Externalizing an eating disorder is a therapeutic strategy that became more widely known through Jenni Schaefer’s book Life Without Ed, cowritten with her therapist Thom Rutledge. The book summarizes Jenni’s recovery from an eating disorder.
Jenni describes how in her treatment she learned to personify the eating disorder as “Ed,” an abusive boyfriend. As explained in the blurb on her website, “By thinking of her eating disorder as a unique personality separate from her own, [she] was able to break up with Ed once and for all.” The book details the various exercises she used in her recovery, including creating a formal “divorce decree” with the eating disorder and pushing back on him at every turn. In an Academy for Eating Disorders tweetchat (2014) on the topic, Jenni Schaefer tweeted, “Ed could say whatever he wanted. To be in recovery, I had to make the decision to disagree with and disobey him.”
This “externalization” strategy is borrowed from narrative therapy. A key principle of narrative therapy is that the person is not the problem – instead, the problem is the problem. The problem is viewed as something with which the person is in a relationship, not as something that is part of the person. It follows then that the person can separate themselves from the problem and reduce its effects on them.
Family-based treatment (FBT), the leading evidence-based treatment for adolescent eating disorders, adopts narrative therapy’s externalization strategy in dealing with the eating disorder. The perspective taken by FBT clinicians is that the teen must be extricated from the eating disorder’s clutches.
When working with families, the FBT therapist encourages them to treat the eating disorder as an external force that has invaded the teen and hijacked their brain. Some families will even name the illness after a favorite villain such as “Voldemort” or refer to it as “the monster.” The therapist then rallies parents and other family members to unite against this common enemy to help their teen fend it off.
Many patients and family members can relate to this externalization strategy because the teen does appear to transform into a “different person” under the spell of the eating disorder, especially around mealtimes. This externalization allows families to reframe the situation: the teen does not want to restrict their eating—instead, that the eating disorder is an alien force that makes them restrict their eating.
While both Life Without Ed and FBT have given externalization popular traction, research has not definitively answered whether it is a helpful technique. While we do have research showing FBT to be highly effective, FBT includes so many elements it’s possible that it might work without the externalization component. In order to know for sure, we would need special research in the form of dismantling studies that test each individual element of a full treatment—to determine the role of externalization on the overall treatment outcome. This has not been a high priority for researchers.
What are some advantages of externalizing the eating disorder?
It offers a convenient and relatable metaphor: “The eating disorder is possessing you.”
It can make it easier to call out certain behaviors as problematic even if they do not feel troubling to the patient themselves.
Experiencing the eating disorder as an unwelcome invader may help marshal the patient to fight back against it.
Redirecting the anger of families and caregivers towards the eating disorder allows them to retain compassion for the patient.
It puts everyone on the same team battling a common enemy: the eating disorder.
It can help the patient become accountable for their own recovery by learning to rebel against and defy Ed.
Reasons you might not want to externalize the eating disorder
Some professionals worry that giving the eating disorder its own persona gives it too much power and might encourage patients to blame the eating disorder while absolving them of any responsibility for recovery. Some people find externalization too trendy and are put off by it.
Some people with eating disorders feel like the eating disorder is a part of them. Many of the characteristics of patients with eating disorders—such as perfectionism—are actually personality traits that by themselves are not problematic. So by associating these characteristics with an external agent, there is a risk of inadvertently criticizing the patient. They may find the externalization technique dismissive or invalidating of their experience and may become angry when their family members externalize the eating disorder.
So, should you do It?
Clinicians and family members considering externalization should assess the potential risks and benefits of this technique. If you are a person with an eating disorder and this metaphor makes sense to you, you can learn more about the strategy by reading Life Without Ed. If you are a family member of a person with an eating disorder and/or a parent doing FBT, it can also be helpful to consider this as a strategy for talking about the eating disorder with your loved one. Life Without Ed is also good reading for parents and even some teens in recovery.
If you are supporting a person in recovery and they dislike your ascribing the eating disorder its own persona, then you can refrain from talking about it in front of your loved one but still use it as a way to frame your own understanding of the situation.
Eating disorder expert Carolyn Costin, MA, MED, MFT suggests a similar but alternative strategy to externalization: think of the patient as having two aspects of their own self, a “healthy self” and an “eating disorder self.” Eating disorder researcher Kelly Vitousek, Ph.D. offers another option: abandon the metaphor altogether and explain these behaviors to the patient as symptoms of starvation. These alternatives to externalization might be preferable to some people with eating disorders.
Finally, it is important to emphasize that, regardless of the way an eating disorder is framed, behavioral change is critical for recovery. Many of the symptoms and dangers of an eating disorder can be related to nutritional deficits and these symptoms are often improved with proper nutrition and normalization of eating behaviors.
Parents doing FBT often struggle with “normal parenting concerns” and setting limits while doing FBT. They’re refeeding their teens at home, doing the hard work often done by professional staff at treatment centers, but they still have to parent. It’s exhausting. Their teens who have eating disorders are often experiencing the psychological and physical consequences of malnutrition while also being a teen and facing the challenges that typically come with that stage of life —social and academic pressures, family stresses, desire for more independence, and puberty.
It’s not uncommon for teens to be a little rebellious or to challenge limits. Some parents may feel they should ignore any defiance from teens in recovery or may be afraid to confront behaviors they would normally not tolerate in their children. Other parents may want to clamp down on all undesirable behaviors.
