Misconceptions About Family-Based Treatment (FBT)

When Maris Degener stepped down from inpatient treatment for her eating disorder, her care team recommended family-based treatment (FBT). After learning that her parents would be in charge of what she and when she ate—as well as making sure she completed her meals, and, if she didn't, having her drink a nutritional shake—she was scared. “It felt really overwhelming,” she says. “The last thing any teen wants is for their parents to be up in their business for any reason. I didn't understand why my parents needed to be so involved—shouldn't this be my decision?”

Once she began FBT, Degener, now Equip’s Director of Peer Mentorship, made progress toward recovery—and also took steps back. This dance continued for some time, but Degener and her parents committed to the process and, like many others, discovered that it works. Still, many patients and families are resistant to FBT, uncertain of what exactly it entails, who it works for, and whether or not they can handle it. Read on to learn more about FBT, the truth behind common FBT myths and misconceptions, and how to find FBT-trained providers for your loved one.

What is FBT?

FBT stands for family-based treatment, and, as the name suggests, families are key to the process. Based on the Maudsley Method, which was developed at the Maudsley Hospital in London, FBT empowers families to play a central role in their loved one’s recovery. A key premise of FBT is the belief that healthy family members are the ones best equipped to help young people recover from eating disorders, and this allows medically stable patients to recover at home, rather than being sent away from their life and loved ones for treatment.

Unlike other eating disorder treatment approaches, FBT doesn't focus on the causes of the eating disorder. Instead, the initial goal is renourishment, and weight restoration if necessary. This is essential, because an undernourished brain has a hard time thinking clearly and rationally, and malnourishment perpetuates psychological symptoms like rigid or obsessive thoughts about food, depression, and anxiety. During the renourishment phase, parents or other family members make decisions about their loved one’s food and eating, ensuring the patient eats regularly, consumes enough food, and avoids disordered behaviors, like purging or otherwise “compensating” for food eaten.

During the second phase of FBT, once a patient has been renourished, gained adequate weight (if needed), and shows few or no eating disorder behaviors, they gradually regain independence and control over their eating. Then, during the third and final phase of FBT, the treatment team helps the patient and family develop skills to prevent relapse and build a full life, free of the eating disorder.

Why FBT is the gold standard for treating eating disorders in young people

FBT is the gold standard for treating eating disorders in children, adolescents, and young adults because it has more empirical evidence than other treatment approaches, says Renee D. Rienecke, PhD, FAED, Director of Research at Galen Hope. She adds that when compared head-to-head with other treatment approaches for this age group, FBT proves to be much more effective.

“Eating disorders compromise a young person's judgment, internal motivation, and ability to self-regulate, plus the adolescent brain is continuing to develop. All of this means that process therapies alone are largely ineffective for this age group,” explains Melodie Simmons, DHA, LPC, CEDS-C, clinical instructor at Equip. “FBT prioritizes restoring health in a way that honors both the urgency of the illness and the family's critical role in recovery.”

Various studies show that for patients diagnosed with anorexia, FBT is more likely to lead to full remission after six and 12 months and leads to significantly faster weight gain, compared to other types of treatment. And for patients diagnosed with bulimia, FBT leads to significantly higher rates of abstinence from binge eating and purging episodes compared to other treatment approaches.

All of this evidence is why FBT is the front-line choice for practice guidelines in the U.S., U.K., Canada, Australia, and New Zealand, Rienecke says. “We want to try to do FBT for as many families as we can,” she adds.

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Common myths and misconceptions about FBT

Even though the evidence clearly points to FBT as the best, first-line approach for treating eating disorders in young people, many families are still resistant or hesitant when it comes to trying it. Part of that is due to various myths and misconceptions about this approach—let’s break them down.

Myth 1: FBT is only for certain types of families

Despite what you may have heard, you don't need to be a “perfect”, functional family for FBT to help your loved one. “I've been doing FBT for more than 20 years, and I've seen hundreds and hundreds of families,” Rienecke says. “There isn't any evidence to show that you have to be a certain type of family to benefit from FBT.” In fact, she co-authored a study that found that single-parent and two-parent families do just as well with FBT, and Equip’s own independent research shows that demographic factors (like socioeconomic status or family configuration) have no effect on FBT success.

