Family-based treatment (FBT) is the leading evidence-based treatment for teens with anorexia nervosa and bulimia nervosa. While in an ideal world, every person with an eating disorder would have access to a full treatment team including a therapist, a dietitian, a medical doctor, and a psychiatrist, FBT calls only for a therapist to guide the parents and a medical doctor to manage medical needs. A dietitian is not required, but I have found that a dietitian who works primarily with the parents can provide valuable guidance. Sometimes there are other treatment providers. If there are multiple providers, it is important that team members are in agreement about treatment philosophy and goals. Otherwise, a nonaligned team can potentially be detrimental.
Overview of FBT (3 phases)
Family-based treatment is a manualized therapy, presented in a “manual” with a series of prescribed goals and techniques to be used during each phase of treatment. It focuses on empowering the parents to play a central role in their child’s recovery, using contingencies to reverse malnutrition, increase weight, and eliminate symptoms including restrictive eating, bingeing, purging, and overexercise. FBT is based on five principles:
- Agnostic view of illness—there is no need to find a cause or underlying issue that caused the illness.
- Initial symptom focus—the focus is on reversing malnutrition and eliminating other eating disorder behaviors.
- Family responsible for refeeding/addressing behaviors—parents are empowered to take charge of all meals—including planning, cooking, serving, and supervision—to ensure they are consumed as well as preventing other behaviors such as bingeing and purging.
- Non-authoritarian stance—the therapist is a guide and partner that empowers parents to help their child.
- Externalization of illness—the illness is seen as an external force that is threatening the child’s life.
FBT consists of three phases:
- Phase 1: Parents are fully in charge of and supervise all meals until behaviors have largely ceased and weight is nearly restored.
- Phase 2: Once behaviors are largely eliminated, weight is nearly fully restored, and meals are going smoothly, parents gradually hand back some control of eating to the adolescent in an age-appropriate manner.
- Phase 3: Once the adolescent has resumed age-appropriate independence over their own eating, the focus of therapy turns to other adolescent development issues, any remaining comorbid problems, and relapse prevention.
When to Add Other Providers
Many parents are incredulous that family-based treatment is a standalone treatment. It is primarily a behavioral treatment focused initially on a brain rescue 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 for the patient with the eating disorder to the team. This is not always advisable. Sometimes, in FBT, less is more; the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT. Additionally, research shows that at least in the case of bulimia nervosa, no additional therapy may be needed: issues with depression and self-esteem resolved during FBT treatment.
In one case series of families with “failed FBT” several families pivoted to individual therapy and the teens later admitted that “they had asked for individual treatment as a deliberate strategy to exclude their parents because they knew it would mean that there would be less pressure for weight gain and more chances of avoiding stress and conflicts around the challenges related to their eating behavior.” This should serve as a caution against adding an individual therapist reflexively just because the teen is asking for it.
For families that want to work with a dietician who is familiar with FBT, my colleague, Katie Grubiak, RDN, and I have worked out the following successful protocol. In Phase 1 of FBT, the dietitian is only included when needed and only meets with the parents. This helps to empower the parents and prevents the dietitian from inadvertently colluding with the eating disorder. When a dietitian meets the teen too soon, we have found that the eating disorder tries to ally with the dietitian and the teen spends the time trying to negotiate for preferred “eating disorder foods.” We find it more effective to avoid giving the eating disorder that voice. Parents—who have after all been feeding their child since birth—know what their teen truly likes and can avoid being manipulated by the eating disorder.
The situations in which I have found the dietitian to be necessary include the following:
- The adolescent has another issue that necessitates dietary restriction such as celiac disease, diabetes, or a food allergy.
- The teen’s eating has been extremely restrictive and the range of foods at the outset is extremely small
- There is concern about medical issues such as refeeding syndrome and intake must be more closely measured
- There is a history of an eating disorder in a parent and they feel insecure about challenging their child’s eating
- The parents are highly anxious and unusually overwhelmed and benefit from greater support and direction from a dietitian.
Towards the end of Phase 2, I find it very valuable to have the dietitian begin meeting individually with the teen. This can be helpful in trying to increase the teen’s responsibility for their own recovery. The dietitian can also bridge the gap between the parents being in charge and the child being in charge by temporarily overseeing the child as the parents relax control. We have found it very beneficial for the dietitian to help the adolescent work on determining portion sizes and exposure to fear foods and eating in different contexts and to have some initial meals without the parent and see how they do.
Resources are limited: families have limited finances and there are not enough eating disorder providers to meet the demand of people with eating disorders. I believe that in most cases we should wait until Phase 2 of FBT before adding additional therapies. In this way, we can see what issues resolve on their own when weight is restored. After a teen has resumed regular eating and has nutrition sufficient to support higher level brain functioning, individual therapy can be added if it is needed. This is the point in therapy at which the adolescent is likely to be more receptive and able to benefit from individual therapy.
Having worked alongside several individual therapists providing individual therapy while I provided FBT, I have some suggestions that can help keep all providers on the same page and maximize benefits to the family. The most common scenarios I have encountered include the following:
- Dialectical Behavior Therapy (DBT) therapist addressing emotion regulation
- Exposure and Response Therapy (ERP) therapist addressing obsessive-compulsive disorder (OCD) or symptoms
- Adolescent therapist addressing comorbid anxiety, depression, self-esteem, or interpersonal issues
The biggest problems I have encountered occur when individual therapists focus on coaching the adolescent to individuate and stand up to parents. This is inconsistent with the early stage of FBT, which requires the parents to be empowered to make all food decisions for an adolescent who is incapable of making reasonable decisions about food given their brain starvation. In FBT we don’t encourage independence in eating until the teen shows they can handle it. Similarly problematic are providers who educate the adolescent about his parents being too “enmeshed.”
On the other hand, I have had great experiences with individual therapists who understood that keeping the parents in charge of eating was crucial for the teen’s recovery. Instead, these therapists worked to empower the parents to help the teen eliminate other obsessive behaviors such as compulsive exercise. I have also worked with successful DBT teams that focused on teaching the adolescent skills to manage their distress while not attempting to question or undermine the parents’ authority over food decisions.
Advice for The Individual Therapist
My advice for the individual therapist:
- Don’t blame parents for causing ED
- Don’t disempower the parents
- Don’t question parents being in charge of food
- Don’t suggest compromising on food choices
- Don’t describe parents as enmeshed—instead, reinforce their instincts in attending to a very ill child
- Don’t focus on empowering the adolescent to share frustrations about parents being in charge
- Do focus on empowering the adolescent to demonstrate recovery behaviors even if it is for show (“acting as if”)
- Help the adolescent to develop coping skills to use when the FBT process is upsetting to them
- Respect parents’ choice to stop activities until they eat (delineate consequences before meals)
- Help the adolescent fill their life with other things
- Remind the adolescent that the parents will be able to give back control as the adolescent demonstrates readiness
- Let the adolescent vent about their frustration over parents being in charge
- Acknowledge that although there are many things the teen can do on their own that are developmentally appropriate, at the present time eating independently is not one of them