When your child has an eating disorder, the treatment and the therapists you choose will make all the difference. Which treatments are recommended? How to you identify a good clinician? Is it better to treat at home, within the family, or in an inpatient unit?
In many countries you have to shop around for a good treatment provider, so I'll guide you here.
In the UK, where I am, we have no choices unless we go private. Happily, much of the NHS treatment is excellent — though post-covid the waiting times have in places become too long. The private providers used to be appalling but as they update themselves, many are now great too.
If you're in the US and in a hurry, I recommend you read the short booklet Port in a storm: A F.E.A.S.T guide to eating disorder treatment – how to choose a treatment team for a loved one with an eating disorder in the U.S. Some of the guidance is great for people in any country.
Which eating disorder treatment approach should you go for?
The outcome from research makes your choices quite simple. As described in the UK's NICE guidance:
A family-based approach is your best bet. That means someone trained in Family-Based Treatment (FBT), which comes from Lock and Le Grange. Or someone trained by the Maudsley's service for children and adolescents (Eisler's team), where they tend to call the approach FT-AN or FT-BN (Anorexia/Bulimia-focused family therapy).
Personally I'm not too bothered whether the family-based approach comes from Lock/Le Grange or from Eisler's team — having a great clinician matters more. I explain these approaches here. In the UK, standards require the NHS to offer you a family-based approach first.
The next recommendations are for Cognitive Behaviour Therapy (CBT) and Adolescent-Focused Therapy (AFT). Follow my links for lots more on these. The CBT must be a version that is designed for eating disorders — it's quite a bit more focused on behaviours than the usual CBT.
Both CBT and AFT are individual treatments: your child will be having to make their own efforts to manage challenges such as meals, weight gain, reducing exercise, managing restaurants, and so on. How much you are involved will depend on the therapist, so if this matters to you (and my view is it matters a lot), interview them first. In a family-based approach you learn to take the lead with these tasks, and support your child to manage. This usually means faster progress (and avoiding severe deterioration) as you're not waiting for your child to gain motivation in weekly therapy sessions.
My resources focus on helping you, as parents, to help your child. Mostly along family-based treatment lines, but everything to do with communication, connection, and your own wellbeing, is relevant, whatever the treatment path you follow.
Who should be in your child's treatment team
Ideally you don't just have one therapist, you have a team. Most of the time you see one clinician who delivers the family-based approach. They may be a psychologist or a dietitian or nurse or social worker. And some of the time you see other members of the team, who are also specialised in eating disorders.
For instance a psychiatrist may review the need for medication or conduct assessments for co-occurring disorders. A dietitian may advise if your child has particular issues. A psychologist or occupational therapist may get involved with an autistic child, or one suffering from OCD.
What qualifications are you looking for?
Read 'Is Your Eating Disorder “Specialist” Really a Specialist?' by Alli Spotts-De Lazzer and Lauren Muhlheim, especially if you are in the US.
If a clinician is a 'Certified FBT therapist' then you know they've had months or years of training and supervision from people who were trained by James Lock or Daniel Le Grange, authors of the FBT manual. That's a high standard, and there are certified FBT therapists in many countries. I list some of those who can work by video call here.
The team from Maudsley's service for children and adolescents (Eisler's team) have done a lot of training in the UK. You can read about it in Eisler, Simic et al's paper 'Implementing service transformation for children and adolescents with eating disorders across England: the theory, politics, and pragmatics of large-scale service reform'. My view is that this, along with mandatory NHS standards, had made much of the treatment of youngsters good or excellent. But yes, there's still a postcode lottery. The training isn't necessary deep enough or there's not enough supervision or updates — the usual difficulties in getting high standards everywhere.
I must warn you, when you ask clinicians what their qualifications are, where they trained, who with, whether they get supervision, what methods they are trained in, and so on — all questions which make perfect sense for a caring parent — you don't always get clear answers. It doesn't mean the clinician isn't great, you just don't know. So you have to ask more questions to find out what they know about eating disorders and how they intend to treat.
Questions to identify good clinicians… and the red flags for outdated anorexia treatment
I propose a set of question to help you identify good treatment providers, in Chapter 12 of my book. It's all here on this website.
