What You Need to Know about Family Based Treatment for Anorexia Nervosa

Your child has an eating disorder and you are trying to figure out what comes next. In your search for treatment for your daughter or son, you start hearing terms like the Maudsley method or Family Based Treatment (FBT).  Clinicians explain that it is perhaps the most effective treatment for adolescents with anorexia nervosa, but you’ve got lots of questions about what exactly this approach is all about and what it will mean for your family.

I get it. I am a therapist who provides FBT here at the Columbia Center for Eating Disorders, where we offer this treatment to some of the teens (and their families) participating in our longitudinal study of anorexia nervosa in teens. I routinely field questions from families considering FBT and want to share a little more about the treatment with you as you make your decision about what’s best for your child and your family.

Treatment Rationale and Structure

What is Family Based Treatment?

FBT is an evidence-based psychotherapy for adolescents with anorexia nervosa. Generally, this treatment puts the patient’s parents at the forefront of the battle with the illness and encourages siblings to provide support as well.

The treatment evolves over the course of three phases. Phase I emphasizes the renourishment of the patient. Initially, parents take control of areas of the adolescent’s life that may be impacted by the illness, specifically eating and exercise.  All meals are prepared and supervised by parents. In Phase II, parents gradually hand back control to their adolescent. What this means really depends on the child and the family’s circumstance. Examples include the adolescent having unsupervised lunch at school or going to dinner with friends 1-2 nights per week.  Helping your child get back to adolescent life is the goal of Phase II. In the final phase of treatment, the emphasis is on returning to a healthy, balanced life. The expectation during this phase is not overly idealized, but rather that the family – and the adolescent – will be engaged in more common, developmentally appropriate struggles rather than eating disorder-related conflicts. Think negotiations about curfew rather than calories!

Who attends sessions and how frequent are the appointments?

The family meets altogether with the FBT therapist throughout the treatment.  Each family member’s role is critically important to the patient’s recovery.

Sessions become less frequent as the treatment progresses.  During the first phase of treatment, the family meets with the FBT therapist once per week, and, in the second phase of treatment, sessions are 2-3 weeks apart.  In the final phase of treatment, sessions occur monthly.

Are there other components of the treatment? Will we be meeting with a dietitian as well?

During FBT, your child will be medically monitored by her / his pediatrician.  Dietitians are not typically part of the FBT treatment team.  The reason for this is that prior to the onset of the illness, parents were able to successfully feed their child, and parents have an idea of what foods will most benefit a starving child. However, if parents feel they would benefit from nutritional guidance, the parents (not the adolescent) are certainly able to meet with a dietician. Otherwise, the FBT therapist provides general tips and guidelines regarding what foods will be most successful in renourishing an adolescent.   

Common Concerns and Potential Conflicts

Okay, but we’ve tried getting her to eat at home. She won’t eat.  Now what?

This is an excellent observation.  If your child has anorexia nervosa, eating is at the very crux of the illness – she or he cannot eat (without your help and support).  If you’ve started to try to help your child eat at home, you’re already off to a great start!  Your FBT therapist will work with your family to help you utilize the unique skills you’ve already used to parent your child up to this point.  You have experience in helping your child do things she/he feels can’t be done or doesn’t want to do (such as finish a school project, take medicine, get a vaccine, etc.).  The general framework involves a zero-tolerance policy for not eating.  How you as parents implement that plan will be unique to you and your family, and your FBT therapist will be by your side to help with problem-solving the challenging moments.

I work full time, and my child is in school. How will I be able to supervise all meals?  

Given the severity of this illness, many parents decide to take a leave of absence from work and coordinate with the school so that their child can stay home during the first few weeks of treatment.  Other parents are able to adjust and/or coordinate their schedules to be available for breakfast, snack, and dinner during the week as well as all weekend meals.  These parents work with their child’s school to find a trusted teacher/counselor/nurse who can be available to supervise lunch.  Some parents have a close relative or caretaker supervise a meal if they are not available.  If a relative or caretaker will be supervising meals, your FBT therapist will most likely recommend that this individual attend family sessions. 

My child really dislikes our FBT therapist and oftentimes doesn’t want to go to therapy.  Should we look for a different one?