In FBT we talk about separating the child from the eating disorder and joining with and loving your child while waging war against the eating disorder threatening your teen’s life. This model may be helpful in decisions about how to parent. I recommend first trying to determine whether the behaviors you are concerned about are part of the ED or not.
This may not be obvious at first glance, but if defiance or anger or disrespectful language or threatening behavior comes out at, just before, or after meals or during an FBT appointment or a weight check—or around discussions of food, body, the eating disorder, or treatment—assume it’s the eating disorder and not your child. Remember that your child with an eating disorder has a decreased ability to regulate emotions as a result of malnourishment and that they are in a state of terror at these times. This is the fight-or-flight reaction seen during episodes of high anxiety. The eating disorder will make them lash out in hopes of avoiding the source of the anxiety (food, weighing, etc.). During those moments, I recommend speaking to them compassionately and recognizing the underlying emotion of anxiety, and not reprimanding the behavior in the moment.
During times outside of meals or treatment—which may seem few and far between for those just beginning this journey—this behavior is less likely to “be the ED.” At these times, you should parent largely as you would normally do, with the caveat that your child is under increased stress from treatment. If you would normally reprimand or give a consequence to your child for inappropriate language, staying out after curfew, or screaming at you, feel free to do so. You do not have to tolerate rudeness and defiance and can require appropriate behavior.
As you do this, do keep in mind that the intense process of recovery—including exposure to what is often 6 meals per day—is putting your child under additional stress. I like to remind parents that in many cases, teens go to residential treatment centers. While these centers have their pros and cons, one helpful aspect of residential treatment is that it removes the teen from the everyday stresses of school and home life (annoying brother, curious extended family, and heavy academic loads, etc.) so they can focus entirely on treatment. It can be easy to overlook how these stressors add up.
You might want to pick your battles so your teen doesn’t feel battered all the time. Some smaller things—like clothes on the floor of their room or not cleaning their bathroom—may need to be overlooked. You will want to prioritize addressing behaviors that affect you—for example, rude language—or that interfere with the goals of treatment, including weight gain and normalizing eating. So, if your teen doesn’t come back in time from an outing with friends and misses a snack or meal, that would be a high priority to address. On the other hand, you might choose to let go of their not going to bed on time (as long as it doesn’t keep them from getting up in time for breakfast).
If you are unsure whether the behaviors are part of the eating disorder or not and how to respond, I encourage you to consider whether their behavior is different than it was prior to the eating disorder. A normal developmental trajectory may be contributing to the changes in behavior. An older adolescent may be more challenging of authority and may exhibit behaviors that were not a part of the repertoire 6 to 9 months earlier, before the start of the eating disorder. If the behavior is different, consider whether it might be related to the stress of recovery, the result of malnutrition, or something else entirely. If it seems different and/or persists, speak to your treatment providers or have your child assessed. It may be that they have another mental health disorder that needs to be addressed. If the behaviors were there before the eating disorder, you should also talk to your treatment providers and see if additional support is needed to help you address them.
Finally, keep in mind that this is a tough time. You have a lot on your plate. Parenting and treating an eating disorder is a lot all at once. Try to separate your teen from their eating disorder and develop a list of priority behaviors to address so you don’t take on too much at once. Talk to your treatment team about your concerns. And remember you don’t have to abdicate all parenting just because you are also on their treatment team.
Two of my favorite teen parenting books:
Get Out of My Life, But First Could You Drive Me & Cheryl to the Mall?: A Parent’s Guide to the New Teenager by Anthony E. Wolf
Parenting Teens with Love and Logic: Preparing Adolescents for Responsible Adulthood by Jim Fay and Foster Cline
If you have an eating disorder, or your child has one, there is a good chance that weight gain will be an essential part of the recovery process. This is true not just for people in objectively small bodies, but also for people in larger bodies who are diagnosed with Atypical Anorexia, a weight-biased diagnostic category included in the DSM-5. It is even true for people recovering from bulimia nervosa and binge eating disorder.
The eating disorders field lacks consensus on how to set recovery weights. I know a respected professional who argues adolescents should be routinely restored only up to the 25th percentile weight for age. They argue that this reduces their potential for experiencing weight stigma and reduces their anxiety. However, I see a problem with this, as do many of my colleagues and many families and recovered people.
This article discusses why weight recovery is a priority; what the research on weight suppression says; how we use growth curves in setting recovery weights; what evidence suggests that many providers set recovery weights too low; and how this applies to people in larger bodies.
Why Prioritize Weight Recovery
We know that while weight recovery in anorexia is not sufficient for recovery in and of itself, it appears to be a prerequisite for full psychological recovery. Eating disorder cognitions as well as most of the physical symptoms appear to recede only with full weight restoration. Food is medicine not just for the body, but for the brain as well. That is why we often say, “Food is medicine.”
The research on timelines for eating disorder recovery show that remission of eating disorder behaviors such as binge eating and purging takes an average of eight or nine months, and weight recovery takes on average 12 months. But it takes even longer to end eating disorder thoughts, including the preoccupation with shape and weight and urges to restrict, purge, or exercise. These thoughts can persist for nearly a year after a person has reached a normal weight, has stopped engaging in behaviors, or both.
Weight Suppression and Negative Energy Balance
We also know that weight suppression—defined in adults as the difference between a person’s current weight and their previous higher adult weight—predicts continuation of eating disorder symptoms including binge eating. In children and adolescents, weight suppression would be defined as a negative deviation from one’s expected weight curve (more on growth curves below). Therefore, at EDTLA we prioritize full weight restoration for all patients in all body sizes and with all eating disorders. Failing to fully restore a person to their recovery weight for body and brain could prevent them from a full recovery.
