Family-Based Therapy for Eating Disorders: Putting Parents at the Front of the Eating Disorder Treatment
Advice for families embarking on Family-Based Therapy (FBT) and recommendations for families looking for alternative treatment options.
It is clinically acknowledged that including families in the treatment of eating disorders is good practice, in the vast majority of circumstances. The degree of involvement will depend upon several factors, taking into consideration the needs of the young person and the family, together with the type of treatment and whether treatment is in-patient, residential, partial in-patient or based in an outpatient setting.
The Maudsley Family Therapy, otherwise known as Family-Based Therapy (or FBT), is one of the most established treatment interventions for adolescent Anorexia Nervosa (AN) and there has been some indication for its use in the treatment of Bulimia Nervosa (BN).
Anorexia Nervosa is an eating disorder characterised by restrictive eating patterns, often accompanied by a low body weight and an intense fear of gaining weight, with a distorted perception of weight and body shape. Teenagers and young people diagnosed with Anorexia Nervosa will often use a variety of methods and extreme rigidity and restriction to control their food/water intake weight.
In pre-teens, anorexia may delay the onset of puberty and prevent normal growth. In older teens, menstruation may cease. Teens and young adults will often demonstrate denial in relation to the severity of their low body weight and symptoms.
Bulimia Nervosa is an eating disorder characterised by uncontrolled periods of binge eating, where the child or teen will eat much more than they intended to or much more than would be expected at a normal mealtime. This is followed by compensatory behaviours that fall into three types: ‘Purging’, ‘Nonpurging’ and ‘Mixed Type’.
Young people who purge may use self-induced vomiting, misuse laxatives, diuretics or enemas. Those who are non-purging may use excessive excercise, fasting or go without food for long periods. The mixed type may alternate between both purging and non-purging behaviours.
The Maudsley Approach
MFT was developed by clinicians at The Maudsley Hospital, London. (slam.nhs.uk)
Drs Daniel Le Grange and James Lock further developed Family-Based Treatment, publishing a manual by the same name in 2002, later revised in 2013.
Maudsley Family Therapy (also known as MFT, Family-Based Therapy or Anorexia-Focused Family Therapy), primarily measures improvements in the areas of weight restoration and the normalising of eating patterns and behaviours.
This takes place at home, with parents fully involved in both the treatment planning and delivery.
A large part of the treatment is delivered by the parents who take responsibility for their child’s nourishment and the restoration of their child’s eating during the first phase of treatment.
MFT is an amalgamation of several types of clinical approach that have been used in the successful treatment of Anorexia Nervosa in children and teenagers. There has been some indication for the use of FBT in the treatment of Bulimia Nervosa and adaptations used for the treatment of eating disorders in adults. Research continues in this area, with few studies available at the time of writing.
Maudsley Family Therapy is considered a well-established treatment method and is included in NICE Guidelines (National Institute of Clinical Excellence) for the treatment of Anorexia Nervosa in children and teenagers.
However, more than 40% of parents of adolescents choose to discontinue MFT treatment reporting ongoing psychological distress, static or increased eating disorder symptoms and/or decreased communication within the family.
The Benefits of The Maudsley Approach
Family-Based Treatment has the potential to prevent hospitalisations and the potential of related medical trauma. Treating children at home can result in faster weight restoration periods, which has a positive impact on the normal adolescent developmental trajectory.
Treatment at home has an implied cost benefit for families who would otherwise require the services of partial hospitalisation, residential or in-patient eating disorder treatment programs.
Parents are seen as a valuable resource and lead the treatment plan. FBT relies on the valuable bonds and information held within the family and empowers parents to be decision-makers throughout the treatment period.
What Does Family-Based Therapy Mean for Parents and Teens?
FBT centres on intensive periods of home-based re-nourishing (sometimes called refereeing) interventions in the family home. It requires a significant time commitment from the family for a minimum of one year or longer, as required.
Family-Based Therapy is much like any other emergency-focused medical care. The focus of the treatment is on the stabilization and recovery of the child or teen and requires loving commitment as well as emotional energy and availability. Routines, jobs and other commitments may need to change in order to prioritise recovery.
