Family-Based Treatment (FBT) is the most effective, evidence-based approach for treating eating disorders in young people. It consistently shows better outcomes than individual treatment, and while residential treatment centers (RTCs) are often the default choice for care, 50% of those who attend an RTC need to be readmitted within a year.
FBT is built on the radical idea that healthy family members are the ones best suited to help their loved one recover from an eating disorder. Whereas traditional treatment focuses on talk therapy or intensive treatment away from home, FBT recognizes that young people who are malnourished simply can’t make healthy choices, and tasks family members with first and foremost renourishing their loved one. At Equip, our treatment model is based on FBT and enhances the approach with a dedicated 5-person treatment team that’s delivered virtually—which our research shows to be just as effective as in-person treatment.
FBT is a bold approach, which means that—despite a large body of evidence pointing to its effectiveness—clinicians may have hesitations about recommending it for their patients. This is understandable. Cara Bohon, PhD, Equip’s Senior Vice President of Clinical Programs, answered some common questions and concerns that healthcare providers have about Family-Based Treatment for eating disorders.
Doesn’t FBT take away a patient’s agency? It seems misguided for adolescents and teens to lose control over their eating, movement, and other parts of daily life.
Eating disorders are brain-based illnesses and not a choice. The eating disorder itself limits the agency of the patient before treatment begins. Their world revolves around food choices, body checking, or exercise, but not because they want to be thinking or doing those things—the eating disorder brain processes are driving these behaviors. I hear family and friends say “Why can’t they just eat?!” or “Why can’t they just stop binge eating or purging?!” about their loved one with an eating disorder. But it’s not that simple. It’s not a choice.
I say all of this to illustrate that FBT is not taking away anything that the eating disorder did not take away first. Instead, FBT is creating an environment that takes away the eating disorder’s control over the patient and allows the patient to recover their own agency.
It’s important to note that FBT is individualized and adaptive. Many patients begin treatment with the eating disorder almost fully eclipsing their true selves. We can often see that from loved ones’ assessment of behaviors, values, interests, and mood before and after the eating disorder began.
When a patient is in a state where their eating disorder dictates their every move, FBT guides loved ones to make food choices that align with what the patient would have wanted if the eating disorder weren’t present. Family members monitor meal completion so that the eating disorder doesn’t have the opportunity to restrict, as well as bathroom usage and other post-meal behavior to prevent purging.
As the eating disorder’s hold on the patient slips away, FBT guides loved ones to return independence around eating back to the patient in a safe and supportive way. This may mean restrictions on movement or limitations on social or physical activities, as these are instances in which the eating disorder is more likely to take control. But a key part of FBT is using the family’s knowledge of their loved one to guide choices and return independence as soon as they are able.
FBT seems like a huge ask for parents and family members who have no training in treating eating disorders. Can they really take all of that on effectively?
I won’t lie. FBT is a lot of work. Eating disorder recovery is not easy on anyone. But providers trained in FBT are positioned to support the family in succeeding. Families know their loved one and their family, and providers know eating disorders and the treatment strategies and skills that get people to recovery.
Families and providers work together as a team, collaboratively determining what approaches will work best for each family. Despite common misconceptions, it’s not a one-size-fits-all set of solutions for a family to take on, but rather a collaborative and adaptable process. Families and providers talk together about what possible solutions will help them be successful in challenging the eating disorder’s hold on the patient.
And despite the hard work of implementing FBT, families report reductions in their sense of burden and burnout once they’re in treatment. The eating disorder itself is more disruptive to families than treatment, where there can finally be a sense of hope.
Won’t FBT harm the patient’s relationship with their family?
In the midst of FBT, many families worry about their relationship with their loved one. The eating disorder creates a lot of distress as it weakens, as if in an attempt to sabotage treatment and remain present and strong. But while the treatment hurts in the moment, patients and families describe a sense of healing afterward.
A patient’s father once told me, “I would never wish an eating disorder upon anyone, but this process has brought our family closer together than we ever were before.” Equip’s Director of Peer Mentorship has written about her experience hating treatment and fighting with her parents, but later being grateful for their choice to do a treatment that saved her life. She wrote, “If I could send one message to parents supporting their children in this journey, it’s that the disorder gets louder, meaner, and angrier when it feels threatened: and that can be a sign that you’re truly helping your child break free from its grasp.” And that life-saving gift is one that often brings families closer through recovery.
Are there any types of families for whom you wouldn’t recommend FBT?
I have learned over the years that we are pretty bad at predicting who would or would not do well in FBT. My initial instinct was that families with a stay-at-home parent who could be dedicated to meal support were the only ones who could truly make this treatment work. I was wrong. Then I thought that perhaps working parents could do it, but divorced parents would certainly struggle since they often couldn’t get along well. Wrong again. Then I thought, “Well, certainly single parents or those with multiple jobs wouldn’t be able to do FBT.” Families of all kinds have proven me wrong every time.
I have had families with a stay-at-home parent struggle and families with a single parent achieve great success. The truth is that we do not have any good predictors of which families will do well or not. FBT is adaptable, and a well-trained provider will work with families to identify what resources they have available to support their loved one and meet their needs. Virtual treatment, which is as effective as in-person treatment, allows families to join treatment sessions from work breaks or between shifts of jobs, as well as bring extended family members who can provide additional support. The most important thing is a strong collaborative relationship between the family and provider team to create a plan that fits—and leads to lasting recovery.
- Lock, J. An Update on Evidence-Based Psychosocial Treatments for Eating Disorders in Children and Adolescents, Journal of Clinical Child & Adolescent Psychology, 44:5, 707-721, 2015. DOI: 10.1080/15374416.2014.971458
- Couturier, J., et al, Efficacy of family-based treatment for adolescents with eating disorders: A systematic review and meta-analysis. Int. J. Eat. Disord., 46: 3-11. 2013. https://doi.org/10.1002/eat.22042
- Accurso, Erin C et al. “Attitudes Toward Family-Based Treatment Impact Therapists' Intent to Change Their Therapeutic Practice for Adolescent Anorexia Nervosa.” Frontiers in psychiatry vol. 11 305. 23 Apr. 2020, doi:10.3389/fpsyt.2020.00305
- Steinberg, D. et al. (2023) Effectiveness of delivering evidence-based eating disorder treatment via telemedicine for children, adolescents, and youth, Eating Disorders, 31:1, 85-101, DOI: 10.1080/10640266.2022.2076334