Contributed by Abby Sarrett-Cooper, LPC, CEDS
FBT is an evidence-based treatment for adolescent eating disorders that places parents and caregivers at the center of the treatment. The FBT therapist is an expert consultant to parents, bringing parents into the treatment team that includes a physician and sometimes a psychiatrist. The FBT therapist is NOT the individual therapist to the person with the eating disorder, and the team is not waiting for or working toward “buy in” from that young person. Instead FBT focuses on bringing the effective interventions used in higher level of care settings into the home where parents use the love, care and knowledge of their unique child to shape these interventions for their family. The result is an individualized, effective treatment that eliminates the added trauma of family separations while focusing on refeeding, nutritional restoration, behavioral management, return to typical child/youth development and family functioning.
There are several core principles of Family Based Treatment. Foremost is the agnostic assumption of the cause of the eating disorder that removes blame and shame from parents. Further, the presumption is that parents are competent agents of change. This respects the unique strengths and challenges of each family where all members are viewed as resources. This focus on what makes each family unique individualizes treatment while simultaneously being a core principle that applies to every family. Finally, FBT respects the adolescent’s need for autonomy outside of eating disorder behaviors, based on age and developmental readiness.
It is important to be aware that treatment guidelines for children and adolescents with eating disorders strongly recommend that treatment should be offered at the least intensive level of treatment feasible, especially for children/adolescents with anorexia nervosa with a duration of illness less than 3 years. In other words, it may be best to start out with outpatient treatment if possible, and increase gradually to higher levels of care if and when needed.
In FBT, treatment moves through stages or “phases”. In Phase I, the FBT therapist helps the caregivers separate the illness from the person with the illness while calling attention to the dire circumstances faced by the family. In FBT there is no “anorexic” or “bulimic” There is a young person with a life-threatening illness who urgently needs to be renourished. That task begins in Phase I with a family meal where the caregivers provide a meal designed to renourish their child. The therapist observes, asks questions, provides feedback to the family on what is effective, and offers options for increasing their effectiveness. Parents are supported in trusting themselves and their knowledge of their child. During Phase I parents are fully responsible for all decisions around nutrition and activity. This includes timing of meals and snacks, quantity of food, variety of foods, any ritualized eating behaviors, and whether or how much movement is permitted. Phase I continues with weekly meetings where the young person is weighed to assess progress, provides feedback if willing, and the family details successes and challenges in managing the above tasks.
When steady weight gain toward the goal range has been established and parents are confident in their ability to manage eating disorder behaviors around meals and activity, the family is ready for Phase II. Phase II focuses on a gradual transition from total parental responsibility for nutrition and activity to co-management of these tasks with their child in a manner that suits the age and development of the child. This will, of course, look very different for a 10-year-old than for a 17-year-old. The FBT therapist will ask parents to assess what they think their child is ready to make decisions about, maybe picking a snack from a few options or plating their own dinner. For some families the process happens organically based on observations at home, meal to meal, and sometimes the process requires more didactic learning where the parent instructs and models. During Phase II weights continue to be taken at each session and sessions are reduced to every other week.
Criteria for Phase III includes achieving a stable weight within the goal range, the elimination of all disordered behaviors, full (age appropriate) responsibility for meals along with parent confidence that eating disordered disturbances will no longer occur. Phase III goals focus on reestablishing the relationship between parent(s) and child so that it is now based on increased autonomy for the young person and the adults, and where food and illness are no longer at the center of the family. This is a time to reflect on progress and highlight the strengths that brought the family together to effectively combat the eating disorder. These sessions are optimistic, while also encouraging vigilance against the return of any eating disorder related behaviors. Phase III sessions may be spaced at monthly intervals and are designed to create an opening for dialogues that will continue after treatment termination.
Our Caregiver Skills Toolkit offers great guidance for mealtimes (among other things)!
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