Family Based Treatment (FBT; commonly known as The Maudsley Model) is currently one of the leading choice of treatment for children and adolescents living with Anorexia Nervosa and Bulimia Nervosa. FBT emphasises the involvement of the family system in supporting the young person in overcoming their eating disorder. FBT acknowledges the integral role families can play in overcoming this illness and helping restore their young person back to health.
FBT centres on the principle that weight restoration is the first step and the key to bringing physical and mental health back to young people suffering from an eating disorder. The initial focus of treatment is on weight regain, rather than the psychological aspects associated with the eating disorder, which are addressed after weight gain is progressing. Food is centralised within recovery, and you are sure to come across the phrase ‘Food is Medicine’!
Who is involved?
The young person and their family work with a team of health professionals. This team includes a general practitioner and a psychologist. Depending on the family’s needs, a paediatrician, psychiatrist, and dietician may also be involved.
What does treatment look like?
There are three distinct phases within FBT.
Phase 1: REFEEDING AND WEIGHT RESTORATION
Parents assume full responsibility of refeeding their young person and managing eating disorder behaviours. This means all meals are prepared and supervised by parents and physical exercise is limited. Clinicians coach parents in managing behaviours, brainstorming barriers to refeeding, and assisting with food refusal in a compassionate, consistent, and firm manner. Where possible, siblings are charged with the task of providing encouragement and support to their sister/brother. Phase 1 is typically the most challenging, yet most important, part of treatment. Research has shown that significant weight gain in the early phase of treatment is a strong predictor of good treatment outcome.
Phase 2: RETURNING CONTROL OF EATING TO YOUNG PERSON
With careful planning and lots of support, the young person gradually takes back age-appropriate responsibility in their own eating, food preparation, and exercise. Together with the clinician, the young person and parents decide regarding the support needed (practical and emotional), the pace of transition, and more. This step is important to allow the young person to slowly gain confidence in fighting against anorexia independently while feeling held and supported by parents. This phase often involves a range of ‘trial periods’ or ‘experiments’ to see how things go. Slowly, the focus begins to shift from weight and food to relevant family and relationship issues.
Phase 3: RETURNING TO NORMAL DEVELOPMENT AND TREATMENT COMPLETION
By phase three, the young person is weight restored and eating independently. The focus moves to adolescent issues and strengthening the young person’s identity without the eating disorder. Relapse prevention is also addressed.
Treatment typically occurs over a period of 6-12 months. It is important to remember that each family is different, and factors may contribute to a reduced or increased treatment time frame. Always consult with your team throughout treatment for tailored advice and support.
FBT is challenging. Here’s some ideas that may help.
- FBT is rigorous and often time and labour intensive. In the early stages, parents/carers are asked to supervise their children at all times to ensure they are consuming set meals/snacks and prevent them from engaging in eating disorder behaviours. This can be an exhausting experience and may pose challenges for family members in managing important commitments (e.g., self-care, relationships) outside of caring for the young person. It may help to think about the cliché but true “short term pain, long term gain”. This experience is difficult while absolutely necessary for the young person’s life. You may want to draw on your existing support network or be creative with ideas – devise a plan with your partner so both can have time to rest, no matter how short. Ask family/friends to help with errands, meal preparation, or siblings pick up/drop offs – a lot of the times they want to help but don’t know how.
- Specific dietary advice is not provided as part of FBT, as parents are believed to know their children best and know what they require to gain weight. Some parents may find this to be a frustrating and confusing part of treatment – particularly when feeling a lack of confidence in taking on this task. Speak to your treatment team if you have concerns regarding this. There are lots of resources available to carers which provide guidance around refeeding and weight gain. Also remember, you had the skills to provide sufficient nourishment to your child before anorexia invading their lives. If your child is otherwise healthy previously, it usually more about caloric/energy intake than specific micronutrients (e.g., vitamins, proteins, or carbs). Of course, you and your treatment team may also think a referral to a dietician is appropriate.
- Because the young person with anorexia is significantly malnourished, weight restoration is the focus in this treatment, and other issues that may be impacting on a young person’s life (e.g., body image, anxiety, depression, OCD) are not specifically addressed in Phase 1. While your FBT therapist will often work with parents to empower you in managing the young person’s strong emotions and/or with the young person to develop strategies, the bulk of that work cannot be dealt with until the young person’s body is more nourished. Our ability to regulate emotions or to concentrate in non-food matters do not return until the body knows we are out of famine. After all, you can’t fight biology. Some may also benefit from having medication, receiving psychotherapy afterwards to deal with residual concerns, or even alongside FBT (although less common for reasons mentioned).
- FBT can be a difficult experience for the young person and families may find it challenging to see their loved one in distress. This is particularly relevant in early stages of treatment. Again, self-care and support are so important for carers. Some parents find it beneficial to engage in their own counselling for extra support.
- It may also be confronting for the family to have such heightened emotions when the young person might normally be calm and gentle. Instead of asking the young person to “calm down” or logically explain the need for eating, young people tend to find it helpful if you stay with them calmly and accompany through these scary and otherwise lonely moments. When facing such big fears, rationality tends to be out of the window and no amount of talking will help. Your psychologist will be able to provide some specific suggestions for how to respond when the young person is distressed. Carers often report that as their young person reaches a healthy weight range, distress and anxiety begin to decrease.
Some parts of FBT may work for your family, whilst some may not. Always consult with your team throughout treatment for tailored advice and support.
- Help Your Child Start to Recover from Anorexia Nervosa A Practical Guide by Andrew Wallis and Colleen Alford
- Anorexia and other Eating Disorders: how to help your child eat well and be well by Eva Musby
- Helping Your Teenager Beat an Eating Disorder by James Lock and Daniel le Grange
Support groups and resources for carers