Which eating-disorder treatments work?

What are the principles of successful therapies? What should you look for when choosing a therapist or treatment centre? And what are the red flags for poor treatment? I tell you more about family therapy and other approaches, suggest how to work in partnership with clinicians and when it might be better to find a new team. I also highlight what to look for in psychological support for yourself.

This is the whole of Chapter 12 of my book.

I want you find excellent treatment fast, and not waste time with ineffective approaches! 

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The parent’s quest for good treatment

In Chapter 4, I outlined the essentials of treatment for an eating disorder. In this chapter, we’ll look more closely at what works. Ideally, you could relax and ignore this chapter because you have a family doctor who promptly connected you with great specialists and you’re getting guided every step of the way.

But let’s acknowledge how stressful it is when we question the competence of treatment providers. It can be more upsetting than the day-to-day work of caring for our children. We entrust our child’s life to others and need to know the care is excellent.

What are the best methods? Who might have the up-to-date training as well as a lot of experience and skill? High fees are no indicators of quality. Even the most expensive private treatment providers are unlikely to collect or publish statistics on their outcomes. Sure, their beautiful websites boast the ‘many’ patients who achieved ‘positive outcomes’, but where are the numbers?^[i] And what methods exactly are they using?

In countries without a national health service, such as the US, parents may be glad to have a choice of treatment provider,[ii] but there can still be waiting lists. Too many people face difficulties with medical insurance and accumulate large debts.

Add to the stress the exhaustion from driving huge distances to access treatment or to visit an ill child in hospital. Fortunately, sessions by video call are now commonly available.

There’s also the pressure of time. Every day your child restricts food, they’re losing weight and eating disorder behaviours are reinforced. Prompt treatment gives the best chance of recovery.

Also, our children have limited tolerance to trying one clinician after another. I dreaded the day my daughter would point-blank refuse to see someone new – someone who I felt might be ‘the one’.

With a restrictive eating disorder, you can expect your child to resist treatment. If a child ‘hates’ a particular therapist, it might be because the therapist is doing a great job requesting that food be eaten. On the other hand, if you, the adult, feel uncomfortable about any treatment provider, this matters. You need to trust their competence, to be comfortable with them and trust them. I became effective when we got a specialist I really gelled with. Before that, I was so frustrated with our (unspecialised, non-FBT) family therapy sessions that I’d schedule support for myself immediately afterwards.

The bottom line is that counsellors, psychiatric nurses, psychiatrists, nutritionists and general practitioners can unwittingly lead you down harmful routes if they’re not highly knowledgeable about eating disorders in children and adolescents.

On a positive note, you could already be with an excellent therapist without realising it. For the 11 months that my daughter was in hospital, I had no idea that some of the people sitting silently around the table at review meetings were top experts who would later help us make rapid progress. When my child returned to outpatient services, I researched some private treatment options, unaware of how excellent our family therapist would turn out to be – unaware that we were already getting the best in evidence-based treatment. I also now know that if we had been rich enough to opt for those particular private treatments, our ordeal would have lasted much longer.

In this book, by ‘therapist’ I mean ‘clinician’: any health professional, including psychotherapists, doctors, nurses, dietitians, occupational therapists, speech therapists, physiotherapists, and so on.

Eating disorder treatments that are likely to cause harm

Before I tell you about treatments that have been shown to work, I’ll take a short detour and mention harmful approaches which, sadly, are still common. They may seem like ‘common sense’ if you’re new to this field, as they reflect the culture we’ve all grown up in. Even among therapists committed to evidence-based approaches – that is, treatment validated by research – it’s natural for beliefs from the old models to leak through occasionally.

Stay away from blame

A lot of harm has been caused by the belief that parents cause the illness or are maintaining it. I’m grateful to the pioneers at the Maudsley hospital – the children and adolescent service – who postulated that parents might actually be an asset. And for the pragmatism of FBT – showing that we can treat successfully without guessing or inventing causes for the illness.

Mothers don’t get blamed for autism or schizophrenia any more, but when it comes to eating disorders, you may still get the message that you need ‘fixing’. Some parents are told they have issues with anxiety, depression, control, over-attachment, under-attachment, avoidance, enmeshment, or codependency. Whatever kind of parent you are, it’s a problem! The awful consequence is that you become disempowered. Your hospital visits may be curtailed or even forbidden,^[iii] and your child is deprived of the most powerful tool for recovery.

