Is the (Eating Disorder) Treatment Your Child is Getting FBT?

When new families talk to me about Family-Based Treatment (FBT), I often find that they are confused about what it is and what it isn’t.

FBT is a type of evidence-based treatment for adolescent eating disorders. This treatment was developed at the Maudsley Hospital in London in the 1970s and 1980s; Doctors Lock and Le Grange manualized it into its current form in 2001. Because of its name, FBT is often confused with more general “family therapy.” Be careful, because these are not the same thing—while both involve the family, FBT is a very specific, behaviorally-focused therapy.

While a treatment that includes some elements of FBT—but falls short of the full manualized treatment—may work for some eating disorder cases, it may not work for more difficult cases. When FBT doesn’t work it is important to know whether the child has had an adequate course of the true treatment in its evidence-based form. This can be tricky—in the field of psychotherapy, most therapists identify as eclectic, meaning they adhere to no single therapeutic orientation but combine techniques from several (just scroll through any Psychology Today therapist profile to get a taste for how many different theoretical approaches most therapists endorse). We don’t yet know which elements of FBT are critical to its efficacy and make it such a successful treatment. This would take expensive dismantling studies in which different partial treatments are tested against each other. Except for studies documenting a separated FBT (where only the parents attend sessions), no such study has been cited in the literature. Until we have good evidence that suggests otherwise, treatments that stay true to the original, already-tested treatments are the safest bet.

I once worked with a patient with panic disorder who had had previous treatment. He told me that his previous therapist had conducted cognitive-behavioral therapy (CBT), widely accepted as the best evidence-based treatment for panic disorder. When I dug deeper, I found that his therapy had included no exposure to the sensations of panic—considered to be the core element of CBT treatment for panic disorder.  Instead, the treatment had focused on discussing his anxiety thoughts—a very different protocol. From this experience I learned to inquire carefully about the treatment my patients have previously received before accepting that it cannot work for them.

So it is with Family-Based Treatment. Sometimes parents tell me that they think they tried FBT but are not sure. If your child was treated in an academic center, it’s more likely they got the evidence-based treatment of FBT in its full form. However, some parents who tell me that FBT didn’t work also tell me:

  • They did FBT on their own, with no therapeutic support
  • They had meals with their child, but that the therapist met primarily with the adolescent alone
  • They didn’t supervise all meals because their child resisted it. 

In each of these situations, it is obvious to me that the treatment is not what I would consider FBT. And while it is true that including some aspects of FBT or even a “watered down” FBT may be better than no FBT or parent inclusion at all, it’s important to know whether your child had the real thing or not, especially if they end up needing more or different treatment.

Often, parents who tell me they struggled with renourishing a child on their own find that things go much better once they started working with me or another therapist. That’s not to say that parents should never try to renourish a teen on their own—just that supporting a child with an eating disorder is extremely hard work and best done with the support and guidance of a professional at their side.

Signs Your Child Received FBT

Accordingly, I created the checklist below for parents to determine whether the treatment their child received (or is receiving) is really FBT. To how many of the following statements can you answer “YES” (the more the better)?

  • My therapist received training through the Training Institute for Child and Adolescent Eating Disorders.
    • The basic training is a 2-day workshop. Have they attended one?
    • Have they received or are they receiving clinical consultation or supervision by a staff member of the institute?
    • Are they certified in FBT by the Training Institute (meaning they have completed the 2-day training and received 25 hours of consultation by a staff member around their treatment of 5 patients)?
  • My therapist owns, seems familiar with, and refers to the FBT treatment manual.
  • My therapist refers to and acknowledges the three phases of FBT:
    • Phase 1 —full parental control
    • Phase 2 — a gradual return of control to the teen
    • Phase 3 —establishing healthy independence
  • My therapist is familiar with the work of Drs. James Lock and Daniel Le Grange, developers of the FBT treatment.
  • My therapist adheres to the five principles of FBT:
    • I was specifically told I was responsible for restoring my teen nutritionally and interrupting behaviors that interfere with recovery (including bingeing, purging, and overexercise). I was specifically told I was responsible for planning, preparing, serving, and supervising all meals.
    • I was told we don’t know for sure what causes an eating disorder and it doesn’t matter.
    • Initial attention of treatment focused solely on restoring health including weight gain and stopping eating disorder behaviors.
    • Rather than being given prescriptive tasks, I was empowered to play an active role and to discover those strategies that worked best for my family and the child whom I know best.
    • I was taught to externalize the illness and see it as an outside force that has hijacked my child, threatens his or her life, and makes my child do things he or she wouldn’t normally do. My child did not choose the eating disorder.
  • I have had a family meal at the therapist’s office.
  • My therapist spends most of the time with the full family, meeting only briefly with the adolescent alone at the beginning of the session (or in the case of “separated FBT,” all of the time with parents).
  • My therapist or another member of the treatment team tracks my child’s weight and gives me feedback after every weigh-in on how he or she is doing.
  • I was specifically told I am responsible for supervising all meals and snacks to ensure completion. If purging has been a problem, I was told to supervise the child after eating to prevent purging.
  • If my child has been exercising excessively, I was told to prevent this.
  • After weight was restored and bingeing and purging and other behaviors had ceased, my therapist guided me in gradually returning my teen control over their own eating.
  • I was told it was important to be direct with my teen about eating adequate amounts of food.
  • My therapist discusses the importance of both “state” and weight to recovery—meaning my therapist explains that weight recovery is a step towards psychological recovery, but not an end goal in itself.

