Family-Based Treatment for Eating Disorders

Eating disorder treatment needs to be tailored to the family and specific needs of the individual being treated. With this being said, there is also much to learn from evidenced based, standardized treatment approaches. Family-Based Treatment (FBT) is one such approach. Of all of the various treatment options available for teens, FBT has the best outcomes and strongest research base. FBT is the first line of treatment for adolescents who suffer with anorexia nervosa and bulimia nervosa. FBT has also been successfully applied to specific adult cases and other types of eating disorders. 

So what is Family-Based Treatment and could it be successfully adopted for your family?

The Nuts and Bolts of Family-Based Therapy 

FBT is a highly standardized, hands-on approach that empowers parents and caregivers to take an active role in the treatment of their loved one. It  requires parents, caregivers and siblings to be a part of meals, snacks and overall support. FBT can best be understood by looking at the phases and tenets of the treatment plan. 

The basic tenets of FBT, as outlined by the Journal of Eating Disorders, are as follows:

• The therapist holds an agnostic view of the cause of the illness.  In FBT, the therapist is not focused on the parents as causal agents in the development of the eating disorder. Instead, the therapist works to recruit and mobilize the family as the primary agents to bring about behavioral change in their child. Therapists work to contain the parents anxiety and to empower them as the primary caregivers for their child. The therapist reinforces the parents innate knowledge of how to care for their child in order to  restore their child’s weight, health and nutrition status. 

• The therapist takes a non-authoritarian stance in treatment. The FBT model positions the care team as consultants to the parents rather than as the central figures dictating how the child should be rehabilitated. The treatment team and parents collaborate about the different details of treatment. For example, if the child wants to be involved in the menu planning at home and the parents are uncertain, the therapist will help them think through the pros and to determine if this request is being motivated by the eating disorder or by other factors.

• The parents are empowered to bring about the recovery of their child. This tenet involves building the parents confidence in knowing how to nutritionally rehabilitate their child. Refeeding is mundane and repetitive work, as the child needs to be fed every 2-3 hours. This task is best managed by the parents who already have established patterns of eating with the child. The parents are reminded that they are the most important part of the therapeutic process and encouraged to fill this role on their child’s behalf. Parents are urged to confidently and firmly push back against the eating disorder and to insist upon what is best for their child. 

• The eating disorder is separated from the patient and externalized. In the treatment of eating disorders, it is crucial that the eating disorder be separated from the child. Parents will understably experience a range of difficult emotions as they witness their child losing weight and refusing food. The change can feel sudden and drastic, and often terrifying. By separating, or externalizing, the eating disorder from the child, it allows for the parents to push back against the disorder, rather than putting negative emotions on the suffering child. An example of this might look like a parent refusing to back down as a child cries over a portion of food. An FBT-centered response would be for the parent to say, “I see how upset you are about this snack, and the ED is telling you to refuse, but we both know this is what is best for you.”

• FBT utilizes a pragmatic approach to treatment, with the focus on the here and now. While engaged in FBT, each session is centered upon key pieces of data regarding the child’s progress. Is the child gaining or losing weight? What was eaten for meals and snacks? Was their compliance or high resistance? Were there compensatory behaviors such as purging or exercising noticed? Staying centered on these outcomes keeps the FBT moving forward and lets the parents and patient know that treatment and recovery are the primary focus. 

In addition to these basic tenets, FBT is also treated through a series of phases. Phase 1 is centered around the physical and nutritional stabilization of the child. Primary caregivers are given full responsibility for all of the child’s food needs. What, when and how much food is determined by the parent and support is present for all meals. Exercise is also monitored during phase 1. As weight begins to improve, treatment moves into Phase 2 and the focus becomes developing age-appropriate dynamics around food and exercise. For a teenager preparing for college, this might mean going out with friends to eat without the parents supervision. For a younger child, this might mean giving them permission to plate their own food at meal times. Finally, FBT finishes with phase 3. During this time, the treatment focuses on body acceptance, development changes up ahead and important life decisions. Additionally Phase 3 will begin more focused therapy around extenuating anxiety that has influenced the development of the pathological eating patterns. 

Who is Appropriate for Family-Based Therapy?

While FBT is the primary recommendation for treating AN and BN in adolescents, it is not a good fit for all families. Both the adolescent and the parents need to be stable enough to undergo this rigorous and long process. A high level of commitment is required from both parents. Parents need to be unified and have their own therapeutic support in order to provide what their child needs. Friends and family are often encouraged to attend support groups for just this reason. Additionally, parents need to model a balanced relationship with food and exercise. The recovering child will be greatly influenced by his or her parents’ relationship with food. If any caregiver or sibling in the household is struggling with disordered eating, FBT might not be the recommended approach. A final consideration is the medical stability of the patient. If lab values are seriously compromised, then residential treatment will be recommended over the out-patient FBT approach. 

If you are considering treatment options for your child, be sure to consult an FBT trained therapist, dietitian or physician. Undergoing treatment with a specialty-trained group of clinicians will ensure the best outcomes for your family. If you would like to read more about the Family-Based Treatment approach, look at the National Eating Disorder Alliance website for articles. Recovery from an eating disorder is possible, and help is available.