As the director of the National Institute for Mental Health in the US noted with frustration:

“Many professionals, who have no training in neuroscience, still find a neurobiological approach to mental disorders as misguided and frankly alien to all of their experience. […] In an earlier decade, focusing on the medical basis of cancer and AIDS helped us out of the blame and shame phases of these disorders.”[iv]

Most parents are eager to learn skills that help them support their child as effectively as possible. There are approaches that are empowering and non-blaming. Both TBT-S and EFFT[v] strike me as true to this goal – and I hope I’m succeeding too.

If you’ve attended skills training through the ‘New Maudsley Method’[vi] and find you’re blaming yourself for getting things wrong – even though you’re told to treasure your mistakes – you’re not alone. You’re presented with a menagerie of animals you shouldn’t be like (rhinos, ostriches, terriers, and so on). And when you do your best to manage immediate risks without adequate support, you may be labelled as ‘accommodating’ or ‘enabling’. All this to say, take the communication tips that empower you from any training, and feel free to ignore the rest.

Focusing on motivation, readiness or insight: not recommended

Does your treatment provider believe that your child must ‘own’ their recovery – that nothing can happen until they have the motivation to recover? For children and teenagers, this is not evidence-based treatment, it’s not a family-based approach, and it’s not the recommended first line of care. Waiting for motivation delays the effective action parents can take. Meanwhile, the illness can become entrenched and the person sicker.

Parents – and even professionals – can be misled when they don’t realise that a method developed for long-term sick adults is not validated for teens. The ‘New Maudsley Method’ I mentioned earlier is one example, with its focus on moving a person along a ‘readiness for change’ scale within the ‘motivational interviewing’ cycle.[vii]  

Some adults with anorexia do have motivation to beat the illness, and plenty of insight into its mechanism. This may get them as far as signing up for treatment. But when dinnertime arrives, eating is so unbearable that all too often, any shred of motivation slinks off, whimpering. Motivation is overrated. People need practical support. And for those of us with children at home, that’s where we’re able to make a difference.

The ‘reaching rock-bottom’ folly

Tragically, when the only tool in the box is motivation, therapists and parents can resort to extremes. Beware of the ‘reaching rock bottom’ fallacy.^[viii] It may sound like, ‘Let her experience the consequences of her choices so she learns to take responsibility for herself.’ This stance comes from the field of addiction, where it is controversial. With anorexia it equates to, ‘Let her not eat. Let her get hungry and weak and desperate. Let her mess up her studies and lose friends. Let her experience the consequences of her actions. When she’s reached rock bottom, she’ll finally see sense. Then she’ll want to get better.’

I have talked to weary parents who tried this because they believed they were out of options – such as a couple who let their underweight young adult go trekking in Africa. To my knowledge, the outcome of such gambles is always the same: the person hits rock bottom… and stays there until they have to be rescued.

The fact that well-meaning therapists and loving parents are ready to use such high-risk strategies tells me two things. First, they don’t appreciate that the longer a patient is malnourished, the harder anorexia is to shift. And second, the parents are being deprived of competent, specialised support.

The best evidence-based treatment

 Health organisations worldwide regularly evaluate the quality of published research, to determine which treatments to recommend.[ix] On the whole, their conclusions are the same.

For anorexia and bulimia in children and adolescents, there’s a clear consensus that a family-based approach is the first-line treatment – that’s the type of family therapy described in this book. UK guidelines advise that only if family therapy turned out to be ‘unacceptable, contraindicated or ineffective’ should you consider one of the next two best approaches:[x]

• For anorexia or bulimia: individual cognitive-behavioural therapy (CBT) specifically for eating disorders
• For anorexia only: adolescent-focused psychotherapy (AFP)
• For binge-eating disorder, the recommendation is for a guided self-help programme, then if necessary, group or individual CBT.

Principles validated by research

The successes of CBT indicate that whatever the person’s age or type of eating disorder, key concepts include regular meals, weight recovery and cessation of bingeing or purging behaviours. For adolescents, the successes of a family-based approach uncover the following additional principles:

• Your child hasn’t consciously or unconsciously chosen to have an eating disorder, and they are not the eating disorder. The illness is driving their distorted beliefs and behaviours.
• Treatment works without waiting for your child to gain insight or to be motivated to eat or get well.
• Families should be treated as a resource, not a cause or hindrance.
• Parents should be empowered to feed their child and normalise eating, weight, and behaviours at home.
• Rapid weight gain, exposure to food and overcoming fears may be part of how the treatment works.
• Treatment should be delivered by experienced clinicians, preferably within a team specialising in the treatment of eating disorders.

Family therapies: they’re not all the same

The approaches I support you with in this book come under many names. I’ve chosen the terms ‘family therapy’ or a ‘family-based approach’. If your treatment looks very different yet has a similar-sounding name, read on. Some of the confusion is harmful. For instance, you’ll hear clinicians and parents say they are ‘doing FBT’ even when they’re contradicting key principles of the treatment.

