A Guide to Family Based Treatment for Eating Disorders

Family-Based Treatment, also known as “FBT” or the “Maudsley Method,” is widely recognized as the preeminent evidence-based therapy for anorexia nervosa in children and adolescents. FBT is also considered a primary treatment for young individuals with bulimia nervosa. 

At the heart of FBT lies parent* empowerment, where parents or primary caregivers are equipped with skills, techniques, and confidence to aid their child in normalizing food intake and achieving a healthy weight. 

One of the notable benefits of FBT is that it allows children, teens, and young adults to receive treatment at home, thereby averting the significant disruption of hospitalization, even in severe cases of eating disorders.

If you’ve heard of Family Based Treatment and want to learn more, or are simply trying to find the best recovery option for your child, this guide is just what you need.

*Of note, in this piece, the terms "parent" or "parents" can refer to any dedicated adult(s) who live with the child.  Similarly, when we refer to "child" or "teen," you can also think of young adults, as FBT is appropriate for young adults who have caregivers available and ready to support their recovery process.

How Does FBT Work?

Family Based Treatment is unique in both the approach and framework. Not only does it take place at home, but it puts parents at the center of the treatment process. Let’s get into exactly how FBT works for eating disorder treatment.

Getting Started

FBT begins with a comprehensive assessment. For young individuals grappling with eating disorders, involving caregivers in the assessment process is essential. Parent insights and concerns contribute significantly to understanding the full extent of their child's condition. 

The outcome of the assessment shapes the treatment plan. 

Parents are made aware of the full spectrum of available treatments for their child and gain sufficient knowledge about FBT from the outset to feel confident in making the decision to actively pursue FBT as their treatment of choice.

FBT requires that young patients are medically cleared and then followed closely by a qualified family doctor or pediatrician. FBT is an appropriate intervention, even for severe cases of eating disorders, if the child is medically stable and appropriately monitored for any physical complications.

The Structure of FBT

FBT stands out for its remarkable efficiency because it empowers parents swiftly with the tools to support their child’s recovery right at home. This empowerment significantly reduces the need for excessive therapy appointments and constant guidance from providers. 

A central goal of FBT is to reduce parental dependence on providers and increase their sense of confidence in feeding their child – independently.  After all, your family therapist won’t be there at the dinner table with your child every night!

In the beginning, FBT typically involves one 60-minute session per week. Yes, that’s it… just one session per week. This is typicallly enough to get parents trained up to implement feeding at home. As treatment progresses, these meetings may become bi-weekly and flow as such:

• Start with individual check-ins with the patient.

• Followed by separate meetings with parents.

• Then everyone coming together for the remainder of the session. 

In certain cases, parents may meet independently with the provider while the child or teen attends sessions less frequently. This approach, known as Parent-Focused FBT, has proven to be just as effective as traditional FBT.

While one session per week may seem like very little, the sessions are dense and instructive, so parents usually find that they are ready to jump in right away.  The therapist is usually available for some parent coaching between sessions if the need arises.

FBT offers a valid—and usually preferablea—alternative to residential or partial hospital treatment.  In FBT, the child stays at home with family members and engaged in meaningful activities like school and socializing, as long as meals can be consistent, hearty and supervised by a trusted adult.  

FBT is not only efficient in terms of time and finances but also ensures that the most impactful work happens in the familiar environment of home. Every meal and snack become an essential part of the therapeutic journey. 

Typically spanning 6-12 months, FBT embraces families in a journey of healing and growth.

Overview of FBT

The strongest predictor of long-term recovery from anorexia nervosa is achieving full weight restoration. Bringing the body back to its optimal physical state and fostering a healthy growth trajectory are crucial for achieving stability and overcoming disordered thoughts and behaviors in the long run. 

Once the body and brain are functioning at their best, FBT transitions to supporting a gradual return to age-appropriate independence.

Given the importance of renourishment and weight gain for physical, emotional and behavioral recovery, the very first phase of FBT focuses intensely on feeding strategies to get the patient renourished as swiftly as possible.  

In Phase 2, the emphasis shifts to maintaining progress while the patient gradually assumes more responsibility for self-care and nourishment. Throughout the FBT process, there is careful assessment of factors that maintain the eating disorder. This structured approach also allows for addressing co-existing concerns such as anxiety, depression, and OCD.

Ultimately, the goal of FBT is for the patient to achieve freedom from disordered thoughts and behaviors and to thrive independently. 

Let’s break this all down into the core principles that dictate Family Based Treatment.

Food Is Medicine: Nourishment First

When someone is malnourished, underweight, or struggling with erratic eating patterns, the first priority is restoring health through nourishment. FBT recognizes that without addressing the physical aspects of starvation, effective psychotherapy is on hold. Therefore, FBT starts with a laser focus on establishing a clear path to re-nourishment. 

As the body stabilizes and the brain moves out of survival mode, attention can then shift to addressing underlying factors that may have contributed to the onset and maintenance of the eating disorder. 