Other research also found no difference in treatment efficacy between single- and two-parent households and homes with different household income.

“FBT fits with so many families, and part of the reason is that so many treatment decisions are left to the family, because they're the expert on their family,” Rienecke explains. “The therapist isn't saying, 'This is what you do’ in every case. Instead, they work with the family to figure out what is going to work best for them. It's flexible in that regard and can be helpful for a lot of different types of families.”

Myth 2: FBT is only for certain types of patients

FBT can help any young person struggling with any eating disorder.

FBT was initially developed to treat anorexia, so that’s where most of the research focuses. However, there's strong evidence that it helps treat bulimia, and it shows promising outcomes for binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), and other specified feeding and eating disorders (OSFED).

About 90 percent of participants in most FBT studies are cisgender girls. While more research on other populations is needed, so far trials show FBT works for every gender identity. Two small studies found that it helps cisgender boys and transgender, gender expansive, and gender minority youth reduce eating disorder symptoms at similar rates.

Myth 3: FBT takes away the patient’s autonomy

This is the most common misconception that Rienecke hears. “FBT takes control away from the eating disorder,” she clarifies. “If a child needs treatment for an eating disorder, they're probably no longer in control of their eating—the eating disorder is in control. FBT takes control from the eating disorder and temporarily gives it to parents until the child is strong enough to take that control back.”

Myth 4: FBT only focuses on food, not the underlying psychological issues

FBT does start off heavily focused on weight restoration, because the brain needs nourishment in order to work properly. “We know from the Minnesota starvation experiment that weight restoration fixes a lot of psychological symptoms,” Rienecke says. “You need to be physically healthy before you can be psychologically, mentally, and emotionally healthy. Get the mind and body nourished, and all these things fall into place—anything the eating disorder brought on tends to resolve.”

Research shows that weight gain improves depressive symptoms, eating restraint, eating concerns, and overall eating disorder symptoms. Improvement is greatest during the earliest phases of weight restoration, a phenomenon that Degener experienced firsthand. “Weight restoration brought me out of complete fight-or-flight mode,” she says. “It turned down the volume on the urgency of everything and gave me space to do the hard inner work I needed to do.”

Myth 5: FBT will ruin my relationship with my child

“This is a common concern,” Rienecke acknowledges. “But I have never once seen a kid stay angry at their parents. Once the eating disorder starts to recede and the kid comes back online, everyone realizes the eating disorder was mad at the parents—and the kid realizes their parent or parents did what they did out of love to help them get better.”

That doesn’t mean that there won’t be tension and pushback along the way—there almost certainly will be. That’s because in order for a person to recover, the eating disorder has to be challenged; so if you’re effective in treatment, the eating disorder won’t be happy. And at first, your kid won’t be either. “Kids generally don't like FBT. It's not fun,” Rienecke says.

But stick with it, and this will change. In fact, Simmons says she has seen many families report stronger, more trusting relationships after working through the recovery process together.

When Degener started FBT, things initially felt harder than when she was in inpatient treatment. “My parents and I had screaming matches and explosive fights,” she says. “There were a lot of moments of 'What are we doing here?' I was frustrated because I felt like I was taking tiny baby steps.” But with consistency and time, things got better, and she went on to recover. Today, she realizes all of the conflict she and her parents went through was her eating disorder trying to maintain control.

Myth 6: We won’t have time for anything else if we do FBT

It’s true that FBT can be a lot of work. You need to attend therapy and dietitian sessions, and put in the time at home to plan and cook meals to meet your child's nutritional needs. And then there's the emotional work of supporting your child, helping them through eating challenges, pushing them when necessary, and facing their resistance.

First, know that if you are in the throes of FBT, you're doing an amazing job. You determined that your child needed help, and you got it for them. Second, remind yourself that even though FBT takes up a lot of time now, dealing with an eating disorder for years, decades, or even a lifetime takes up much more time. “Eating disorders are already all-consuming of a family's time, energy, and peace. FBT provides a roadmap to reclaim your life and have that balance again,” Simmons says.