Here’s a quick guide (and I go into more detail on my website).

If ‘Yes’ to any of the following, you’re probably getting a family-based approach. Is your treatment called ‘FBT’ (Family-Based Treatment), with some level of adherence to the FBT manual?[xi] Or is it perhaps called ‘FT-AN’ or ‘FT-BN’ (Anorexia/Bulimia-focused Family Therapy) or FT-ED (Eating Disorder focused Family Therapy)? Does your clinicians’ training originate from Lock, Le Grange or their colleagues (mainly in the US)? Or from the Maudsley Centre for Child and Adolescent Eating Disorders in London?[xii], [xiii]  In the UK, are you getting NHS treatment from a Community Eating Disorder Service (CEDS)? 

Are you getting Multi-Family Therapy (MFT)?[xiv] This is an adjunct to a family-based approach and is fully compatible.

Are you getting ‘family therapy’ or ‘systemic family therapy’? As long as it takes into account the particularities of an eating disorder, it’s just another name for a family-based approach. You’ll need to check: is there work on normalising eating, regaining lost weight and interrupting eating-disorder behaviours? Are parents valued as an expert on their child? If not, the family therapy on offer is not a recommended eating disorder treatment.^[xv]

Indeed, too many treatment centres deliver a ‘family therapy’ that’s the opposite of FBT: parents are led to believe they’re part of the problem. They’re told to let their ill child make their own decisions. The therapy is about changing how family members relate to each other.

A really old-school family therapist may even believe that a child has anorexia to try and fix the family’s problems. I know some brave parents who have endured blame, session after session, in the hope the process will save their child. Tragically, while the family dynamics was put under the microscope, the young person was losing weight, purging and over-exercising.

On to the next source of confusion.

If your professionals say they treat with ‘Maudsley’ or the ‘Maudsley Approach’, I hope they mean FBT. But … these days they’re more likely referring to a very different model – confusedly called the ‘New Maudsley Method’.[xvi] While the communication skills it teaches are universal, I mentioned earlier that some aspects are not compatible with FBT, and not part of first-line treatment for children and adolescents.

On my site: Family therapy for eating disorders: what is FBT / Maudsley/FT-AN? [xvii]

Family therapy: the first line of treatment for children and teens with anorexia and bulimia

If you’re in a hurry, here’s the main message: there is clear evidence – and advice from professional organisations worldwide – that family therapy specialised for eating disorders should be your first port of call. If a treatment centre isn’t offering that, they’re not up to date and your child will be missing out on a treatment that is twice as effective as the next best approaches. If, for some reason, family therapy really isn’t for you, then yes, there are other approaches.

How effective is Family-Based Treatment (FBT)?

Before family therapy came along, there was no scientific evidence that anything worked particularly well.[xviii] Then the Maudsley hospital conducted some trials which indicated success with a family approach. A while later Lock, Le Grange and others nailed down a protocol (a detailed manual) for family therapy, called it Family-Based Treatment (FBT). By now, several randomised controlled trials[xix] have made a family-based approach the gold-standard treatment.[xx]

It doesn’t work for everyone

Your child’s best chances, statistically, are with a family-based approach. Still, the figures show it doesn’t work for everyone. That’s not a reflection of personal weakness. It means it’s time to try something else and keep reviewing. We’ll look at alternatives later in this chapter. Note that your child will continue to benefit from your support whatever the type of treatment: family matters whether the treatment is family-based or individual.

Family therapy for anorexia in younger children

The studies I refer to above are for adolescents aged 12 to 18. It seems that family therapy is also the best approach for younger children. That makes sense, given they generally have little capacity for the introspection required of talking therapies, and that it’s natural for parents to be making decisions.[xxi]

Family therapy for anorexia in adults and younger adults

A family-based approach can be adapted for adults. There’s been a bit of research on this, involving more teamwork, more buy-in from the young adult, and less of parents making the decisions. All the same, parents are expected to commit to help their child gain weight and normalise eating.[xxii]

A method I’d like to see more of, as it makes good use of parents in a non-judgemental way, is TBT-S (Temperament-Based Therapy with Supports).[xxiii] Given that most adult treatment disempowers parents the minute their child turns 18, most parents who want to stay involved find their own way. The main point is they actively support meals.

“Our D is now over 21 and was first diagnosed at 16. Three and a half years ago, she had a big relapse. Prior to that treatment was not really coordinated and we had no Maudsley Family-Based Treatment. Since we found our special educator and her Maudsley Approach we have steadily travelled the journey to recovery and still find the Maudsley Approach very valid for an adult child.”