The transitional phase after weight restoration has been achieved, allows for a more thorough assessment of individual therapy needs, such as targeted treatment for anxiety or OCD, ensuring comprehensive support for full recovery from the eating disorder and other co-occurring conditions.

Parents Drive Recovery

FBT places a strong emphasis on empowering parents, helping them build the skills and confidence needed to effectively support their child's recovery. Parents play a pivotal role in nearly every FBT session. 

Confidence is key for parents to navigate the challenging task of ensuring that their child receives the necessary nutrition (and keeps it down when there is purging behavior). When parents are equipped and confident, they can stand firm in the face of resistance from the eating disorder and maintain their resolve in difficult situations without doubting themselves.  

Common question: Do I Force Feed?

Believe it or not, there are effective—and humane!—strategies for getting your child to eat; there is absolutely no “force feeding.” We shape parents to show consistency and resolve in the face of the eating disorder. There are no negotiations (after all, you should never negotiate with a terrorist, right? And the ED is the terrorist in your family right now).  

There is just firm, loving, calm, insistence from parents. It’s powerful. And remember, you’re just asking your child to feed their starving body. It’s completely reasonable and comes from a place of great care and concern for their well-being.

Parents Are the Experts – Not the Therapist

In FBT, the therapist is the eating disorder expert at the start, while the parents are seen as the foremost experts in their child but soon enough, parents master a broad scope of their child’s recovery needs. 

Therapists play an active role in guiding families, offering strategies, education, and support for problem-solving, but they do not dictate actions to parents. Instead, in FBT, parents are recognized as the most knowledgeable and attuned guides in their child’s life and the primary agents of change within their child's recovery journey.

This approach fosters a collaborative and empowering environment where parents take a lead role in their child's treatment and progress.

Separating the Child from the Illness

In FBT, it's important to separate the illness from the person. Anorexia and bulimia profoundly impact emotions, thoughts, and behaviors. FBT focuses on combating the illness itself, rather than attributing behaviors like refusal to eat to willfulness or stubbornness in the child. 

Instead, we recognize these behaviors as manifestations of the eating disorder exerting strong control over the child. Our objective is to address the disorder while supporting the child and alleviating them of this burden.

Agnostic Viewpoint

In FBT, our focus is on swiftly addressing and correcting the eating issues without delaying over the search for underlying causes of the illness. While we acknowledge that personal history and vulnerabilities are significant, our priority is to ensure prompt nourishment, which is crucial for both physical and emotional health and healing.  

For this reason, FBT stays present-focused throughout the weight restoration phase of the treatment.

Practical Methods

FBT is a hands-on, behaviorally oriented method that prioritizes practical strategies. It focuses on the specifics of implementation: what to serve, how much, when to serve it, and how to handle resistance from children and teens. 

Parents are coached to develop expertise in managing the eating disorder and supporting their child's sustained recovery over time.

Moving Swiftly

Eating disorders are serious, sometimes even life-threatening conditions, underscoring the need for swift and effective intervention. Given their severity, wasting time is not an option. In FBT, we act urgently to ensure prompt nourishment and foster a path back to health. 

Even as the situation stabilizes, FBT providers maintain a vigilant approach because we understand that eating disorders can re-emerge unexpectedly if our diligence wanes.

Moving Through the Stages of family based treatment

Family Based Treatment works in three phases, each one moving the child progressively through treatment. Each phase builds upon itself, ensuring that the child is ready for what’s next.

Phase 1

During the first phase of FBT, parents assume full responsibility for all food-related decisions for their child. This includes ensuring adequate nutrition for weight restoration in cases of anorexia  or eliminating binge eating and purging behaviors via increased monitoring in cases of bulimia. 

Parents maintain this supportive role until the eating disorder no longer exerts significant influence over the child's thoughts and behaviors related to food. This phase emphasizes parental guidance and supervision as crucial elements in the recovery process.

Phase 2

After achieving weight restoration and ceasing eating disorder behaviors such as restricting, binge-eating, and purging, the responsibility for age-appropriate food choices, preparation, and portioning is gradually transitioned back to the child or adolescent. Phase 2 involves continuous monitoring to ensure the child can independently nourish themselves while maintaining a healthy weight and other positive health behaviors. This phase focuses on empowering the child to take on more autonomy in their eating habits while providing ongoing support and guidance as needed.

Phase 3

The priority now is to ensure that the child or teen resumes their developmental progress after the disruption caused by the eating disorder. This phase is dedicated to discussing strategies for preventing relapse and addressing any lingering co-existing conditions, such as anxiety or depression, which still require attention.

FAQ’s About Family based treatment

We get a lot of of the same questions at Columbus Park about Family Based Treatment. I want to take some time to answer them for you here in case they’re helpful for you too. 

How does the effectiveness of FBT compare to that of other treatments?

When evaluating effectiveness, FBT stands out as the preferred treatment for young individuals with anorexia nervosa and is thus typically recommended as a first line intervention.  

While research on FBT for bulimia nervosa is more limited, current studies indicate that FBT yields superior results compared to individual therapy at the 6-month follow-up stage. 

