Family-Based Treatment (FBT) for Eating Disorders

Family-based treatment (FBT, also sometimes referred to as the Maudsley method) is a leading treatment for adolescent eating disorders including anorexia nervosa, bulimia nervosa, and other specified feeding or eating disorder (OSFED).

It is a manualized treatment delivered by trained professionals. It is primarily delivered in outpatient settings, although there are some residential and partial hospitalization (PHP) programs that incorporate FBT.

It should therefore usually be considered as a first-line approach to treatment for children, adolescents, and some young adults with eating disorders.

Alternative Approach

FBT represents a radical departure from more traditional treatments. Older theories about anorexia and eating disorders, advanced by Hilde Bruch and others, ascribed their onset to family enmeshment or other dysfunction within the family. Mothers were believed to be the primary cause of the eating disorders of their children, as they were in the case of schizophrenia and autism.

The typical treatment instructed parents to step aside and turn their children with anorexia over to individual treatment or residential treatment centers—an approach we now know to have been, in many cases, detrimental to both the families and the patients.

Genetic studies indicate that approximately 50% to 80% of a person's risk of an eating disorder is due to genetic factors.

Research

The literature has rediscovered older starvation studies demonstrating that a number of characteristic behaviors of anorexia are actually the result of malnutrition that accompanies anorexia.

It is also believed that many clinicians made a basic selection bias error: observing the dynamics of families as they were seeking treatment, clinicians naturally saw families locked in a life-and-death struggle over food. This struggle is, however, a symptom of the disorder, not a cause—in the years preceding the eating disorder, their dynamics likely looked no different than other families.

Acknowledging that the weight of evidence had shifted, in 2010, the Academy for Eating Disorders published a position paper specifically refuting the idea that family factors are a primary mechanism in the development of an eating disorder. This is a positive shift because it has resulted in the greater inclusion of parents in treatment in general and greater acceptance of and demand for FBT.

FBT vs. Family Therapy

FBT should not be confused with the similarly-named but potentially fundamentally different approaches under the umbrella of family therapy. Traditional family therapy often takes the view that the child with an eating disorder is expressing a family problem.

It focuses on identifying and solving that problem in order to cure the eating disorder. This approach has not been supported by research and is challenged by the AED position paper.

In the 1970s and early 1980s, the clinicians at the Maudsley Hospital in London, England, conceived a very different form of family therapy, treating parents as a resource, not a source of harm. The Maudsley team has continued to develop and teach the approach, which they do not refer to as the Maudsley approach, but as anorexia-focused family therapy.

Meanwhile Drs. Daniel Le Grange and James Lock further developed the model in a manual (published in 2002 and updated in 2013), naming their manualized version Family-Based Treatment (FBT).

The FBT approach is rooted in aspects of behavioral therapy, narrative therapy, and structural family therapy. Lock and Le Grange have established the Training Institute for Child and Adolescent Eating Disorders, an organization that trains therapists in this treatment and maintains a list of certified therapists and therapists in training.

Principles of FBT

FBT takes an agnostic view of the eating disorder, meaning therapists do not try to analyze why the eating disorder developed. FBT does not blame families for the disorder. On the contrary, it presumes the powerful bond between parents and children and empowers the parents to use their love to help their child.

In FBT, the eating disorder is viewed as an external force that is possessing the child. Parents are asked to join with the healthy part of the child against the eating disorder which is threatening to take their child away. Full nutrition is viewed as a critical first step in recovery; the role of parents is to provide this nutrition by actively feeding their child.

FBT sessions usually involve the entire family and include at least one family meal in the therapist’s office. This gives the therapist an opportunity to observe the behaviors of different family members during a meal and to coach the parents to help their child eat.

Because patients with eating disorders may present with medical complications, they should be monitored by a physician during the course of treatment.

Three Phases of FBT

FBT has three phases:

• Phase 1: Full parental control. Parents are usually in complete charge of meals as they help their child to reestablish regular patterns of eating and interrupt problematic eating disorder behaviors such as bingeing, purging, and overexercise. If weight gain is indicated, the goal is 1 to 2 pounds per week. The therapist works to empower the parents to take on these tasks and helps the parents learn to manage the child at mealtimes. 
• Phase 2: A gradual return of control to the adolescent. This phase typically begins once weight is mostly restored, when meals are going more smoothly, and when behaviors are more under control. Control is gradually handed back to the adolescent in an age-appropriate manner: for example, the child may start to have some meals or snacks away from the parent. There can be backsliding and parents may have to reassert control from time to time until the adolescent is fully ready; this is part of the process.
• Phase 3: Establishing healthy independence. When the adolescent is able to eat with an age-appropriate level of independence and does not exhibit eating disorder behaviors, the focus of treatment shifts to helping them develop a healthy identity and catch up on other developmental issues. Other comorbid problems may be addressed. The family is helped to reorganize now that the child is healthier.

Advantages of FBT

Brain starvation can cause anosognosia, a lack of awareness that one is ill. As a result, there can be a long time lag before the minds of adolescents in recovery are capable of the motivation or insight to maintain their own recovery.

FBT assigns the work of behavioral change and full nutrition to the parents and gives them skills and coaching to meet these goals. As a result, it helps the child to recover even before they have the capacity to do so on their own.

Because it tends to work faster than other treatments, FBT reduces medical repercussions and increases the chances of a complete recovery. It allows the child to remain at home with their parents and is often more cost-effective than residential treatment.

Research on FBT

Research has shown that adolescents who receive FBT recover at higher rates than adolescents who receive individual therapy:

• A study out of the University of Chicago and Stanford shows that at the end of a course of FBT, two-thirds of adolescents with anorexia nervosa have recovered; 75 percent to 90 percent are weight-recovered at a five-year follow-up.
• A recent study compared FBT for bulimia nervosa with CBT for bulimia nervosa. The findings indicated that FBT led to faster and sustained abstinence rates for teens.
• Preliminary research and case studies also indicate that FBT is an acceptable approach for young adults.

FBT appears to be most effective for families in which the length of illness is less than three years. An early positive response to the treatment (commonly by week four) is prognostic of a long-term successful outcome.

FBT Is Not for Every Family 

Parents often believe that FBT will not work for them. “My child is too old.” “My child is too independent.” “I’m not strong enough.” “We are too busy.” Yet none of these issues have shown to necessarily be a barrier for a successful FBT treatment execution. Research and clinical experience demonstrate that many diverse families are able to successfully implement FBT.

However, it is not for every family. It is rigorous and requires a strong commitment by the family members. It is not recommended for families in which the parents are physically or sexually abusive or are abusing substances.

For families where parents tend to be critical, a variation of FBT, called separated FBT, can be a great option. In this approach, the therapist meets only with the parents while the child's weight is monitored by medical personnel.

A Word From Verywell

The above exceptions represent only a minority of cases. Families who have used this approach are generally very enthusiastic and grateful to have been a part of the solution. Helping to play an active role in your child's recovery can be a very rewarding experience.