On my website: 'Adults or young adults: treatment for a restrictive eating disorder'[xxiv]

FBT for bulimia

Both FBT and CBT-A – a cognitive behaviour therapy for adolescents with bulimia – show similar outcomes 12 months after treatment. The recommendation for first line treatment in the UK is FBT, likely because it tends to deliver improvements sooner.[xxv]

What happens in a family-based approach?

Parents can easily read both the FBT manual and the Maudsley (child and adolescent) service manual.[xxvi] They’re similar so I’ll just outline how FBT works. It’s an outpatient treatment lasting 6–12 months (20 to 40 sessions).[xxvii] The clinical team usually consists of one lead clinician and a co-therapist – often child and adolescent psychiatrists, psychologists or social workers. They may be supported by a consulting team that includes a paediatrician, nurse, or dietitian. Parents are recognised as the experts on their child, providing meals and loving support at home.

When you first visit an FBT therapist with your child, the focus will be on weight restoration and normalising behaviours (Phase I). You take responsibility for your child’s meals and prevent excessive exercise, bingeing, or purging. The therapist ensures you and your spouse are consistent in your commitment and clarifies the role of siblings, offering them support too. After about ten weekly sessions, if the child is close to a healthy weight and meals are relatively stress free, Phase 2 begins (see Chapter 10). An age-appropriate level of autonomy is gradually handed back to the young person. Sessions may become less frequent – the manual allocates five sessions for this phase. Finally, Phase 3 (around three sessions) is about returning to normal family relationships, addressing the young person’s life beyond food issues, and planning for the future.[xxviii]

Should your child like the family therapist?

With FBT it’s important that you, the parents, feel well supported. As for your child:

“My daughter hated her ED therapist at first sight. She would swear at her, storm out of the room. You name it. That’s when I knew we had found the right one. Our previous therapist was lovely but didn’t push my daughter or challenge the eating disorder enough.”

Is it OK to tweak the method?

I discuss this in Chapter 4. Short answer: the greater someone’s knowledge and experience (yours and your clinicians’) the more likely that any modifications will be well chosen to suit your child’s needs. Conversely, when people are not very experienced, there’s a risk that they ‘don’t know what they don’t know’.

Individual therapies

I’ll now describe CBT and AFT, as they are recommended if a family approach is ‘unacceptable, contraindicated or ineffective’.^[xxix] These are individual therapies, meaning your child will mostly meet the therapist one-to-one – without you – and will mostly be expected to progress through their own efforts. Check carefully what your involvement will be and if you are comfortable with that.

If a person in individual therapy makes no progress, the therapy may end (quite rightly, in my view). So then you’re back to looking for good family-based support, or possibly an inpatient unit.

Sometimes an individual therapy can usefully complement and finish off the work done in family therapy.

Cognitive behavioural therapy (CBT) adapted for eating disorders

Cognitive Behavioural Therapy for eating disorders (often called CBT-E) is a specialised variant of CBT. Like FBT, it focuses on normalising behaviours and on nutritional restoration. Whereas with FBT, the parents make this happen, with CBT the responsibility rests on the young person. Through individual sessions, they’re taught education and logic intended to motivate and enable change. Parents are asked to ‘support’ and ‘gently encourage’—but not to ‘interfere with’—the decisions made by their teen in one‑to‑one therapy.

Handing over your child and having a professional do the hard work can sound wonderful!  I wish I’d seen some of that magic with my daughter, whose good progress with us was jeopardised by a (well-qualified) CBT therapist. Research indicates that when completed, the method is as effective as FBT in the long run. But – and it’s a big, risky ‘but’ if your child is losing weight – there are no prompts to increase calories before Week 5. I suspect much CBT isn’t done by the book, which partly explains why some children are stagnating or declining. To learn more about CBT, see my endnotes.[xxx]

* Cognitive behavioural therapy (CBT-E) for eating disorders *[xxxiii]

Adolescent focused individual therapy (AFT)

The other evidence-based individual treatment on offer is adolescent focused individual therapy (AFT) – in the UK it’s referred to as ‘adolescent-focused psychotherapy for anorexia nervosa’ (AFP-AN).[xxxi] The therapist guides the young person to change their behaviours, restore weight, and develop emotional awareness. Parents have only a supporting role. Research comparing AFT and FBT found that for most youngsters with anorexia, FBT is more effective –roughly twice as effective as AFT. Still, because FBT doesn’t work for everyone, the conclusion is that ‘AFT remains an important alternative treatment for families that would prefer a largely individual treatment.’^[xxxii]

