Family-Based Treatment for Eating Disorders

What is Family-Based Treatment for Eating Disorders?

Family-based treatment (FBT) is one of the most successful treatments for eating disorders in children and teens with anorexia nervosa, bulimia nervosa, and other specified feeding or eating disorders (OSFED). To distinguish it from other forms of family therapy, parents sometimes call it “Maudsley Family Therapy,” a reference to its initial development at the Maudsley Hospital in London. Our owner and clinical director, Dr. Muhlheim wrote one of the leading books for parents about this treatment. Dr. Muhlheim and several other of our therapists provide expert-led FBT therapy for families in California and some other locations. We also deliver FBT in the context of a full team including a medical doctor and dietitian.

FBT is a specific treatment that follows a manual. Parents—supported by trained professionals—deliver FBT in an outpatient setting. Some residential and partial hospitalization programs incorporate principles of FBT in their programs.

FBT Centers the Family

FBT differs significantly from traditional treatments for adolescent eating disorders. Earlier approaches to eating disorders suggested that parents caused eating disorders in their children—as far back as 1873 William Gull wrote that “relations and friends” were “generally the worst attendants” for patients with anorexia nervosa. During the 1960s and 1970s leading treatment models for eating disorders continued to blame parents, especially mothers. Through the twentieth century, many professionals continued to view eating disorders as a struggle for independence from a dysfunctional family system. Professionals, as a standard practice, removed patients from their families and sent them to treatment facilities.

Today this myth persists. Some providers continue to focus on unearthing a family problem that needs solving and helping a teen to individuate in order to recover. However, more recent research clarifies that families do not cause eating disorders. We now understand eating disorders to be complex illnesses caused by a complicated interplay of biological, psychological, and environmental factors. FBT is at the forefront of the research that demonstrates that families are not a detriment but often an integral part of the solution to their teen’s or child’s eating disorder.

The Problem with Traditional Eating Disorder Treatments

Traditional treatments that wait for a teen to develop insight and the motivation to get better pose risks. They waste precious time trying to find an underlying problem that likely doesn’t exist. In the meantime, the eating disorder’s physical consequences continue to ravish the young person’s health. FBT works faster than other treatments and is often more cost-effective.

Teens and children with eating disorders often lack the motivation to eat and get better. FBT recognizes this and can work around it. Your child will likely reject treatment. That is okay. FBT can work in spite of their resistance. Until your child is ready to want their own recovery, you can want it on their behalf. No one loves your child more than you do; this uniquely positions you to help them recover.

What Is So Different About FBT?

FBT involves the whole family in solving their child’s eating disorder. Unlike traditional family therapy, it does not blame the family. FBT prescribes family sessions with a therapist at first once a week, decreasing over the course of treatment. However, because the parents are empowered to be a part of the treatment team, the treatment is much more intensive than is typically possible in outpatient treatment. FBT often provides a level of care that is similar to residential or partial hospitalization programs (PHP).

Typically, our therapist meets with the entire family—or, at a minimum, the person with the eating disorder and one parent—for one hour per week, either in our office or by telehealth. We prioritize the meal above everything else, much like a treatment center would do. However, instead of attending treatment all day, your teen participates in as much of their life as possible. As long as they are eating enough, they may be able to attend school and other activities.

FBT typically includes at least one family meal at the beginning of treatment in the therapist’s office. This gives the therapist a chance to observe the behaviors of different family members during the meal and to assist the parents in helping their child eat.

FBT requires active participation by parents and leverages parents as agents of change. In FBT, family meals form the core of the treatment: parents take charge of nourishing their teens with eating disorders by providing energy-dense meals. Parents plan, prepare, serve, and supervise all meals. A typical recovery meal plan includes three meals plus two to three snacks per day. If purging is an issue, they provide supervision after meals. They implement strategies to prevent purging, excessive exercise, and other eating disorder behaviors. I liken FBT to providing a residential treatment center in your house for a single patient—your child.

FBT centralizes the role of food in recovery. Your teen may fear eating but the cruel irony is that recovery cannot happen without regular energy-dense meals. We often say in FBT that “Food is medicine.”

Feeding your teen with an eating disorder regularly is essential even if they have another illness like a cold, flu, vomiting, and/or diarrhea.

Principles of FBT

FBT has five core principles:

Agnostic view of illness: FBT takes an agnostic view of the eating disorder, meaning we do not waste time trying to analyze why the eating disorder developed.
Initial symptom focus: FBT prioritizes full nutrition and prevention of eating disorder behaviors.
Parent empowerment: Caregivers provide full nutrition by taking charge of meals for their child. They also prevent behaviors such as purging and exercise.
Non-authoritarian stance: The therapist actively collaborates with parents who are full members of their child’s treatment team. Parents are the experts on their child.
Externalization of illness: The illness is an external force that has possessed the child and is attacking their health. Parents and providers join forces with the healthy part of the teen to fight off the eating disorder.

