Family-Based Treatment

What is Family-Based Treatment?

Family-based treatment (FBT) is a therapeutic approach that was developed in the 1980s for management of anorexia nervosa [1]. In FBT, the therapist has an agnostic view where no time is spent analyzing why the eating disorder developed. In this approach, food is seen as “medicine” and the therapy prioritizes full nutrition recovery and prevention of disordered eating behaviours [2].

Family-based treatment is an outpatient therapeutic method for children and adolescents with a diagnosis of anorexia nervosa or bulimia nervosa [3].  In this therapeutic approach parents or guardians learn how to help their struggling child or adolescent using both the behavioural and psychological strategies necessary for weight restoration and eating disorder recovery [1]. An advantage of FBT is that it empowers families to address and reverse the factors that maintain the eating disorder [4]. A common misconception of FBT is that it involves force-feeding, but it is no different than what is done in a hospital or residential treatment program [5]. In fact, FBT is advantageous compared to the aforementioned programs as it utilizes the deep parental understanding of their child and love which empowers families to refeed their child at home [1].

 

Family-based treatment is the recommended approach for children and adolescents with anorexia nervosa and bulimia nervosa [6].

What does Family-Based Treatment involve?

Generally, FBT is divided into 3 phases which take approximately 1 year of therapy. The table below outlines the estimated duration as well as an explanation of what the phase involves [2].

Why is Family-Based Treatment recommended?

As FBT is the gold standard of care for children and adolescents with eating disorders, there are many benefits to this therapeutic approach [7]. One of the cornerstones is that the therapeutic approach centers on the family [2]. Traditional treatments for eating disorders in children and adolescents postulated that the eating disorder was a result of an adolescent’s struggle for independence and placed blame on the parents [2]. However, more recent research demonstrates that families do not cause eating disorders. Eating disorders are complex mental illnesses resulting from an interplay of predisposing factors (ex. genetic vulnerability), precipitating factors (ex. perfectionism, trauma, LGBTQ+ youth), and perpetuating factors (ex. physiological consequences of starvation) [8].  In fact, parental blame can have a negative impact on treatment and outcomes [4]. As such, FBT is recommended because it repositions parental behaviours by empowering parents to refeed their child [4].

High quality research studies have demonstrated that among children and adolescents with anorexia nervosa undergoing FBT had higher weight gain and remission rates compared to individual treatment methods [6]. Similarly, children and adolescents undergoing FBT with bulimia nervosa had significantly higher remission rates compared to cognitive behaviour therapy and supportive psychotherapy [6].

 

Supporting your child through this process

To best support your child during FBT it is important to understand the thoughts and feelings your child is experiencing, including: fear, anxiety, shame, and beliefs. For example, your child may be fearful of eating and weight gain. Similarly, they may have anxiety around food and losing control over what they are eating and they may be ashamed of their eating disorder. Therefore, it is important to demonstrate empathy, seek to understand, and ensure that your child is aware of your commitment to them. You may consider saying things such as “we believe in you, we’re not giving up on you, and/or we’re always here for you.” You may also consider asking your child to explain what they are feeling and to describe what they are going through [9].

It is likely that your child is experiencing fear during mealtimes, so we’ve included strategies you can try to use to support your child during meals.  For more information check out this video and website by Eva Musby, a parent that has gone through FBT and refeeding her child.

 

Strategies to help your child during meals

 
  • Eat alongside your child and remember that it is okay to eat less than them.
  • Provide distraction before, during and after meals using games, conversation, or television.
  • Try to avoid using logic. People with eating disorders experience a lot of anxiety which heightens their nervous system, limiting their ability to be rational and think logically.
  • Use confidence and explain to them that you’re the expert, and that they can trust you.
  • Try to avoid discussing ingredients and calories with your child. It is best to provide affirmation and confirmation.
  • Use direct prompts such as “have another bite”, “please keep going” or “have a bite of (something specific on their plate)”.

Finally, to support your child through the FBT process it is imperative that you continue to take care of your own wellbeing and needs as research shows high rates of caregiver burnout.

 

Conclusion

Recovery from eating disorders is greatest for patients who are treated early in the course of their illness. Based on the current literature, the 2020 Canadian Practice Guidelines make a strong recommendation for the treatment of children and adolescents with anorexia nervosa or bulimia nervosa with FBT. If you worry that your child or adolescent is suffering from an eating disorder and don’t know where to turn to for FBT  please reach out to our team at info@sooma.ca or 514-437-4260.

Written by

Aviva Rappaport

Registered Dietitian

References

  1. The Treatment of Eating Disorders: A Clinical Handbook. New York: The Guilford Press; 2010.
  2. Lock J, Le Grange D: Treatment manual for anorexia nervosa: A family-based approach. Guilford publications; 2015.
  3. Hamilton Health Sciences: Family Based Treatment. In Adolsecent Medicine: Hamilton Health Sciences; 2015.
  4. Lian B, Forsberg SE, Fitzpatrick KK: Adolescent Anorexia: Guiding Principles and Skills for the Dietetic Support of Family-Based Treatment. J Acad Nutr Diet 2019, 119:17-25.
  5. What is Family-Based Treatment [https://www.feast-ed.org/what-is-family-based-treatment/]
  6. Couturier J, Isserlin L, Norris M, Spettigue W, Brouwers M, Kimber M, McVey G, Webb C, Findlay S, Bhatnagar N, et al: Canadian practice guidelines for the treatment of children and adolescents with eating disorders. J Eat Disord 2020, 8:4.
  7. Nutrition Care FAQs [https://www-nutritioncaremanual-org.proxy3.library.mcgill.ca/topic.cfm?ncm_toc_id=270538]
  8. Treasure J, Schmidt U: The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. Journal of eating disorders 2013, 1:1-10.
  9. Parent and Caregiver’s Guide to Eating Disorders [https://bodyprideca.files.wordpress.com/2019/05/nedic-parent-resource-web-version.pdf]

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