT, even if their circumstances are challenging. “We have to be creative as clinicians,” he says. That might mean helping parents juggle work responsibilities or financial difficulties, bringing in extended family for support, or helping parents navigate disagreements with each other. “Some situations are much tougher than others, without a doubt,” says Dr. Le Grange. “But that just means that we as clinicians have to work harder and be more supportive.”
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Family therapy for anorexia more effective than individual therapy, researchers find
October 3, 2010 - By Erin Digitale
Family-based therapy, in which parents of adolescents with anorexia nervosa are enlisted to interrupt their children’s disordered behaviors, is twice as effective as individual psychotherapy at producing full remission of the disease, new research from the Stanford University School of Medicine , Lucile Packard Children's Hospital and the University of Chicago shows. The study is the first head-to-head comparison of these two common treatment approaches for adolescents suffering from the eating disorder.
“This research was desperately needed,” said James Lock , MD, PhD, one of the study’s two lead authors and a professor of psychiatry and behavioral sciences at Stanford. “Anorexia nervosa is a life-threatening illness, and it’s really remarkable how little information we have about how to treat it. There are serious cons to not knowing what to do.”
The research was published Oct. 4 in the Archives of General Psychiatry .
Patients with anorexia nervosa inaccurately believe they are fat, and use food restriction and exercise to maintain dangerously low body weights. The disease, which affects about 0.5 to 0.7 percent of adolescent girls, kills about one in every 10 patients.
Lock’s team at Stanford collaborated with researchers at the University of Chicago to test family-based therapy against individual psychotherapy therapy in 121 male and female anorexia patients aged 12 to 18. In family-based therapy, the clinician trains the patient’s parents to help ensure that their child eats enough and does not overexercise. Individual psychotherapy, in contrast, focuses on resolving the patient’s underlying anxiety and emotional problems, with only minimal involvement from the family. In order to control for differences between clinicians, all therapists in the study had patients in both treatment groups.
The researchers evaluated each patient’s condition at the start and end of the one-year treatment period, and then again six and 12 months after treatment ended. Patients were considered in full remission if they reached 95 percent of normal body weight and had a normal score on a standardized psychiatric assessment of attitudes about eating. At the end of the study, 49.3 percent of family-based therapy patients were in full remission, whereas 23.2 percent of individual psychotherapy patients were in full remission. The two treatments were equally effective in helping patients achieve partial remission, characterized by reaching a body weight of 85 percent of normal.
“Although both treatments were helpful to a proportion of patients, this study strongly suggests that as first-line treatment, in general, family-based interventions are superior,” said Lock, who is also psychiatric director of the Comprehensive Eating Disorders Program at Packard Children’s .
“For the first time, we can confidently present parents with a treatment we consider the gold standard for this patient population,” added Daniel Le Grange, PhD, the other lead author of the study and a professor of psychiatry and behavioral neuroscience at the University of Chicago.
Lock noted, however, that individual psychotherapy works better in some cases, and that he and his colleagues at Packard Children’s routinely offer both types of therapy. The scientists are now further analyzing the data to see if they can figure out how to identify which types of patients should be directed toward each therapy.
Although the study did not determine exactly why family-based therapy was more effective, Lock speculated that the treatment might have worked better because “it’s a more direct approach.”
“Restrictive eating and overexercise contribute to the maintenance of anorexic thinking,” he said, noting prior research has shown that even healthy individuals develop anxious, obsessive, ritualistic thinking patterns about food when they are starving. “If you disrupt the maintaining behaviors of anorexia and get the patients eating, you disrupt that sequence of thinking. The traction of the thinking itself becomes less.”
Prior to the study, Lock said, the investigators had speculated that individual psychotherapy might have better long-term results because it attempts to resolve the psychological problems that may underpin the disorder. “The interesting thing to me is that relapse was a lot greater in the individual psychotherapy group,” he said. “It suggests that the behavioral components of anorexia nervosa are very powerful at maintaining the disease.”
