When JD Ouellette’s daughter was first diagnosed with anorexia, it came as a shock. “But it also made all the puzzle pieces of symptoms and behaviors come together,” Ouellete, Equip’s Director of Lived Experience, says. As her daughter’s health quickly deteriorated, Ouellette and her family sprung into action—but they felt less than prepared for the journey ahead. “All of my understanding of anorexia at that point came from Lifetime TV movies, ABC Afterschool Specials, and Karen Carpenter,” Ouellette says. “So I held all the outdated beliefs about parents and trauma causing eating disorders and controlling your food because you couldn’t control anything else in your life.”
Soon, Ouellette realized that the stereotypes she’d been holding onto weren’t necessarily rooted in reality. “Our parenting, our family, our child, and our life was nothing like any of that,” she says. “We were a close, functional family of six and our daughter, until recently, had been happy, healthy, confident, and full of hopes, dreams, and plans.” But this understanding didn’t get her any closer to knowing how to help her child.
In her urgent search for support, Ouellette heard about an anorexia treatment known as family-based treatment (FBT) and decided to pursue it. “Doing FBT was experiencing and walking through pain and trauma alongside my child,” she says. “It involved feeling like I was the source of her pain because I was the one feeding her, going through my own heartbreak and grieving—and coming out the other side with a healthy daughter and a bond that was forged in steel.”
Today, Ouellette is a passionate advocate for families going through FBT, based on both her own lived experience and the evidence showing that FBT gives children, adolescents, and even young adults the best chance to fully recover. “Eating disorders are incredibly serious, life-impacting, and threatening illnesses,” she says. “FBT is a treatment model that doesn’t put the patient ‘over there’ to be fixed, but instead helps parents or caregivers and the rest of the family to understand the eating disorder, drive treatment progress, and learn how to support their loved one for the long term. FBT makes home—which is after all where life is lived—a place where recovery can be achieved and sustained.”
When confronted with the option of FBT, many parents may feel unprepared and overwhelmed, just like Ouellette was at the start of her journey. While some fear and trepidation are common parts of the process, advocates like Ouellette emphasize that FBT is an incomparable treatment option. With the right tools and preparation strategies, all families can confidently navigate FBT — here’s how.
What is FBT?
Originally known as the Maudsley Method, FBT is an eating disorder treatment approach that focuses on empowering the family to actively participate in a loved one’s recovery. FBT is considered the gold standard for eating disorder treatment in children, adolescents, and young adults, and is used to treat anorexia, bulimia, binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID) and other specified feeding or eating disorder (OSFED).
“FBT is a form of therapy for eating disorders focused on empowering the family to renourish their loved one and interrupt disordered eating behaviors,” explains Equip Therapist Lead Ana Gardner. “Eating disorders have high mortality rates and the potential for lifelong consequences; for this reason, FBT does not focus on what caused the ED, but on early and effective intervention. Time is of the essence, especially in adolescence, as we would like to stop the disorder in its tracks and minimize the chaos the eating disorder can cause in that patient's life.”
The primary objective of FBT is to give patients the opportunity to recover in their familiar home environment, with the support of their loved ones. The treatment protocol first targets eating disorder symptoms and behaviors (and weight restoration, if necessary), and then moves on to address psychological, emotional, and relational aspects later. FBT is typically split into three phases that give the patient increasing independence as they move toward recovery:
- Phase 1: Reduction of symptoms and weight restoration (when needed)
- Phase 2: Development of skills and independence
- Phase 3: Identity formation and relapse prevention
“It's important to note that the longer the eating disorder is around, the more entrenched it can become in a person's life,” Gardner says. “This is why early action is emphasized. Parental empowerment builds confidence in carers as the primary change agents of the recovery process.”
Gardner points out that an important aspect of FBT is that it distinguishes between the patient and their eating disorder, a process known as externalization. “It can be helpful to visualize the patient and the eating disorder as separate entities,” she says. “Many patients name their ED and identify it as a villain. Like a villain or alien—or any other analogy with a negative connotation—this ED is guiding the patient's thoughts, feelings, and behaviors. Externalizing the eating disorder is critical for reducing shame and blame, and gearing up the carers to band together to push out the ED.”
Why can FBT be so hard?