A negative energy balance—taking in less energy than one’s body needs—may be a primary contributor to the development of an eating disorder in someone who has the innate susceptibility. Cindy Bulik, Ph.D. describes how a negative energy balance lowers anxiety for a person with this vulnerability, creating a trap. Restriction becomes seductive under these conditions. Couple this with the evidence that the weight loss leading to the development of anorexia nervosa could be unintentional—such as a side effect of an illness or an overexpenditure of energy for sports combined with undereating. Together these suggest the best defense against relapse is maintaining an adequate energy balance and a healthy weight where the brain is functioning well enough to not act on residual thoughts.
Using Growth Curves to Estimate Recovery Weights
In this section, I will discuss why using individual growth records is so important. We have received guidance from our colleagues specializing in adolescent medicine and eating disorders. Like many eating disorder dietitians, one of the things we do is look at childhood growth records when they are available. This method is more tailored than using population averages such as BMI to set recovery goals.
In the US, most pediatricians and family medicine doctors document children’s growth on the CDC growth chart, which plots height, weight, and body mass index (BMI) against age-based averages. In healthy children and teens, height and weight each increase along a consistent growth curve. Some children and teens grow steadily along the 95th percentile, some along the 75th percentile, some along the 50th percentile, and still others along the 25thh percentile.
But not every body is the same, and it’s normal for individuals’ height and weight to follow different growth curves. For some children and teens, a weight along the 75th percentile and height on the 25th percentile is normal. This defines the growth curves for that individual. Just as not every woman of average height wears a size 8 shoe, not everyone of average height is meant to be at the 50th percentile for weight. There is always a normal distribution in a population. These growth percentages appear to be largely genetically determined.
A deviation on an individual’s growth curve for weight, height, or BMI—even in the absence of actual weight loss—may indicate there is a problem such as an eating disorder. A child should be growing and gaining weight during this time, so the failure of a child or teen to gain the appropriate weight can be equivalent to weight loss. This means that when there is actual weight loss, the amount of suppression—the difference between current weight and where one should be on a growth trajectory—is usually even greater than the actual pounds lost.
Thus, a parent may come to us and say, “My child has only lost 10 pounds.” However, when that weight is plotted and we notice that the child also failed to gain any weight in the months before they lost weight, we might now look at their curve and see that in fact, the child should gain 20 pounds (or more!) to catch up to where they should be on their own unique growth curve. Some kids may not have lost any weight at all—but have fallen short of their appropriate gain for so long that they now should gain at least 10 pounds.
This is why we also often say that weight is a moving target. To remain in recovery, a year from now an individual’s goal weight must be higher than the weight that would be healthy at their age today. And this is true even for children who are no longer getting taller, as it is normal for weight to continue to be gained through about age 20.
Please be aware that some non-ED specialist pediatricians/health professionals may not be well-informed about this individualized process of setting goal weights. I once had a pediatrician who told a teen’s parents she would be happy if my patient got to a certain weight because that was the weight that the pediatrician—who was herself quite petite—had weighed at the patient’s age.
What? A pediatrician setting a goal weight for a patient based on her own unique growth history!?? When you take your clothes in for alterations, does the tailor cut the clothes to fit the tailor? Do you see the problem here?
Speaking of growth curves, the use of growth curves to spot early eating disorders is an underutilized practice. In a recent study on pediatric patients hospitalized with an eating disorder, 48% of patients experienced a deviation in the growth curve a median of almost 10 months prior to the first eating disorder symptoms being reported by parents.
We will also show you how your teen’s weight should be tracking on the weight curve. Teens generally gain 30 to 40 pounds in the course of puberty. While many children gain weight and grow naturally during this period, we find that children who have had an eating disorder may need continuing guidance to help their weight keep pace with their age and height. We encourage parents to keep an eye on their teen’s weight to make sure weight continues to track along the expected curve. We respect parents and educate them on this.
At EDTLA, we do our best to challenge our own weight biases and that of our patients and their families. We believe that facing the anxiety of a patient or a child restoring to a slightly higher weight has benefits that outweigh the costs. We help the family challenge the belief that being fat is worse than remaining ill. I never want to be the provider who set a goal weight so low that it contributed to prolonging a mental illness from which it may take a patient 9 to 22 years to recover.
Challenging weight bias and setting higher weights goals does not always make us popular. Teens with eating disorders are by definition, terrified of gaining weight. In her blog, eating disorder specialist pediatrician Julie O’Toole discusses the setting of goal weights and how parents fear that too much weight gain will make their teen more depressed and anxious. Dr. O’Toole emphasizes the importance of basing treatment goals on data rather than placating the eating disorder.
Remember that an irrational fear of weight gain is often a symptom of the disorder. The anxiety over one’s body size often improves significantly with recovery, which requires more regular eating patterns and—ironically—weight gain. Please note this is rarely immediate. It may take up to a year of being at one’s healthy weight and learning to tolerate a changed body before the eating disorder thoughts fully subside. On the other hand, appeasing the fear of gaining more weight can maintain the fear and potentially the disorder.
How Does This Apply to People in Bigger Bodies?