Lock also noted that family-based therapy obtained better long-term results than previous trials in which patients have been hospitalized for anorexia nervosa. Although the earlier trials showed that hospitalized patients gained weight, they often lost much of the weight soon after they returned home.
“In contrast, patients receiving family-based therapy had to learn to eat enough in the context of their real life,” said Lock, who on Oct. 10 received the National Eating Disorders Association’s Price Family Award for Research Excellence. “They didn’t face a step off the cliff into the real world.”
Lock hopes the study’s results will encourage those who treat adolescent anorexia nervosa to learn to use family-based therapy.
“I would like clinicians to see that parents can be helpful,” he said. “The model of putting kids in the hospital, which excludes parents, or of professionals expecting young adolescents to manage their own eating without their parents’ help when they’re immersed in anorexic thinking, really should be reconsidered.”
Future research will be needed to test whether teens treated with family-based therapy continue to do well after they move away from home, Lock noted.
Lock’s collaborators at Stanford were Stewart Agras, MD, professor emeritus of psychiatry and behavioral sciences; senior scientific programmer Susan Bryson; and Booil Jo , PhD, assistant professor of psychiatry and behavioral sciences.
The researchers have written two books on family-based therapy. With Le Grange, Lock wrote a book for parents called Help Your Teenager Beat an Eating Disorder (Guilford Publications, 2005). Lock, Le Grange and Agras are co-authors of a book for clinicians called Treatment Manual for Anorexia Nervosa: A Family-Based Approach (Guilford Publications, 2002).
The research was funded by grants from the National Institutes of Health . Information about Stanford's Department of Psychiatry and Behavioral Sciences, which also supported the work, is available at http://psychiatry.stanford.edu/ .
About Stanford Medicine
Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .
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Perspective article, rebooting “failed” family-based treatment.
- New Zealand Eating Disorders Clinic, Auckland, New Zealand
Family-based treatment (FBT) has become well established as the first-line evidence-based treatment for adolescents with anorexia nervosa. However, fidelity to the FBT model can be poor, and treatment is often augmented or modified in various untested forms in the hope of increasing its effectiveness and acceptability. The New Zealand Eating Disorders Clinic, a private specialist outpatient clinic in New Zealand, has been seeing increasing numbers of families presenting for treatment reporting an experience of “failed FBT”. All of the families who presented with a child under the age 19 living at home agreed to restart FBT with the author when re-engaging in treatment. This essay summarizes the experience of the author in repeating FBT with previously “failed” FBT cases over 20 months between 2017 and 2019. Common themes of the first course of FBT were identified that raised questions for the author as to whether FBT had been implemented with sufficient fidelity and proficiency the first time around. This clinical perspective essay describes how these identified issues were addressed when FBT was administered again. It does not intend to make broad claims, but instead is intended to be helpful to clinicians who are implementing FBT, to assist them in carefully examining and assessing whether key FBT principles and procedures have been exhausted before evaluating the need for modification or augmentation. Furthermore, this perspective provides suggestions as to how the identified common themes can be addressed if families re-present for FBT treatment after having had a course of “failed FBT”.
Introduction
Manualized family-based treatment (FBT) is an empirically supported treatment for adolescents with anorexia nervosa with outcomes of full and sustained remission in 35–45% of cases ( 1 – 3 ). Full remission is defined as percent median body mass index (BMI) greater than 95% as expected for age and an Eating Disorder Examination (EDE) score within one standard deviation (SD) of the population mean ( 4 ). The efficacy data to date for manualized FBT are promising ( 5 , 6 ). FBT has been established as a first-line treatment for adolescent anorexia, which is now reflected in treatment guidelines for eating disorders ( 7 , 8 ). However, the effectiveness and acceptability of FBT in its manualized form has been questioned ( 9 – 11 ). There is also a growing trend among clinicians and treatment providers to describe the treatment they provide as “FBT informed” or “modified FBT,” although, to date, there is no definition of what these terms actually mean. Based on anecdotal discussions among colleagues and presentations at conferences, it seems that a “modified” approach entails some or all of the following: additional individual treatment for the adolescent, the use of a dietitian to provide dietary advice or meal plans, the use of adjunct groups (e.g., self-compassion, distress tolerance), or a planned hospital admission or residential stay to assist with weight restoration or management of eating disorder behaviors. Incorporating these kinds of interventions deviates from the empirically tested manualized version and is not informed by any research. There are indications that “modified” versions of FBT might even be more commonly practiced than the manualized version. In a study of 40 therapists providing treatment to youth with anorexia ( 12 ) concluded that there remained not one participant who reported practicing FBT with fidelity to the model. An online study examining FBT adherence demonstrated that one third of respondents deviated from the model ( 13 ). A study of therapist adherence to manualized FBT showed that adherence to the model decreased over time, and that adherence was strong only on behavioral interventions focused on meals and eating but weaker on other elements of the treatment such as modification of parental criticism and attending to general family process issues ( 14 ).