FBT advocates for parents to take the lead; children and teenagers who are not adequately nourished are not able to make great decisions for themselves. The young person’s starving brain needs nourishment and the active involvement of their parents to succeed in recovery.
‘FBT relies on the core parental capacity to feed your child.’
Daniel Le Grange, PhD (one of the founders of FBT and a professor at The University of California, Eating Disorder Program)
Communication in the family is also an essential aspect of successful Family-Based Therapy in the treatment of both children and teenagers. Empathy, understanding and sticking to the process are essential components of successful FBT treatment at home.
Parents and their children are encouraged to join together in the fight against the eating disorder. Externalising the eating disorder is beneficial as the young person is able to place the illness outside of themselves, which can lead to improvement in the harsh internal critical messages that young people often describe.
Family-Based Therapy: A Roadmap to Recovery for Parents and Teens
Family-Based Therapy is led by parents with the support of Adolescent Eating Disorder specialists who will help the family to promote boundaries around food and mealtimes. The parents will usually meet with their clinical team weekly for support and guidance.
Many families feel grateful and relieved to have a roadmap to follow in early intervention and treatment. Having felt confused, exhausted and fearful, parents report that having a manual-based therapeutic intervention with support from eating disorder professionals encourages positive family involvement.
Trained eating disorder therapists and psychiatrists will help the family to prepare ahead of beginning FBT treatment at home. Many therapists will ask the family to bring a typical family meal to the therapy session. This initial step prompts parents to trust in their ability to produce an adequate meal and increases parental awareness.
The family is often encouraged to eat together in their therapy room. This may be videoed by their ED therapy team and replayed to assist in further therapeutic interventions.
Will My Child or Teenager Agree to Family-Based Therapy?
Let’s be honest – it’s unlikely. And that is OK.
FBT, or any other eating disorder treatment, is going to focus on confronting your child or teenager’s eating disorder head on. It’s really unlikely that they are going to like that. The eating disorder would prefer that we all go away and leave it to take hold in peace.
So, beginning treatment is likely to cause short-term conflict, arguments and an increase in unpleasant behaviours. This is OK – it will be short-lived and if you stick to no negotiation and no wriggle room, normality will soon resume.
Parents: Planning, Providing, Supervising and Encouraging
Therapist will be looking for the family to encourage their child to eat more than they would usually eat during the family mealtime. This may be by encouraging an addition spoonful or to try a new flavour or food that has previously been refused.
Research has concluded that direct positive messages during mealtimes, for example, ‘Pick up the sandwich and take a bite’, are more effective than reasoning, bargaining or providing choices and information. A starving adolescent brain, simply cannot respond to decision-making and processing in the same way as a well-nourished adolescent brain.
Many of the characteristics of Anorexia Nervosa are the result of the malnutrition that accompanies the illness. For example, Anosognosia is thought to be caused by brain starvation – this results in the lack of awareness that one is ill, a common feature in Anorexia Nervosa.
Phase One: Weight Restoration Phase
Parents take the lead in re-establishing regular eating patterns and regulating compensatory and problematic behaviours; purging, restricting, overly selective, laxative use, excessive exercise use, rigidity and rituals. As weight restoration is a goal during this phase of treatment, eating disorder clinicians will look for 0.5–1kg per week. Parents remain firm, fair and consistent in their approach to establish new behaviours and routines at mealtimes.
An eating disorder therapist will support and encourage the parents to feel empowered in their ability to facilitate positive changes in early eating disorder treatment. The parent’s role is to reduce ED-related behaviours and ensure that all meals are completed and re-nourishment takes place.
Phase Two: Returning Control Over Eating to the Young Person
Phase two is often accompanied by a sense of relief within the family. Taking control of the eating disorder, establishing regular eating patterns and a steady path of weight regain, and increased mood stability are signals to move into phase two of the planned treatment approach.
Parents are able to begin to work with their child or teen to hand over increased and age-appropriate responsibility for food choices. Families continue to focus on flexibility and begin to introduce eating with other people or in different settings. Parents work to incorporate all fear foods into the eating plan.
Phase Three: Developing a Sense of Identity
As the child or teenager approaches 95% or above of their ideal body weight, phase three of the treatment begins, with the focus on the emerging identity of the young person.
