An Introduction to Family-Based Treatment for Anorexia Nervosa

India woman with her family

Contributed By: Dr. Elizabeth Mariutto, PsyD, CEDS and Clinical Director of Eating Disorder Services of Lindner Center of HOPE

Puberty is a risk factor for eating disorders, especially among girls (Klump, 2013) and anorexia nervosa has the highest mortality rate of any mental health diagnosis (Arcelus et al., 2011). As many parents start to see signs of restriction becoming more severe in their children, they feel helpless. However, family-based treatment can help parents to assist in their child’s recovery.

Parents watch their previously healthy, oftentimes responsible, child begin losing weight, appear preoccupied with food, withdraw socially, and seem consumed by thoughts of dieting. Often, parents feel highly emotional and struggle to redirect their teens in effective ways.

They may negotiate with the eating disorder by accommodating their child’s food preferences (“I just want him/her to eat something”), induce guilt about the effect these behaviors have on other family members, or simply beg their teen to eat to little or no avail.

Family-Based Treatment for Anorexia Nervosa

NICE guidelines support family-based treatment as the first line of treatment for adolescents with anorexia nervosa (National Institute of Health and Care Excellence, 2017). Family-based treatment (FBT) rallies parents as a resource in helping their teenagers recover from their eating disorders (Lock, LeGrange, Agras, & Dare, 2001).

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FBT empowers the parents to do what they need to do to feed their starving child. The therapist serves as a consultant on eating disorders, with the parents making the majority of decisions on what would work within their family.

Stage One of FBT

The first stage of FBT involves parents taking full responsibility for preparing, serving, and monitoring their teen’s eating (Lock et al., 2001). They monitor breakfasts, lunches, dinners, and snacks.

During the academic year, parents may be going into their child’s school to eat lunch with them or asking a school nurse, teacher, or counselor to fill this role so that they can ensure that lunch is eaten. Food is treated as medicine, and parents are asked to take a firm yet compassionate approach in directing their child’s eating (Lock et al., 2001).

Parents are taught to recognize which food preferences or behaviors have resulted from the eating disorder (including vegetarian or vegan diets) and which are simply typical food preferences, using a timeline of how their child acted before the eating disorder began. Some teens feel relief at this stage.

They may be so anxious and uncomfortable around food that relinquishing control and not having to make food-related decisions is liberating. However, many push back strongly against both parents and therapists.

They may not have a lot of motivation to get better, feel they won’t be able to tolerate the weight gain, and feel threatened and unseen. They often have difficulty separating out what thoughts are consistent with their true selves and what thoughts, actions, and feelings are only there because of their eating disorder. Many are even in denial that they have an eating disorder and try to disprove the therapist at any chance they get.

Stage Two

Lady and daughter going through family-based treatmentDuring the second phase of FBT, the teenager is gradually given control back. At this stage, they have typically reached at least 87% of their ideal body weight, have been cooperative in eating what their parents have asked of them, and parents have reasonable confidence that they can manage a meal or snack on their own (Lock et al., 2001).

This often begins as small, gradual steps, such as the teen plating their meal at a family dinner or ordering for him or herself at a restaurant with the parent present. Gradually, snacks and meals are less frequently monitored (Lock et al., 2001).

The Final Stage

As the teenager becomes more and more independent with food, they enter the third stage, where they no longer require monitoring of meals and snacks (Lock et al., 2001). During this stage, therapy focuses primarily on non-food related issues.

Therapists speak with the family on how development and eating disorders intersect and where the patient developmentally is versus where he or she is expected to be. Problem-solving is addressed with the family on issues other than food, and relationships between all family members are discussed.

One goal of FBT is for all of the relationships to be stronger after the treatment than before it. Transitioning to leaving home and college is processed, and relapse prevention work is completed.

This final stage is purposefully only four sessions (Lock et al., 2001). Some parents struggle with doubting their abilities to identify and prevent relapse, so the therapist works with the family on developing confidence that they can leap into the world without close follow up, be aware of signs that they may need more help, and return if needed.

While FBT is a lot of work for both patients and parents, it can be more effective for adolescents with eating disorders than individual therapy. For example, one randomized controlled trial comparing family-based treatment to adolescent-focused treatment found that FBT had significantly better full remission rates at both 6 and 12 months post-treatment. (Lock et al., 2010).

There is data supporting the use of FBT in the treatment of bulimia, that FBT can be delivered via telehealth, and that it can be adapted for use with the young adult population (Gorrell, Loeb, & Le Grange, 2019).


Resources:

[1] Arcelus, J. et al. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. Achives of General Psychiatry, 68, 7, 724-31.

[2] Gorrell, S., Loeb, K. K., & Le Grange, D. (2019). Family-based treatment of eating disorders: A narrative review. Psychiatric Clinics of North America, 42, 2, 193-204. Doi: 10.1016/j.psc.2019.01.004

[3] Klump, K. (2013). Puberty as a critical risk period for eating disorders: A review of human and animal studies. Hormones and Behavior, 64, 399-410.

[4] Lock, J., Le Grange, R., Agras, W. S., & Dare, C. (2001). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford Press

[5] Lock, J., Le Grange, D., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with Anorexia Nervosa. Archives of General Psychiatry, 67,10, 1025-1032.

[6] National Institute for Health and Care Excellence (NICE; 2017, May). Eating disorders: Recognition and treatment. Retrieved from https://www.nice.org.uk/guidance/ng69/chapter/Recommendations#treating-anorexia-nervosa


Lindner Center LogoLindner Center of HOPE offers a disciplined approach to eating disorder treatment that combines psychiatric management, psychotherapy, nutritional services, and family engagement throughout the entire process. Board-certified clinicians offer the wisdom, compassion, and proven treatment modalities to successfully treat complex illnesses such as eating disorders, returning patients, and their loved ones, to more fulfilling lives.

The Harold C. Schott Foundation Eating Disorders Program at Lindner Center of HOPE includes services for adults and adolescents, females and males, while also incorporating research.


About the Author:

Dr. Elizabeth Mariutto, PsyD, CEDS ImageDr. Elizabeth Mariutto, PsyD, CEDS, is a psychologist and Clinical Director of Eating Disorder Services at the Lindner Center of HOPE. She is a Certified Eating Disorders Specialist through the International Association of Eating Disorders Professionals and a certified Family-Based Treatment therapist with training in other modalities of eating disorder treatment, including Cognitive Behavioral Therapy-Enhanced (CBT-E), Dialectical Behavior Therapy, Radically-Open Dialectical Behavior Therapy (RO DBT). She is an Assistant Professor of Psychiatry and Behavioral Neuroscience at the University of Cincinnati College of Medicine and a consulting psychologist at Cincinnati Children’s Hospital Medical Center.


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 January 11, 2021, on EatingDisorderHope.com
Reviewed & Approved on January 11, 2021, by Jacquelyn Ekern MS, LPC

About Baxter Ekern

Baxter is the Vice President of Ekern Enterprises, Inc. He is responsible for the operations of Eating Disorder Hope and ensuring that the website is functioning smoothly.