Family Based Treatment for Eating Disorders

Does your child have an eating disorder?

If you are a parent of a child/teen with an eating disorder (ED), you are likely feeling overwhelmed and scared. It is hard to watch your child refuse to eat and it is even more scary if they continue to lose weight. The ED is often running the show at home; it makes meal time difficult, enforces certain dietary rules, and decides where/when/what the family will eat. You may be left wondering where your child went and how to get them back. 

Family-Based Treatment for Eating Disorders

Family-Based Therapy (FBT), also known as the Maudsley Method, is a practical treatment approach that empowers the family to help their child recover from the ED. FBT was originally developed for Anorexia Nervosa (AN) to help parents re-nourish their child. It has been widely studied and is the most effective treatment for children with AN. Over the years, FBT has also been shown to be effective for Bulimia Nervosa (BN), Binge Eating Disorder (BED), and Avoidant and Restrictive Food Intake Disorder (ARFID). 

FBT for AN: 

AN is characterized by a low weight, refusal/fear of weight gain, restrictive eating, and a inaccurate perception of one's body. Lack of nourishment affects your child’s mood and their mental and physical functioning. In addition to losing body fat, there is also a decrease in the heart, brain, bones, and other vital organs. AN has the highest death rate of any mental illness. It is important to seek help immediately and before symptoms get worse. The longer someone has the illness, the lower the chances of recovery.  In order for treatment to be effective, the body and brain need adequate nourishment. FBT helps the parent take back control of the AN so that the ED is not in charge of your teen and the family. The goal is to re-nourish your child. As weight restoration is achieved and the child is gradually given more autonomy around eating, you may notice his/her old self coming back.

FBT for BED or BN: 

Whether the child engages in binge eating alone (BED) or compensates (i.e., purges) by self-induced vomiting, laxative use, fasting, or excessive exercise, the family can play a crucial role in stopping the binge eating- purging cycle. Purging can lead to many physical conditions such as dehydration/electrolyte problems, heart problems, digestive system damages, and teeth/gum disease. FBT helps the family provide structure around meals and both emotional support and supervision during and after eating. The therapist may help the child understand triggers to their ED behaviors, teach healthier coping skills, and facilitate communication within the family so that the family can help the child implement better coping skills. Registered dietitians can assist families in providing a structured progressive meal plan to ensure nutritional adequacy and appropriate food challenges through exposure response therapy and healthy movement guidelines that challenge and remiss binge-purge behaviors.

FBT for ARFID:

ARFID involves restrictive eating, failure to gain weight, or nutritional deficiency. Food avoidance may occur due to low interest in eating, picky eating, fear of choking/vomiting/pain, or food sensory sensitivities (e.g., food texture). FBT helps parents support their child in gradually expanding the variety of foods eaten with the goal of restoring nutrition and weight. 

How does it work??

The main focus of FBT is on meal times. FBT is broken down into three phases, typically completed in 20-25 sessions over 12 months but can vary depending on the severity of the condition.

In the early phases of FBT, the therapist will empower the family to be in charge of meal times and weight restoration. This includes planning, preparing, and plating foods, as well as support during eating and supervision after meals. As a family progresses through the phases, the child begins to have more independence and autonomy around eating. The ultimate goals are weight restoration and "normalization" around eating.

If the child is too young or unwilling to participate, FBT still works! The therapist can still work with the parents to support them in being the vehicle to change in their child's recovery. Parents will learn how to handle food refusal, support the child during emotional outbursts, offer rewards and consequences, and staying strong. At any point, if willing, the child may have a separate individual therapist who can help him/her with any struggles. The individual therapist is separate so that the child can have a safe and confidential space to talk openly about his/her feelings and concerns. A registered dietitian may be recommended to help your child slowly increment their eating in a safe way. We ask that your child's medical provider oversee medical symptoms and labs.

A modified FBT can also be used with young adults who live at home or away at college. Given that they are now adults, patients have more autonomy and independence but families can still be used for support and guidance around meals. Parents may provide privilages and rewards for recovery and also withhold other means of support (financial, use of car, paying for an apartment, funds in college), if the patient is not engaging in treatment.