This perspective essay summarizes the author’s learning and reflections of providing FBT a second time around for cases with a reported history of “failed” FBT. Using the families’ narratives of their previous FBT treatment the author amalgamates identified issues into five key themes that appear to have contributed to the failure of the first course of FBT. Each of these themes will be discussed with a description of interventions of how these themes have been addressed in the second course of FBT.
Summary of Case Data
Since this clinical perspective essay is based on reflections on a cohort of cases it is helpful to provide a summary of the key data of the cases. Nine cases in total presented to the New Zealand Eating Disorders Clinic over a 20-month period between October 2017 and May 2019, reporting “failed FBT”. All of them agreed to re-engage in FBT for a second time with the author. One family dropped out, four families are still in treatment, and four families have successfully completed treatment. The mean age at beginning of treatment was 17.3 years (range 14–19 years), with an average illness duration of 3 years (range 1–8 years). All are female with two cases with separated parents. Two cases identify as having 50% Maori descent. Seven cases have a diagnosis of anorexia nervosa restricting type, and one with anorexia nervosa binge-eating/purging type. Mean BMI at the beginning of treatment for all eight cases was 17.8 (range 16.6–19). Four cases have completed treatment after a mean of 21.75 sessions (range 17 to 25) with a mean BMI of 20 (range 18.5–21.6) and resumption of menses at EOT. Three completed an EDE-Q at EOT, all with a total score within one SD of community norms. The four cases still in treatment are also on track to achieve the same recovery standard, despite a longer duration of illness for two of the cases (>4 years). All of the cases are seen by the author, who is a certified FBT therapist and certified supervisor and has worked with eating disorders for 19 years and practicing FBT for 10 years. The author has regular specialist FBT supervision.
Getting It Right From the Beginning
Theme one relates to whether families “started well”. All families reported knowing what FBT was; they had done their own reading about FBT; they had often connected with support groups and online forums. However, they reported mixed experiences of treatment delivery. In all cases, families were aware of the core tenets of FBT, namely externalization of the illness, parents being in charge of re-nourishment, being united, and not criticizing their child. In all cases, the entire family, including siblings, had been present at the first two sessions. It seemed that the structural components of the therapy had originally been set up appropriately. However, the depth of understanding and knowledge of these core principles and their translation into treatment appeared deficient. The parents reported that they felt they were prescribing something to their child in an inauthentic and mechanical way rather than embodying it. When session one was re-done, every family commented that they had not really “gotten it” the first time around. Particular attention was paid by the therapist to helping the parents truly understand the nature of anorexia and how it affected their child. Persistent circular questioning was used to draw out the parental understanding of the connection between what they knew about anorexia and its specific manifestations in their child. Multiple analogies and examples were re-visited until the therapist and family felt satisfied that the session one tasks had been fully addressed. Session two, the meal session, was a session that families wanted to skip because significant anxiety had been generated during the previous experience. The therapist needed to spend more time at the initial set-up exploring with sensitivity any reservations the families had and setting the right “tone”. This included empathy for the previous experience of the family and at the same time being mindful of the necessity of this session. It was framed up as a new learning opportunity, to assess where the anorexia may have taken ground; to supply the input needed to help set the family back on track, and to discover where unhelpful “blind spots” may have developed. In all cases, the intensity of the meal session was slightly reduced because the families had done it before. However, the participants had greater openness to learning because they “knew” the anorexia better. This provided an opportunity to empower the parents to utilize knowledge and experience they had already acquired in dealing with any problem areas that arose during the session.