Anorexia Nervosa can impact the normal developmental of children and teenagers. Phase three encourages the family and the young person to access what has been and what lies ahead. Parents are encouraged to reassess their life together following the intensity of the previous phases and look at plans for the future. During this phase co-occurring mental health or behavioural health concerns may be addressed in therapy and any developmental issues are approached.
Family-Based Therapy and Mealtimes at Home
FBT requires families to choose and prepare the food at home and be present during mealtimes. Parents who have been through the complex rollercoaster of emotions involved in the treatment of childhood Anorexia Nervosa may find that their confidence in dealing with their child and the illness has been shaken. FBT advocates active parenting and regaining the confidence in ‘good enough’ parenting styles.
The ‘family meal’ is a concept that is used readily in FBT. Families have adequate experience of nourishing their child. Families are often asked to recall infancy and early childhood and remember the joys of nourishing their children.
Siblings at Home and Family Based Therapy
Siblings are encouraged to provide an active and supporting role in the treatment of Anorexia Nervosa at home, utilising the principles of FBT. Emotionally supportive sibling relationships are know to be incredibly beneficial in phase one where weight restoration requires nurturing and loving support at home.
Could Family-Based Therapy Damage My Relationship With My Child or Teen?
We hear parents who have concerns about their relationships with their children and teens. Often relationships are strained within the family following ongoing fears and worries around disordered eating and later whilst the young person is active in eating disordered behaviours.
40% of families report ongoing distress and symptomology following intensive FBT/MBT at home. One of the difficulties that some young people and families describe during and following FBT is the lack of focus on the psychological underpinnings of the eating disordered behaviour. FBT is primarily focused on weight regain and the ‘now’. This can leave young people feeling unheard and frustrated. This exasperates the underlying trauma and can see young people returning to eating disordered behaviours or symptoms appearing in other areas.
Your clinical team may not recommend FBT if the family would benefit more readily from individual treatment approaches and family therapy to address any unresolved anger or contributing factors.
Family-Based Therapy v Residential Eating Disorder Treatment for Teens
Residential eating disorder treatment provides teenagers and young adults with a very different experience from home-based FBT. It also provides parents with a support network and a team of professionals specialising in the care of young people with eating disorders.
Whilst parents are also involved in treatment that is delivered within a residential treatment program for eating disorders, the treatment team will make the majority of the day-to-day decisions and will be responsible for the re-nourishing or regulating of the young person. This is supported by medical care, which many parents of very sick young people find reassuring.
This can be an important decision for parents who are not able to dedicate a year or longer to FBT or those who feel intimidated by the refereeing requirements in phase one. It is important that parents fears and concerns are heard and that treatment reflects the needs of the whole family.
Eating disorders often co-occur with other mental health concerns, including:
- Obsessive and Compulsive Behaviours.
While FBT does not address underlying mental health concerns, residential treatment has the additional benefit of providing psychiatric care and addressing all concerns simultaneously. Whilst this will not apply to all families and young people, it is worth discussing with your child’s psychiatrist or therapist.
Young people in residential care also have the benefit of sharing the experience with others of a similar age, with similar life experiences. The process of sharing with others at all stages of treatment is beneficial to treatment outcomes, reduces shame and loathing and provides encouragement through the challenges of the ED recovery journey.
Connection, community and peer support are essential in any type of mental health recovery. Eating disorders are lonely and thrive in isolation. Residential treatment offers the opportunity to use the community in the healing process.
Trauma-focused treatment programs that are able to offer skills building, education, volunteering and global citizenship prepare young people for a life that is very different from the one that they leave behind as long term recovery from their eating disorder becomes the goal.
Parents can read more about the success of trauma-focused treatment programs on The Wave website.
Can I Combine Residential Care and The Maudsley Treatment Approach?
When your child leaves residential care at the end of a prescribed treatment episode, it is likely that they will have reached the milestones that were indicated upon admission and in subsequent reviews of the treatment plan.
Young people who leave treatment early or have abortive treatment episodes or those whose families withdraw them from treatment, usually do so against medical advice. This is usually counterproductive and can place further strains on the family system and mistrust in therapeutic and family relationships.
