Family-based therapy (FBT), also known as the Maudsley method, is an established treatment intervention for adolescent eating disorders. Including families in the treatment of eating disorders can be highly beneficial to the vast majority of young adults. The degree of involvement will depend upon several factors, considering the needs of the young person and the family, together with the type of treatment and whether treatment is inpatient, residential, partial inpatient, or conducted in an outpatient setting.
Types of Eating Disorders
There are many types of eating disorders, but family-based therapy is usually focused on only a few. Anorexia nervosa is an eating disorder characterised by restrictive eating patterns, often accompanied by low body weight and an intense fear of gaining weight. Teenagers and young people diagnosed with anorexia will often use various methods and extreme restrictions to control their food and water intake to keep their weight low. In pre-teens, anorexia may delay the onset of puberty and prevent normal growth, and in older teens, menstruation may cease. Teens and young people will often be in denial about the severity of their low body weight and symptoms.
Bulimia nervosa is an eating disorder defined by uncontrolled periods of binge eating, where the child or teen will eat much more than they intended to. This binge is followed by compensatory behaviours that fall into three types:
- Mixed behaviour
Young people who purge may use self-induced vomiting, misuse laxatives, diuretics or enemas to rid themselves of food. Teens who are non-purging may use excessive exercise, fasting or go without food for long periods. Those with mixed behaviour may alternate between purging and non-purging behaviours.
Family-based therapy primarily measures improvements in weight restoration and normalising eating patterns and behaviours. This treatment takes place at home, with parents fully involved in treatment planning and delivery. FBT is commonly used to treat anorexia, although it is beginning to be used to treat bulimia as well.
What is Family-Based Treatment?
Clinicians developed family-based therapy at The Maudsley Hospital in London. Dr’s Daniel Le Grange and James Lock further developed family-based treatment, publishing a manual by the same name in 2002, and this was later revised in 2013.
The Maudsley method, or family-based therapy, is an amalgamation of several types of clinical approaches that have been used in the successful treatment of anorexia nervosa in young adults. There has been some indication for the use of FBT in treating bulimia nervosa, with one study finding that FBT facilitated faster recovery rates for young adults.
Parents lead family-based therapy with the support of adolescent eating disorder specialists who help the family promote boundaries around food and mealtimes. The parents will usually meet with their clinical team weekly for support and guidance.
In family-based therapy, therapists do not analyse why the eating disorder developed or blame the family. Instead, it uses the bond between family and children to help with the healing process, with parents being viewed as experts on their children and members of the treatment team.
The eating disorder is presented as an external rather than an internal condition. Externalising anorexia can be highly beneficial, as young adults can place the illness outside of themselves, improving the harsh internal critic and negative messages that young people often face.
Phases of FBT
There are three phases during family-based therapy that aim to treat eating disorders:
Phase One – Weight Restoration
Parents take the lead in re-establishing regular eating patterns and regulating behaviours such as purging, restricting, and excessive exercise. If weight restoration is a goal during this phase of treatment, eating disorder clinicians will look for a weight gain of 0.5 – 1kg per week. Parents remain firm, fair and consistent in their approach to establishing new behaviours and routines at mealtimes.
An eating disorder therapist will support and encourage the parents to feel empowered to facilitate positive changes in early treatment. The parent’s role is to reduce eating disorder-related behaviours and ensure that all meals are completed.
Phase Two – Returning Control
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 regaining weight and increased mood stability are signals to move into phase two of the planned treatment approach.
Parents can 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 introducing eating with other people or in different settings. Parents work to incorporate all fear foods into the eating plan. There can be some backsliding during this phase, but this is normal, and in this case, parents will reassert control again until their child is ready to accept more responsibility.
Phase Three – Developing Identity
As the child or teenager approaches 95% or above of their ideal body weight, phase three of the treatment begins to focus on the emerging identity of the young person.
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 developmental issues are approached.
Family-Based Therapy and Mealtimes
FBT requires families to choose and prepare the food at home and be present during mealtimes. Parents may find their confidence in dealing with their child and the illness has been shaken. FBT advocates active parenting and regaining confidence in their parenting style.
The family meal is a concept that is used readily in FBT. Families have adequate experience of feeding their children. Families are often asked to recall infancy and early childhood and remember the joys of nourishing their children.
The Benefits Of The Maudsley Approach
Family-based treatment has the potential to prevent hospitalisation and reduce the chances of related medical trauma. Treating children at home can result in faster weight restoration periods, which positively impacts the normal adolescent developmental trajectory. Treatment at home also has an implied cost-benefit for families who would otherwise require the services of partial hospitalisation, residential, or inpatient eating disorder treatment programmes.
FBT approaches from the viewpoint that parents are a valuable resource in treatment, as they know their children the best. They are given more authority and responsibility in leading the treatment plan to help their child recover. FBT relies on the valuable bonds and information held within the family unit and empowers parents to be decision-makers throughout the treatment period. Teenagers and young adults struggling with eating disorders can experience anosognosia, a total lack of awareness that they are ill. Family-based therapy gives a lot of responsibility to the parents, which allows their child to begin to recover with them, before recovering independently.
One study from the University of Chicago and Stanford revealed that FBT is highly beneficial for adolescents struggling with anorexia nervosa. At the end of a course of FBT, this study showed that two-thirds recovered, and after five years, up to 90% were weight-recovered.
Family-based therapy has been proven as an effective form of treatment for eating disorders such as anorexia nervosa and bulimia nervosa. By placing the family at the forefront of recovery, the child has a solid network that can support them at home. However, family-based therapy is not for every family – it requires a strong commitment and sustained effort for many weeks. Despite this, many parents and families find this a highly rewarding experience that can aid hugely in their child’s recovery.
 Lock J, Le Grange D. Can family-based treatment of anorexia nervosa be manualized?. J Psychother Pract Res. 2001;10(4):253–261.
 Le Grange DL, Lock J, Agras WS, Bryson SW, Jo B. Randomized Clinical Trial of Family-Based Treatment and Cognitive-Behavioral Therapy for Adolescent Bulimia Nervosa. Journal of the American Academy of Child and Adolescent Psychiatry. 2015;54(11):886–894.e2. doi:10.1016/j.jaac.2015.08.008
 Epstein LH, Paluch RA, Wrotniak BH, et al. Cost-effectiveness of family-based group treatment for child and parental obesity. Child Obes. 2014;10(2):114-121. doi:1.1089/chi.2013.0123
 Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry. 2010;67(10):1025–1032. doi:10.1001/archgenpsychiatry.2010.128
Fiona Yassin is the International Clinical Director of The Wave Clinic. Fiona is a UK Registered Adolescent and Family Psychotherapist and Clinical Supervisor (Licence number #361609 NCP/ICP), further trained in the specialty of Eating Disorders and Borderline Personality Disorder Treatment. Fiona is trained in FBT (Family Based Therapy), CBTE for eating disorders, FREED (King’s College, London), EMDR for eating disorders (EMDRIA) and has a Post-Graduate Diploma in Neuroscience and Trauma from the University of Tennessee, Knoxville.
Fiona works with international families and family offices from the UK, Dubai, Kuwait, Singapore and Malaysia. Fiona can be contacted by email on [email protected].