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, it has sometimes been referred to as “Maudsley Family Therapy,” a reference to its initial development at the Maudsley Hospital in London.
FBT is a specific treatment that follows a manual and is delivered in an outpatient setting by parents supervised by trained professionals. 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 posited that parents were to blame for the problem—this dates back as far as 1873, when 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 assign blame to parents, especially mothers. Eating disorders were viewed as a struggle for independence from a dysfunctional family system. The practice of removing patients from their families and sending them to treatment facilities became the norm.
While there remain providers who continue to focus on excavating a family problem that needs solving and helping a teen to individuate in order to recover, more recent research has clarified that families do not cause eating disorders. Eating disorders are now understood to be complex illnesses that result from a complicated interplay of biological, psychological, and environmental factors. FBT has been at the forefront of the research that shows that families can be an integral part of the solution, not a detriment, 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 are a liability. They waste precious time trying to find an underlying problem that likely doesn’t exist. In the meantime, the physical consequences of the eating disorder 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 not want to have treatment and that is okay; FBT can work in spite of their resistance. Until your child is ready to want their own recovery, you can be the one who wants it on their behalf. No one loves your child more than you do; this uniquely poises you to help them recover.
What Exactly IS FBT?
FBT is a treatment that involves the whole family in solving their child’s eating disorder. Unlike traditional family therapy, it does not blame the family. In FBT, family sessions with a therapist are held once a week at first and then decrease in frequency. 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 can often provide a level of care that is similar to residential or partial hospitalization programs (PHP).
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 the core of the treatment is family meals: parents take charge of nourishing their teens with eating disorders by providing energy-dense meals. Parents plan, prepare, serve, and supervise all meals. 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 be extremely frightened of 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 seen as the experts on their child.
- Externalization of illness: The illness is seen as 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 a 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.
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 medical needs. While a dietitian is not required, 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?
There is strong research support for FBT 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 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, the goal is 1 to 2 pounds per week. Parents help their teens to start 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. The teen is gradually given 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. In this phase there can be 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. There will be stress and challenges, and your FBT therapist will support you in managing them. 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.
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 a successful execution of FBT. We support you in doing this with love and compassion and we believe that most parents can successfully implement FBT.
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. With speedy diagnosis and early intervention it can sometimes be shorter. 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 weight gain is required 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 progress we will encourage intensifying treatment or a higher level of care.
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 figuring this out.
Doesn’t My Child Need Also Need to See an Individual Therapist?
Not necessarily! FBT is primarily a behavioral treatment focused initially on rescuing a malnourished brain, and then on eliminating symptoms. 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. 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, it can always be added 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.
Can You Provide FBT by teleconference?
Yes! Providers in our practice are licensed in the states of California, New York, Florida, Texas, and Indiana and generally cannot see patients outside of those five states. For families that cannot travel to our office but reside in one of those states, we are able to provide FBT by teleconference. In the face of the COVID-19 pandemic we have moved entirely to telehealth.
Find an FBT Therapist outside of California, New York, Florida, Texas, and Indiana
If we are not in your area and you are looking for an FBT therapist, the Training Institute for Child and Adolescent Eating Disorders is an organization that trains therapists in this treatment and maintains a list of certified therapists and therapists in training.
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
- Is Your Young Adult with an Eating Disorder Ready for College?
- Are we Setting Recovery Weights Too Low?