A brief overview of the leading treatment option for children and adolescents with eating disorders
Overview of FBT
Family-based treatment (FBT) is the leading treatment option for children and adolescents who are struggling with eating disorders. The early studies of family therapy for anorexia nervosa were done at the Maudsley Hospital in London. Studies showed promising results due to integrating parental involvement into treatment goals.
After early studies, family-based interventions were expanded upon and manualized for families who have children struggling with anorexia, bulimia, or a sub-clinical version of either of these disorders. The manualized version of FBT is broken up into 3 phases and typically takes place over a period of 6-12 months.
As one of the most successful interventions, in the early stages of treatment, FBT can be exhausting and challenging for families. The work is worth it! Treatment can be time-consuming and can cause increased emotionality for the adolescent as the eating disorder gets challenged. However, families are encouraged to keep persisting and express any concerns with their family’s treatment team to see what adjustments can be made for the process to be more sustainable.
Also, it’s important to note that FBT doesn’t fit all families. There are other interventions that also accommodate family and individual needs during such difficult times. Of note, due to the emphasis on family interventions, the treatment is best suited for younger clients, such as children and adolescents. In addition, FBT is time-consuming. In the early stages of treatment, parents are essentially available during all hours of the day, other requirements are discussed and assessed in the initial phase.
Five Tenets of FBT
Family-based treatment is a leading treatment option for children and adolescents with eating disorders who are medically stable enough to receive outpatient care. It works for clients of differing backgrounds because it involves people close to the client, allowing treatment to be tailored to meet each family’s situation. FBT can be individually tailored because the intervention centers care around five fundamental tenets:
1. The therapist holds an agnostic view regarding the cause of the eating disorder.
The FBT model of treatment doesn’t focus on exploring the cause of the eating disorder. Instead, FBT works to use the family as a resource for behavioral change. It is understood that eating disorders are complex illnesses that develop due to a myriad of genetic, sociocultural, personality/temperamental, and metabolic factors. Parents aren’t viewed as a causal factor in the eating disorder’s development, and no blame is assigned to parents or caregivers.
2. The therapist takes a non-authoritarian stance in the treatment.
In FBT, the therapist is seen as an expert on eating disorders and treatment, while the parents are seen as the experts on their child and family. The therapist actively offers psychoeducation and guidance during treatment, but the parents make the decisions about how to implement treatment.
FBT therapists must remember that there isn’t a one-size-fits-all approach to treatment. Therapists can’t possibly know all the family’s preferences, routines, habits, or the personal influence of the family’s cultural, ethnic, or religious backgrounds. The therapist must believe that their guidance is all that’s needed. Families will find their own answers, which will be more effective than anything the therapist could prescribe.
3. Parents are empowered to bring about the recovery of their child.
Empowering parents means building their sense of capability to act as agents of change in their child’s recovery process. Empowered parents can stand firm when faced with resistance from their child’s eating disorder and avoid second-guessing their instincts when faced with challenging moments. For parents to do this, they must be confident that they can effectively sit in the driver’s seat of their child’s recovery.
In FBT, therapists play a vital role in empowering parents by acknowledging their trust in the parents’ instincts and letting the parents make decisions regarding their child. The therapist’s belief in the parents helps build confidence in their decision-making skills, further strengthening their ability to guide their child’s recovery.
Check out the article Supporting Parents of Children with Eating Disorders for more resources and thoughts on this topic.
4. The eating disorder is separated and externalized from their child.
Typically, when parents are struggling with eating disorder treatment, it is because they are having trouble separating the eating disorder from their child. When parents see their child engaging in eating disorder behaviors, such as restricting their food intake, binging, purging, or overexercising, they can get emotional.
Parents may feel frustrated, fearful, worried, or angry. This is understandable. However, when anger or frustration is directed at their child, it can be unhelpful. Parents need to remember that their child is in the grip of a complex disorder that is impacting their thoughts, feelings, and behaviors and overshadowing the healthy child or adolescent underneath.
5. Both the therapist and the family take a pragmatic approach to treatment.
The fifth and final tenet of FBT keeps the family and therapist focused on the main task, which is symptom reduction. FBT is a present-focused and symptom-focused intervention with a strong behavioral approach to treatment.
Eating disorders are dangerous illnesses that affect individuals both mentally and physically and can cause long-term medical consequences. However, early intervention decreases the risk of long-term damage and prevents the eating disorder from becoming entrenched in the child’s personality, identity, and thought processes. Because time is essential in preventing the development of a chronic disorder, FBT remains laser-focused on symptom reduction, especially in the early phases of treatment.
Understanding these five tenets of family-based treatment gives clinicians and families a better understanding of the goals and beliefs that form the foundation of this treatment option. After understanding the tenets from which FBT is built, we can then go on to examine the three phases of treatment.
Three Phases of Treatment
FBT treatment is divided into three distinct phases. During treatment, a trained therapist supports the family through these phases as the adolescent meets their recovery goals. The timeline for treatment varies from family to family, depending on their child’s needs. However, a good rule of thumb is to expect treatment to last between 6-12 months. This section will briefly review each phase’s essential characteristics to understand why you should expect a longer timeline.
Phase 1
In phase 1, parents are put in the driver’s seat. Parents are given the responsibility of bringing about weight restoration with the help and aid of the therapist. The tasks are focused on for adolescents with anorexia to eliminating binge eating or even diminishing purging behaviors in the case of bulimia. Parents make all eating-related decisions and typically curtail physical activity, as well, in an effort to loosen the eating disorder’s grip on their child’s behaviors.
Many parents are apprehensive about taking control of their child’s treatment, which we understand. This can be a scary idea! But don’t worry. Therapists equip parents with an abundance of resources for how to push back against their child’s eating disorder effectively.
Phase 2
In the second phase of treatment, eating responsibilities are slowly given back to the adolescent to whatever extent is age-appropriate and typical for the family. This transition is typically done over trial periods, during which control is handed back to the adolescent, and then the attempt’s success is debriefed in family sessions.
Phase 3
Phase 3 is the final stage of FBT. During this phase, attention returns to building a healthy adolescent identity free from the eating disorder. Before a family enters this phase, the child has eliminated eating disorder behaviors, is at a stable weight, and is eating independently.
Determining if FBT is Right for Your Family
As it was briefly discussed above, FBT is not suitable for every family. In fact, Hilltop Behavioral Health will get calls from some families who have attempted FBT but were unsuccessful. This can happen. Even FBT’s tenets will say that there isn’t a one-size-fits-all approach to treatment and that different families have unique needs.
The best way to gauge if FBT is a good option for your family is to set up a free consultation call with us at Hilltop Behavioral Health. During these calls, we can get more insight into your family’s situation and offer thoughts on whether FBT would be appropriate. The therapists at Hilltop are trained in family-based treatment options and will be able to provide expert advice into whether FBT is compatible with your family.
References
Loeb KL, le Grange D. Family-Based Treatment for Adolescent Eating Disorders: Current Status, New Applications and Future Directions. Int J Child Adolesc health. 2009 Jan 1;2(2):243-254. PMID: 20191109; PMCID: PMC2828763.
Rienecke, R.D., Le Grange, D. The five tenets of family-based treatment for adolescent eating disorders. J Eat Disord 10, 60 (2022). https://doi.org/10.1186/s40337-022-00585-y
