FBT for Eating Disorders: Who Does It Really Work For and What Happens If It’s Not You

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Family-based therapy (FBT) is the most established treatment for anorexia nervosa among children and adolescents. FBT empowers family members to engage in the treatment process and focuses on restoring the physical health of a young person.

At the start of FBT, parents are given full control over a young person’s eating before gradually returning the responsibility to the young person as treatment progresses.

Research has found that FBT effectively supports many young people with eating disorders to reach a healthy weight. However, FBT isn’t for everyone.

Some young people and their families don’t see improvements with FBT, especially if a young person has co-occurring disorders, families face internal challenges, or parents have their own mental health concerns.

Many mental health professionals present FBT as the only option for parents who are seeking treatment for their children. This means that when FBT doesn’t work, parents can feel helpless and distressed about their child’s recovery.

But in reality, there are several other evidence-based treatment approaches for anorexia nervosa that can support a young person to recover from their eating disorder and stay well in the long term.

This blog offers some more information about FBT, how it works, and for whom it works best. It also outlines some of the reasons that FBT may not be effective for young people and their families and what other options are available that promote a meaningful and lasting recovery.

How Does Family-Based Therapy Work?

Family-based therapy aims to help young people recover from anorexia nervosa or other eating disorders at home rather than in an inpatient setting. It’s based on the idea that children or adolescents who are living with an eating disorder aren’t able to make good decisions about the way that they eat and asks that parents take over this responsibility.

As a young person’s physical health improves, they are allowed more and more control over their eating until they can maintain a healthy eating routine by themselves. The final phase of FBT focuses on a young person’s developmental needs and challenges they may face in the future.

During FBT, parents are also asked to prevent a young person from doing too much physical activity. FBT for bulimia nervosa involves parents intervening in and preventing bingeing and purging cycles.

FBT encourages young people and their families to understand that eating disorders are not caused by the young person or their family. It discourages parents from criticising their child, something that can harm their recovery journey.

What Are the Limitations of FBT?

FBT focuses on restoring a young person’s weight and understanding their physical health (weight and menstruation) as the measure of recovery. While FBT recognises that many young people with eating disorders also live with co-occurring conditions, such as anxiety, depression, or PTSD, it suggests that many of these symptoms may improve or disappear as their physical health improves.

This means that FBT doesn’t address the psychological distress that often underpins a young person’s disordered eating behaviours or treat other underlying issues like perfectionism, interpersonal difficulties, and low self-esteem. 

While some young people’s psychological symptoms may improve with their physical health, research suggests that mental health concerns often remain.

One randomised control study on the long-term effects of FBT found that while 90% of young people achieved weight gain following the treatment course, 40% still had significant ongoing psychological distress at follow-up.

Psychological symptoms not only affect the well-being and quality of life of young people but may also lead to a relapse of disordered eating behaviours.

Despite FBT’s previous reputation as a ‘gold standard’ for eating disorder treatment, its effectiveness is uncertain for many adolescents, especially concerning aspects of their well-being other than their weight.

Some young people have said that FBT’s emphasis on physical rather than psychological symptoms is unhelpful and dehumanising. Parents whose children did not gain weight with FBT have expressed helplessness and fear that a front-line treatment did not work for them.

Among parents whose children’s weight is restored, many feel unease and discomfort at the ongoing presence of disordered eating behaviours and are unsure where to turn next.

Many families struggle with how to continue when FBT doesn’t work, or their child continues to have mental health issues, especially if they’ve been told that FBT is the only evidence-based treatment available. But in reality, there are other options available.

As research into eating disorder treatments continues, increasing evidence supports the effectiveness of treatment options that take a whole-person approach to recovery.

Who Benefits the Most From FBT and When Is It Less Likely to Be Effective?

Clinicians and parents have identified certain factors that may affect the effectiveness of FBT. Some of them relate to a young person’s mental health and the causes of their eating disorder, while others involve family dynamics or age.

Co-Occurring Disorders and Complex Presentations

Young people who have co-occurring disorders and symptoms like PTSD or self-harm may not benefit from FBT, which leaves these symptoms unaddressed.

During therapy sessions, therapists may have to focus on reducing the risk of self-harm and other behaviours, especially when expectations of weight gain can make the risk higher. In these cases, it’s difficult to follow the usual structure of FBT and sometimes the treatment is stopped for a young person’s safety.

For many young people, co-occurring disorders, experiences of trauma, and other mental health symptoms can sustain disordered eating behaviours.

When these symptoms are left untreated, young people may rely on disordered eating as a coping mechanism for their thoughts and emotions and find it more distressing to change their eating behaviours.