We are often asked why a person who has historically been at a higher-than-average body weight must be returned to a weight that is higher than average. We recognize that bodies naturally come in a variety of shapes and sizes. Some people are meant to be larger. We often encounter patients and families who say “but they looked better when they were a few pounds less” and want to use the eating disorder as an opportunity to keep a person’s weight suppressed. We believe that using an eating disorder as an opportunity to avoid returning to a previous higher weight could hinder the individual from reaching full recovery. And the research on weight suppression supports this. In the words of Julie O’Toole, “Rarely can a child who is genetically programmed to be larger than average be safely held at a ‘thin’ body weight. Size acceptance may be a part of the family’s treatment challenge.”
Of Course, Recovery is About More Than Weight
Remember, though, that an estimated recovery weight is just that—the best estimate of where recovery will occur. I think it is important for parents to have a roadmap and to know generally whether they might be needing to add (at least) 10 pounds or 20 pounds or 40 pounds because it gives you a realistic expectation of how long the weight recovery phase may take. Again, this may change over time and our estimates are usually a minimum weight and bodies may go higher.
Ultimately, recovery is about state, not weight. And recovery means more than just weight recovery. We are looking for recovery of physical health—normalization of heart rate, blood pressure, and body temperature and resumption of menses when appropriate—as well as psychological recovery which includes improved mood, decreased eating disorder thoughts, return of normal hunger cues, and more regular eating, a less fraught relationship with food, improved social functioning, and a return of interest in other age-appropriate activities.
In one informal survey of 29 parents whose teens were given a recovery goal of 19 BMI, most reported recovery actually occurred at a BMI of 23 or greater and none achieved recovery at a BMI lower than 21. Parents will report that often, with an additional ten extra pounds, their teens were more likely to attain state recovery. If someone is not doing well at what we initially estimated to be a recovery weight, we will review that and may suggest after a few months that we raise the goal weight a little.
This post has described our thinking, which is informed by research, parent feedback, and expert opinions by leaders in the intersection of adolescent eating disorders, FBT, and Health at Every Size ®. We hope it helps you understand our recommendations.
But you don’t have to take our word for it. We invite you to do your own research. Below we’ve compiled some resources from leaders and colleagues in the field. And we strongly suggest you watch this video by Eva Musby.
As I’ve talked about in depth here, the transition to college away from home is challenging for most young adults. It is especially fraught for young adults with eating disorders. In that article I provided a College Readiness Checklist for students who are either considering their first move away from home after a history of an eating disorder or returning to college after being diagnosed with an eating disorder. I have learned the hard way. I’ve witnessed the heartbreaking reality of what can happen to students who go away before they’re ready. I may seem stringent, but we’re talking about one of the most deadly mental illnesses and this is your child’s life and future.
I was recently asked whether the same standards should apply in the current climate. I replied that I thought the standards should actually be more stringent given the pandemic. This has been on my mind all summer; now, I am prepared to sound the alarm.
Students with eating disorders of all types—anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant restrictive food intake disorder (ARFID)—often have a narrow range of foods they are comfortable eating. They often struggle with flexibility.
The pandemic has thrown a wrench—really, a whole toolbox—into the college experience. Among the changes this fall is that most dining halls have pivoted to prepackaged meals. This will be an added challenge for students with eating disorders. Students have already reported that the results are long lines as they wait for food, far fewer food choices, no option to portion their meals themselves, and no option to mix and match. These prepackaged meals may be insufficient in nutrients or energy, especially for students in recovery who have high energy needs.
Add to this the experience of students who are quarantining either due to outbreak or exposure, or as required by the college upon return to campus as a preventative measure. Most are in dorm rooms without access to a kitchen. Social media has exploded with unfortunate food stories:
Meals comprising things students cannot eat—a vegan student who gets a steak and cheese salad; a student allergic to gluten who gets a sandwich on wheat bread
Meals never received, received several hours late, or 3 daily meals batched into one delivery at the end of the day.
These stories are garnering attention, people find it laughable, and the colleges are receiving criticism, but I can only think about how the students with eating disorders are impacted.
Eating disorder recovery requires eating at regular intervals and meals sufficient to maintain recovery. Even a small negative energy balance can increase the risk for relapse in individuals with anorexia nervosa or increase the risk of binge eating for those with bulimia nervosa or binge eating disorder.
Students who are not very stable in their recovery may not be able to handle the current climate. They may not be able to seek additional food if portions are too small. People early in recovery often experience shame about hunger. It could be very triggering to receive portions that are not satisfying. Patients with eating disorders may not be able to advocate for their nutritional needs or do the problem-solving required to make sure the meals are sufficient. Finally, receiving an entire day’s worth of meals at the end of the day would be a natural trigger for those who have struggled with binge eating—or for most people!
Add to this the stress of academics and social issues and the uncertainty about the rest of the semester, and you have a perfect storm for relapse.
If you have any doubts about whether your student may be ready for college under these challenging circumstances, I strongly encourage you to consider keeping them home this semester. If there ever was a time to err on the side of caution, it is now.
With most classes online and social options at college significantly limited, this provides a unique opportunity to keep them home so they have more recovery time under their belt before they have to face such eating challenges. They will not be missing much, and you can work on strengthening recovery so that when the pandemic is over they can return as a healthier student capable of embracing the full college experience. You can use my article—which outlines steps to prepare a student for the challenges of navigating recovery in college— to make sure they are fully prepared when the time is right.
In a previous post, I have discussed who is typically on an FBT team. In its traditional manualized form, the core team is a therapist, a medical doctor, and the parents. The team can also include a registered dietitian nutritionist (to guide the parents) and may include a psychiatrist.