Personally I would try and pose questions, and vet a provider, without my child being present. Just in case the clinician really is not up to standard and does harm. (In the UK we tend to have no information and no choice on the therapists appointed for our case. We can do our best to ask questions over the phone, pre-appointment. And we can console ourselves that the NHS sets high standards).
If you've had time to browse through my book, you'll have a better sense of what sounds reassuring.
Is your child with an eating disorder better treated at home or in hospital?
If your child is medically stable, then treatment at home, as an outpatient, using a family-based approach, is your best bet. This is the conclusion from various institutions of psychiatrists or paediatricians over the world (e.g. in the UK, the NICE guidelines for eating disorders).
The culture in the US is to treat people outside the home full time or part-time. This may say more about the financial setup of institutions than about what is best for your child.
If your child is physically unwell, then a short stay in hospital — a medical / pediatric unit — is life-saving… and often it gets your child used to eating again, so that it will be easier for you to take over at home later. In the US these are called Inpatient units (IP) and may be in a medical or a psychiatric facility. In the UK, a pediatric ward tends to discharge once the child is medical stabilized — sometimes they keep the child a little longer to ensure the family can succeed with the transition home (or while waiting for a bed in a psychiatric unit).
If your child doesn't particularly need medical care, but the illness is such — or your circumstances are such — that they just cannot manage to eat and weight gain at home, then they will need a higher level of care. First, check if your treatment providers will send an intensive mental health team to your home to support some of the meals — in the UK a small number of NHS units can do this and it can turn things around.
If home meals really are not working then ideally there will be a day unit near you (or online) where your child gets meal support some of the time, and hopefully you also get information and support sessions as parents. This can break a pattern of restricted eating, so that parents can continue at home. These may be called 'intensive day service ' or 'intensive outpatient program (IOP)' or 'day treatment program'. In the US there's also partial hospitalization programs (PHP).
Many countries don't have day programs, so if the person cannot be helped at home, the only option is an an inpatient psychiatric or eating-disorder unit — in the US, this is called 'Residential care'. These are likely to keep youngsters for many week or months. They attend to nutrition, safety, and also various activities designed to be therapeutic. The best residential care units involve parents and provide education and practice so that your child will have a smooth transition back home as soon as possible.
Some youngsters need to stay in a psychiatric unit for a long time because of their high level of distress, self-harm, suicidality. There they can have 24 hour one-on-one supervision as well as NG tube feeding.
Issues with costs and insurance for eating disorder treatment
In the UK, please know that the NHS is bound by high standards in treating youngsters with an eating disorder. Still, the care you receive may be poor because of one inexperienced clinician. Say 'It's not a good fit' and ask for another clinician on the team. Sometimes an entire service is poor because of the people at the top. In this case, if you can afford it, find an excellent private provider. Some of them are amazing, and some have insufficient training and experience, or never updated their learning. So you'll need to vet them carefully.
See my page on England for more help with costs and with support services in the UK.
In the US, learn more about the insurance system with Port in a storm: A F.E.A.S.T guide to eating disorder treatment.
If you don't have access to good treatment providers
If there is no good provider of eating disorder treatment close to you, or if you're facing unacceptable waiting lists, what are your options?
Nowadays, many clinicians treat by video call, so the world is your oyster. If you can afford them, you will be well guided. There is some research to show that remote FBT treatment works (e.g. Steinberg et al. 'Effectiveness of delivering evidence-based eating disorder treatment via telemedicine for children, adolescents, and youth')
If that's not possible, then see Chapter 12 'Which eating-disorder treatments work?' where I say more about how parents have got their child to complete recovery pretty much alone, with the support of a family doctor. These are parents who got super-well informed, and of course my own resources are part of that.
See my book or this website for Chapter 3: The parent's part in eating disorder diagnosis for my guidance on getting your child diagnosis and referred to a specialist.
The whole of Chapter 12: Which treatments work? is also on this website. It includes questions to evaluate a good provider and to steer your child's care in hospital.
Again, I recommend, especially for the US: Port in a storm: A F.E.A.S.T guide to eating disorder treatment – how to choose a treatment team for a loved one with an eating disorder in the U.S.
This site has pages devoted to several different countries.
Confused? See my Start Here page.