In children and adolescents, FBT has shown greater effectiveness than individual therapy in the 6- to 12-month period after treatment. Studies indicate that 50 to 70% of patients achieve recovery with Family-Based Treatment.

How can I decide if FBT is the right choice for our family?

FBT is generally suitable for the majority of children and teens affected by anorexia, bulimia and avoidant-restrictive food intake disorder (binge eating disorder is typically managed with a different therapeutic approach).  FBT requires that the child or teen be medically stable and living with parents or caregivers who can actively engage in the treatment process. At least one caregiver must be available to attend sessions and oversee all meals and snacks, either independently or with support from trusted individuals (family members, teachers, advisors etc) who can assist when necessary.

My child/teen is very determined and independent-minded. Can I really get them to eat?

Absolutely, you can. Who better than you, with your deep love and commitment to your child, to take on this important role? Rest assured, FBT gives you the skills needed to be effective. 

There is a clear method. FBT therapists support parents in guiding their child's behavior and setting up natural rewards and consequences tied to meeting nutritional goals.

It can help parents to think of it this way: If your child had a medical condition requiring chemotherapy multiple times a day, wouldn’t you make sure they received every treatment, even if they resisted because of the side effects?

We encourage parents to approach mealtime with this same determination and urgency; eating is essential for health and recovery.

Can FBT work if parents are divorced or if you're a single parent?

Yes, FBT can absolutely work with parents who are divorced, separated or single.  For divorced or separated parents, attending sessions together can help present a unified approach to support the child or teen. 

We strive to maintain consistency between households, especially in cases of shared custody. Single parents can also effectively participate in FBT. We'll collaborate to address any challenges, ensuring there are additional resources available for both emotional support and practical assistance as needed.

Common Concerns About FBT

As an approach that’s new for many parents, it’s normal to have concerns. Here are some of the most common concerns we hear from parents about Family Based Treatment and how it works.

If my child/teen starts gaining weight, they might become very anxious and stop eating altogether.

It's understandable to have this concern, but this situation rarely occurs. In fact, weight restoration, when necessary, significantly improves the patient's physical and emotional well-being and actually reduces anxiety and preoccupation with one’s body weight. Further, as the child gets renourished, they become progressively more receptive to feeding. They start to feel better and this makes the work much easier.  

As the body replenishes and stabilizes with proper nutrition and energy reserves, distorted thinking gradually diminishes; the most significant eating disorder thought patterns begin to slip away. While weight gain can be daunting for someone with an eating disorder, parents play a crucial role in maintaining consistency and emphasizing the importance of restoring health and full functionality to the body. 

I'm worried that taking on so much control could strain my relationship with my child or teen.

FBT fosters stronger family bonds. It emphasizes honesty, encourages tackling difficult conversations, and promotes validation and understanding. Parents often find that their child is at least on some level, grateful to be relieved from the overwhelming responsibility of feeding themselves. 

This type of treatment encourages parents to approach their child with warmth, validation, and determination. There are no secrets and no tiptoeing anymore; instead, we involve the child in the collaborative effort to restore their health. 

We're not asking anything unfair of the child or teen; we're insisting that they eat because their lives depend on it.

I was advised not to interfere with my teen's eating; they need to maintain a sense of control.

While supporting age-appropriate independence and separation in other aspects of your child's life is important, when it comes to food and eating, your child has shown they are struggling to manage on their own. They require assistance in this area until they regain the ability to make responsible choices for their health.

Eating disorders involve a loss of control over one's health-related behaviors, and the consequences can be severe.

Hope At Home 

Family-Based Treatment emerges as a beacon of hope for families grappling with eating disorders in their young members. By empowering parents and caregivers to play a central role in their child's healing journey, FBT not only addresses immediate nutritional needs but also fosters stronger family bonds and resilience. 

Among the many benefits, admission to hospitals and residential programs is averted.  As we advocate for early intervention and comprehensive support, this treatment options remains a pivotal strategy in guiding young individuals toward sustained recovery and a healthier future ahead.

Schedule a free consultation to learn more about Family-Based Treatment and whether it might be the right intervention for your family. Columbus Park is passionate about our work with children, teens, and their families and we offer adherent Family Based Treatment.

Resources for Families

• A dense and powerful article about the importance of weight gain in anorexia recovery.  The article also provides expert guidance around setting target weights for recovery: Weight Restoration: Why and How Much Weight Gain?

• Here is a video of Q&A’s with expert, Dr. Cynthia Bulik. Dr Bulik talks about the Genome-Wide Association Study.

• Emily Boring, writer, scientist, Yale Graduate and anorexia survivor, wrote a powerful piece: “When in Doubt, Aim Higher: What I Wish I’d Known About Target Weights in Recovery”

• Jenni Schaefer is an advocate, author, coach, speaker and anorexia survivor. Here is her best-selling book called Life Without Ed: How one woman declared independence from her eating disorder and how you can too. 

• A family’s battle with anorexia: Brave Girl Eating, by Harriet Brown.