Equally, in the absence of other coping mechanisms, they may turn back to previous behaviours after treatment has ended, leading to relapses of disordered eating.

Some clinicians have noted that clinical trials for FBT mostly took place in the US, where treatment is more expensive and access often depends on a higher socio-economic status.

They suggest that young people participating in the trials may not represent the general population, but a part of the population that’s less likely to have complex presentation than others.

They argue that the success of FBT in clinical trials may reflect its effectiveness among young people with less complex presentations, while it may be less suitable for those with additional vulnerabilities.

Family Dynamics

FBT relies on a supportive home environment where parents can dedicate time and energy to their child’s recovery.

Families that are facing challenges or instability – whether that’s internal conflict, stressful events, grief, or any other cause – may find it difficult to follow the FBT treatment plan. FBT may also be less effective when parents also live with mental health disorders.

Age

Family-based therapy may be more effective with younger adolescents and children where it is more age-appropriate for parents to control their eating. Older teenagers may be more resistant to the idea and less willing to engage in FBT treatment.

What Other Treatment Approaches Are Available?

While FBT is the go-to treatment for many clinicians, there are several other evidence-based approaches for young people with anorexia nervosa or other eating disorders.

Residential Treatment for Eating Disorders

FBT focuses on a young person’s family as the care system that supports a young person’s recovery. During residential treatment, on the other hand, a young person’s recovery is supported by a team of mental health professionals, support staff, and other members of the centre’s community.

Residential treatment offers young people a safe and supported environment away from the stresses of everyday life.

It provides the space for young people to carefully address issues of trauma and other underlying concerns and the opportunity to develop new skills and coping mechanisms without encountering triggers, conflicts, or distressing situations that may arise in their home communities.

Residential treatment programs may address co-occurring disorders alongside eating disorders, as well as life skills, education, and the chance to form lasting friendships in a new community.

Enhanced Cognitive-Behavioural Therapy (CBT-E)

CBT-E takes a transdiagnostic approach to eating disorders. It focuses on the shared psychopathology of disordered eating behaviours as an over-evaluation of shape and weight.

Through a series of individual therapy sessions, CBT-E aims to change the thought and behavioural patterns that underpin disordered eating behaviours while supporting young people to develop healthy eating habits and a positive relationship with food.

While initially designed for adults with eating disorders, evidence suggests that CBT-E is also effective for adolescents.

In one study, two-thirds of young people completed the treatment program, all of whom showed substantial weight gain along with a marked decrease in eating disorder psychopathology. Over the next 60 weeks, these positive changes were mostly maintained despite little follow-up treatment. 

The ‘broad version’ of CBT also considers wider psychological issues that may underlie disordered eating behaviours.

Taking a whole-person approach, it addresses issues such as perfectionism, interpersonal difficulties, and low self-esteem alongside other aspects of eating disorder treatment, promoting lasting recovery.

Integrated Trauma and Eating Disorder Treatment

Research shows that experiences of trauma are common among adolescents with eating disorders. One study found that 75% of adolescents entering residential treatment for eating disorders had experienced at least one type of childhood trauma.

Unprocessed trauma and symptoms of PTSD (post-traumatic stress disorder) can complicate the treatment process and cause disordered eating behaviours to restart after the end of a recovery program.

In a move away from one-issue-at-a-time approaches that only address experiences of trauma in the later stages of treatment, research has turned towards eating disorder (ED) programs that integrate trauma therapy from the start.

A recent study found that integrating trauma therapy (based on the principles of cognitive processing therapy) into ED treatment led to significant, lasting improvements in both eating disorder symptoms and symptoms of trauma. 

The Wave Clinic: Transformative Treatment Programs for Young People

The Wave Clinic offers transformative recovery programs for teenagers and adolescents, supporting them to plan and build better futures. Our whole-person approach treats trauma and other co-occurring disorders alongside disordered eating symptoms, helping young people to heal, change, and grow.

The Wave offers a highly specialised treatment program for eating disorders that provides expert medical care and psychological support.

We’re experienced in treating the most complex cases with fun, love, and comfort. We understand that recovery from an eating disorder is challenging.

Our residential programs give young people the opportunity to explore new places, learn life skills, and build lasting friendships throughout their recovery journey, helping them to stay committed to recovery and passionate about the life ahead of them.

If you would like to know more about our programs, get in touch today. We’re here to make a difference.

Fiona - The Wave Clinic

Fiona Yassin is the founder and clinical director at The Wave Clinic. She is a U.K. and International registered Psychotherapist and Accredited Clinical Supervisor (U.K. and UNCG).

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