This is something many parents will hear from their child as they begin FBT.  Your therapist expects your child to do what anorexia nervosa fears the most – eat and gain weight – so treatment can, for a little while, feel worse than the illness itself for patients.  Your FBT therapist’s role is to support your child and family; however, even with the kindest and most compassionate therapist, FBT treatment may feel hard or bad for your child (and maybe even you), at the start.

What types of food should I feed my son/daughter? 

A guiding principle for families is to incorporate foods their child enjoyed eating before the illness set in.  Generally, we recommend energy / calorically dense foods and a wide variety of different types of energy-dense foods because these foods help adolescents to normalize eating and are associated with better outcomes based on research.  Your FBT therapist won’t provide a strict meal plan.  You knew what to feed your child prior to the onset of the illness, so you’ll be coached to use your intuition and some general guidelines provided by your FBT therapist to determine what’s on the menu at mealtime.

My daughter/son doesn’t think they have a problem.  Is this an appropriate treatment for her/him?

This treatment really puts parents in charge of fighting back against the illness.  Most adolescents won’t want to eat even if they do feel like their illness has negatively impacted their life and acknowledge that their eating disorder is a problem.  It will be important for you to be firm and consistent with your child.  Your FBT therapist will support you, as a parent, in consistently communicating your expectations and what will happen if those expectations are not met.

This doesn’t seem consistent with my style of parenting.  Are there certain types of parenting styles or families FBT is not a good fit for?

This treatment is not designed for a specific parenting style or type of family.  Simply put, food is viewed as medicine, and taking responsibility for ensuring your child takes their medicine is key to saving their lives, no matter your parenting style.  Though taking control of a part of your child’s life might seem inconsistent with your parenting style, there are many ways to personalize the therapy.  FBT provides a general framework and parents decide how to implement it.

In fact, this treatment does not rely on “traditional” family units for its effectiveness.  Families of all types have been successful with this treatment – single-parent families, divorced or separating families, and blended families.  FBT instead focuses on helping the adults involved in the adolescent’s life work together and provide consistency in order to fight back against the illness.

My teenager is almost 18, and this treatment seems like it would be most appropriate for young children.  Will this treatment interfere with her / his adolescent development?

FBT might sound counterintuitive as the first recommendation for a developing adolescent.  But remember, due to anorexia nervosa, some parts of usual adolescent development are being disrupted. In FBT, parents are to take control of only the areas where the eating disorder is in control, mainly eating and exercise. FBT is intended to be both effective and efficient so that your child can return to adolescent development as quickly as possible.

My daughter/son excels in (basketball, soccer, ballet, track, – fill in the blank with your choice exercise-related activity).  Will she/she have to stop this activity?

At the start of FBT, the focus is on renourishment.  Medically, it may not be safe for your child to be active.  And to help expedite renourishment and minimize medical risk, the recommendation by your FBT therapist will most likely be for your child to stop or significantly limit physical activity temporarily.  As your family moves into Phase II, your child will gradually begin participating in physical activity again. Participation in organized physical activity can, for some teens, be a useful motivator for improved eating.

Learning More

Who serves as an FBT therapist? How can I find one?

Generally, FBT therapists are mental health clinicians who have experience working with adolescents as well as experience in the assessment and treatment of eating disorders.  Certified FBT therapists have undergone a two-day training and several hours of consultation with a faculty member at the Training Institute for Child and Adolescent Eating Disorders.

The Columbia Center for Eating Disorders is able to provide FBT (when clinically indicated) at no cost for patients who are interested in and eligible for research participation.  Other NY based programs offering FBT include Mount Sinai’s Eating and Weight Disorders Program and Montefiore. If you live elsewhere in the U.S., you can find other FBT therapists listed here.

Where else can I learn more about eating disorders treatment for adolescents and young adults?

Websites

• Maudsley Parents
• Families Empowered and Supporting Treatment of Eating Disorders (FEAST)
• National Eating Disorders Association
• The Feed Blog

Books

• Help Your Teenager Beat an Eating Disorder by James Lock & Daniel le Grange
• Decoding Anorexia by Carrie Arnold
• Goodbye ED, Hello Me by Jenni Schaefer

Documentary

• Parents to Parents

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