If FBT ever gets to feel too overwhelming, talk to your child’s treatment team. They can help you find other sources of support, whether that means a therapist for you, support groups, or getting help from other people in your life, like grandparents or neighbors who can step in to take care of other responsibilities, like watching siblings or running errands. If you’re in treatment at Equip, there are many support groups for parents going through FBT, and your treatment team includes a family mentor who has lived experience helping their child recover from an eating disorder. Both of these resources can provide you with actionable tips and strategies, as well as much-needed empathy.

And if you haven't yet started FBT because you're concerned about the commitment it takes, consider this: “What would you be willing to do if your child had cancer?” Rienecke asks. “Anorexia is a deadly illness, with the second-highest mortality rate of any mental illness. If you were willing to do whatever it took for your child to get better from cancer, this shouldn't be any different.”

Myth 7: Shouldn’t experts be in charge of this?

The experts are in charge, Rienecke says—you, the parents, are the experts. “A therapist doesn't know all of the family's likes, dislikes, routines, habits, preferences, and cultural, ethnic, and religious practices that impact eating habits. The family knows that,” she explains. “The therapist guides and encourages the parents to figure out what is best for their family. What they come up with is better than the therapist could tell them to do because they know their kid best.”

Additionally, you’ll work with an eating disorder-informed dietitian, who will help you develop meal plans that work with your family’s unique habits, preferences, and lifestyle, and will also provide you with skills and tips for getting through tough eating moments.

Are there evidence-based alternatives to FBT?

FBT is the first-line, gold standard eating disorder treatment for young people. But if for whatever reason FBT is not working for a young person, there are other evidence-based treatment approaches that can work in this age group (note that all of the approaches below can also work in conjunction with FBT). These include:

Enhanced cognitive behavioral therapy for eating disorders (CBT-E): Also known as cognitive behavioral therapy for eating disorders, CBT-E is the gold standard treatment for adults diagnosed with anorexia, bulimia, binge eating disorder, and other specified feeding or eating disorders (OSFED). However, CBT-E is less proven to help children and young adults. Structured around four phases, CBT-E operates on the principle that our thoughts, feelings, and behaviors are interconnected, and modifying any one of these will trigger a change in the others.
Dialectical behavior therapy (DBT): This form of talk therapy aims to help people cope with challenging emotions in a healthy way. Rather than turning to disordered behaviors, the patient learns other coping skills. DBT has the most evidence for helping adults with binge eating disorder.
Exposure and response prevention (ERP): A type of CBT, ERP helps patients gradually confront and learn to overcome their fears. In the case of eating disorders, this may mean fears of specific foods, food-related situations, weight gain, exercise, or social events. There aren't a lot of studies on ERP for eating disorders, but the evidence we have suggests it can be effective.

How to get started with FBT

Even though families play a central role in FBT, it’s generally not something that you’ll want to do entirely on your own—the support and guidance of a multidisciplinary treatment team is almost always crucial. This team should include at the very least a therapist and dietitian, but may also include other team members, like a medical provider or psychiatrist.

You can find an FBT therapist by searching the list from the Training Institute for Child and Adolescent Eating Disorders or the Academy for Eating Disorders directory. You’ll also want to work with a PCP who understands eating disorders so they can monitor and manage any physical symptoms. If your child's pediatrician isn't well-educated in eating disorders, ask your FBT therapist if they know anyone in your area. An eating disorder-informed dietitian can help with creating meal plans that support weight restoration; your therapist may also be a good resource for finding a dietitian. Lastly, some patients benefit from teaming with a psychiatrist, who can prescribe medication for underlying mental health conditions, like anxiety and depression, which often co-occur with eating disorders.

At Equip, patients have access to a therapist, dietitian, medical provider (which may include a psychiatrist), and mentors for both the patient and the parents. This multidisciplinary team works collaboratively with one another, so caregivers don’t have to worry about communicating and coordinating among different providers.

Although it takes effort and time, with the right care team, FBT can be the key to a richer, fuller life for both the patient and their family members. “FBT is harder and messier than anyone can imagine,” Degener says. “But my parents saved my life. They intervened when I wasn't in a position to do that work on my own, and I'm forever grateful for that.”

To learn more about FBT treatment at Equip, schedule a free consultation.