Family Based Therapy for Adolescent Eating Disorders
Family-Based Treatment: Development and Practical Usage
Family Based Therapy (FBT) is a manualised version of the Maudsley Method for addressing dietary disorders in adolescence. This outpatient treatment is a leading evidence based treatment for eating disorders that is performed at home.
FBT vs. Family Therapy
FBT should not be confused with similar but perhaps fundamentally different approaches under the umbrella of family therapy.
Traditional family therapists often assume children with eating disorders are experiencing a family issue. They work to identify and treat this problem for a cure for food disorders. These approaches do NOT support research based research.
The clinicians of the Maudsley Hospital in London, England developed in the early 1980s and early 1970’s a very different family therapy approach. Let let's dive into what this means!
Principles of Family Based Therapy for Eating Disorders
The principles of FBT are key for the implementation of this therapy approach!. The key principles of FBT have been identified as important for families to work on, in order for full recovery. The FBT therapist's role is to help guide parents in supporting their child, by using these principles.
Family Involvement
FBT recognizes the importance of family involvement in the treatment process. Parents or caregivers are considered key allies in helping the adolescent overcome their eating disorder. The family is actively engaged in treatment sessions and plays a central role in supporting the adolescent's recovery.
Externalization of the Disorder
FBT encourages the family to view the eating disorder as separate from the individual. This helps shift the focus away from blaming the adolescent and instead directs attention toward defeating the disorder as a united family unit!
Normalization of Eating
FBT emphasizes the normalization of eating behaviors, including restoring regular and sufficient food intake to promote weight restoration and physical health. Parents are empowered to take charge of meal planning, preparation, and supervision to ensure that the adolescent is adequately nourished.
Empowerment of Parents
FBT empowers parents to take an active and authoritative role in their child's recovery. Parents are supported in making decisions about meals, setting clear expectations around eating, and implementing boundaries to prevent eating disorder behaviors.
Interrupting Maladaptive Behaviors
FBT focuses on interrupting and challenging maladaptive behaviors associated with the eating disorder, such as restrictive eating, excessive exercise, or purging. Family members work together to identify triggers for these behaviors and develop strategies to address in a way that feels best for your family.
Restoring Weight and Nutrition
FBT prioritizes weight restoration and nutritional rehabilitation as essential components of recovery. Parents are responsible for ensuring that their child consistently consumes an appropriate amount of food to support healthy growth and development.
Addressing Underlying Emotions and Concerns
While FBT primarily targets behavioral symptoms of the eating disorder, therapists also work with families to explore and address underlying emotional concerns, such as low self-esteem, anxiety, or family conflicts, that may contribute to the development or maintenance of the eating disorder.
Gradual Transition of Control
As the adolescent progresses in treatment, FBT supports a gradual transition of control over eating and decision-making back to the adolescent. This process is guided by the family based therapist and occurs once the adolescent demonstrates readiness and stability in recovery.
Collaborative Approach
FBT is conducted collaboratively between the therapist, the family, and the adolescent. Therapists provide guidance, support, and psychoeducation to empower families to implement treatment strategies that lead to sustained recovery.
Relapse Prevention
FBT includes strategies for relapse prevention to help families anticipate and address potential setbacks in recovery. Families learn to recognize early warning signs of relapse and develop coping skills to navigate challenges while maintaining progress.
Three Phases of the Recovery Process
Family Based Therapy is different than traditional family therapy or individual treatment as it is a structural family therapy that consists of three phases.
Firstly, FBT takes an agnostic view of its cause, making it impossible to speculate about the possible cause of eating disorders. Instead, the illness is viewed as a complicated multi-factorial disease in which several different factors need to be integrated to solve the eating problem. However, FBT aims to identify what needs to happen to encourage a teenager to move forward quickly with recovery from the trauma and loss that occurred at home.
Phase 1 - Weight Restoration and Parental Control
Initially designed for those suffering from anorexia, FBT aims at restoring weight. It also concentrates on immediately stopping the child's eating disorder behaviors.
During this first session, the eating disorder therapist explains the severity and provides education, counseling, and empowerment techniques to caregiving clients. This aims at helping families to control their child's refeeding process and work towards symptom reduction. Parents are tasked with taking control of the eating disorder by making the decisions around food. Caregivers can manage their child's diet and exercise, as well as decide how much the child eats.
Phase 1 also consists on a family meal, where the FBT therapists demonstrates to parents how to actively support their child.
