Family Based Treatment (FBT)
Family Based Treatment (FBT)
- Anorexia Nervosa
- Bulimia Nervosa
- Avoidant-Restrictive Food Intake Disorder (ARFID)
- Binge Eating Disorder (BED)
- Other Specified Feeding or Eating Disorders (OSFED)
- Family-Based Treatment for Transition-Aged Youth (FBT – TAY)
- Parent-Focused Treatment (PFT)
- Family-Based Treatment + Cognitive-Behavioral Therapy (FBT + CBT)
Family-Based Treatment (FBT), also known as The Maudsley Method, is a highly practical, solution-focused, evidence-based treatment for eating disorders that enlists the patient’s family as a vital resource in supporting recovery at home. Clinical trials have demonstrated that FBT is more effective than individual therapy in helping patients achieve and sustain remission from eating disorders. Initially developed to treat adolescent anorexia nervosa, FBT has been adapted to treat Bulimia Nervosa, Binge Eating Disorder, and Avoidant-Restrictive Food Intake Disorder (ARFID).
FBT involves three distinct phases. In Phase I, parents are empowered to take charge of their child’s eating behaviors and interrupt eating disorder symptoms. It is understood that the eating disordered patient is suffering from a brain illness which is largely beyond his or her control, and thus needs significant parental support to overcome his or her symptoms and restore health. Phase I typically involves parents choosing, preparing, and supervising the child’s meals and snacks. For anorexia nervosa and other restrictive eating disorders, the primary goal of Phase I is to re-nourish the patient, helping her to restore weight steadily until she reaches her individualized optimal body weight range. For Bulimia Nervosa and Binge Eating Disorder, Phase I involves eliminating dieting and re-establishing a pattern of structured, normalized meals and snacks at regular intervals to interrupt binge eating behaviors. When patients have purging symptoms, parents step in to support their child after meals by providing emotional support, distraction, and supervision.
Phase II begins when the patient is well-nourished, weight-restored, medically healthy, and abstinent from binge/purge behaviors. The goals of Phase II are to re-establish normal eating patterns and to help the patient re-learn to eat on her own with an age-appropriate level of independence. Parental supervision and support are gradually withdrawn as the patient demonstrates increasing ability to make health-promoting food choices without resorting to eating-disordered behaviors.
Phase III begins when the patient able to eat with an age-appropriate level of independence while maintaining a healthy weight and remaining abstinent from binge/purge behaviors. Eating disorders cause significant disruption to adolescent development and place major strain on an entire family. The goals of Phase III are for the patient to re-establish a healthy identity independent of the eating disorder and for the family to resume a normal life, which is finally possible, now that the eating disorder is in remission. Any individual or family struggles that have been put aside while dealing with the eating disorder are now brought into sessions for discussion and resolution. If the patient is struggling with a co-morbid condition, such as an anxiety disorder or depression, or is still experiencing lingering psychological effects of the eating disorder, such as body image distress or difficulty with emotion regulation, she may begin individual therapy with me during Phase III to address these issues. Relapse prevention planning is also part of Phase III.
A full course of FBT typically requires approximately 20 – 25 sessions over the course of 12 months. However, the length of treatment and time to recovery varies considerably based on the type of eating disorder diagnosis, the severity of the eating disorder, and the presence of comorbid conditions.
- Anorexia Nervosa (AN) is a potentially fatal, highly heritable, neuro-behavioral illness characterized by restriction of food intake, weight loss, and inability to perceive one’s body size and shape accurately. Many individuals with AN have an extreme fear of eating and weight. AN may lead to a variety of severe medical and psychiatric consequences, including cardiac complications, osteoporosis, hypothermia, depression, obsessive-compulsive behaviors, amenorrhea, kidney failure, infertility, and suicide. Scientific research has demonstrated that the risk of developing AN is largely genetic. Other variables, such as puberty, temperament, and experience, also play a role in the manifestation of this illness. For those who are predisposed to AN, an energy deficit (consuming fewer calories than the body requires to meet energy needs) caused by dieting, illness, stress, athletic training, or a simple decision to “eat healthy,” triggers a self-perpetuating cycle of decreased food intake and weight loss. Once AN is set into motion, it becomes extremely difficult for the person to break free from this cycle without significant support. AN has the highest mortality rate of any psychiatric disorder.
- Although the disorder typically begins in adolescence, AN occurs in people of all genders, all ages, and all shapes and sizes. It is not possible to tell if someone has AN simply by looking at them. While many people with AN have a thin or “underweight” appearance, others appear to be “normal weight” or even “overweight.” In fact, recent research indicates that nearly 1/3 of individuals who are hospitalized for AN are not underweight. Further, given that nutritional and physical recovery usually precede psychological recovery, people who are recovering from AN may appear to be “healthy” and “normal” based on their body size, while still suffering tremendously from food anxiety, body dysmorphia, depression, or other mental symptoms.
