Family Based Treatment (FBT) for Eating Disorders in the San Francisco Bay Area

FBT is currently the front-line treatment for adolescents and young adults with eating disorders in the outpatient setting. FBT, also known as the Maudsley Method or Maudsley Family Therapy, are terms used interchangeably as they support the same approach to recovery: families take a central approach to their loved one’s recovery with the support of trained clinicians.

FBT has three phases, with the initial phase focused on ‘refeeding’ efforts and helping your loved one become medically safe. This may require weight restoration or it may just refer to stopping eating disorder behaviors. Weight restoration, if needed, and behavioral change are the first goals of treatment because an undernourished brain is often an anxious brain and one that is usually less interested in making positive changes. We can’t expect psychological shifts to happen until the brain becomes nourished and essentially comes back online. This same is true for individuals who may not be underweight but struggle with compensatory behaviors (eg. purging, excessive exercise, etc.) or find it difficult to get a wide variety of nutrition in. FBT supports caregivers to take a highly structure approach to eating at home and to help their loved one challenge eating disorder thoughts and urges until they are able to do this on their own.

Once the young person with an eating disorder is medically stable and able to eat with regularity, caregivers begin to transition autonomy back over to the person in phase two.

Lastly, phase three focuses on supporting the young person with processing development issues and what are known as ‘maintaining factors’. This essentially refers to all of the things that if left unaddressed may cause relapse down the road. Maintaining factors may address family dynamics, such as shifting the whole family’s approach to eating, or may be more intrapersonal, as in identity formation. See more about the three phases of FBT below.

FBT originated in the 1980’s at the Maudsley Hospital in London. In an effort to reduce inpatient hospitalizations for young persons with eating disorders, the hospital staff brought in family members and trained them in how to be the most effective caregivers for their loved one’s recovery. Turns out, family can really help the healing process because repeat hospitalizations reduced significantly and people started getting better.

Since that time, FBT has been studied all over the world and has demonstrated to be a highly effective treatment, especially for newly diagnosed eating disorders in adolescence. We’ve learned that resourcing caregivers will skills and education, coupled with professional support, has demonstrated to have the most effective long-term outcomes.

Family Based Treatment has five core principles:

-Agnostic view of illness: Meaning we don’t want to get sidetracked trying to figure out why the eating disorder developed. Eating disorders are multifactorial and quite complex, so this can take us down a never-ending rabbit hole. We ultimately don’t need to know the ‘why’ to know how to treat eating disorders.

Initial symptom focus: FBT prioritizes full nutrition and prevention of eating disorder behaviors as the first step. For anyone to recover from an eating disorder, their brain needs to be nourished.

Family is responsible for refeeding efforts: Caregivers provide full nutrition by taking charge of meals for their loved one.

Non-authoritarian stance: Caregivers are seen as the experts on their loved one. Clinicians actively collaborate with caregivers; they are essential members of their loved one’s treatment team.

Externalization of illness: The illness is seen as an external force that has taken over the person and is attacking their health. Caregivers and providers join forces with the healthy part of the teen to fight off the eating disorder.

While FBT is considered the ‘gold standard’ for eating disorder treatment for young persons (children, adolescents, and transitional aged youth (18-24yo), FBT may not be right for every family. If FBT is not indicated, your treatment team will outline a more effective treatment approach for your family. Adolescent-Focused Therapy (AFT) is the runner up intervention that is most often considered when FBT is not used. Outcomes research on FBT and AFT informs us that both treatment interventions have positive outcomes, yet FBT has demonstrated greater positive markers of recovery in a shorter amount of time, and AFT has shown to be less effective on more severe cases.

AFT also focuses on creating behavioral change, like stopping eating disorder behaviors and swapping these out for healthier coping mechanisms, while simultaneously working on achieving medical stability, including weight restoration if needed. Unlike FBT where caregivers take the lead for refeeding their loved one, AFT empowers the teen to take the lead in their recovery. The teen and treatment team work collaboratively to identify what topics, processes, and behaviors to address. With this model, caregivers are still involved in the recovery in a supportive manner but have a less directive role.

There are alternative approaches to eating disorder recovery in addition to FBT and AFT, including the following:

-Cognitive Behavioral Therapy for Eating Disorders (CBT-E)

-Dialectical Behavioral Therapy (DBT)

-Acceptance and Commitment Therapy (ACT)

Your treatment team will be sure to review all of the recommended approaches with you to best determine which one is right for you.