The Power of Parents: A Look at Family-Based Treatment
Family-based treatment, or FBT, is a form of treatment for adolescents with eating disorders. It is unique both in its approach, which is probably different from other forms of therapy that families might have tried in the past, and in its efficacy. This means that it works, and is largely more effective than other forms of treatment to which it has been compared. Before I review what FBT actually looks like, let’s review the basic tenets of FBT. This will help put the treatment approach in better context.
The Five Tenets of FBT
1) FBT take an agnostic view of the cause of the illness. The central idea of this tenet is that FBT does not spend time trying to figure out why an eating disorder started. Wondering what caused the eating disorder is a natural question for families to ask. We know that eating disorders are complex illnesses, caused by a “perfect storm” of genetic, biological, personality, and sociocultural factors. Because they’re so complex, we rarely can say for sure why a particular person developed an eating disorder. And even if we could, knowing that information doesn’t necessarily help that person get better. What we do know, however, is that no one is to blame for developing the eating disorder. The eating disorder field has decisively moved away from blaming families for causing the disorder, and FBT instead views parents as the most important resource in their child’s recovery. Likewise, adolescents aren’t blamed for developing their disorder. People do not choose to develop eating disorders. It is not anybody’s fault, and pointing fingers is not helpful for anyone.
2) Parents are empowered to bring about their child’s recovery. As I’ll describe below,
parents play a crucial role in their child’s recovery. Parents often wonder, how can I do this? The simple answer is, because parents know their child best, they love them more than anyone else does, and no one else is as invested in their child’s recovery as parents. And, parents know how to feed their children. After all, they raised a healthy child up until the eating disorder came along. Once it develops, the eating disorder causes parents to second guess themselves and doubt their ability to help their child, but parents have all the knowledge and ability they need. With their FBT therapist’s guidance, parents will access this knowledge and take the lead role in helping their child recover.
3) The FBT therapist takes a “joining” approach to treatment. In other words, the FBT
therapist doesn’t tell parents exactly what to do to help their child get better. Parents often want specific advice, but it’s important to remember that parents are the experts on their own child and their own family. The therapist is the expert on eating disorders and on FBT, but therapists are not in the best position to tell parents how and what to feed their child – parents already know this. This can sometimes feel scary for parents at first, but the FBT therapist will support parents as they regain their confidence and throughout treatment.
4) The eating disorder is “externalized” from the patient. It can be easy for parents to
become frustrated with their child when they see them restricting their food intake, or engaging in binge eating or purging. Parents might notice that their normally happy, respectful child turns into a different person at mealtimes. It is vitally important for parents to remember that in those cases, they are not dealing with their normal, healthy child. In those cases, they are interacting with the eating disorder. Eating disorders are powerful disorders that overtake people, particularly when it comes to issues of food, eating, shape, and weight. Instead of blaming these unwanted behaviors on the person, FBT places the blame where it belongs: on the eating disorder. That’s why many families in FBT will name the eating disorder, sometimes “Ed”, so that parents can remind themselves during frustrating moments that they are battling with the disorder, not their child. This can keep parents from getting angry at their child, which is critical for the success of the treatment.
5) FBT takes a pragmatic approach to treatment, focusing on the here-and-now. Eating
disorders are dangerous and potentially fatal illnesses, with possible long-term medical consequences, perhaps particularly for still-growing adolescents. Early, effective intervention is crucial to help adolescents avoid these long-term consequences and recover as quickly as possible. So, the FBT therapist keeps a laser-like focus on bringing about the behavioral changes necessary to help achieve this recovery. Parents may want to talk about other issues, like how their child seems more depressed, or is having difficulty concentrating at school, or doesn’t want to spend as much time with their friends anymore. The truth is, these issues are usually secondary to the eating disorder and will often resolve themselves quickly with the resolution of the illness.
The Three Phases of FBT
To fully understand FBT, one of the most important things to understand is that eating disorders have profound and deleterious impacts on a person’s cognitive functioning. Anorexia nervosa in particular is what is called an “ego-syntonic” disorder. Simply put, what this means is that for people with anorexia nervosa, there is a part of them that is ambivalent, at best, about getting better. As unhappy as the disorder makes them, they may be reluctant to let go of it and embrace recovery. But, these are dangerous disorders, as we just discussed. This is a bad combination! Adolescents with eating disorders generally cannot get better on their own because the disorder has too strong of a hold on them. This is why parents play such an incredibly important role in treatment.
1) Phase one. Because the eating disorder will not let the ill person make smart and healthy
decisions about what they need to eat and do in order to get better, parents take over this role for them, just temporarily, until the adolescent is able to do it again themselves. In practice, what this means is that parents will make all eating-related decisions for their child during the first phase of FBT. Again, this may sound scary, but the therapist guides parents through this process until they are ready to move on to phase two.
2) Phase two. Once the adolescent has gained weight and/or stopped binge eating or
purging, and the eating disorder thoughts have begun to improve, then choices regarding eating will gradually be handed back to the adolescent, to whatever extent is age appropriate and normal for that particular family.
3) Phase three. The last phase of FBT reviews healthy adolescent development and ensures
that the patient is back on track and feels equipped to face upcoming developmental challenges without reverting back to the eating disorder to cope with stressors.
FBT is generally 10-20 sessions over 6-12 months, with sessions starting weekly and gradually spacing out to every 3 or 4 weeks by the time families get to phase three. FBT is not family therapy in the traditional sense; the focus is squarely on mobilizing family resources to help the adolescent recover from the eating disorder.
When to Consider FBT
FBT is the most efficacious treatment available for adolescents with eating disorders. A sizable body of research has repeatedly shown that it is the best option for families today, and in fact, it is the leading form of treatment for adolescents with eating disorders according to the national practice guidelines of the US, the UK, Canada, Australia, and New Zealand. I would encourage families to consider FBT at the first sign of any concerns they might have about their child’s eating behavior.
Concerning symptoms may include the following:
· Significant and/or rapid weight loss or weight gain
· Food missing (due to binges)
· Evidence of self-induced vomiting or laxative misuse
· Overexercising
· Excuses being made to avoid eating meals with the rest of the family
· Increased irritability, anxiety, or depression
· Increased preoccupation with weight, food, calories, or exercise
· Negative body talk
· Increased use of social media related to dieting or appearance
· Difficulty concentrating
· Food rituals (e.g., cutting food into small pieces, eating foods in a certain order)
Again, early, effective intervention is critical to preventing long-term damage and keeping the eating disorder from becoming chronic. Eating disorders become more difficult to treat as time goes on, as the disorder becomes more entrenched in a person’s personality, identity, and way of thinking. Parents should trust their gut and seek treatment as soon as they are concerned, even if they are unsure that their child has a full-blown eating disorder. There is no need to wait for things to become worse before starting FBT. It is also important for parents to keep in mind that they should seek treatment quickly, regardless of whether or not their child is in agreement with the plan. Chances are, they won’t be. This is a situation in which parents need to do what is best for their child, even if it might make their child unhappy in the short term. Ultimately, this important decision could save their life.
By Dr. Renee Rienecke
