Being a parent of a child or teenager who struggles with an eating disorder can be scary, and then some. Family-Based Treatment (FBT) can provide structure and support for the recovery process.
Because eating disorders are so complex and consuming, it might even feel like your child has turned into an entirely different person. You probably also feel like there’s a huge strain on your relationship with them that wasn’t there before.
First, let me validate that you’re not alone here. It’s common (and natural) to have all of these feelings and more when your child is struggling with an eating disorder.
At Ruby Oak Nutrition, we offer nutrition support for teens who struggle with eating disorders and disordered eating. Although treatment looks different for everyone, we most often use a Family-Based Treatment (FBT) model.
Family-Based Treatment (FBT) is an evidence-based approach to the treatment of eating disorders, particularly for adolescents and young adults.
Also called the Maudsley Method, family-based treatment is an alternative to other forms of eating disorder treatment (like residential or inpatient care) for adolescents. (Note: Sometimes residential or inpatient treatment is necessary, and family-based treatment isn’t an option.)
In FBT, parents take on a very active role in their child’s recovery from an eating disorder. Parents completely take over planning and preparing meals, and are responsible for making sure that their child completes all meals and snacks.
Because FBT is challenging, it’s crucial to work with a treatment team — a therapist, primary care doctor, and dietitian at the very least. As dietitians, we help parents plan meals that contain the right amount of energy and nutrients. We also provide support for parents during the FBT process, since getting an adolescent who’s stuck in an eating disorder to complete meals can be really challenging.
FBT involves the whole family in the treatment process and aims to empower parents or caregivers to play an active role in supporting their loved one’s recovery. Here are the three phases of FBT:
- Phase One: Weight Restoration.
In the initial phase of FBT, the focus is on restoring the client’s (AKA the adolescent’s) weight to a place that’s appropriate for them. This target weight is typically set by a physician, but might be set by a dietitian in some cases. (More on that below.) In order to reach this weight, the dietitian will outline a flexible meal plan that provides adequate nutrition for weight gain.
Parents or caregivers are responsible for ensuring that the client eats according to this plan, and monitoring their behavior to prevent any compensatory behaviors like purging or over-exercising. During this phase, the dietitian sometimes works primarily with the client’s parents/caregivers to coach them through feeding their adolescent.
- Phase Two: Returning Control to the Client
Once the client’s weight is at a level that’s appropriate for them, the focus shifts to gradually returning control over eating to the client. Both the client’s dietitian and their therapist are crucial in this process. The dietitian and therapist will also help guide the family in empowering the client to make their own food choices and manage their eating behaviors.
During this phase, the client will slowly start plating their own meals and making decisions about what to eat. They’ll have more autonomy over their food choices, and will be able to spend more meals away from their parents. Learning to cook, or learning to cook new things, can also be a part of this phase.
- Phase Three: Establishing Healthy Adolescent Identity
The final phase of FBT aims to help the client develop a healthy adolescent identity, which includes a healthy relationship with food and a positive self-image. The client will continue working with their therapist to identify and address the emotional and mental health aspects of the eating disorder.
It’s recommended that the client continues working with their dietitian during this phase as well. It typically takes years to fully recover from an eating disorder, so a dietitian can help manage anxieties around food that continue coming up. Dietitians can support the work done in therapy sessions by providing accountability for food choices, supporting the client in pushing back against eating disorder thoughts, and helping with meal planning and preparation.
Family-based therapy has been found to be effective for a wide range of eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder.
When done properly, FBT essentially mimics a treatment center environment, but from within the client’s home.
The benefits of FBT over residential treatment include:
- No need to miss school
- Sleeping in your own bed every night
- Not being separated from family for an extended period
- Outpatient treatment is less expensive than residential treatment
- No risk of being triggered by other adolescents who are also struggling with eating disorders at the treatment center
- You can stay with your existing outpatient providers
The challenges of FBT include:
- It can be tough on the relationship between parents/caregivers and the child
- A parent will need to understand the meal plan, then prepare and be present for every meal
- You’ll be home, but your life will feel different than normal because you won’t have as much freedom
- You won’t be able to do sports or other types of movement — for some people, this means lots of extra free time
- You’ll need to go to several weekly appointments with your doctor(s), dietitian, and therapist
FBT is the right choice for some people, but it’s not for everyone! It’s absolutely OK to realize that FBT isn’t working for you, and that residential or intensive outpatient treatment would be a better fit. It doesn’t mean that you’ve failed as a parent if you’re not able to keep up with FBT. Many, many parents struggle with it because it really strains their relationship with their teenager. We’ve heard many eating disorder clinicians say that they’re not sure they’d be able to do it with their own children!
A little more about weight restoration and appropriate body weights…
As mentioned above, phase one of family-based treatment lasts until the client is at their appropriate body weight, also called an estimated body weight (EBW). This weight is typically set by a doctor, but sometimes it’s set by the dietitian.
EBWs are often a point of contention for clients (and sometimes their parents, too!). They’re individual, and based on a client’s growth charts — which, ideally, go as far back as birth. An eating disorder specialist will look at the client’s growth charts and see what percentile their height, weight, and BMI have typically fallen on throughout their lives. Most people trend along a certain curve (for example, the 40th percentile, or the 90th percentile) pretty consistently throughout adolescence.
During an eating disorder, many adolescents ‘fall off’ their curve — AKA, their weight drops below the percentile they’ve been trending on. For example, they might go from the 55th percentile to the 25th, or from the 90th percentile to the 50th. The goal of weight restoration is to get the client back on their growth curve. If they’ve been trending along the 90th percentile throughout adolescence, their estimated bodyweight will be set around the 90th percentile. If they’ve been trending on the 40th percentile, their estimated bodyweight will be set around the 40th percentile.
This can create lots of fear and anxiety for both the clients and their parents. If someone has trended at a higher percentile throughout their life, they may feel that an estimated bodyweight in a lower percentile would be a more appropriate target. But, getting back on their established growth trajectory really increases the chances of a full, permanent recovery.
If you’re struggling with an eating disorder or disordered eating, we can help! We’re a group of dietitians who takes an anti-diet, body-positive, identity-affirming approach to recovery and healing your relationship with food. . Learn more about nutrition counseling, offered in Raleigh, NC, and virtually to clients in several states. Not ready to commit to counseling but want more information about the anti-diet approach? Subscribe to our weekly newsletter.