Last updated on October 14th, 2021
Family-Based Treatment (FBT) is one of the best-researched treatments for adolescent eating disorders. Parents are tasked with supporting eating and normal behaviours in their teens, without waiting for motivation. FBT is supported by a manual. Some people incorrectly call 'FBT' any approach along similar principles.
This used to be a synonym for FBT (Family-Based Treatment) but is less in use. Do not confuse it with "The New Maudsley Method".
The best evidence (and recommendations of professional bodies world-wide) is for a family-based approach, so look for names like FBT, "Maudsley Approach"(as opposed to "New Maudsley") and FT-AN. Key principles include mobilising the family to support weight recovery and normalisation of behaviours — this is more effective than previous methods prioritising motivation and insight.
The kind that focuses on relationships and may lay blame. It may waste time as parents may not get empowered to be effective.
This is an umbrella term for the gold-standard treatment according to England's NICE guidelines. A key principle is that parents take a central role to support their child at home. The term includes FBT and the slightly different approach currently taught by Maudsley's child and adolescent unit in England.
Yes, if it's another term for FBT or FT-AN — if sessions support the parents to take a central role in helping their son or daughter in practical ways. But if it's a general family therapy focusing on relationships, it's not an eating disorder treatment (though it might sometimes be a useful adjunct).
New Maudsley gives parents/carers communication skills to support the motivation and readiness of chronic adult patients undergoing individual therapy. Do not confuse with "The Maudsley Approach" or FBT, which gives parents of teens a bolder, more central role. Some New Maudsley skills are useful, whatever the person's age, while some may clash with the tasks of FBT.
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… fast
- 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 mus 'take responsibility for their recovery'.
There is some promising research on variants of FBT for young adults (university age). However 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.
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 "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)".
"The Maudsley Approach" versus "The NEW Maudsley Approach"
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'. The word 'New' would make you think it's the better, latest model. Actually it's a different model that comes from adult services.
New Maudsley complements the patient's treatment (usually individual therapy) by teaching parents communication skills so that they will act like gently guiding 'dolphins' and avoid being 'terriers'.
Some (but not all) aspects of New Maudsley instructions might hinder progress with FBT (and with rapid weight gain, which is a predictor of success in anorexia recovery). This is because FBT requires parents to be persistent so that they succeed in feeding nourishing regular meals and stopping purging behaviours.
Once parents understand the difference and learn compassionate persistence, they can enjoy better connection with their child through New Maudsley training (in particular, becoming aware of when they are shouting or blaming like a 'rhinoceros' or sinking into despair like a 'jellyfish').
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. There is a service manual outlining the steps of family therapy for eating disorders.
This form of family therapy, like FBT, follows the principles of England's NICE guidelines for FT-AN ('anorexia-focused family therapy'). Indeed the NICE guidelines 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 when, in some cases, they don't seem to be familiar with the FBT manual. FBT seems to have become a bit of an umbrella term world-wide.
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’ even though it's now a bit different from what is done at the Maudsley service.
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.
Strictly-speaking, people should only say they're giving FBT treatment if they're following the FBT manual. In practice, "FBT", like "Maudsley" has become a bit of a generic term for any approach where parents are tasked with supporting eating and the return of normal behaviours.
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 family based treatment
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.
How my resources will guide you through family therapy 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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