- In FBT for AN, parents are empowered to take control of their child’s eating habits to reverse the process of starvation, require her to consume full nutrition, and support her in restoring a healthy weight and healthy body functions. Once physical health is achieved and weight is fully restored, control over eating is gradually returned to the patient as she demonstrates ability to maintain her weight and eat independently at an age-appropriate level. In the last phase of treatment, any lingering psycho-social issues are addressed, the family is supported in re-establishing a normal family life, and the patient and family collaborate with me to develop a written relapse prevention plan.
- The length of time required to complete FBT varies dramatically depending on individual and family variables. Some individuals – typically those with milder symptoms and no comorbid conditions – may complete FBT in as little as 6 months. Others – typically those with more severe forms of AN who have been ill for longer and also suffer from comorbid disorders – may take 2-3 years to complete their treatment. In my practice, weight restoration through FBT is completed in an average of 3.6 months, and a full course of FBT resulting in full recovery requires an average of 27 sessions over the course of 17 months.
- Bulimia Nervosa (BN) is a serious, potentially life-threatening eating disorder involving repeated cycles of binge eating followed by compensatory behavior such as self-induced vomiting, laxative abuse, fasting, strict dieting, or compulsive exercise. In most cases, BN is initially triggered by dieting and weight suppression. Many individuals who suffer from BN also experience depression, anxiety, substance abuse, or other mental health disorders.
- In Family-Based Treatment for BN, the restrict-binge-purge cycle is discussed openly among family members in an environment free of blame, guilt, and shame so that patterns and triggers can be identified. Parents are empowered to interrupt their child’s binge-purge cycle by requiring complete, balanced, structured meals and snacks at regular intervals, ensuring that their child is always well-nourished. Parents also learn to prevent episodes of binge eating and purging by providing emotional support, supervision, and distraction at their child’s most vulnerable times. When the patient has established a consistent pattern of balanced meals and snacks and has been abstinent from binge/purge symptoms for a period of time, control over eating is gradually handed back to the patient. Once the patient is able to eat healthfully with an age-appropriate level of independence, any lingering individual or family issues are addressed. In some cases, this may mean that the patient begins individual therapy sessions with me to address depression, anxiety, body image distress, or other issues. In the final phase of treatment, the patient and family collaborate with me on a written relapse prevention plan. A full course of FBT for Bulimia Nervosa resulting in full recovery typically involves an average of 20 sessions over the course of 6-12 months.
- Avoidant-Restrictive Food Intake Disorder (ARFID) is a relatively new diagnostic category which describes an eating disturbance resulting in failure to meet one’s nutritional needs. Individuals with ARFID may experience weight loss, failure to gain weight and grow as expected, significant nutritional deficits, and/or significant interference with social functioning as a result of their food avoidance or restrictive eating patterns.
- Several subtypes of ARFID have been identified: 1.) Those who lose weight or experience nutritional deficiency due to poor appetite or apparent lack of interest in eating, 2.) Those who are extremely picky eaters and avoid many foods due to sensory sensitivities, and 3.) Those who avoid eating based on fear of the potential negative consequences of eating. The latter category encompasses individuals who restrict food intake due to fear of swallowing, fear of vomiting, or fear of abdominal pain.
- FBT for ARFID enlists parental support in helping the patient overcome their food restrictions and avoidances. The specific strategies used and goals of treatment will differ depending on the patient’s symptoms. For selective eaters, parents work with the therapist to gradually expand the patient’s variety of foods to ensure balanced nutrition. For those who have lost weight or failed to gain weight due to ARFID, parents are empowered to ensure that their child increases his caloric intake, gains sufficient weight, and begins to grow as expected. For individuals who have a fear of vomiting or swallowing, parental support is enlisted to help the patient challenge the thoughts, beliefs, and behaviors that perpetuate the illness.
- Binge Eating Disorder (BED) involves recurrent episodes of binge eating which cause significant distress. A “binge” is defined as eating, in a discrete period of time, a much larger amount of food than what most people would eat under similar circumstances, and feeling a lack of control over eating during the episode. Individuals with BED often feel ashamed, disgusted with themselves, and guilty after eating binges. Over time, BED often leads to unwanted weight gain, poor self-image, depressed mood, and avoidance of previously enjoyed activities.