Because families are the core of FBT, they bear the responsibility for most of the real work of recovery. And while FBT is typically done with the support of trained professionals and follows a specific, structured protocol, this work can still be incredibly challenging—especially in the beginning. “As a parent, doing FBT can feel like counterintuitive parenting,” Ouellette says. “I tell other parents that an eating disorder and FBT require you to be the parent your child needs versus the parent you are comfortable being. Initially, most of us feel terrified and ill-equipped, we’re sometimes in shock, and it feels like we’re being tasked with an impossible endeavor.”
Ouellette says that in her case, the most challenging pieces were treating her mature and highly independent 17-year-old “like a toddler” at the onset of FBT, and navigating times when her daughter’s eating disorder defended itself by pushing back against the rules and requirements of treatment. “My daughter’s eating disorder was so clever at making me doubt myself that for a time, I just couldn’t have long or deep conversations,” she says. “I had to stick to being brief, direct, loving, and firm. It felt like being ‘cruel to be kind.’”
Gardner says the emotional obstacles Ouellette encountered are not only common, but anticipated as integral parts of the FBT experience. “Discomfort and challenges are normal and expected in FBT treatment,” she says. “FBT directly challenges the eating disorder’s control and autonomy—oftentimes, this means significant monitoring for the patient. The eating disorder is fighting to stay alive and will often push back with tenacious tactics. To be clear, the ED is the one who is pushing back, not the patient.”
This pushback from the eating disorder is so common that there’s actually a term for it: “extinction bursts,” which refers to the eating disorder’s desperate attempts to retain control as treatment begins to successfully undermine its power. “When the eating disorder is no longer able to operate as successfully as it had, it will hold on for dear life,” Gardner says. “This may mean more intense tantrums, intense food refusals or sneaky attempts to engage in old behaviors. It can be hard to witness, but it's a sign that the ED is losing its footing and is trying to re-entrench the patient in previous behaviors. Continual monitoring, consistent boundaries and a calm demeanor are some of the most powerful ways carers can help defeat the eating disorder—even during an extinction burst.”
Because FBT can feel so counterintuitive, Ouellette says it can be misinterpreted by those who don’t fully understand eating disorders—outsiders may be skeptical, or see it as a violation of children’s autonomy to insist that they eat a certain amount or avoid certain behaviors. “So it can be a very isolating experience, even if you have friends and family trying to understand and support you,” she says.
For Ouellette and her family, the payoff for all these challenges went far beyond her daughter’s recovery. “It taught all of us about ourselves and the kind of team we are as parents and a couple, as parents and children, and our children as siblings,” she says. “We don’t have to assume we would do whatever it takes to help one of us in their time of need—we have done it. We will be there no matter the work needed, how hard the work is, or how long the work takes. In addition to cementing our strength as a family, the dialectical behavioral therapy skills that were part of our FBT treatment have made us more effective communicators, better able to emotionally regulate in stressful times, and able to be better in touch with and more direct about our needs with and from one another.”
Common FBT challenges and how to overcome them
Parents and other caregivers can feel confident in choosing FBT—there’s no doubt that this approach gives patients the best chance of achieving full recovery—but that doesn’t make the challenges go away. “It's not easy, but it’s possible!” says Gardner. “When carers take responsibility for meals and interrupting eating disorders behaviors—like food refusal, selective eating, weight manipulation—it’s common that it will get harder before it gets better.” Thankfully, there are expert-endorsed strategies, tools, and tips to make it easier to navigate the hurdles and challenges that tend to arise.
Caregiver alignment
Enforcing the boundaries of FBT can be challenging enough on its own, but trying to do so in alignment with a spouse or partner can be doubly tough. “Everyone is stressed, this is hard, and different personalities can struggle more than others with the structure and hard lines of FBT,” Ouellette says. “I am a huge fan of using some therapy sessions just for parents to hash out what things will look like—even when there are separate homes—and what division of labor will be. I don’t think everyone has to do everything and playing to your strengths, while growing and changing to fit the situation, is helpful. I love to have a very brief written document with the schedule and some agreed upon rules and motivators and contingencies. It’s better to make decisions away from the pressure and influence of the eating disorder than in the moment.”