Focusing on Symptoms Versus Underlying Issues

FBT focuses on achieving recovery by treating the symptoms directly. Some parents and even some treatment providers worry that this approach is superficial and ignores the underlying issues. I can understand this. Focusing on food, regular eating, and regulation of weight and health may seem mundane. But it works!

We also prioritize returning a teen to their unique weight curve as we believe this improves chances for a full recovery. We also believe the family can become a treatment ally by standing up to diet culture.

Who is On an FBT Treatment Team?

An FBT treatment team can be small compared to those encountered in other types of eating disorder treatment. The team requires a therapist to guide the parents and a medical doctor to manage their medical needs. While FBT does not require a dietitian, we have found that a dietitian who works primarily with the parents can provide valuable guidance. We believe a dietitian should not meet alone with the teen or child during the early part of treatment because FBT places parents in charge of food decisions.

Of course, additional providers can be added as needed. If there are multiple providers, it is important that all team members are aligned about treatment philosophy and goals. Otherwise, a nonaligned team may be detrimental. We can provide referrals to dietitians, pediatricians, adolescent medicine doctors, and psychiatrists.

Who Is FBT For?

FBT is supported by research for children and adolescents with anorexia nervosa and bulimia nervosa. FBT can also be effectively applied to young adults and other adults with anorexia nervosa and other eating disorders including other specified feeding or eating disorder (OSFED). Finally, FBT can also be effective with ARFID in children and teens. FBT works in all kinds of family configurations including separated and divorced families.

Three Phases of FBT

FBT has three distinct phases:

Phase 1: Full parental control. Parents are fully in charge of meals, helping their child to reestablish regular patterns of eating and interrupting eating disorder behaviors, including purging and overexercising. If weight gain is needed, we set a goal of 1 to 2 pounds per week. Parents help their teens to reincorporate foods they have dropped from their repertoire.
Phase 2: A gradual return of control to the adolescent. This phase usually begins once most weight has been restored, when meals are going more smoothly, and when behaviors are mostly under control. We gradually give the teen more independence over their own eating in an age-appropriate manner. For instance, they may begin to have some meals or snacks independently from their parents. Families continue to focus on building flexibility in their teen’s eating. The teen begins to eat with different people and in different settings and incorporates all fear foods. This phase can be characterized by some backsliding and parents may have to reclaim control until the adolescent is fully ready; this is part of the process.
Phase 3: Establishing autonomy. Once the adolescent has resumed an age-appropriate level of independence and no longer exhibits eating disorder behaviors, treatment shifts in focus to helping them develop a healthy balanced life and catch up on other developmental issues. Other co-occurring mental health problems can be addressed. Relapse prevention is incorporated.

Feed, Love, Heal

Feeding and helping your child recover is a loving act. However, love is not always easy or gentle. The strength and resolve you show will nurse your teen back to full health. our FBT therapist will support you in managing the stress and challenges of the process. We will teach you how to tolerate your own distress as well as your child’s and how to teach your child to tolerate distress. This will not be easy, but it can be one of the most important things you will do as a parent.

Common Questions About Family-Based Treatment for Eating Disorders:

Will FBT Work for Our Family?

We’ve heard it all: “My teen is too old.” “My child is too independent.” I’m not strong enough.” “We are too busy.” None of these factors has proven to be a deal-breaker for the successful execution of FBT. We support you in doing this with love and compassion, and we believe that most parents can successfully implement FBT. FBT appears to be most effective for families in which the length of illness is less than three years.

What if My Teen Doesn’t Want to Do FBT?

No problem! FBT does not require your teen to agree. In fact, we expect your teen will not want to do FBT because we will be confronting the eating disorder head-on. This will cause discomfort for your teen (and you) in the short run, but it will bring about change more quickly and completely.

Can FBT Be Used if The Eating Disorder is Not Full-Blown?

Unfortunately, many pediatricians have counseled families, “It’s not time for FBT yet,” as things seem mild, and they encourage a more “wait and see” approach. However, FBT can be employed as an early intervention and may even be more potent and faster when employed in mild or early situations.

How Long Does FBT Take?

It varies! Treatment may take a year, but can also take longer. Speedy diagnosis and early intervention can drive a faster result. But eating disorders are difficult illnesses. If weight gain is slower than desired, it can take longer. Some teens also struggle with independent eating and so benefit from a longer period of supervised eating. Early behavior change is key! If the teen’s condition requires weight gain, we want to see 4 pounds of weight gain by week 4; otherwise, the research shows that FBT is unlikely to be successful. If we do not see progress, we will encourage intensifying treatment or a higher level of care.

Do We Need A Meal Plan?

No, you don’t need a meal plan. FBT empowers parents to serve foods that will nourish their starving teen back to health rather than feeding them according to what the eating disorder wishes to eat. Your therapist or an FBT-aligned dietitian can help you identify foods and meals from those your teen previously enjoyed and your family has traditionally eaten. In some cases, you may also incorporate the use of nutritional supplements to promote weight gain.