Facilitating Parental Empowerment
A strong early predictor of success in FBT is achievement of weight gain of 2.3 kg or more over the first month of treatment ( 15 – 17 ). In the reviewed cases, all patients had achieved weight gain of 2.3 kg or more in the initial stages of the first FBT treatment, which has been established by the above studies as a key predictor of increasing recovery chances. This raises the question, what happened? The parents described hearing the message clearly that weight gain was needed, and reported having been mobilized to ensure their child was eating sufficient amounts to gain weight. However, it seemed that the need to “re-feed” had become the only goal of FBT. The parents described the feeling of being in panic mode and managing to achieve early weight gain but eventually becoming stuck. Three families reported staying in phase one for up to 30 sessions and not being able to transition to phase two. Two families had transitioned to phase two on the recommendation of the previous therapist despite disagreeing. In two cases, at the suggestion of the therapist, when weight gain became stalled or distress remained high, the adolescents had received concurrent individual therapy, as an adjunct to FBT.
All parents, when seen for the second time, reported feeling exhausted, hopeless and sometimes feeling guilty about being a “failure” at parenting, or failing to feed their daughter. This situation called for particular attention. The issue of parental empowerment is a core tenet of FBT and one that is commonly misunderstood ( 18 ); yet it is the fundamental principle that underpins FBT. Empowerment is more than “being in charge of food,” which appeared to be the predominant understanding of the term. Parental empowerment is a complex concept, which refers to the process of parents becoming more confident in making decisions in the context of the tasks required to help their child recover from anorexia. Empowerment can only be achieved if the parents are on the same page, can understand the illness fully, and learn how to transfer their general parenting skills to the specific needs of treatment. If this is not achieved from the beginning and continually attended to throughout treatment, it can contribute to a number of problems in the long run. Problems in managing the anorexia behaviors that had been identified with the parents needed to be explored with the author for long enough to ensure that there was agreement and certainty about the plans and strategies the family were to implement. This also involved detailed and focused discussions when reviewing how plans had succeeded and what could have been done differently. Families are complex, and they do not have the knowledge or experience of anorexia at the beginning of treatment. The therapist needs to sensitively attend to issues such as parents not being in agreement or when one parent takes more control than the other. The therapist also needs to avoid being overly directive or too passive, thereby inhibiting the learning process for the parents. It is not easy to detect whether parents are not really empowered . This was one of the critical issues that required careful attention when undertaking FBT the second time. The empowerment of parents involves recognizing nuances of the delicate balance of actively identifying the family’s perspectives and strengths, reinforcing healthy decision making together, and simultaneously, setting clear expectations for treatment tasks and goals ( 18 ).