It is not uncommon for medical providers unfamiliar with FBT and treatment centers to encourage additional individual therapy for the patient. As I have said previously, this is not always advisable. In FBT, less can be more—the work of the parents may be undermined by an individual therapist who either does not believe in or does not support FBT.
So, I thought it would be useful to describe in greater detail the situations in which I think additional therapies are warranted and which therapies are most aligned with FBT.
FBT is primarily a behavioral treatment, administered by parents. The two therapies I discuss below—Dialectical Behavior Therapy and Exposure and Response Prevention—are also behavioral treatments that can be applied consistently alongside FBT without confusion. By contrast, non-behaviorally-based therapies may create splitting or confusion when offered alongside FBT. In particular, you should be cautious about and avoid therapies that do not reinforce the parents’ authority over eating or introduce different theories about the cause of an eating disorder.
Comprehensive Dialectical Behavioral Therapy
Dialectical Behavioral Therapy (DBT) is a form of cognitive-behavioral treatment (CBT) developed in the 1980s by Marsha Linehan, Ph.D. It was developed to treat chronically suicidal individuals diagnosed with borderline personality disorder and is now considered the most effective treatment for this population. Research has demonstrated its effectiveness for a range of other mental disorders including substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.
DBT stands out as the treatment of choice for people with difficulty regulating emotions—those prone to outbursts of anger and impulsive behaviors such as self-harm and purging. It focuses on the teaching of skills to tolerate emotions and improve relationships.
Be aware that there are many therapists (including us!) who use DBT skills in individual therapy with clients. Some therapists also may offer a standalone DBT skills training group. However, while these individual elements of DBT treatment may be beneficial, comprehensive DBT has a powerful advantage.
For DBT to by comprehensive it must comprise the following components:
DBT skills training. This almost always occurs in a group format run like a class. Group leaders teach behavioral skills and assign homework. Groups meet weekly for 24 weeks to complete the curriculum. Skills training consists of four modules: Mindfulness, Distress Tolerance, Interpersonal Effectiveness, and Emotion Regulation.
Individual therapy. Weekly sessions run concurrently with the skills training. The individual therapist helps clients apply the DBT skills.
Phone coaching. Clients are encouraged to reach out to their individual therapists to receive in-the-moment support applying skills during times of need.
DBT Consultation Team to Support the Therapist. All the members of the DBT team (group therapists and individual therapists) support each other in managing these clients who are in high distress.
When a teen is in comprehensive DBT, there is usually a parallel track for the parents that includes a parent skills group and a parent phone coach so that the parents receive help supporting their teen who is learning to apply DBT skills.
Exposure and Response Prevention
Exposure and Response Prevention (ERP) refers to specific CBT strategies used to address obsessive-compulsive disorder (OCD) or similar symptoms. OCD is characterized by distressing and intrusive thoughts and compulsive behaviors in which a person engages to try to reduce the distress. In ERP, the patient is exposed to the distressing situation and encouraged to prevent their compulsive behavior so they can learn to tolerate the distress. Once a person feels capable of handling their distress they will no longer need to engage in the compulsive behavior.
OCD and eating disorders commonly co-occur, and eating disorders can result in compulsive behaviors that require additional attention, such as compulsive exercise or other rituals not related to eating. Patients with eating disorders who engage in these behaviors may benefit from the addition of ERP.
As of March 2020, the advent of the COVID-19 pandemic is bringing dramatic changes to all aspects of our lives.
One of the most significant impacts of social distancing is a change in the mode of delivery of psychological treatment. It appears that most outpatient therapists, dietitians, and medical doctors are moving entirely to telehealth sessions (over the computer). Even many intensive outpatient (IOP) and partial hospitalization (PHP) programs appear to be shifting to a telehealth delivery model. Further, it appears that admissions to residential treatment centers may be reduced and limited to only the most severely medically compromised patients.
As a result of more stringent admission standards as well as travel restrictions and the transition to online sessions, it appears that a larger number of eating disorder patients will be in the home. Fortunately, Family-Based Treatment (FBT) is a treatment naturally poised to fill the gap created by the Coronavirus.
FBT has emerged as a leading therapy with empirical support for the treatment of adolescents with anorexia nervosa who are medically stable. It also shows support for adolescents with bulimia nervosa and young adults with anorexia nervosa. FBT makes the role of parents central to challenging their adolescent’s eating disorder. The hallmark of the treatment is family meals which parents plan, prepare, serve, and supervise. If purging is an issue, they supervise after meals. They implement strategies to prevent purging, excessive exercise, and other eating disorder behaviors. I have often said that FBT is like providing residential treatment in your house for only your child.
FBT is a manualized treatment and usually takes place in approximately 20 weekly sessions with an FBT therapist over a period of about 6 months. A teen should also be monitored by a medical doctor and a dietitian may be involved in helping the parents with meal planning. Fortunately, FBT sessions can be delivered via telehealth.
Telehealth is the delivery of medical or mental health treatment over live video. There are numerous HIPAA-compliant platforms that treatment professionals use such as Doxy, Zoom, and Vsee. Aside from a reliable internet connection and a private setting, there are no additional requirements for telehealth delivered mental health care. Telehealth interventions have been used in various forms since 1972. In general, the research shows that therapy delivered via telehealth can be effective for a variety of problems. Telehealth has been successfully applied to both family therapy and the treatment of eating disorders.