- It is not possible to tell whether a person has BED simply by looking at them. While most people with BED are overweight or obese, the majority of overweight and obese individuals do not suffer from BED. Further, some individuals who suffer from BED are slim or average weight.
- Many individuals begin dieting after developing BED. In fact, a sizeable portion of people who seek treatment at weight-loss centers are actually suffering from undiagnosed BED. In other individuals, binge eating begins as a response to the chronic food deprivation of dieting. Either way, dieting is an unhealthy behavior which is very likely to trigger, perpetuate, or exacerbate binge eating. For this reason, a key component to treating BED is abandoning the diet mentality and instead developing balanced, nourishing, sustainable eating habits along with enjoyable physical activity.
- Family-Based Treatment for BED enlists parents to help their child stop dieting and establish a consistent pattern of eating balanced meals and snacks at regular intervals, consuming enough quantity and variety of food to interrupt the urge to binge. Parents and children are assisted in developing effective patterns of communicating around food and urges to binge so that parents can help to support, distract, soothe, or redirect their child at times when he is more vulnerable to binge eating (e.g., after a very stressful day, while feeling lonely or bored).
- Other Specified Feeding or Eating Disorders (OSFED) is a diagnostic category which encompasses individuals who experience significant distress, impairment in functioning, and/or health risks due to an eating disturbance, but do not meet full criteria for another eating disorder diagnosis. OSFED encompasses a wide variety of symptom presentations, including Purging Disorder, Night Eating Syndrome, and patterns of food restriction, binge eating, and/or purging that do not fit neatly into other diagnostic categories. OSFED is more prevalent than any other eating disorder diagnosis.
- FBT for OSFED differs depending on the specific symptoms that the patient is experiencing and the goals of treatment. When food restriction is involved, parents assist their child in re-establishing patterns of full nutrition. When weight is suppressed, parents create an environment at home that is conducive to weight restoration. When binge or purge symptoms are present, parents collaborate with their child to identify triggers and set limits around these symptoms by providing support, supervision, and distraction.
- Family-Based Treatment for Transition-Aged Youth (FBT – TAY) is a modification of standard FBT which is used for college students and young adults (ages 17-25). Just like in traditional FBT, parents are fully informed and actively involved in treatment at every step of the process, and parents are empowered to take an active role in interrupting eating disordered behaviors by providing meal support, facilitating weight restoration, and stopping binge/purge behaviors. However, FBT-TAY differs from standard FBT in that the patient is invited to play a more active role in her treatment from the beginning by collaborating with her parents and therapist. Older teens, college students, and young adults are naturally more independent and capable than younger adolescents, and are usually very invested in maintaining that independence (or regaining it as soon as possible, if they have lost it due to illness). FBT-TAY encourages parents to utilize privileges and financial support as leverage to inspire their young adult child to participate in treatment and engage in recovery-oriented behaviors. While parents are usually the most actively involved members of the support team in FBT-TAY, this approach often utilizes a broader support system as well, which may include a romantic partner, roommate, adult sibling, or best friend. Most young adults live at home temporarily while undergoing FBT-TAY; for example, by taking a leave of absence from college for a semester or a year. However, in some instances, the patient may not be living with her parents, and other support persons play a more active role in these cases.
- Parent-Focused Treatment (PFT) is an alternative version of Family-Based Treatment (FBT) in which the parents participate in therapy sessions but the patient herself does not attend the sessions. In PFT, the patient’s participation in treatment is limited to a weekly weigh-in, which may be done in my office, at home under parental supervision, or at a physician’s office. In PFT, as in FBT, parents are the primary vehicles of change in early recovery. I typically use PFT as an alternative to FBT in situations where the patient is very young, very anxious, very angry, and / or very resistant, to the point that she is unwilling or unable to participate meaningfully in therapy sessions. PFT empowers parents to create an external structure and safety net around the patient and guide her towards recovery, despite her inability to engage in treatment or her refusal to attend sessions. In many cases, as the patient heals and moves closer to recovery, she develops a willingness and an ability to participate in therapy and begins attending sessions with her parents. Research has demonstrated that PFT is even more effective than FBT in helping patients achieve full remission.
- Family-Based Treatment + Cognitive-Behavioral Therapy (FBT + CBT) is an effective combination of therapies that I often use concurrently for Bulima Nervosa, Binge Eating Disorder, and Avoidant-Restrictive Food Intake Disorder (ARFID). With this combination of therapies, sessions are often divided in half, with the patient receiving individual CBT for the first half and the parents joining the session for the second half. Some patients with Anorexia Nervosa transition into individual Cognitive-Behavioral Therapy in Phase III of FBT, or after completing a course of FBT, to address lingering symptoms or co-morbid conditions.