Two therapeutic approaches have been garnering increased attention in recent years but have different ways of conceptualizing and treating eating disorders in adolescents; Family Based Treatment (FBT) and Enhanced Cognitive Behavior Therapy (CBT-E).
Both approaches are designed to eliminate eating disorder behaviors but conceptualize the role of parents and patients differently and offer significantly different approaches to treatment.
What is Enhanced Cognitive Behavioral Therapy (CBT-E)?
Cognitive Behavioral Therapy (CBT) and Rationally Emotive Behavior Therapy (REBT) were developed by Aaron T. Beck and Albert Ellis, respectively. Both are based on the idea that “how we think (cognition), how we feel (emotion) and how we act (behavior) all interact together.”  Another way to think about is that an event leads to distorted thoughts and results in distressing emotions and behaviors.
Enhanced Cognitive Behavioral Therapy (CBT-E) was developed by Christopher Fairburn, Emeritus Professor of Psychiatry, at the University of Oxford in England, specifically for the treatment of eating disorders. Riccardo Dalle Grave, MD at Villa Garda Hospital in Italy, adapted CBT-E for use with adolescents. 
What is Family Based Treatment (FBT)?
Family-Based Treatment, initially known as the Maudsley Method, was developed by a treatment team at the Maudsley Hospital in London, England, in the 1980s. FBT conceptualizes the eating disorder as an external problem that has happened to the teen and focuses on empowering parents to support healthy adolescent development and recovery. 
Questions of Cooperation
According to the developers of CBT-E, it is a collaborative approach designed to encourage the patient to develop healthy self-control and overcome their problems with eating.  “Before embarking on weight regain, patients and therapists spend the first weeks of this treatment carefully considering the reasons for and against this change. The goal in CBT-E is that patients themselves decide to regain weight rather than having this decision imposed upon them.” 
On the other hand, FBT views the eating disorder as something that requires parental intervention to restore the child to a natural path of development. The teen is not considered to be in control of their behaviors and therefore needs the guidance of parents who will increase their control over their eating patterns. 
In other words, for CBT-E to be effective, the focus begins with increasing motivation and enlisting the cooperation of the teen in the goal of recovery. The FBT model is initially unconcerned with the motivation of the teen and seeks to restore parental authority over eating patterns.
To better understand the pros and cons of these two approaches, professionals from three different organizations co-authored an article in the Journal of Eating Disorders titled, “A conceptual comparison of family-based treatment and enhanced cognitive behavior therapy in the treatment of adolescents with eating disorders.” The article provides a helpful overview of the two approaches.
Similarities Between FBT and CBT-E
Despite the differences, the authors of the article identified several similarities between the two approaches. This includes addressing the maintaining mechanisms of eating disorder behaviors while helping the patients restore health weight. They both also have the goal of eventually increasing individual autonomy for the child once the eating disorder has been resolved.
Differences Between Family Based Treatment and Enhanced Cognitive Behavioral Therapy
While there are common goals, there are significant differences between the two approaches. According to the article, in FBT, “the problem or symptoms belong to the entire family, and therapy works to separate the illness from the patient (externalization), enabling parents to temporarily take control of their child or adolescent’s eating.”
“CBT-E, on the other hand, views the illness as belonging to the individual,” and is based on self-evaluation that overemphasizes shape and weight.
Additionally, the role of parents is viewed quite differently. In FBT, the parents’ involvement is central to recovery, and a great deal of time, commitment, and perseverance are required. In fact, FBT is discouraged for families who cannot make these commitments. On the other hand, with CBT-E, parental involvement is encouraged but not essential. Because of this, CBT-E may be a better fit when the family system is significantly disrupted or unavailable.
The role of the child or adolescent is also different in the two approaches. For FBT, the child is not actively involved initially and plays a more passive role—the focus is on the parents. In CBT-E, the child is actively encouraged to be involved from the very beginning.
Further Research is Needed
Because there is growing evidence that both FBT and CBT-E are helping in treating eating disorders among adolescents and children, the authors recommend that randomized controlled trials be conducted to better understand which approach should be used and with what types of patients and families.
The article concludes with the statement that FBT might be better “suited to the needs of younger adolescent patients. In contrast, CBT-E might have its greatest effect in older adolescent patients in whom the mechanisms that maintain eating disorder psychopathology are fully operating. Older adolescents might also better accept an ‘adult’ form of treatment rather than a family style one.”
REFERENCES: Mcleod, S. (1970, January 1). Cognitive Behavioral Therapy. Retrieved March 4, 2020, from https://www.simplypsychology.org/cognitive-therapy.html  CBT-E Website. (n.d.). The Originators of CBT-E – CBT-E. Retrieved March 4, 2020, from https://www.cbte.co/about-us/the-originators-of-cbte/  Walden Eating Disorder Centers. (2018, September 10). Family-Based Treatment (FBT) for Eating Disorders: 5 Things You Didn’t Know. Retrieved March 4, 2020, from https://www.waldeneatingdisorders.com/blog/family-based-treatment-fbt-for-eating-disorders-5-things-you-didnt-know/  Grave, R. D., Eckhardt, S., Calugi, S., & Grange, D. L. (2019). A conceptual comparison of family-based treatment and enhanced cognitive behavior therapy in the treatment of adolescents with eating disorders. Journal of Eating Disorders, 7(1). doi: 10.1186/s40337-019-0275-x  CBT-E Website. (n.d.). A Description of CBT-E – CBT-E. Retrieved March 4, 2020, from https://www.cbte.co/what-is-cbte/a-description-of-cbt-e/  Grave, R. D., Eckhardt, S., Calugi, S., & Grange, D. L. (2019). A conceptual comparison of family-based treatment and enhanced cognitive behavior therapy in the treatment of adolescents with eating disorders. Journal of Eating Disorders, 7(1). doi: 10.1186/s40337-019-0275-x  Grave, R. D., Eckhardt, S., Calugi, S., & Grange, D. L. (2019). A conceptual comparison of family-based treatment and enhanced cognitive behavior therapy in the treatment of adolescents with eating disorders. Journal of Eating Disorders, 7(1). doi: 10.1186/s40337-019-0275-x
About the Author:
Travis Stewart, LPC has been mentoring others since 1992 and became a Licensed Professional Counselor in 2005. His counseling approach is relational and creative, helping people understand their story while also building hope for the future. Travis has experience with a wide variety of issues which might lead people to seek out professional counseling help.
This includes a special interest in helping those with compulsive and addictive behaviors such as internet and screen addiction, eating disorders, anxiety, and perfectionism. Specifically, he has worked with eating disorders since 2003 and has learned from many of the field’s leading experts. He has worked with hundreds of individuals facing life-threatening eating disorders in all levels of treatment. His website is wtravisstewart.com
The opinions and views of our guest contributors are shared to provide a broad perspective on eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals.
We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.
Published March 12, 2020, on EatingDisorderHope.com
Reviewed & Approved on March 12, 2020, by Jacquelyn Ekern MS, LPC