When to Add an Individual Therapist in FBT-Phase 1

Individual therapy in FBT
Photo by Priscilla Du Preez on Unsplash

When I am working as the Family-Based Treatment (FBT) therapist for a teen in recovery, their parents will often ask whether the teen should also see a therapist individually. Unlike other therapy situations, in FBT there is no expectation that there is both an individual therapist and a family therapist. It’s there in the name: “Family-Based Treatment.” FBT is not just “family therapy” aimed at solving family problems—it is a specific, comprehensive, evidence-based treatment. In fact, the developers state that they called it Family-Based Treatment when they were manualizing the approach because they wanted to distinguish it from being viewed as a type of family therapy.

As I have stated elsewhere, I think most teens who receive FBT will never need individual therapy for an eating disorder. I actively discourage the addition of an individual therapist in Phase 1 (nutritional rehabilitation). When we arrive at Phase 2 (handing back of control to the teen), we can better assess which issues remain unresolved with weight restoration. This is the point at which the adolescent is likely to be more receptive and able to benefit from individual therapy. Even here, I think additional therapy is only needed when there is a specific additional diagnosis or specific problem. Adding an individual therapist when one is not needed adds risk and can even undermine the FBT.

Among the reasons I discourage adding an individual therapist in Phase 1 is that the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT. Additionally, in one case series of families with “failed FBT”, does not believe in or support FBT. Additionally, in one case series of families with “failed FBT” teens later admitted asking for individual therapy as a deliberate strategy to exclude their parents and reduce the pressure for weight gain. I have observed teens who ask for individual therapists in Phase 1 and by Phase 2 no longer make such a request.

Reasons parents sometimes cite for wanting their teen to have an individual therapist include processing the underlying issue and having someone to listen. I do not think these are valid reasons for adding an individual therapist during Phase 1, given the risks that it could deflect from the focus on nutritional restoration. And, as discussed elsewhere, there is not usually an underlying issue to process.

Curious where other providers stand on the issue, I asked a few colleagues under what circumstances they would add an individual therapist in Phase 1 of FBT. These were their replies.

Never, if there isn’t a comorbid issue. I would not ever add an individual therapist to address the eating disorder during FBT treatment. The only time I do it is for some kind of comorbid issue, and even then, I usually don’t do it during phase 1. – Natalie Wingfield, LPC

I strongly discourage it and talk a lot about fidelity to treatment, commitment to the program, and how we want to ensure they are getting the full benefits of FBT. I also talk a lot about lack of research support for adding a therapist and the potential for therapy burnout from seeing multiple providers. But, I’ve had some families where they were very resistant to pausing individual work and I thought a lot about the cost/benefits of them not getting any eating disorder treatment if I remained rigid in my stance. In those rare circumstances, I’ve had success in asking to talk to the individual therapist about the treatment and role delineation/expectations. In my experiences so far, this has resulted in the other therapist either voluntarily pausing their treatment in support of FBT or really good communication between myself and the other therapist to help prevent mixed messages. I could definitely see it going sideways though and it’s not something I casually agree to with families. And it’s always a red flag to me when families won’t back down because it usually means they will be asking for additional changes to the treatment and will struggle with the structure. – Amy Henke, Psy.D.

I wouldn’t for the reasons stated above and more. If they are in phase 1 and therefore undernourished, they are not likely going to be able to engage productively in therapy anyway. I can see a lot of processing how difficult phase 1 of FBT is, and expressing a ton of distress which naturally most therapists would feel compelled to solve. This could only lead to the individual therapist interfering in the FBT process or at the very least introducing doubt about its usefulness to the client and family. Overall, “0/10 would not recommend” is my stance. I think it also confuses the idea that renourishment is really the key to resolving many of the presenting behavioral and psychological symptoms. If one therapist is talking about regular meals and the other is talking about self-esteem, 9 times out of 10, an overwhelmed parent is going to pick self-esteem as the issue to address. Then we risk losing the client to something that is not going to help them. – Christine Knorr, LCSW, CEDS

Usually I don’t recommend that as it creates a lot of cooks in the kitchen. We know how challenging the beginning of FBT can be for the whole family, I think as clinicians we just support them. – Shelly Bar, MD

Agree with recommendation to hold off adding an individual therapist in Phase I. I haven’t seen that ever go well. I have a few cases now where the individual therapist was brought in Phase I. I’m constantly trying to uphold the power to the parents, because therapists want to find a way to give voice and choices to the child. – Katie Grubiak, RDN

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