Family therapy for eating disorders: what is FBT / Maudsley/FT-AN?

Above, I have tried to give short answers. People — even therapists — get these various terms mixed up, or don't appreciate the differences. This can waste time, if someone misses out on the recommended treatment. Below, I explain all this in more depth.

What is family therapy for eating disorders?

Family Therapy for eating disorders means you, the parents, are supported to treat your child at home. The evidence is this is the best treatment for anorexia and bulimia in teenagers.

With family therapy, the treatment parents give is

• mealtime support, or mealtime management: refeeding your child if underweight, and supporting him or her to eat… for fast progress
• supporting your son or daughter to return to normal behaviours
• helping everyone return to normal life

A family-based approach: the best treatment for teenagers with anorexia and bulimia

The research on family therapy for adolescents with anorexia is especially strong. With bulimia, it used to be a toss-up between family-based treatment and a specialised form of cognitive-behavioural therapy, but with the latest review of evidence by NICE (which I review here), a family-based approach is now recommended first.

If your child suffers from binge-eating disorder, there is no research to give you strong guidance, so you might want an adaptation of Family-Based Treatment (FBT), or one of the approaches in the the NICE guidelines.

Does family-therapy work for adults with an eating disorder?

The best therapists choose methods according to their patients' needs and abilities, not their age. They recognise that patients of all ages are likely to benefit from skilled support from their family. An adult may be very motivated to beat anorexia and may find the courage to attend weekly therapy, yet be unable to overcome the terror of eating the required meals alone.

Experts in family work deplore that so many youngsters are denied a family-based approach on their 18th birthday, when dedicated parents are suddenly told to back off on the grounds that their child must 'take responsibility for their recovery'.

There has been some promising research on variants of FBT for young adults (university age) but I'm not seeing it being used much. There is no research comparing a family approach with any of the traditional adult treatments, which consist of various forms of individual or group psychotherapy, or hospital treatment. More on adult and young-adult treatment here.

Careful – not all family therapies are suitable for young people's eating disorders

Family Therapy for eating disorders is different from general family therapy. General family therapy is sometimes offered as an add-on to individual therapy, to help family members better get on with each other. That does not constitute treatment though in skilled hands, as an adjunct, it could be useful or lovely.

The type of family therapy I would caution you against, the general kind, examines how problems affecting a child could be solved by having the parents and the rest of the family interact differently. Therapists may assume that family dynamics drive the eating disorder and/or impair recovery. Sessions may well focus on faults with the parents, instead of skilling and empowering them. This could delay your child's recovery because:

• there could be an assumption you are pathological parents, or harmful in some way ('colluding' with the eating disorder, 'enabling' it). The therapist may disempower you quite openly. Your child will be steered away from you, losing their most important resource towards eating-disorder recovery.

• the focus of systemic family therapy might be on your interactions, rather than on the urgent job of supporting you to feed your adolescent and keep him or her safe.

The family therapy that is indicated by the research for teens empowers parents and gives them a central, hands-on role — at least in the first phases of treatment. In spite of this, many centres treating teen eating disorders offer general family therapy, not the specialised eating-disorder kind, so you'll need to read between the lines or ask questions.

Confusingly, "systemic family therapy" may refer to general family therapy (the kind that focuses on your dysfunctional relationships) but it may also refer to the specialised form that is recommended for eating disorders. So if your team mentions "systemic family therapy" you'll have to ask what this means.

What kind of family therapy is best for anorexia or bulimia?

For young people, check that what's on offer is "family therapy specialised for eating disorders" or "family-based treatment (FBT)" or "Eating disorder focused family therapy (FT-ED)" or "Maudsley" (not "New Maudsley"– as I explain below) .

In the UK, the name for the recommended form of family therapy is "anorexia-nervosa-focused family therapy (FT-AN)" or, you guessed it, "bulimia-nervosa-focused family therapy (FT-BN)".

* More: What's the best eating disorder treatment for children and young people? The very latest guideline from NICE *

"The Maudsley Approach" versus "The NEW Maudsley Approach"

Before I say more about FBT, I'll make a detour to talk about 'The New Maudsley Approach'. The name leads to confusion because people in the United States often refer to FBT as "The Maudsley approach", as its roots are in the  Child and Adolescent Eating Disorders Service of the Maudsley hospital, London. When you hear 'New Maudsley' you could assume that this is some kind of improvement of FBT/Maudsley. Actually it's a different proposition and the 'New Maudsley' book makes no reference to FBT/Maudsley at all.