Effectiveness of FBT

FBT is not traditional family therapy. It is a specific type of therapy that focuses on empowering parents to help with renourishment and healthy behaviors. FBT focuses on the eating disorder, not the individual, and the FBT therapist helps the parents externalize AN from the teen. ²

Research studies have compared FBT to other treatments for AN and have found that FBT is the most effective evidenced-based intervention for treating teens with AN. ³ ⁴

Teens who receive FBT recover quicker than with individual therapy. ⁴

Up to 90% of teens who complete FBT fully or partially recover from AN and remain in recovery years later. ³ ⁴

Phases of FBT

PHASE 1: Full parental control. The primary goal is to restore weight, provide nourishment, and work on disordered eating behaviors. Parents are in control of food, provide structured meal times, supervise during/after meals, limit physical activity. 

PHASE 2: Begins after weight restoration medical stability, and elimination of ED behaviors. Focuses on gradually returning control of eating over to the teen. The child slowly starts to make decisions about their food and they begin to serve themselves with guidance from the parents as needed.

PHASE 3: Begins when the child is able to eat healthfully with little to no supervision. The child has autonomy regarding eating and the family resumes their pre-ED functioning. The child may work on other issues such as depression, anxiety, self-esteem, and other teen issues with the goals of learning healthy coping and relapse prevention. 

Dietitian appointments with adolescents

Parental Involvement

FBT is grounded in the belief that families are a critical resource in their child’s recovery. Therefore, parental involvement in dietitian sessions is not only helpful, it is essential. Our goal is to provide parents with the tools they need to be effective allies in their child’s healing journey. With the right structure, support, and collaboration, recovery is not only possible—it can be achieved more quickly and sustainably.

At the start of treatment: We require that at least one parent or guardian attend a session without the child within the first 1–2 weeks of beginning treatment. This session allows us to:

• Gather important context about the child’s history, environment, and current challenges

• Offer education on eating disorders and the recovery process

• Provide parents with tools and strategies to support their child at home

Ongoing treatment: Depending on your child’s individual needs, we may request that parents attend sessions with the RD without the child present. Parent-only meetings are a critical component of effective treatment. Research and clinical experience show that recovery is significantly faster and more sustainable when parents are fully engaged and supported.These parent-only sessions are used to:

• Review treatment progress

• Make adjustments to meal planning and feeding structure

• Offer support and guidance for challenges arising at home

• Collaborate on a unified approach to treatment

A faster recovery not only benefits your child’s physical and emotional health, it also reduces the overall cost and duration of care.

What if we need more help outside of sessions? Questions should be addressed early to avoid treatment delays. Parents are welcome to schedule more frequent appointments. For your convenience, we offer between session appointments in 15, 25, and 50 blocks so that we can assist you during the week. Due to the complexity of meal planning and calculations of needs, we do not revise meal plans via email or phone calls. Clinical questions are best answered during an appointment due to the risk of HIPPA violations, miscommunication regarding treatment planning over email, and the time required to provide thoughtful, accurate responses. These sessions are also often covered by insurance or the discounted self-pay cost will be pro-rated for shorter appointments.

everyBody Behavioral Health is here to support your healing journey

Contact us today to learn more, or for quicker support, schedule an evaluation now.

-Jennifer Shapiro, PhD, CEDS

Eating Disorders Specialist

Clinical Director & Clinical Psychologist

References

1. Lock, J., Le Grange, D., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67(10), 1025–1032. 

2. Couturier, J., Kimber, M., Barwick, M., Woodford, T., Mcvey, G., Findlay, S., Webb, C., Niccols, A., & Lock, J. (2021). Family-based treatment for children and adolescents with eating disorders: a mixed-methods evaluation of a blended evidence-based implementation approach. Translational Behavioral Medicine, 11(1), 64–73. 

3. Muhlheim, L. (2018). When your teen has an eating disorder: Practical strategies to help your teen recover from anorexia, bulimia, and binge eating. New Harbinger Publications.

4. Alexa L’Insalata, Claire Trainor, Cara Bohon, Sangeeta Mondal, Daniel Le Grange, & James Lock. (2020). Confirming the Efficacy of an Adaptive Component to Family-Based Treatment for Adolescent Anorexia Nervosa: Study Protocol for a Randomized Controlled Trial. Frontiers in Psychiatry, 11.