Reluctance to take full control over renourishment
Taking control of your child’s eating is the central component of FBT, at least during the first phase. But doing this can be extremely hard, and may feel unnatural or even “wrong.” According to Gardner, overcoming this obstacle hinges on understanding why carers are tasked with monitoring and re-nourishing. “Often, patients will attend an in-person higher level of care where they gain weight, stop ED behaviors, and are then discharged home,” she says. “Yet once they return home, the behaviors resurface, leading to renewed weight loss and disordered eating patterns. FBT empowers caregivers to intervene directly in the home environment, disrupting disordered behaviors and supporting a sustained recovery.”
According to Gardner, consistent monitoring for weight manipulation, secretive exercise, food avoidance, hiding or discarding food, and more is vital to a child's success. “Supervised meals and limiting time alone after eating can minimize opportunities for ED behaviors to re-emerge,” she says. “Professional support can help coach families through how to manage these behaviors while maintaining compassion and connection.”
Gardner adds that it’s also important to arm parents with education on how eating disorders function and what to look for. “Families are encouraged to understand that this is not their child ‘being difficult’—it's the ED speaking. Learning the language, tactics, and patterns of ED behavior can help carers separate the illness from the child and respond more effectively.”
Food preparation
The actual food prep part of FBT can present its own unique challenges for caregivers who have to make sure each meal and snack is in compliance with the patient’s specific plan. “I encourage thinking of the meal plan as a nutrition prescription and the food as a dose of antibiotics to be dosed at specific intervals and in specific amounts—and understand that skipping doses can make things worse,” Ouellette says. “It’s a different way of thinking about and preparing food, and usually that’s everything society has been telling us not to do.”
Ouellette says that a few strategies that helped her were to meal prep while her daughter slept and to simplify what she was offering. “And for those who have friends and family wanting to help out, having them prepare meals for you can allow you to use your energy where it is most needed: getting the food in and the weight on,” she says. “And if you don’t cook, you can still do this, and your dietitian and other caregivers can help!”
Pushback from the patient
“For many carers, it can feel like a battle with the ED to renourish the patient,” Gardner says. “It can be excruciating to see your child completely entangled in an eating disorder. Any pushback or combativeness from the patient's ED can be frustrating—and also expected. Remember, recovery is not linear,” Gardner says. “Some days may feel endless while others may offer a glimmer of hope.”
To overcome this obstacle, Gardner offers the following strategies:
Have planned distractions during meals (while carers are still providing ongoing monitoring). Think: music, audiobooks, calming conversation. “Having a distraction after meals like playing a board game or watching a TV show may also be helpful,” Gardner says.
Set time limits (e.g., 30–45 minutes for a meal) for each meal. If the meal is not finished when the time limit is up, there may be a logical consequence (such as drinking a nutrition shake). You can talk with your dietitian to figure out the best time limit and how to enforce it.
Keep language simple and calm. “At Equip, we often teach the ‘loving and firm’ approach,” Gardner says. This may look like any of the following scenarios:
Scenario 1:
Child: “I’ve already eaten enough! I don’t want to eat anymore”
Example response: “I know this can be scary. Your body still needs this food to heal. I’ll be with you every step as you finish.”
Scenario 2:
Child: “Why are you doing this to me? You’re ruining my life!”
Example response: “I know it feels that way right now. I’m doing this because I love you too much to let the eating disorder stay in control. We’ll get through this together.”
Scenario 3:
Child: “I don’t want to eat. I feel disgusting!”
Example response: “I’m so sorry you're feeling that way. Those feelings are real, but they don’t mean you don’t need food. Let’s take one bite at a time- I’ll be right here.”
Scenario 4
Child: “Just let me skip one meal. One won’t matter!”
Example response: “I understand that’s what the eating disorder wants you to believe. But every meal matters. We can do this together. Let’s start now.”
Limited time and activities
In addition to the mental and emotional toll FBT can take, the treatment can also be logistically challenging and take up a lot of time. “Taking full control over plating and meal prepping can be a large time commitment and this may be a shift for scheduling,” says Gardner.
“This is an intense treatment for a potentially deadly illness,” Ouellette says. “It will disrupt your life, and the more you lean into that and pare down your life and family’s life and attack the ED head on, the sooner you get back to a more normal life. I encourage parents and caregivers to use the thought exercise ‘What would we sacrifice for treatment if this were curable cancer?’ I use this metaphor with the blessing from several parents who have been unfortunate to deal with both cancer and EDs among their children.”