How Much Food Do We Feed?

In FBT, we usually encourage feeding high-calorie meal plans that yield weekly steady weight gain. It’s usually way more than parents expect to feed because teens with eating disorders have high energy needs.

How Do I Supervise All Meals?

This can be daunting, especially for busy families. One or both parents may take a leave of absence from work. Sometimes grandparents and other extended family members can help with supervising meals. You may need to coordinate lunches with your child’s school or keep your child home from school for some time. Many parents bring lunch to school and eat with their teens in the car. We are always amazed by the creativity our parents show in figuring this out.

Can My Teen Continue to Play Sports?

Excessive exercise is often a symptom of the disorder, and it can be dangerous for malnourished teens to engage in sports. Therefore, we usually recommend limiting activity during Phase 1 and reintroducing activities in Phase 2 of FBT.

Doesn’t My Child Need Also Need to See an Individual Therapist?

Not necessarily! As a primarily behavioral treatment, FBT initially focuses on rescuing a malnourished brain, and then on eliminating symptoms. Both medical providers unfamiliar with FBT and treatment centers that insist on having complete teams may pressure families to add an individual therapist. This is not always desirable. In FBT, less can be more; an individual therapist who either does not believe in or support FBT can potentially undermine parents’ authority. In one case series of families with “failed FBT” several families pivoted to individual therapy and the teens later admitted that “they had asked for individual treatment as a deliberate strategy to exclude their parents because they knew it would mean that there would be less pressure for weight gain and more chances of avoiding stress and conflicts around the challenges related to their eating behavior.”

A return to healthier eating behaviors and stabilization of weight often relieves many of the eating disorder-and related symptoms including anxiety and depression. Additionally, research shows that at least in the case of bulimia nervosa, no additional therapy may be needed. If indicated, you can always add it later and you may avoid spending money on unnecessary services and treatment. Sometimes patients may benefit from specific adjunctive therapies.

What About Residential Treatment Instead of Family-Based Treatment?

We believe higher levels of care, including residential and partial hospitalization programs, have their place. Sometimes, parents cannot make enough headway against the eating disorder, or the child has extreme reactions to relinquishing control to parents, or parents just get worn out and need a break. There is no shame in sending your child to a higher level of care if needed. Parents assume a vital role after the child returns home. We can provide referrals to various treatment programs as needed.

How Do I Know The Treatment My Child is Receiving is Really FBT?

Sometimes providers who provide aspects of FBT say they provide FBT, but it’s not true FBT. Read how to distinguish FBT from FBT-informed therapy.

Can You Provide FBT by Teleconference?

Yes! Providers in our practice hold licenses in the states of California, Indiana, Florida, New York, and South Carolina. For families that cannot travel to our office but reside in one of those states, we can provide FBT by teleconference. In the face of the COVID-19 pandemic, we increased our telehealth capabilities. Research shows that FBT can be successfully delivered over video.

Find an FBT Therapist outside of California, Indiana, Florida, New York, and South Carolina

We cannot provide services for patients outside these five states. If we are not in your area and you are looking for an FBT therapist, the Training Institute for Child and Adolescent Eating Disorders trains therapists in this treatment and maintains a list of certified therapists and therapists in training.

Can We Use Insurance for FBT?

We are proud to be one of 3 US-certified FBT clinicians who accept Medicaid and part of the one-third of certified FBT providers who accept any insurance. Check our fees and insurance page to see which insurances we can bill directly.

Get Help Implementing FBT through our FBT Parent Support Group

To learn more about FBT and/or implementing these strategies to support a loved one, we encourage you to register for our FBT Parent Support group open to caregivers in any location. This group is led by FBT expert Dr. Muhlheim and postdoctoral fellow and FBT researcher Carly Poynter. This group meets monthly over Zoom and the cost is only $40 per session. Ask your FBT questions, get answers, and receive support.

Learn More About Family-Based Treatment

Check out our other pages to learn more about how to navigate some specific situations in the course of FBT:

Begin Family-Based Treatment in California

You do not have to continue to struggle to help your teen with their eating disorder alone. Counseling can help your teen gain weight and reestablish a healthy relationship with food and body. Our Los Angeles, California practice has caring therapists who specialize in the treatment of anorexia, bulimia, and other eating disorders in teens. To start your counseling journey, follow these simple steps:

Contact Eating Disorder Therapy LA
Complete our google form and we will match you to an FBT therapist
Start your teen on the path to full recovery.

Other Counseling Services at Eating Disorder Therapy LA

At Eating Disorder Therapy LA, we specialize in evidence-based treatments for all eating disorders and related issues. We provide therapy for Anorexia Nervosa, Atypical Anorexia, Bulimia Nervosa, Avoidant/Restrictive Food Intake Disorder, and Body Image.