Importance of Attending to Anorexic Behaviors, Not Just Weight Gain
In its first phase, FBT is highly focused on weight restoration ( 19 ). However, this does not occur at the expense of allowing anorexia behaviors and habits to go unchecked. All families reported that they had been instructed to keep a sustained focus on weight gain, and all families had achieved partial weight restoration the first time they did FBT. Families also reported that despite some weight restoration, eating disorder cognitions and body image concerns had remained unchanged. When this theme was explored further with the families, it became apparent that they had been under the impression that weight restoration was the only key to recovery, “As long as they eat and gain weight.” Families appeared to have an insufficient understanding of the need to challenge eating disorder-related behaviors. Instead, the families were offered individual treatment or a hospital admission for that purpose. Many of the adolescents admitted that they had hidden food, used water loading and weights, or secretly exercised throughout previous treatment. Families had not tackled fear foods or transitioned to normal levels of exercise before transferring responsibility back to the young person. The question of why cognitions were not changing had not been fully explored with families. This was a perplexing theme, as the FBT manual discusses the need in phase one as “Directing, redirecting and focusing the therapeutic discussion on food and eating behaviors and their management until food, eating and weight behaviors and concerns are relieved” (p.125, 19 ). Phase two involves gradual transfer of responsibility from the parents back to the child. The second time around, the first task the families had to learn was to take particular notice of anorexia behaviors, or uncover them, when the only cue was high distress and anxiety of their child. Parents also learned how to solve problems and how to extinguish all unwanted behaviors systematically. Parents reported that this was a new concept to them, a concept that had not been highlighted in their previous treatment, and, in some cases, had not even been mentioned. Frequently, these anorexia behaviors had become habit-based, and the adolescents and young adults were initially anxious about having to “give them up”. However, as the behaviors reduced over time, they were able to experience less anxiety and agitation with accompanying quieting of cognitions; the adolescents became very active participants during the later parts of phase two. Attending to the behaviors fully contributed to the affected adolescent feeling more “heard” and “understood,” and the experiments with parents became more collaborative as phase two progressed. Adolescents reported that in their previous treatment the focus had only been on increasing food amounts and that the lack of recognition by their parents and therapists of how distressing this was for them had increased their resistance to treatment and ultimately had resulted in their lack of faith and trust in their parents and in the effectiveness of FBT.
Therapeutic Alliance and Compassion
A common theme raised by almost all of the parents was the concern about a lack of a therapeutic alliance between the previous therapists and their children. This is of interest because the therapeutic alliance in FBT has been demonstrated to be positive with parents and the adolescent ( 20 , 21 ). In seven cases, the families had transitioned to individual treatment when FBT was “failing”. However, following this transition, every one of those seven patients deteriorated in weight and symptoms. The patients themselves later admitted that they had asked for individual treatment as a deliberate strategy to exclude their parents because they knew it would mean that there would be less pressure for weight gain and more chances of avoiding stress and conflicts around the challenges related to their eating behavior.
Re-booting FBT after the adolescent has already had individual treatment is always more challenging because of the reluctance of the young person to renounce their perceived control and autonomy. With five of the families who restarted FBT, this issue was addressed by agreeing that the young person would have more individual time at the beginning of sessions (the adolescents were older than 17 years of age). Initially, individual time was approximately 15 min (as opposed to 5–10 min), with sessions being 60–70 min in duration. However, it had to be made explicit that this was not “individual treatment” and the therapist was mindful of continuing to empower the parents, of the need to not be drawn into potentially divisive behaviors, and of reiterating the need for the parents to be part of conversations that involved making decisions. Particular attention was given, in a compassionate way, to linking the young person’s distress to being under the influence of anorexia and, at the same time, frequently acknowledging that it would be a normal instinctual response to want to avoid “feeling worse” by experiencing the intense anxiety when challenging the anorexia. This required the therapist to fully understand and believe that exposure was required to overcome these anorexia anxieties and to have a genuine, compassionate understanding for the affected adolescent and the parents, knowing how difficult it was to agree to decisions that would lead to having to tolerate distress and anxiety. Demonstrating compassion for the struggle of the adolescent is inherent to FBT and so is giving the adolescent more individual time as treatment progresses.
In all cases the second time around, there was never a question raised about the quality of the therapeutic alliance with the therapist. It is important for therapists to understand and feel confident that it is absolutely possible to maintain a strong therapeutic connection with the affected person without compromising the relationship with the parents and the fight against the anorexia. Although it is more challenging to restart FBT following individual treatment, it was useful that all families and adolescents acknowledged that the individual sessions had not resulted in the desired outcomes. This was helpful in directing the parents to the FBT framework without having to address requests for alternative forms of therapy at times of difficulties.