Dead giveaways your child did not get FBT

Below are some indicators that your child might not have “gotten FBT” and might be receiving some conflicting messages:

  • I have been told that we, the parents, had caused the eating disorder.
  • My therapist spends the majority of therapy time alone with the teen.
  • My therapist spends a lot of time talking about the past and reasons my child wanted, needed, or otherwise developed the disorder.
  • A dietitian has met alone with my teen and given him or her nutritional recommendations.
  • My child has been given a meal plan.
  • I have been told that it is an option to not supervise all meals or prevent all purging.
  • The FBT therapist has provided individual CBT, DBT, or ACT with the teen during the weight restoration phase.
  • I have been told from the start of treatment to “not be the food police” (in FBT, this might happen toward the end of treatment, or in Phase 2 with an older teen).
  • My child has been in charge of making his or her own meals from the outset of treatment.

Summary

In conclusion, FBT has been proven to be the most effective treatment for adolescents in clinical trials. That said, not every treatment works for everyone. In my opinion, it is best to start with something that has a backing and then try something else if that doesn’t work. When you have sought out an evidence-based treatment, it’s important to make sure you’re getting the treatment in its researched form.

Presentation at NEDA 2015 conference

Lauren and Katie presenting NEDA 2015

Katie and I had the honor of presenting in the Individual, Family, and Friends track at the National Eating Disorder Association Conference in San Diego yesterday.  The title of our talk was:  Family Based Nutrition Therapy:  Creating A Supportive Environment.  It was a chance to share the way we work to support families who are helping children with eating disorders.

Here are some of the key points of our talk:

Parental direction works, but don’t expect your kid to be happy about it: Research on The Family Meal in FBT

Slide1Parents charged with helping their children to recover in Family-Based Treatment often wonder 1) how to actually get their children to eat and 2) whether they will harm their children or the parent-child relationship by requiring them to eat. A recent study addressed these concerns by looking at the family meal.               

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

Hannah J. White BSc (Hons), Emma Haycraft PhD,*, Sloane Madden MD, Paul Rhodes PhD, Jane Miskovic-Wheatley DCP/MSc, Andrew Wallis MFAMTher, Michael Kohn MD and Caroline Meyer PhD (Article first published online: 26 JUN 2014)

The above study in the International Journal of Eating Disorders looked at the family meal in Family-Based Treatment (FBT), the best-researched outpatient treatment for adolescent anorexia. In FBT, the family plays a central role in treatment. Parents take responsibility for weight restoration and interruption of eating disorder behaviors, and family meals are an essential part of this process. Typically the second session of Family-Based Treatment is a family meal in which the family brings a picnic meal to the therapist’s office. The goal of the session is for the therapist to empower the parents to get their child with anorexia to eat one bite more than the child was prepared to eat.

The strategies used during mealtimes by parents of adolescents with anorexia have not been previously documented. Some believe that the eating habits of these adolescents have regressed and that the adolescents should be viewed as younger children who need more feeding assistance from their parents. Thus, parental strategies used to encourage eating would be similar to the strategies used by parents of younger children with and without feeding problems, which have been studied: these parents have been noted to use both encouragement and pressure to eat. Little is known about the response of adolescents with anorexia to their 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 who were undergoing 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 be applicable to family meals occurring in the home.

Specifically, the researchers found:

1)   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 adolescent), 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”).

2)   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.

3)   in general, the more the parents prompted the child to eat and the more successful they were, the more negative the adolescents became. It makes sense that attempts to encourage eating, which contradict the anorexic tendencies, would cause psychological distress and a more negative emotional tone.

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 implementing a 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.”

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:

  1. parents need to directly prompt or pressure their child with anorexia to eat.
  2. offering choices and providing information is generally less effective in getting children with anorexia to eat.
  3. 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 child 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 children 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 child will have a negative reaction 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 in order to support their child’s recovery.  Over time, this persistence will challenge the anorexia and encourage change and recovery.