Weight restoration and stabilisation will have been a priority in residential treatment. Young people who have competed this phase of their treatment would be unlikely to benefit from phase one in FBT.
When looking for a treatment program for your child, it is useful to consider the completion rates in Eating Disorder Programs.
Is Family-Based Therapy Always the Most Appropriate Option for Treatment?
Family-based treatment certainly has much to offer in the treatment of children and adolescents in some but not all families and home environments. The premise of the strong parent and child bond and the ability of participating parents to commit to a year or more of dedicated one-to-one care are not suitable for many participants in Eating Disorder Treatment.
Young people who report a high ACE score (Adverse Childhood Experiences) or where there are current mental health issues, substance use issues, emotional unavailability, high conflict relationships or other difficulties in the family home are unlikely to be candidates for FBT as a first line therapy.
CBT-E has been shown to be effective in the treatment of children and teenagers. It can therefore be considered a good alternative to Family-Based Therapy for adolescents and pre-teen patients.
How Do I Know if Family-Based Treatment Will Work for My Child?
FBT appears to be most effective as an early intervention strategy. FREED (King’s College London) consider treatment in the first three years of onset to be a timely intervention. This is three years from the beginning of the onset of the eating disorder behaviours and mindset, which is usually significantly earlier than parents or families notice that ‘something seems wrong’.
FBT has been noted to be most effective in adolescents who show positive early indications of improvement in the signs and symptoms of Anorexia Nervosa. This positive treatment effect is usually seen within the first four weeks of treatment.
Trauma and Family-Based Therapy
Is Family-Based Therapy trauma-focused?
The short answer is no. In the purest form, FBT in the initial stages is not designed to look at the root cause of the eating disorder or the trauma responses that may be present. FBT is about the physical, weight restoration and establishing family boundaries. It is not designed to look at the psychological cause and effect or to look at adverse childhood experiences or trauma throughout the lifespan.
Whilst Family-Based Therapy teams will concentrate on empowering parents to commence re-nourishing and re-feeding in phases one and monitoring in phase two, there is no suggestion of further psychological or psychotherapy sessions until phase three.
EMDR (Eye Movement Desensitisation & Reprocessing) is utilised with outstanding outcomes in the treatment of Anorexia Nervosa, other eating disorders and trauma.
What Happens if Family-Based Therapy Does Not Work for My Family?
Family-based therapy does not work for everyone. In fact, just under half of all families who begin family-based therapy find long-term recovery.
FBT is discontinued by families for many reasons. If family-based therapy has not worked in the family, the most important step is not to give up. There are many other valuable treatment options for children and teenagers who have been diagnosed with Anorexia Nervosa.
The take away message is that young people should be getting the help that is ‘right for them’ and right for their family. There is no one way to treat anorexia, nor is there one particular method that is ‘better’ or more effective than another.
A skilled professional will listen to the child’s needs and the needs of the family, take a really good history and help you all to find solutions. When the fit is right, families feel a sense of safety and connection and that is the first step in all good treatment services. The best eating disorder treatment in the world is the one that works for your child and your family.
Family-Based Therapy Around the World
Finding a therapy team that will support your family whilst embarking on your FBT journey is incredibly important. It is essential that your therapist, psychiatrist and dietician understand and are trained in The Maudsley Approach. Without effective support the likelihood of successful home-based interventions are reduced, which can result in further distress and emergency admissions.
FBT in London and Europe
Maudsley parents.org provides useful resources and professional support for families, carers and young people. Information is also provided in Spanish.
BEAT is the UK’s leading eating disorder charity. Parents can also find lots of useful information on FBT and eating disorders in general, together with plentiful support for carers and young people.
BEAT’s Nexus service provides free coaching and advice for those supporting loved ones.
FBT in the Middle East
Eating disorders in the Middle East are often overlooked and services few and far between. Many families in the Middle East choose residential treatment for this reason.
The Wave Clinic offers eating disorder programs for teenagers, young adults and their families in Arabic and in English. The Wave specialises in culturally competent interventions with families from the Gulf Region and beyond.