The Importance of Full Completion of Treatment
None of the families had previously experienced phase three therefore, this phase was a new concept for them. Some families, the second time around, were tempted to finish treatment after the relief of weight recovery, having established normalized eating and exercise behavior. One study ( 2 ) suggested that phase three may not be needed for some families, but it was noted that cases with high levels of obsessive-compulsive features appeared to benefit from a more extended treatment regime. All patients and families discussed in this essay had already been in treatment for some time and understandably, were feeling exhausted and ready to move on. It took persistence on part of the therapist to ensure that families did not rush to finish or “jump over” the final stages. Typically, phase three is intended to be brief and is aimed at ensuring that the adolescent is on track developmentally. It also helps the family to identify areas of potential deficits that may have left their adolescent child vulnerable in the first instance ( 19 ). Most patients displayed heightened anxiety about “life without anorexia” and felt inept at knowing how to manage developmentally appropriate life challenges like moving away from home or navigating intimate relationships. In those cases, phase three was extended beyond the three to four sessions typically required. The parents also needed help to “let go” and time to experience that their child was genuinely managing well. In all cases, there was additional individual time at the beginning of the sessions. The content of these sessions no longer focused on eating disorder management or related concerns, but rather on other life issues to model age-appropriate developmental independence. The author does not see this as a modification to FBT but rather a reflection of the greater need, made more apparent by a longer duration of illness, to attend to ensuring the patient is developmentally “back on track”.
Conclusions
There are several points worthy of reflection. The most critical one might be that it was possible to achieve full recovery using FBT treatment even after a course of previously “failed” FBT. It might be re-assuring to know for FBT therapists faced with similar cases that revisiting FBT is a valid treatment option. This perspective essay is based on eight cases seen by one therapist in one clinical setting over the course of 2 years. This raises the question of how often this phenomenon of families presenting for treatment as having “failed” may be occurring elsewhere. The themes discussed were present in all cases and, while comprehensive conclusions about the families’ previous treatment cannot be drawn, they were common and clear enough to question whether important key principles of FBT treatment had not been attended to with sufficient fidelity and proficiency the first time the families had engaged in FBT treatment. The emphasized points and solutions discussed in this essay are not outside what FBT clinicians should already be aware of. It might be helpful and reassuring to clinicians to know that with persistence, even a second course of FBT treatment can go well without the need for additional adjunct interventions like individual treatment. In fact, greater success was achieved in these cases by not adding major modifications of FBT. Even though this clinical perspective has not been based on a systematic review, the reflections on these cases warrant the message that, when an FBT case is not going well, deviating from the original FBT model needs to be carefully evaluated. Part of such an evaluation would need to be the clinician’s self-reflection on whether they have been delivering treatment with sufficient proficiency. All of the identified themes relate to key principles and tenets of FBT but their actual practical application might require some additional emphasis in teaching FBT. Clinicians may need to be better supported to develop sufficient depth of practice in FBT. An important step can be to ensure that clinicians receive adequate training and ongoing expert supervision including the need to focus on the themes addressed in this paper. It needs to be acknowledged that the narrative and the assumptions of the families’ previous experience is speculative and has not been systematically checked. Equally, the previous therapists may hold different views about the treatment they provided.
This clinical perspective has been written with the intention to assist practicing FBT clinicians with reflection and new learning. Further research would be helpful to help establish if these findings can be replicated when systematically investigated in a more extensive study.
Author Contributions
KL is the sole author contributing to this paper and its associated contents.
Conflict of Interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Acknowledgments
I wish to thank Dr. Roger Mysliwiec for his generous availability with editing support. I also want to acknowledge my supervisor and mentor, Professor James Lock, for his ongoing advice and expertise.
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Keywords: family-based treatment, anorexia nervosa, adolescents, treatment fidelity, failed FBT, modified FBT
Citation: Lavender KR (2020) Rebooting “Failed” Family-Based Treatment. Front. Psychiatry 11:68. doi: 10.3389/fpsyt.2020.00068
Received: 11 October 2019; Accepted: 27 January 2020; Published: 05 March 2020.
