Family-Based Treatment for Eating Disorders

Traditional approaches to treating eating disorders in children and young adults often involve removing kids from their homes — and their parents — for in-patient psychiatric treatment.

In cases where a young person with an eating disorder needs immediate medical or psychiatric care, in-patient treatment is still recommended. But the treatment experts prefer for most kids with anorexia or bulimia lets kids remain at home, with parents taking the lead in helping them recover. Family-based treatment (or FBT) gives parents the job of strictly supervising the patient’s eating, and evidence shows that it is the quickest way for an underweight child to return to a healthy weight. And in the case of bulimia, parents also learn to monitor the child’s opportunities for binging and purging.

The core of family-based treatment is the assumption that parents are capable of helping a child recover from an eating disorder. “FBT relies on that core parental capacity to feed your child,” says Daniel Le Grange, PhD, one of the founders of FBT and director of the Eating Disorders Program at the University of California, San Francisco. “In practice, it coaches parents to do the same job that nurses in an in-patient program would do.”

Because eating disorders are complex and confusing illnesses that severely disrupt family life, parents of a child with anorexia have often come to doubt themselves, and they may have given up asserting parental authority over the child’s eating. In FBT they take back that role. “Clinicians in FBT reinforce the idea that parents can do this,” Dr. Le Grange says. “We slowly but surely coach them to begin to trust their gut once more.”

In FBT, a clinician guides parents or caregivers in replicating the two major components of in-patient eating disorder treatment: empathy for the child and, in Dr. Le Grange’s words, “an environment in which not eating is not an option.” Just as a parent would insist on treatment for an illness like cancer, even if it is unpleasant, the parent insists that the child comply with FBT guidance. A child with an eating disorder will almost certainly fight eating food that will enable them to gain weight. “But parents need to understand that the disorder is like a malignant tumor,” Dr. Le Grange explains. “They’re not fighting their kid, they’re not trying to make their child’s life miserable. They’re fighting the illness.”

Right at the start of FBT, parents manage their child’s eating, from choosing foods to preparing and serving them. “Essentially, you say to the child: ‘I know this is tough for you, but I’m going to sit here with you until you eat this,’” Dr. Le Grange says. Repeating that process without any exceptions is the core of the initial phase of FBT.

“It can take time,” says Melissa Gerson, LCSW, the founder and clinical director of Columbus Park, a New York City eating disorder treatment clinic. “We may have a parent sitting at the table with the child for an extended period of time, and just waiting for the child to finish.” The idea, she says, is that there’s no room for negotiation. By calmly and confidently directing their child’s eating under a clinician’s guidance, parents are empowered to enforce the boundaries that kids need in order to recover.

Participating in FBT usually means big changes in the family’s routine. For instance, in a two-parent family, the parents might take turns staying home from work to supervise the child’s eating. In single-parent families, it may be necessary to enlist help from extended family or trusted friends. “The first phase of FBT really requires parents to put their lives on hold,” says Dr. Le Grange. Because the treatment can be so disruptive, he emphasizes to parents that eating disorders are an urgent medical threat. “It’s like having a child who’s in renal failure and needs dialysis three times a week,” he says. The change in routine can be hard to manage, but it’s medically necessary.

Ideally, siblings are involved in FBT as well. “Parents are responsible for weight restoration, and siblings are supposed to be supportive of their ill sibling outside of mealtimes,” Dr. Le Grange says. Because the treatment can be stressful and upsetting for the child with the eating disorder, siblings can give the child space to relax and be a kid, away from the structures that the parents impose at mealtimes. Depending on the family circumstances, it may not be plausible to involve siblings without creating more stress, but when possible, they can be an important support system.

In later phases of FBT, the goal is to return decision-making over food intake back to the child or adolescent, once they’ve regained sufficient nutrition and stabilized their weight and behaviors.

FBT has been shown to be efficacious for underweight kids (with anorexia nervosa) and kids with binge eating and purging behavior (bulimia nervosa). FBT has also been used for kids with other eating disorders such as atypical anorexia or ARFID, but the evidence is not quite as robust as it is for anorexia and bulimia.

The thinking behind FBT is that focusing on improving nutrition is more helpful than analyzing the underlying causes of the disorder. That’s because, Gerson explains, “with anorexia in particular, much of the distress around food — and the low mood, and the isolation, and the compulsivity — is caused by starvation. The child is behaving this way mainly because the brain is starved.” Once the child is no longer starving, they’re better able to think through what’s happening and maintain healthier behaviors going forward.

Dr. Le Grange notes that it’s crucial for families to avoid getting trapped in what clinicians call “anorexic debate.” When your child is trying to convince you that it’s fine to eat only salad, he says, “you’re not reasoning with your rational, smart adolescent. You’re having a discussion with a psychiatric illness.” FBT gives parents a structure in which they can avoid those dead-end debates and focus instead on getting their kids nourished.

FBT generally involves roughly 20 weekly sessions, divided into three phases. Throughout all three phases, the clinician works primarily with the parents or caregivers, while being supportive of the adolescent who is in distress. At the start of each session, the child has a short check-in with the FBT clinician to check their weight and get basic mental health support. Then, parents or caregivers, along with the child and sometimes their siblings, meet with the clinician for coaching and support around their work to nourish their child.

The first phase usually lasts for 10 to 12 sessions, and it’s where the bulk of the work takes place. “Phase one is all about re-nourishing the adolescent,” Dr. Le Grange says. During phase one, parents focus on all aspects of the child’s eating.

The child usually does not attend school for the first week or two, in part because they need to conserve energy while they gain weight. Then, if the treatment is going well, the parents might supervise the child a bit less as phase one goes on. “For instance,” says Dr. Le Grange, “by week three the child might go back to school after lunch. And if they keep gaining weight, then maybe by week five the child eats lunch at school, but with a parent or school counselor there to supervise.”

In phase two, which lasts for five or six sessions, the child begins to make some limited decisions about their eating again, and to participate in age-appropriate activities outside of the home. It’s important to move slowly and look out for backsliding in phase two. “These are all very tentative moves, because just a month or two earlier they were still pretty unwell,” Dr. Le Grange notes. “We had a case where the adolescent was doing really well, and they were a very good athlete, but the parents reintroduced physical activity too quickly, and too vigorously, and everything came tumbling down.” If problems do arise in phase two, then the family has to largely return to phase one.

Phase three, the final three or four sessions of FBT, focuses on launching the child back into their normal daily life. It also helps parents learn how to interact with their child again now that their relationship is much less focused on the eating disorder.

If a child or young adult is in a life-threatening medical or psychiatric situation, then hospitalization is necessary. In most other cases of anorexia and bulimia — including those where the young person is very underweight but otherwise medically stable — experts recommend FBT.

Dr. Le Grange emphasizes while FBT might sound daunting, most parents do have the capacity to manage it. “All parents come to us with strengths and weaknesses,” he says. FBT involves coping with each family’s unique challenges and building on their strengths. “And the major strength is that families love their kids,” Dr. Le Grange adds. There are other eating disorder treatments (including enhanced cognitive behavioral therapy, called CBT-E, and adolescent-focused therapy, called AFT) available if FBT doesn’t work or isn’t feasible, but they generally don’t help kids regain weight as fast as FBT does.

Accordingly, Dr. Le Grange urges parents not to rule out FBT, even if their circumstances are challenging. “We have to be creative as clinicians,” he says. That might mean helping parents juggle work responsibilities or financial difficulties, bringing in extended family for support, or helping parents navigate disagreements with each other. “Some situations are much tougher than others, without a doubt,” says Dr. Le Grange. “But that just means that we as clinicians have to work harder and be more supportive.”