Kristen Anderson, LCSW and colleagues did a study of FBT for adolescent anorexia utilizing telehealth. They utilized the same treatment manual utilized in outpatient studies of FBT with minor variations. For example, instead of weighing the patient in the therapist’s office prior to appointments, the parents weighed the patient at home prior to the session and shared the weight with the therapist. The structure of the sessions was the same, with all family members in attendance. The therapist initiated therapy sessions by video conference and met individually with the patient for a few minutes first, followed by a meeting with the entire family for the remainder of the therapy hour.
Anderson and colleagues found that it was feasible to deliver FBT via telehealth. There were no dropouts over the course of the study and the average number of treatment sessions attended was 18.4. Parents found the treatment to be extremely helpful and participant weight increased significantly. Meaningful improvements were also noted in eating disorder symptoms as well as depression and self-esteem. Anderson and colleagues concluded, “these findings suggest that this method of delivering FBT may be effective for meeting the treatment demands of adolescents living in areas of the country where there are inadequate treatment resources such as nonurban or rural settings.”
Little did they know that throughout the world, social distancing would create a need for FBT delivered by telehealth!
If you are looking for virtual FBT support during this time, we can support families throughout the states of California, New York, and Florida in the US, and we can also provide support for families in some other countries. We use a secure online platform. Please ensure you have a stable internet connection and try to position the video so that all members of the family are in view of the video screen. Learn more about our telehealth services.
If you are looking for FBT by telehealth in other states and countries, please check out the following websites:
Family-Based Treatment (FBT) is the leading evidence-based treatment for adolescents with anorexia nervosa and bulimia nervosa. One of the common misbeliefs I hear is that it’s “only for kids or younger teens.” However, I think it has a much wider applicability. In fact, I would say that my FBT training has significantly improved my effectiveness in treating eating disorder patients of all ages.
While there have not been studies of FBT that pull it apart and pinpoint the elements that drive its success, I have a few theories. One of the key underpinnings of FBT is meal support. People with eating disorders experience such crippling anxiety before, during, and after meals that it is no wonder they would do anything they can to avoid eating. When the brain is in a state of overwhelming anxiety, a person with an eating disorder cannot make logical decisions about what to eat—or even to eat. And yet, without eating there can be no recovery. Treatment centers understand this—providing regular meals has been the mainstay of residential and partial hospitalization (PHP) eating disorder treatment for some time. FBT is the in-home parallel to this treatment.
In FBT, parents are charged with nourishing their teens back to health by providing regular nutrient-dense meals and preventing purging, excessive exercise, and other eating disorder behaviors. Parents plan, prepare, serve, and supervise meals and after meals, if purging is an issue. They make all the food decisions. They sit with their struggling child during those terrifying meals and help their teens cope with eating amounts sufficient for them to get well. Over time they return control to their teens, building their capacity to fight the eating disorder on their own. It takes effort and time to change brain pathways that have made eating a scary experience. For this reason, even those patients with eating disorders who go on to higher levels of care usually don’t remain there long enough to develop the autonomous ability to eat enough to sustain recovery. They often continue to need meal support for some time after more intensive treatment.
I think FBT has applicability that spreads wider than just children and teens. There is preliminary evidence of its successful use with transition-age youth up to age 25. Many parents have reported successfully using it with their college-age children. I have used it with this age and the primary variation is that the young adult plays a bigger role in their own treatment. They must agree at least in theory to accept their parents’—or other caregivers’—support. The young adult may choose who will support them during meals. Some, for example, may have a college roommate provide support. Some parents do meal support via FaceTime when the young adult lives far away.
I should clarify that FBT is a manualized evidence-based treatment. To be done with fidelity it must comprise certain components, including a therapist who guides the parents in organizing their strategies to fight the eating disorder. Parents refeeding their child without a therapist’s oversight often state they are “doing FBT”. In this case, it is more accurate to say they are providing FBT-informed or carer-supported feeding. Regardless of the words we use to describe this support and whether or not a therapist is involved, I think it provides a core benefit that we can expand to other populations.
These principles can also be applied to adult treatment. I personally have supported an adult who was in PHP during the day and needed more support with meals outside of treatment hours. I applied the skills I learned in my FBT training to provide meal support to this person. It worked just like it did with teens. Obviously this adult was an active participant in their recovery who asked for my support. This does not mean that I did not encounter the same kind of anxiety and resistance that parents meet around meals.
Take another case —a 20-something patient who still lives with her parents. She has been doing so much better since she asked for help, trading in the restrictive foods she had been eating on her own for several years for family meals prepared by her parents. Or the case of a college student who gets support via FaceTime from her parents who live in another city. When working with young adults with eating disorders who are in loving relationships, we often work to help their significant others develop strategies to support them during meals.
My experience is not unusual. Many other FBT-trained clinicians report success with providing FBT-informed treatment to people from all walks of life. One dietitian has reported great progress working with an employed single adult who moved home to live with his parents so they could support with meals. Sadly, previous providers had pathologized his moving home as a sign of enmeshment. One therapist shared, “I am doing FBT with a 79-year old. She is now in phase 2. She can now go out on dates—she just has to send pictures of her food to her adult children who are taking charge of her recovery and have been in charge of plating her food.”
Many have realized that in-home meal support is a common need for patients, and naturally, it is starting to become a big business with several treatment programs now providing this service. Offered as a service, this individualized meal support can be very expensive. Far more convenient, cost-effective, and loving is meal support provided by parents, other family members, or significant others.