Reviewed by:
Copyright © 2020 Lavender. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Kellie R. Lavender, [email protected]
This article is part of the Research Topic
Innovations in Research and Practice of Family Based Treatment for Eating Disorders
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Family-Based Therapy
Psychologists and psychiatrists use family-based therapy to treat a range of mental health conditions. It is often used with addiction, depression, and mental illness. The approach assumes that family is a key resource for everyone—especially adolescents and young adults, who depend on their families for all types of support.
The Maudsley Hospital in London was the first place to use family therapy to treat eating disorders. The British program focused on teens with anorexia nervosa. Today, we use this approach to help adolescents and young adults with a wide range of eating disorders. Some forms of family therapy assume that a child is acting out to express a family problem. The Maudsley approach treats the parents as a resource, not a problem. It is an evidence-based therapy that uses the latest scientific research and offers an outpatient alternative to hospitalization.
Treatment takes place once or twice a week for six to nine months. We offer therapy to the young person and supportive training to parents. The goal is to get the young person to a healthy weight and help him or her re-learn how to eat in a way that promotes good nutrition. This approach works best for those who have been ill for three years or less. It requires loving support from family members.
This approach targets anxiety related to food, eating, and body image. We address the young person’s worries, fears, and inflexible thinking. To help with inflexible thinking, we often use acceptance-based mirror exposure . We train parents to help the young person learn to tolerate or shift negative feelings about eating and daily functioning.
While we design a plan specifically for you or your child, there are three basic stages to the Maudsley Approach:
- Phase I: Getting to a Healthy Weight : At the beginning of treatment, the young person is not making good health choices, so the parents need to step in. We assess how your family copes with mealtime and make suggestions. The goal is to help parents take charge of mealtime, help their child adjust to regular eating patterns, and encourage them to eat a little more. Our goal is a weight gain of two pounds a week.
- Phase II: Helping Your Child Regain Control : We begin this phase when the young person is at a healthy weight, meals are going more smoothly, and there is no sign of eating disorder behaviors such as bingeing or purging. At this point, we help parents hand over control of eating to their child—and helping the child eat in a healthy manner and continue to gain weight. We strive to achieve this with minimal tension. There may be some relapse. At that point, parents may need to step in again.
- Phase III: Establishing a Healthy Identity : Once your child can maintain a weight at 95 percent of ideal eating at an age-appropriate level of independence, we turn to helping the young person develop a healthy identity. This includes not only eating, but also independence and sexuality. We may address other mental health conditions at this point. We support increased personal autonomy, help develop appropriate parental boundaries, and assist the family reorganize out of crisis mode.
This family-based approach may not work for every family. It requires a loving, supportive family and a strong commitment from everyone involved. Our doctors will assess your family to see if the Maudsley approach would work for you.
Alternatives to Traditional FBT
Exposure-based Family Therapy (FBT-E) approaches treatment of eating disorder through anxiety. We address three core aspects of anxiety as it relates to eating and shape/weight concerns. First, FBT-E targets disgust-based aversion to food and the interoceptive (visceral) body image feelings associated with eating and adapts specific modules for worry (imaginal and worry-based exposure), fear (exposure with response prevention), and the inflexible thinking associated with body image disturbance ( acceptance-based mirror exposure ). We train the parents in how to facilitate exposures to help the patient learn to tolerate and/or shift the negative affect that interferes with eating or daily functioning.
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Keywords: eating disorders, adolescents, family-based therapy, anorexia nervosa, bulimia nervosa. Go to:
The earliest studies of family therapy for anorexia nervosa (AN) were conducted at the Maudsley Hospital in London [3,4,5]
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Evidence shows that family-based treatment (or FBT) for eating disorders is the quickest way for an underweight child to return to a healthy weight.
Lock's team at Stanford collaborated with researchers at the University of Chicago to test family-based therapy against individual psychotherapy
Carers are reminded to consult with health professionals and seek out support during all phases of treatment. PHASE 1: RE-FEEDING.
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FBT has been established as a first-line treatment for adolescent anorexia, which is now reflected in treatment guidelines for eating disorders
Explore family-based therapy (Maudsley approach) and exposure-based family therapy (FBT-E) at the Center of Excellence in Eating and Weight Disorders.