Phase 2 - Returning Control to the Adolescent
Once weight restoration has occurred, phase 2 consists of giving control back to the adolescent. Parents gradually relinquish control over meal planning and exercise, allowing their child to make more decisions around food intake.
The FBT therapist continues to work with the family to facilitate open communication and address any conflicts that arise. The overall focus of this phase is to allow the child to take back control over their own eating related decisions.
Phase 3 - Independance
In the final phase of Family Based Treatment, the focus is on consolidating the process made during treatment and supporting the adolescent in getting their life back. The FBT therapist shifts more towards individual therapy, helping the adolescent explore underlying psychological issues, such as low self-esteem, perfectionism, and anxiety.
Family therapy sessions can continue addressing ongoing family conflicts that effect the child's life. The goal of phase 3 is to help the adolescent develop the skills to maintain a healthy lifestyle and prevent relapse of the eating disorder.
Family Based Treatment for Anorexia Nervosa
Family Based Treatment was originally used for treatment of adolescents with anorexia nervosa, but has been proven effective for bulimia, binging and OSFED for many years. Many FBT manuals focus on weight gain. So the patient with no weight gain can often find the FBT unnecessary.
Family Based Treatment for Bulimia Nervosa
Family Based Treatment was adapted in order to treat patients with other eating disorders. Although the program has some similarities to the FBT-AN, its main goal when working with adolescents with bulimia is to break up binge-eating and purging.
Parents still manage recovery, however, there is a shift in the first phase from weight restoration to normalizing of eating patterns if weight restoration is not needed. With bulimia nervosa, Family Based Treatment puts more emphasis on behavior management.
Telehealth Shifts Treatment Approaches: FBT During COVID-19 and Beyond
The release of COVID-19 has triggered revolutions in health care in that locations do not restrict individual medical treatment alternatives. Family members that cannot access an FBT doctor are now able to have FBT treatment at home.
This required creativity around weigh-ins and getting creative about the entire family within one screen. However, virtual therapy provides an easier way for everyone in the family to attend family therapy at the same time.
Early Intervention is Critical
Those who are treated early on in their lives have more chances of complete eating disorder recovery. Neurological pathways have not defined, behavioral patterns are more easily changed, and physical health is less likely for a person to sustain long-term health problems. The sooner the child gets medical assistance and the less the risk of death the better.
Adaptations to Family-Based Treatment
Although it's fully adapted and taught, FBT has not had a successful treatment outcome in every household or any family. If weight gain has not occurred around the fourth session, it may mean that FBT is not effective in this household.
When the efficacy of treatment is determined, research can begin with what to do with family members whose FBT is ineffective. This may require the family to look into higher levels of care such as partial hospitalization programs, residential, or inpatient treatment programs. The FBT therapist can help determine where would be a good fit for the child.
Feed, Love, Heal
As parents learn to feed their child and heal their eating disorder through family based treatment, they will notice their child become more medically stable and engage more in family life. It is amazing to watch a child recover and gain their amazing personality back and the disordered behaviors dissipate.
If you feel your child could benefit from an FBT therapist, reach out to us here, as Kate Ringwood, LPC is trained as an FBT therapist.
Frequently Asked Questions About FBT:
What does family based therapy focus on?
Family Based Treatment focuses on symptoms rather than the underlying problems. FBT aims to achieve recovery through eliminating eating disorder behaviors immediately.
What is the difference between family-based therapy and cognitive based therapy for eating disorders?
The CBT-E model emphasizes more heavily upon individual problems, and the individual. This is therefore a program that enables the patient to manage eating disorders as part of themselves, encouraging the patient, with no parental control.
What if My Teen Doesn't Want to Do FBT?
Most adolescents do not like the idea of their control of food being taken away from them. In Family Based Treatment they are also going to confront this problem head-on, which is never a fun or easy experience for an adolescent with an eating disorder. This will make them uncomfortable in the short term but it will lead to more transformations.
Can My Teen Continue to Play Sports?
Exercise can sometimes be an eating disorder behavior, but it is ultimately up to the parents to decide if exercise is a piece of the eating disorder or not. In Family Based Treatment, we sometimes need to eliminate movement in order to get the weight gain needed for restoration.
When and how can FBT be used as a treatment approach?
It should only be used for patients with a stable underlying medical condition as well as a particular family environment that is open to family interventions.