New Maudsley is not a treatment in itself. It teaches communication skills for carers. The way I see it, it makes sens for carers whose loved one is in individual treatment (not a family-based approach) or who is currently not engaging with any treatment. New Maudsley could help you if your child is being treated with CBT or AFT, and if you've been told to only support what's been agreed in therapy. New Maudsley provides you with communication tools if your child is being made responsible for their own recovery.

New Maudsley was initially developed for adult patients who have been ill for a very long time (SEED — 'Severe' and Enduring Eating Disorder'). Also, the Maudsley hospital tends to treat adult anorexia patients with a method called 'MANTRA', and family members get New Maudsley training in order to (gently) support the process.. with the person's agreement.

With any independent adult patient, the way I understand it, when they bravely come for therapy you have to tread very gently or they won't come back. Therefore carers are told to work with, rather than 'doing to' their loved one. The emphasis is on communication skills so that carers will act like gently guiding 'dolphins' and avoid being persistent 'terriers' or 'rhinos' (New Maudsley used a lot of animal methaphors).

The audience for New Maudsley has expanded through their training courses. In the UK it informs much of the resources provided by the charity BEAT. When New Maudsley is introduced to parents of children and teenagers treated with a family-based approach, without a proper explanation about the differences, it can lead to confusion. Parents may get pulled in opposite directions, and feel constantly guilty about not doing things 'right'.

For example I was celebrating with a mother how her son was finally managing all meals and starting to regain some health and an improvement in mood. Yet she felt bad, labelling herself as 'a terrier', because she was persistent with making nourishing meals work. It clashed with the message about being 'a dolphin' who only nudges in the background.

The role recommended for parents differs the most in the first phase of FBT. With FBT there is no waiting for motivation or 'buy in'. Parents learn skills to get their child the nourishment required for rapid healing of body and brain. They learn to interrupt harmful behaviours — all at a time when the illness tends to block any motivation or insight (anosognosia). It means the trajectory of decline is turned around. There's a lot less need for inpatient care. To succeed with the first phase of FBT, parents learn to be both kind and persistent.

With New Maudsley, on the other hand, communication skills are taught, not to persuade your child to eat the meals you know they need, but to try and move them at their own pace towards a collaborative stance… they will ask for support when they're ready, and you will only give the support they ask for.

The communication skills of New Maudsley come from 'motivational interviewing', an approach originally developed for patients with substance use disorders. In practice I see those New Maudsley skills as similar to any good communication skills. In the case of New Maudsley the conversations seek to assess our loved one's 'readiness' for change and to nudge them through the 'stages of change'. Once the person wants to get treatment, or asks for help with meals, then we give them the support that they wish to receive (and resist the urge to do more).

My point of view is that you can take the best from any teachings, as long as you understand where the differences lie. It doesn't work for everyone to renourish their child as required in the first phase of a family-based approach. So it's right for variations and alternatives to be available. Indeed the NICE guideline recommend several individual therapies for youngsters if a family-based approach — a very strong first choice — is not working. If your child is having individual therapy, you will appreciate the New Maudsley focus on communication that requires you to take more of a back seat.

In short, New Maudsley may support you if your child is having individual therapy or is resisting any form of treatment. It will help you with communication. (The communication tools in my own resources are similar, if you're wondering. Good communication is good communication). Individual therapies like CBT or AFT are perfectly valid and you should not feel guilty if FBT has not been working for you. If your child's illness is such that you cannot nourish them, then so be it: you need one of the 'runner-up' approaches, and if that is too slow to arrest decline, the renourishment will be done by an inpatient unit, irrespective of your child's motivation or buy-in.

What is Maudsley Model of anorexia nervosa treatment for adults" (MANTRA)?

This is a treatment approach for adults, and may be done in parallel with skills-training for their supporting family members using the "The New Maudsley Approach" described above.

It's for adults, and it's very different from the family-based approach (like DFBT) that is recommended for young people. And again, try and not get confused because some people use the name "The Maudsley approach" to refer to FBT.

Which strand of family therapy for eating disorders is best?

After this detour into New Maudsley, let's return to a family-based approach.

The first trials for the treatment of anorexia nervosa were done in London, at the Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED), where the approach continues to evolve under Ivan Eisler and Mima Simic. Nowadays it may include adjuncts like multifamily therapy. The team are training therapists worldwide but mostly in England and Wales. There is no certification and no obligatory supervision or mentoring, so there is no easy way to know how specialised a therapist will be. There is a very instructive Maudsley service manual, but from interviews I've read, the team are not keen on any rigid adherence to manuals. The manual describes the approach as one of 'systemic family therapy' applied to eating disorders, and refers to it as FT-AN ('anorexia-focused family therapy') or FT-BN, the equivalent for bulimia.

