Pros and Cons of Family-Based Treatment, 2021 Edition
Written by CCTC Staff Writer
Watching a child become consumed by an eating disorder is one of the hardest things a caregiver will ever have to watch. Many treatment options leave family members feeling powerless to help. They want to help the child recover more than anyone else, yet feel left out of the process. Family-based treatment was designed to empower caregivers to play an active role in their child’s recovery, rather than distance them during the recovery process.
Caregivers, siblings — everyone in the household, really — plays a crucial part in family-based treatment (FBT).
Read on to learn about:
The definition and philosophy behind FBT (also known as the Maudsley method, although this term is used less now)
The three phases within the treatment timeline
Who FBT is suited for
Strengths and limitations of this treatment modality
Advancements and modifications of FBT practices
Caregivers do not have to sit on the sidelines when it comes to recovery, even if they can’t do family-based treatment. They can always be a source of support.
Family-Based Treatment (aka Maudsley Method): Development and Practical Usage
FBT is the manualized (formally written down) version of the Maudsley method of treating children and adolescents with eating disorders. This evidence-based eating disorder treatment takes place in the family’s home. This is different from other types of treatment, where the one receiving treatment is removed from the home for a specific period of time.
The idea behind doing treatment at home is that placing a child or adolescent in the hospital or a residential program may be unnecessary, and in some cases, traumatizing. It’s also thought that the child’s family wants to help the most, so they should play the main part in treatment.
Family members are taught how to help the sufferer by a qualified professional. This professional should be (but is not always) someone who specializes in FBT. The entire household engages in therapy, which usually takes place once a week throughout the course of treatment.
Related: Specialization is one of four things to consider during your search for an eating disorder therapist.
3 Phases of Treatment
FBT takes an “agnostic view” on the cause of the adolescent’s illness. This just means that FBT does not focus identifying the things that contributed to the development of the eating disorder. Neither the patient or the caregivers are blamed for the eating disorder.
The main focus is on avoiding higher levels of care. The only way to do this is by restoring physical health and stopping eating disorder behaviors. So, the course of treatment is focused more on behavioral aspects of eating disorders, rather than the thoughts associated with eating disorders.
Phase 1
FBT was originally developed for sufferers of anorexia, so the first phase of treatment focuses on rapid weight gain. It also focuses on immediately stopping behaviors.
In the first session, the clinician conveys the severity of the illness. They also provide education, coaching, and empowerment strategies to caregivers. This information helps them manage their child’s refeeding process. But otherwise, carers are entirely responsible for the refeeding process.
Caregivers take control of the sufferer’s eating and exercise patterns. They decide when the child eats, what they eat, and make sure they do not hide or purge food. Caregivers also monitor the child for secret exercise and other purging behaviors.
It is usually an exhausting process. But FBT prescribes the idea that someone suffering with anorexia can’t see how unhealthy they are, and can’t be allowed to make their own choices.
During this phase, the family’s therapist externalizes the eating disorder. They explain to the family during their first sessions that the child and the eating disorder are two separate beings. And the child is being controlled by the eating disorder. They are forced by the eating disorder to engage in maladaptive behaviors.
Related: How do you tell the difference between your eating disorder self and your true self?
Externalizing the illness makes it easier for caregivers to be firm about when, what, and how the adolescent will eat. It gives everyone in the family a common enemy to unite against. And, in cases where arguments break out, it helps carers understand why their usually sweet child is being so frustrating and resistant.
The FBT manual states that patients are supposed to be weighed at the beginning of each session. The weigh-in sets the tone of the session.
But over one-third of therapists do not adhere to these instructions. The reasons for this vary: someone else may be weighing the patient, weighing at the beginning of sessions is too distressing for patients/caregivers, there’s not enough time during sessions, etc.
Phase 2
The family does not move to the second phase until the patient resumes normal eating and gains a necessary amount of weight. FBT holds the idea that a child cannot think clearly or make good decisions until they are weight restored.
During this phase, control of eating is gradually shifted from caregiver to child.
At the beginning of this phase, therapists ask families to bring a picnic and have a meal during the session. They observe and correct certain maladaptive family dynamics.
Throughout therapy, the family also works on interpersonal issues.
Phase 3
By this point, patients have an age-appropriate level of freedom concerning food and activity.
Potential future challenges are discussed in the last phase of treatment. The patient, the clinician, and the family devise ways for the youth to cope when challenges arise.
When and how can FBT be used as a treatment approach?