FBT in Asia
The rise of eating disorders in Asia is disproportionate to the availability of services. There is a lack of understanding of the treatment of eating disorders within the medical community and little education or awareness programs for parents and carers.
This combined with cultural messaging in relation to food and body shape; leave young people in Asia sadly at increased risk of developing eating disorders that are not treated at early onset. Fiona Yassin, Eating Disorder Program Director at The Wave, Kuala Lumpur has been working alongside Dr Rozainee Khairudin, Associate Professor and President of The Malaysian Psychologists Association (PSIMA) to bring increased awareness and understanding to the wider community of clinical professionals.
Research and interest in FBT in the region is ongoing. The Wave Outpatient Team is able to assist families with ED therapy, dieticians, programs, meal support and outpatient psychiatry online or in person.
Eating Disorder Hope has links to professionals treating eating disorders in south east Asia, with specialists in FBT and other eating disorder clinicians based in the Philippines, Indonesia, Malaysia, Singapore and Bangkok, Thailand.
FBT in Australia
The Royal Children’s Hospital in Melbourne and The Westmead Hospital in Sydney both have successful FBT Programs.
Westmead Hospital, Department of Medical Psychology, Hawkesbury Road, Westmead. NSW 2145. New South Wales.
Telephone: (02) 9845 6686
Sydney West Area Health Service, Eating Disorders Day Treatment Program.
2D Fennell Street, North Paramatta, NSW 2151. New South Wales.
Telephone: (02) 9360 9423
The Melbourne Clinic – Eating Disorders Inpatient Program
Telephone: (03) 9429 4688
Butterfly Foundation, Families & Supports
Telephone: (03) 9822 5771
The National Eating Disorders Collaboration provide resources for carers and families at nedc.com.au
FBT in USA and Canada
There is a multitude of FBT providers and clinical advisors in the USA. The Maudsley parents’ providers list offers some great options for advice and treatment planning.
Survive FBT: Skills manual for families undertaking Family-Based Treatment (FBT) for child and adolescent Anorexia Nervosa. Maria Ganci.
Dalle Grave R, Calugi S, Conti M, Doll HA, Fairborn CG. Inpatient cognitive behaviour therapy for adolescents with anorexia nervosa: immediate and longer-term effects. Frontiers in Psychiatry 2014; 5:16.
Resources for Parents
Resources for Therapists and Clinicians:
The Centre for Research on Eating Disorders (CREDO), Oxford, UK
FREED – King’s College, London
The Clinician’s Guide to Collaborative Caring in Eating Disorders. The New Maudsley Method. Janet Treause, Ulrike Schmidt, Pam Macdonald.
Blog: Dr.S. Rabin
Exploring alternatives for adolescent Anorexia Nervosa: adolescent and parent treatment (APT) as a novel intervention prospect. Maria Ganci, Linsey Atkins, Marion E Roberts. Journal of Eating Disorders. Article 67 (2021).
Implementation of family-based treatment for Asian adolescents with anorexia nervosa. A consecutive cohort examination of outcomes. Chu Shan Elaine, MBBS, MRCPCH, MMed (Paediatrics); Siobhan Kelly, E Eric Tay, Amelie Baeg, Jean Yin Oh.
Fiona Yassin, is the International Clinical Director for The Wave Clinic in Kuala Lumpur and Program Director of The Wave International Eating Disorders Programs, in both Dubai, UAE (opening soon) and Malaysia. Fiona is trained and registered in the UK and is a practising Psychotherapist and Supervisor of Clinicians. Licence Number #361609. Fiona specialises in the treatment of Eating Disorders and Mood Disorders and is a member of the Australian and New Zealand Academy for Eating Disorders and The International Association of Eating Disorders. Fiona is further trained in EMDR and a Full Member of EMDRIA #100054651. A Fellow of ACCPH (UK), CBT-E (CREDO-Oxford) and FREED (King’s College, London). Fiona is an advocate for trauma-focused care in Eating Disorder Treatment and passionate about combining education and treatment to build skills for life.
Fiona is a member of The Association of Child Protection Professionals and an advocate for The Voice of The Child.
General Enquiries and Appointments +60327271799 (Reception)