Family-Based Treatment (FBT) is the best-researched outpatient treatment for teen eating disorders, including anorexia. In FBT, the family plays a central role in treatment. Through family meals, parents restore their teens to health and interrupt eating disorder behaviors. In FBT, parents plan, prepare, serve, and supervise meals. Usually, parents are left wondering 1) how to actually get their teens to eat and 2) whether they will harm their teen or the parent-child relationship by requiring them to eat. A 2014 study addressed these concerns by looking at the family meal.
What is the Family Meal in FBT?
The family meal, an in-office simulation of meals at home, is usually held during the second session. The family is instructed to bring a “picnic” meal for the entire family to the therapist’s office. The therapist observes the family eating with their teen. The therapist assesses the family’s response to the assignment to renourish their teen and teaches strategies to improve the parents’ effectiveness. The goal of the session is for the therapist to empower the parents to get their teen with anorexia to eat one bite more than the teen was prepared to eat.
Study on The Family Meal in FBT
Previously, the strategies used by parents to support teens with eating disorders had not been studied. Some posit that teens with eating disorders have regressed in their ability to eat independently and should therefore be viewed as younger children who need more feeding assistance from their parents. Thus, parental strategies to encourage eating incorporate strategies used by parents of younger children with and without feeding problems. These have previously been studied. Parents of younger children use both encouragement and pressure to eat.
The study aimed to discover how teens with anorexia would respond to parents’ attempts to get them to eat. The purpose of this study was to examine the strategies used by parents and the results. The study included 21 families with children between the ages of 12 and 18 receiving FBT for adolescent anorexia.
The main aims of the study were:
1) to identify mealtime strategies used by parents during the family meal session of FBT.
2) to explore the relationships between these strategies and parental ‘success’ in encouraging eating.
3) to explore the relationships between these strategies and their results with the emotional tone of the mealtime.
While this research was conducted in an artificial setting – a therapist’s office and in the presence of the therapist – the findings should apply to family meals occurring in the home.
Specifically, the researchers found that parents used a variety of strategies to prompt the child to eat: direct eating prompts (e.g., “You’ve got to eat all your eggs” or “Pick it up and eat it”), non-direct eating prompts (e.g. “Keep going” or “Why don’t you eat some more pasta?”), physical prompts (e.g., pushing a plate of food towards the teen), autonomous comments (e.g., “Do you want another one?” or “Which one do you want?”), and information provision (e.g., “Your body needs the calcium” or “This will make your bones strong”).
Most Successful Strategies
According to the research, direct, non-direct, and physical prompts were more successful in getting adolescents to eat than providing information about the food or offering food-related choices to the adolescent. Thus, while it is tempting to try to reason with your teen about their need to eat food and to try to convince them to eat, such attempts rarely succeed.
Teens Became Distressed
The more the parents prompted the teen to eat and the more successful they were, the more negative the teens became. It makes sense that attempts to encourage eating, which contradicts the anorexic tendencies, would cause psychological distress and a more negative emotional tone. But this is necessary and should be expected.
The authors conclude “It is interesting that a behavioral focus on eating (i.e., verbal and physical prompting) was associated with parental success as opposed to other strategies such as offering choices to the adolescent or consequences. This indicates that parents’ direct focus on food may be central to eating behavior and supports the emphasis on behavioral change rather than insight which is central to FBT.”
What Parents Need to Know About Family Meals
Keeping in mind that this is only one small study, the results are consistent with my observations of family meals in my practice and reports from parents refeeding their adolescents:
- parents must directly prompt or pressure their child with anorexia to eat.
- offering choices and providing information is generally less effective in getting children with anorexia to eat.
- the more the parents pressure the child and the more the child eats, the more negative and upset the child becomes.
This study highlights the paradox parents face in implementing FBT. When a teen is in distress, the parental instinct is to try to soothe them. Intentionally upsetting the child runs counter to a parent’s nature. However, for teens with anorexia, food is medicine. The best measure of the parent’s success in FBT is the amount of food consumed. Parents should expect that their teen will react negatively to both pressure to eat and the eating itself. This negativity is not a sign of failure, but a reaction to a treatment that is working.
While these interactions often lead to more short-term conflict and distress, parents must persist and weather the storm to support their child’s recovery. Over time, this persistence will challenge the anorexia and encourage change and recovery.
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White, H.J., Haycraft, E., Madden, S., Rhodes, P., Miskovic-Wheatley, J., Wallis, A., Kohn, M. and Meyer, C. (2015), How do parents of adolescent patients with anorexia nervosa interact with their child at mealtimes? A study of parental strategies used in the family meal session of family-based treatment. Int. J. Eat. Disord., 48: 72-80. https://doi.org/10.1002/eat.22328