FT-AN and FT-BN feature in England's NICE guidelines , which were developed with the participation of Maudsley's child and adolescent eating disorder service.

Confusingly, many therapists in England who received training from the Maudsley child and adolescent team say they're "doing FBT" even if they're not familiar with the FBT manual.

FBT seems to have become a bit of an umbrella term world-wide, which is frustrating for those who'd like you to stick to the manual. There may be a move to use another umbrella term: eating disorder focused family therapy or FT-ED.

What is FBT and is it different from "Maudsley"?

In the US, James Lock and Daniel Le Grange conducted further trials on the family therapy approach originating from London's Maudsley child and adolescent services. To do so they needed to outline with more precision the method they were testing: this resulted in a manual for what they named Family-Based Treatment (FBT). And — confusion, confusion — Americans may refer to it as 'The Maudsley method’, because of its origin.

Watch (at 11:43) Daniel Le Grange explaining how his and James Lock's work on FBT evolved from his work at the Maudsley.

You can read the FBT manual and there's also a book for parents (there's a list of these books and more here). Therapists can go for certification, which offers you, the parent, some confidence that they have gone through a lot of training and supervision. There are also good FBT therapists who don't have the certification (it's an expensive process). My own family got top-notch support from a therapist who was shadowing another therapist who was going through FBT certification.

You will find FBT dotted around the world, in particular in the US, Canada, Australia, New Zealand and Scotland. For a list of certified FBT therapists who are open to working by video call anywhere in the world, see my list here.

Tailoring FBT to your child

To be precise about terminology, treating with FBT means treating according to the FBT manual. But what if your child looks like they need things done a little differently? Research on variants of the original FBT continues, and clinicians deviate more or less from the manual, sometimes with careful testing and monitoring, sometimes not.

There's not enough research on which elements of FBT are crucial, and conversely, which might reduce its effectiveness. For instance, the FBT manual is clear that your child's weight should be measured and discussed at each session, but for some youngsters, parents report they can make more progress with blind weighing.

The issue of individualising treatment to suit a child's difficulties and strengths is especially crucial with the many autistic youngsters who have an eating disorder. I discuss this, with many examples, here.

Hospitals that support a family-based approach

Even if your child needs to go to hospital, at some stage they will need your support to get into normal life. No unit can provide all the recovery work. So there is always a role for treatment involving the family.

If your child or adolescent is medically unstable, if you just can't get him or her to eat, or if they are a danger to themselves (self-harm, suicide) then they may need hospitalisation or a residential or day program.

The approach within a hospital or other program should be to get you, the parents, on board as quickly as possible. That way as soon as you are able to look after your child at home, you can do so. I was told that in Lucile Packard Children's Hospital Stanford, where parents are included along FBT principles, the average hospital stay is just 8 days. In the UK, the trend is to use the paediatric wards of general hospital for the medical stabilisation of children and adolescents, for no more than a couple of weeks. During that time, the community eating disorder specialists visit the young person along with the parents, to support both parents and nursing staff to get the young person to eat. This prepares parents and child for a successful return home as soon as possible. If it works, it's far less intrusive than a long admission to an eating disorder or psychiatric residential unit.

* Can hospital equip you for family-based treatment? A parent's inspirational account *

How my resources will guide you through a family-based approach for eating disorders

Here are the principles which I’m concentrating on in my book and other materials.

• The best results are obtained when parents are central to the treatment.
• Food is medicine, and children are brought back to a healthy weight.
• Parents are best placed to support meals, while also preventing over-exercising, bingeing and purging.
• All this is done within a loving, uncritical, supportive family environment.
• Psychotherapy, insight, self-esteem or motivation are not needed, and many of the mental issues of the illness will be resolve with nutrition and weight-restoration.

My book (and Bitesize audio collection) follow the general principles — rather than the detail — of the FBT manual and the Maudsley service manual.

The experts who developed or use these approaches recommend my resources, appreciating how they give parents some of the hand-holding and answers that may not be available in therapy sessions.

Parents also appreciate the sense of having another parent alongside, who really knows what it's like emotionally and can give practical, do-able guidance.

* For more on family -based approaches, jump to: Which eating disorder treatments work? *

* For more on how to help your child manage meals, jump to: How do you get your anorexic child to eat? *

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