I personally see it as a sign of strength when an adult admits they need more help. There is no shame in needing meal support during your recovery no matter what your age. Moving back home to live with family for support is nothing to be embarrassed by. This disorder robs people of their ability to make decisions around food—outside support is needed by definition. If you struggle around mealtimes with deciding what to eat, only feel safe eating a narrow range of food, have been struggling to make progress in your recovery, or cannot manage urges to purge after eating, you are not alone. You may benefit from the addition of meal support. It may feel scary or embarrassing to ask for help and you may worry you are being a burden. But asking for help is a brave step and you will likely find that there are some people in your life who can do this for you. It sometimes requires a little creativity, but you may find that it makes a big difference in your recovery.
The short answer is: FBT can be for people of any age.
Chen, E. Y., Weissman, J. A., Zeffiro, T. A., Yiu, A., Eneva, K. T., Arlt, J. M., & Swantek, M. J. (2016). Family-based therapy for young adults with Anorexia Nervosa restores weight. International Journal of Eating Disorders, 49(7), 701–707.
Dimitropoulos, G., Freeman, V. E., Allemang, B., Couturier, J., McVey, G., Lock, J., & Le Grange, D. (2015). Family-based treatment with transition-age youth with anorexia nervosa: a qualitative summary of application in clinical practice. Journal of Eating Disorders, 3(1), 1.
Dimitropoulos, G., Landers, A. L., Freeman, V., Novick, J., Garber, A., & Le Grange, D. (2018). Open Trial of Family-Based Treatment of Anorexia Nervosa for Transition Age Youth. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 27(1), 50–61.
It’s almost the first day of school and parents of students with eating disorders have additional concerns to address on top of the usual back to school frenzy. Transitions can be tough for all teens—they are especially difficult for those with eating disorders. However, there are some preparations you can make to help things go more smoothly.
If you have been supervising most meals your teen has been eating over the summer, the shift to a school day brings a significant change in schedule. A considerable portion of your teen’s day will be spent at school. You may need to increase the size of the breakfast your teen will consume before a long day away from home. Practice the breakfasts you will plan to prepare during the school year. Also be mindful that there may be less time for breakfast when you have to get your teen out the door—to ease the transition, have them practice eating within a reasonable time.
During the school day, your teen will typically need lunch and at least one snack. Now is the time to consider how you will handle these meals and snacks. If your teen is early in recovery it may be important to for them to remain under the full supervision of parents for all meals and snacks. If this is the case, you should speak to the school staff now and make arrangements. Most schools will allow a parent to come and have the teen come out and eat lunch in the car and then go back in. Other parents make arrangements for a staff person at the school (favorite teacher, school nurse) to supervise lunch. You may need to do the same thing with a morning snack. You may even consider only sending your teen for part of the school day until meals are going more smoothly.
If your teen is able to eat a meal and or snack on their own, don’t assume that doing so at school will be easy. Any change in location or schedule can increase the challenge for a teen with an eating disorder. I always suggest letting your teen know that if they can’t finish what you’ve packed, they should pack it up and bring the remainder home. It is important for you to know what they couldn’t finish so that you can add food later to make sure they don’t end up with a deficient intake which could lead to relapse. Let them know they won’t be in trouble!
Practice now with the foods you will send to school for lunch. If your teen is accustomed to hot lunches at home, have them practice eating the very foods you will pack in a school lunch to make sure they are comfortable eating those foods. I always suggest packing foods that are easiest for your teen to eat while being adequate nutritionally; save the fear foods for the meals they will be eating at home with you.
If your teen will be eating without supervision, discuss with whom they will eat. Do they have friends they feel most comfortable with? Even better if they have a friend who knows about their eating disorder and they can talk to ahead of time about making plans to eat lunch together. Encourage them to eat with friends who are good eaters.
If your teen will need to have restrictions from physical education, get a note from your treatment team and deliver it to their school.
Finally, I suggest watching closely during times of transition. This means weighing your teen regularly to guard against a significant weight change. Sometimes you can hit a bump and catching a problem early can go a long way in preventing a serious decline.
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.
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:
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
When parents are renourishing a child with an eating disorder and that child gets sick, parents often don’t know what to do. Some families may back off on feeding every time a child gets any illness, which can be a risky practice. Especially during Phase 1 of FBT, ensuring eating is a priority. To help parents, I’ve asked Jennifer Johnson, MD, a medical doctor who specializes in treating patients with eating disorders, to share some advice.
First, let me say that in general, minor illness should not cause a kid with an eating disorder to lose weight. Parents who are refeeding their child know that even missing a meal or a snack makes a difference in their progress. Don’t let illness throw you off course. As you know, failure to gain as expected may occur if nutrition is even a bit compromised. It is absolutely not a given that illness or surgical procedure must cause weight loss. When I hear that someone has lost 3 pounds “because they had a cold” the previous week, I ask a lot of questions – that should not have happened.
Second, plan ahead. After you’ve read through my answers and looked at other parents’ recommendations, be proactive. Make a plan with your child and treatment team about what you will do if they get sick (which they inevitably WILL at some point during recovery). They should know that they WILL still be eating. But talk about what foods they tend to like when they are ill, and think about how to plug maximum nutrition into them. Buy any non-perishable supplies and stock up on over the counter medications for colds, coughs, and fever. (And please have a thermometer on hand! A $10 digital one is plenty good to give us doctors valuable information.)
What should parents do in terms of feeding when a child with an eating disorder has a head cold or sore throat and loses their appetite? Is it necessary to avoid dairy?
