Last updated on January 22nd, 2020
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… fast
- supporting your son or daughter to return to normal behaviours
- helping everyone return to normal life
The best treatment for teenagers with anorexia and bulimia
The research on adolescents with anorexia is especially strong. With bulimia, it used to be a toss-up between FBT 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 FBT.
Treating adults with anorexia
There are moves to adapt the family-based approach to adults, especially young adults (university age). In general, people suffering from an eating disorder need support from their family, whatever their age.
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 but in skilled hands, could be lovely.
Things can get harmful when the type of family therapy offered to young people assumes that family dynamics drive the eating disorder and/or impair recovery. That is my opinion, and when it comes to children and teens there's evidence to back it up: parents need to be empowered to take charge of meals and weight gain.
The type of family therapy I would caution you against examines how problems affecting a child could be solved by having the parents and the rest of the family interact differently. I believe that family therapy that finds fault with parents (instead of skilling and empowering them) 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 and lose their most important resource towards recovery.
- the focus could 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 does the very opposite. In spite of this, many centres treating teen eating disorders offer general family therapy, not the specialised kind, so you'll need to read between the lines or ask questions.
What kind of family therapy is the best for anorexia or bulimia?
Check that what's on offer is "family therapy specialised for eating disorders" or "family-based treatment (FBT)" or "Maudsley" (not "New Maudsley"– see 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)".
Confusingly, "systemic family therapy" may refer to general family therapy or to the specialised form that is recommended for eating disorders.
Another confusion is the term "Maudsley". People in the United States often refer to FBT as "The Maudsley approach", because its roots are in the Child and Adolescent Eating Disorders Service of the Maudsley hospital, London. Don't confuse this with 'The New Maudsley Approach', an adult-orientated approach later developed by the adult eating disorder services in the Maudsley hospital, headed by Janet Treasure. The recommended approach with young people is to empower parents to take charge of re-nutrition and weight-gain fast, because the evidence is that this produces the best results. New Maudsley, on the other hand, teaches a slow 'nudging' approach where the speed of progress relies on the person's motivation. A parent who is taking charge of their child's weight restoration in line with FBT might be labelled as a terrier (which is considered bad) with the New Maudsley approach.
To be clear, FBT (and variants) is the recommended evidence-based treatment for teens.
Which strand of family therapy for eating disorders is best?
The first trials for the treatment of anorexia nervosa were done in the Child and Adolescent part of Maudsley, where the approach continues to evolve under Ivan Eisler and Mima Simic. Nowadays they place quite an emphasis on 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.
In the UK, this form of family therapy will come under the FT-AN category. So will variants, including FBT.
Meanwhile In the US, Maudsley's family therapy got set down in a manual and subjected to further trials. The name given to this manualised approach is Family-Based Treatment (FBT) (and some call it 'The Maudsley method’). You can read the 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, though. My own family got top-notch support from a therapist who was shadowing another therapist who was going through FBT certification.
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.
You will find FBT dotted around the world, in particular in the US, Canada, Australia, New Zealand and Scotland. For a list of FBT therapists who are open to Skyping anywhere in the world, see here.
Hospitals that do family based treatment
Your son or daughter is far more likely to recover with you at home than with nurses and therapists in some artificial environment. Even if your child needs to go to hospital, at some stage they will need your support to get into normal life. 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 hospitalisation or day programmes may be indicated. We need these and at times they provide essential relief to the family.
The approach within a hospital 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. In Stanford, the home of FBT, the average hospital stay is just 8 days. In the UK, the trend is to only admit children and adolescents into hospitals for medical stabilisation, 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.
How my book will guide you through family therapy for eating disorders
Here are the principles which I’m concentrating on in my book.
- 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 doesn't follow the FBT manual, but its principles. My daughter's treament was delivered by clinicians undergoing FBT certification. My book complements the Lock/Le Grange books nicely as it gives you more of the "How", as well as a sense of having a companion who can guide you along the way.
For more on this subject, jump to: Treatment and support for your child and for you
For more on how to help your child manage meals, jump to: How do you get your anorexic child to eat?