Feeling isolated
Eating disorders can be incredibly isolating for the person going through the illness, but they can also leave the caregivers feeling alienated. “Find support where you can—in support groups with other families especially,” Ouellette says. “With such a bizarre, often frightening illness it makes all the difference to see certain behaviors as symptoms and to share with and be supported by people who truly get it.”
Self-doubt and burnout
FBT positions parents as the primary change agents and the treatment team operates more as consultants, and Gardner says this can cause an increase in self-doubt and burnout. To combat those natural and expected feelings, she offers the following strategies:
Respond, do not react. “Before responding to your child, especially if they are refusing a meal or pushing back during meal times,” Gardner says. “Ask yourself: ‘Is this my child or the ED talking? What would the ED want me to do right now? How can I move recovery forward?’ This pause allows you to respond with intention, rather than react out of emotion or exhaustion.”
Use mantras. Parents in FBT often benefit from having written reminders or affirmations visible in the kitchen or dining room, such as:
- “Food is medicine.”
- “I’m saving their life.”
- “This is temporary. Recovery is possible.”
- “I can do hard things. I already am.”
Lean on your treatment team. “Utilize your treatment team to troubleshoot, check in, and define progress,” Gardner advises.
Attend support groups. Hearing the experiences of others can make a world of difference. If you’re in treatment at Equip, make time to attend one of the many caregiver support groups (many families report these groups are one of the most impactful parts of their experience). You can also find other groups through organizations like F.E.A.S.T.
Identify progress. “Recognize that even sitting down for a meal, eating one more bite than yesterday, even showing up after a meltdown—these are wins,” Gardner says.
Find small moments of joy or rest for yourself. “Even five minutes a day can matter,” Gardner says. Ouellette agrees, advising caregivers to “look at the things that keep you going—exercise, time with friends, hobbies, etc.—and see what you can do for 10 min at a time vs. an hour or more at a time. You might not be able to walk for an hour, but you can probably get outside for some fresh air for at least a few minutes.”
The wrath of the eating disorder
“Eating disorders are mean!” Ouellette says. “They’re mean to our kids and often to us. Work on externalizing the eating disorder so you can stay compassionate and consistent; use techniques like visualization to help you with that, and use language like ‘My child’s ED did/said X’ versus ‘my kid did/said X.’ Develop sayings you can repeat in your head. One of mine was, ‘you have to see the beast to slay the beast,’ and later my daughter and I found out we both used ‘this too shall pass’ in our heads.”
The Equip takeaway on succeeding with FBT
While there’s no doubt that FBT can present a variety of challenges, experts continue to endorse it as the most effective option for children and adolescents with eating disorders—and those who have navigated FBT, like Ouellette, say it’s well worth the effort. “All parents say they would do anything to save their child’s life,” she says. “People who do FBT have done ‘anything’ to save their kid’s life. This isn’t meant to judge anyone who has walked a different path with their child’s eating disorder or to say only FBT parents have had this experience, but to drive home the hard work and distress tolerance that powers FBT. I often say the only thing harder than doing FBT is not doing FBT.”
To determine whether FBT is the right fit for you and your family, Gardner recommends talking to an eating disorder specialist or team that can provide you with an understanding of FBT. “Knowledge and research are tools we utilize against the ED,” she says. “I also recommend the book When Your Teen Has an Eating Disorder: Practical Strategies to Help Your Teen Recover from Anorexia, Bulimia, and Binge Eating.
Ouellette says that while her family has always been close, she believes they achieved a new level of trust and bonding through FBT. “What makes it the most worth it is seeing my daughter happy, healthy and living her dreams that were temporarily interrupted by anorexia,” she says. “She has an incredible career she loves, a wonderful husband, two delightful children, and lives not too far from us. Our whole family—my husband and I, our four kids and partners, and our five grandchildren spend time together every summer and over the holidays and we really have a fantastic time and we gather joyfully and freely around food.”
- Grange, Daniel.. 2005. “The Maudsley Family-Based Treatment for Adolescent Anorexia Nervosa.” World Psychiatry 4 (3): 142. https://pmc.ncbi.nlm.nih.gov/articles/PMC1414759/.