If your child is listless and feeling unwell, they will often not be very hungry for a couple of days. A sick child needs care and comfort. Caring for a sick child who has an eating disorder includes keeping up the nutritional intake. You don’t want the eating disorder to think that illness is a good way to sneak through the back door. And, there are other times when your child is not hungry, just from refeeding itself, and they have to eat anyway. So, push ahead, but gently. Present nutrition dense food and beverages that will be particularly appealing to your child. Does a milkshake sound appetizing? You can add a packet of Benecalorie. (There’s nothing wrong with dairy, by the way.) Chicken noodle soup? Maybe add some extra pasta. There are lots of helpful posts from parents on the Around the Dinner Table Parent Forum.
What about if they have a fever?
Having a significant fever (101 or above) increases fluid needs as well as metabolic rate (more calories are burned). Your child will feel better if you control the fever with regular doses of acetaminophen or ibuprofen. Giving the medication at regular intervals, say every 6 hours for acetaminophen, may prevent the fever from getting as high as it otherwise might. This also helps with the headaches that usually accompany fever. Keeping your child hydrated, particularly with something like Gatorade, will also help them feel better – and thus more likely to have some appetite. Some kids maintain their appetite when they have a fever and of course, it’s fine to continue refeeding. Otherwise, know that keeping up nutrition during an illness helps your child feel better sooner, and push on. Again, it’s helpful to adjust what you give them based on their preferences.
What about when kids in recovery have the stomach flu?
What do you do if they’re vomiting?
Generally, vomiting is worst at the onset of an episode of stomach flu and becomes less frequent over the next 24 hours. A parent’s main goal when a kid is vomiting is to keep them hydrated. I recommend not giving anything by mouth for 2 hours after they’ve thrown up. Then you can give them ice chips or a couple of teaspoons of water. This liquid will get absorbed from the mouth. Do this every 5 minutes or so for half an hour. If they haven’t vomited again, you can have them try slightly larger amounts of liquids at less frequent intervals. They should be able to keep down about 2/3 of a cup of liquid, and be hungry, before you try a very small amount of food. Slowly increase the amount you give them. Kids may become ravenous and eat a huge meal, but then throw up everything they’ve just eaten. A kid who throws up a day or two into recuperation may have just overdone it. In that case, you’ll need to let up a bit before pushing back into refeeding.
What about diarrhea?
For kids with diarrhea, we don’t generally recommend giving any medications that are designed to decrease the number of stools (bowel movements). No major food restrictions are needed. There is nothing magical or beneficial about the so-called BRAT diet (bananas, rice, applesauce, toast), which is of low nutritional density. Studies have shown that having diarrhea for a few days does not make someone lactose intolerant. We know that eating when you have a “stomach bug” with diarrhea will generally increase the number of diarrheal stools. But we also know that at the end of the illness, people who have continued to eat will end up better nourished (= digested more calories). And that, of course, is the ultimate goal.
One thought: you may want to speak with your child’s doctor about a proactive prescription for a small number of anti-emetic tablets (that dissolve in the mouth) to have on hand in case your child gets stomach flu. I don’t normally recommend this but refeeding is an exception. We want to minimize the duration of nausea and vomiting to make it easier for your child to eat. Also, many of my patients who have eating disorders are afraid of truly fearful of vomiting (a condition called emetophobia), which only makes stomach flu worse for everyone. If your doctor is willing to do this, they undoubtedly want you to call before you give the medication.
What if your child has no appetite (due to illness)
Biology is on our side. When a kid (or another human being) eats less due to a minor illness, appetite typically returns with a vengeance and we make up for what we’ve missed. For a kid in the early refeeding phase, of course, it is normal to not feel hungry. So you may not know whether your child is not hungry because they’re not feeling well or because they’re refeeding. In either case, your eating disordered child needs you to continue to push forward. Refeeding is the mainstay of treatment and you’re the team leader. Go for it!
Please note that none of the above should be construed as medical advice. If you have concerns about your child’s health, contact their doctor. Some examples of when you should call the doctor are: Bloody diarrhea, high fever (102 or above), vomiting that continues more than 24 hours, weakness, severe dizziness or fainting, or very little urine.
About Jennifer Johnson, M.D., MS, FAAP
Dr. Johnson is a medical doctor. She has more than 20 years’ experience as a pediatrician and adolescent medicine specialist. She practices in Newport Beach (Orange County), California.
Dr. Johnson is certified by the American Board of Pediatrics in Adolescent Medicine as well as in Pediatrics. Dr. Johnson also has an advanced degree in public health. She has been a professor in the Department of Pediatrics at the University of California, Irvine School of Medicine, where she served as director of the adolescent medicine program. Dr. Johnson has taught medical students, residents, faculty, and community physicians, for whom she continues to present educational programs. She has presented at national meetings of many organizations, including the American Academy of Pediatrics and the American Academy of Family Practice. Dr. Johnson has written many research articles and book chapters related to adolescent and young adult medicine.
Dr. Johnson is an advocate for adolescents and young adults. She is a Fellow of the American Academy of Pediatrics (AAP). She has led many activities in the Academy’s Section on Adolescent Health and served as its chairperson. Dr. Johnson is active in the Orange County chapter of the AAP, as well. Current projects include the Teen Safe Driving Initiative and healthcare for GLBTQ teens.
Dr. Johnson has also been active in the Society for Adolescent Medicine. As a member of the medical advisory board for Teengrowth, Dr. Johnson wrote many articles and answers to reader questions. Articles and webcasts by Dr. Johnson are posted at Healthology.com, medbroadcast.com, and the New York Daily News.
Dr. Johnson is on the medical staff of Hoag Hospital in Newport Beach.