FBT can only be used when:
The patient is medically stable
There is no risk of self-harm or suicide
None of the primary caregivers also suffer from an eating disorder
No one in the household has inflicted trauma on the adolescent
The family is able and willing to fully commit to FBT
A professional is able to guide the family in this outpatient process
Challenges and Criticisms of this Approach
1. FBT was initially developed and tested for individuals diagnosed with anorexia.
There is a lack of research on the effectiveness of FBT for bulimia, binge eating disorder, and Other Specified Feeding or Eating Disorder (OSFED).
A lot of the FBT manual focuses on weight gain. So patients who do not have “weight gain” included in their treatment plan may find a lot of FBT unnecessary.
2. Individual cognitive issues are not the primary focus for the majority of family-based treatment.
A huge criticism of FBT is that it doesn’t address any individual contributing factors, such as maladaptive thought patterns, body image issues, and comorbid diagnoses.
Many eating disorder sufferers have comorbid disorders such as anxiety, depression, OCD, OCPD, and PTSD. They are proven to be a contributing factor in developing and engaging in an eating disorder.
Related: This is how comorbid diagnosis and treatment works.
3. Unfortunately, this form of treatment is an unavailable privilege for many families.
Many caregivers have to take time off of work and take their adolescent out of school to monitor their behaviors.
And while caring for their loved one is a huge priority, some family members just can’t afford to leave their places of employment for an extended period of time.
4. Motivation is from an external source for most, if not all, of treatment.
While control does shift back to the youth in later stages of treatment, the majority of the reason the sufferer starts eating again is because they are forced to.
This can speed up the weight gain process.
But the best motivators, the best things that push someone to recovery, come from within themselves. And FBT does not give the patient enough freedom to find what personally motivates them to recover.
Many treatment programs that work with patients to build a restoring connection between the mind and the heart do not use FBT (aka the Maudsley method).
They do include family therapy, during which the patient and the family can face any interpersonal problems that contribute to an eating disorder. But these programs focus more on the individual than the family.
5. Early intervention is critical.
The probability of full eating disorder recovery is significantly higher for those who receive early eating disorder treatment. Neurological pathways are not as affected, behaviors are not as ingrained in the sufferer, and there is less likelihood of permanent physical health consequences.
Adolescents are in a crucial period of physical, social, emotional, and neurological growth — so the earlier they can get treatment, the better.
But finding an FBT provider can be difficult and expensive. Therapists may not have the proper training, or may not be willing to dedicate an extended period of time to facilitate FBT.
Early Advances in FBT Practices
Adaptations for Other Eating Disorders
FBT is being adapted so that it can be used to treat other eating disorders.
In one early study, an adapted form of FBT for bulimia included less of a focus on weight gain. This allowed more time and space for the patients to work on individual issues and comorbid diagnoses.
Subthreshold Eating Disorder Treatment
Many individuals who do not meet the “full criteria of an eating disorder” are not usually diagnosed with one. They are unable to access specialized eating disorder treatment, and caregivers have to seek help for their loved one in the local community.
The lack of access to proper treatment can lead subthreshold eating disorder sufferers to develop a full blown eating disorder.
But early studies have shown that a shortened five-session course of FBT — which could be facilitated by a non specialized mental health professional in the local community — can be an effective early intervention.
But one of the most significant advances happened due to COVID-19 — telehealth.
Related: These are the pros and cons of virtual eating disorder treatment.
Telehealth Shifts Treatment Approaches: FBT During COVID-19 and Beyond
COVID-19 caused a revolutionary shift in healthcare: location no longer limits an individual’s treatment options. Families who cannot find or travel to an FBT specialist can now participate in treatment at home.
Related: These are the challenges and the adaptive methods of telehealth eating disorder treatment in the post-COVID era.
Whether you decide to do FBT or not, family can always be a source of strength.
Many treatment providers offer family therapy sessions. Providers (including us) understand how family can be a source of strength and support for their struggling loved one.
If you think there’s nothing you can to fight against your child’s eating disorder — there are things you can do right now to help. Checking in with them when they seem to be struggling, listening without judgement, and just educating yourself about eating disorders are all great ways to help.
But the most important thing you can do to help your loved one is to seek help from a professional. Eating disorders are serious, life-threatening illnesses that get worse the longer they are left untreated. Your child’s eating disorder isn’t “a phase” or something that will just go away.
A professional can help put your child on the path towards recovery. And you can walk that path with your child, supporting them all the way.
If you or a loved one is suffering from an eating disorder, take the first step today and talk to someone about recovery or simply learn more about the holistic eating disorder recovery programs we offer.