I am often asked if Family-Based Treatment (FBT) works with separated and divorced families. The answer is definitely yes! The treatment can be implemented in a variety of family configurations as long as at least one parent or guardian is involved in the treatment. But, there is to date, little written about this. Research does support that FBT is effective in “non-intact families.” I will share strategies that I have found helpful in working across multiple households supporting a teen with an eating disorder.
First, clarify your local laws regarding who is able to consent to the treatment of a minor child and clarify the custody arrangements. I find it helpful to spend extra time and energy on parental alignment and getting parents on the same page. This often translates into additional parent-only sessions or time in the session. In most two-parent households, parents have different approaches, strengths, and degrees of acceptance of FBT. This can be even more pronounced when the parents have separated due to irreconcilable differences.
Aligning Everyone on the Same Team
I find it helpful to proceed with the assumption that all parents (including step-parents) want what is best for the teen. I express that I believe all members will be able to put any differences aside to work together in the interest of their teen. I find language such as “We are all on team Andrew” to be helpful. As with all families with multiple parents, the teen with the eating disorder benefits from hearing a united message. The eating disorder is masterful at finding disagreements and exploiting them to pit people against each other. This is one reason it is helpful to hold separate parent sessions to align parents versus hashing things out in front of the teen. Even in intact families, parents may disagree on tactics and deserve privacy in coming to a consensus.
If custody is shared between two households, it is important to acknowledge that when one parent is tougher on the eating disorder, the eating disorder (which is operating the teen’s brain) will often express a preference for being at the other parent’s house. So, it is helpful to try to achieve as much consistency between the two households as possible in terms of meal patterns, portion sizes, and consequences.
In cases where one parent is less invested in FBT or less available to provide—or even capable of providing—the level of supervision required, I sometimes advocate for a temporary adjustment of the custody arrangement allowing for the parent with more availability to play a majority role in the refeeding process during phase 1. I emphasize that this is temporary and only to facilitate faster recovery, with the goal being to return to the prior custody arrangements as soon as possible, usually in Phase 2. It should also be noted that practicing having meals in multiple households in which things are done a little differently can actually be good for developing flexibility. While it may be harder in the short run, it can be beneficial in the long run.
Communication is often more challenging when there are two households. I usually suggest creating a shared google doc where parents upload and share menus, meal plans, photos of meals, and any other relevant information including reports from medical visits and weights. This can be a less confrontational way of communicating. Sometimes, where parents continue to share custody, keeping and aligning weights can be a challenge. In a case where a teen (being seen virtually) alternates staying with two different parents a week at a time, I have suggested that each parent have a scale, weigh their teen both when they arrive and when they leave and share the weights with the other parent and me. This allows for scale calibration between two households and it also gives each parent more immediate feedback on their own contributions to weight gain.
In the case of divorced or separated parents, it is even more essential to have the guidance of an FBT therapist who can support the family in working together to fight the eating disorder.
Loeb KL, le Grange D. Family-Based Treatment for Adolescent Eating Disorders: Current Status, New Applications and Future Directions. Int J Child Adolesc health. 2009 Jan 1;2(2):243-254. PMID: 20191109; PMCID: PMC2828763.
Learn more about Family-Based Treatment and how you can support your teen’s eating disorder recovery.
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