Lots more, including pros and cons, on my website:

Adolescent-focused therapy (AFT) for anorexia: how does it compare with family-based treatment?[xxxiv]

Adolescent-focused therapy (AFT): a guide to the joint runner-up treatment for anorexia[xxxv]

Psychotherapy as an adjunct to family therapy

On its own, talk rarely fixes an eating disorder, especially anorexia. Physiology, brain wiring and habits outsmart intellect:

“When treating anorexia nervosa, be aware that:
-helping people to reach a healthy body weight or BMI for their age is a key goal and
– weight gain is key in supporting other psychological, physical and quality of life changes that are needed for improvement or recovery.”[xxxvi]

Initially, individual therapy was not part of FBT – just something you could add on at the end. When I learned this, it was a relief: it gave us permission to end the awful individual therapy that my 11-year-old had been forced into. Psychotherapy is usually a waste of time in the early stages because of the ‘anosognosia’ – a brain condition that accompanies anorexia, which makes a person unable to perceive that they are ill or grasp the severity of their situation. Talk has little power over that.

At the start, most of us put a naïve amount of faith in psychotherapy. Let’s remember that many psychological issues resolve as we work on nutrition and helpful habits:

“When my daughter was at her lowest weight she was OCD for sure, and bipolar was suggested, but my wife and I really put the screws down not to give her that diagnosis in her chart because it would follow her around for ever. Sure enough, once we passed a certain weight on the road to restoration it was like her brain rebooted.”[xxxvii]

Still, throughout treatment we should acknowledge our children as living, emotional human – not an illness to be fixed. Some may gradually engage with treatment rather than having it all ‘done to’ them.

Practices are evolving: now, if your team sees potential benefit in individual therapy, they may integrate it into a family-based approach.[xxxviii] This should not detract from the work of refeeding and normalising behaviours – talk must not get in the way of action. And clinicians must collaborate with each other and with parents.

Some youngsters beg for individual therapy. Be aware that often, what they really want is to feel happier while everyone lets them get thinner. But some genuinely self-reflect and engage. For instance, one girl I knew of, traumatised by fat-bullying in school, did well with EMDR therapy while her parents renourished her.

What’s certain is that psychotherapy can be helpful after family-based treatment has run its course. Consider this if your child is mentally ‘stuck’ even after weight and behaviours are well regulated. At this stage, psychotherapy can address body image, distress tolerance and emotion regulation. I recommend that at least some of this work be done with the family, so parents can support the use of tools in real-life situations.[xxxix]

Later in this chapter I’ll discuss what you can do if your child’s individual therapy is disempowering you.

Psychotherapists don’t have your parent-power

Whether or not you try psychotherapy for your child, remember your own precious powers as loving, dedicated, wise mothers and fathers. No therapist can replace that. You provide a healing balm every time you connect, every time you say, ‘Tell me more. I’m interested. I care. I feel for you.’ Even when your child rejects you. Even when you can’t seem to say anything helpful (but do see Chapters 13 and 14).

The most wonderful professional is only present to your child one or two hours a week, in a somewhat artificial environment. What our children most need is to be loved and supported by us, their parents. There’s no relationship like it. Bring to mind your own parents – doesn’t their love, or their withdrawal, still affect you?

Why would your child engage in therapy?

I have supported parents who use the family therapy approach and are also delighted with the individual therapy their child is receiving – usually for depression or anxiety. The child engages well with the therapist and learns new ways of coping with life’s challenges. Sometimes old traumas are revealed and processed.

For most, though, saying a youngster may not engage with psychotherapy is an understatement. Commonly, they blank the therapist out, they’re rude, they must be dragged into the building, and they run away. Whatever your child is doing, it’s probably normal – and for all we know, is a sign of great sanity.

My daughter’s psychotherapists revealed that even without an eating disorder, most of the children and adolescents they see one-on-one don’t engage. If so, aren’t the sessions a waste of resources?

Many of our youngsters are intensely private and emotionally regressed. They fear they’ll be judged. They feel awkward and ashamed in front of a stranger. When they do bare their soul, it’s usually in unscheduled moments of connectedness with their loving parents. They hate the abnormality of being pulled out of school. My daughter detested the ugly institutional rooms, the plastic toys piled in the corner, and the women’s magazines (‘Get beach-body ready!!!’) littering the waiting area.

If in doubt, use this reality check: are therapy sessions making your child eat as required? If not, why bother?

On my website: Don’t beat up your child (or yourself) for failing in spite of therapy[xl]

How to identify effective treatment providers

How do you choose a therapist, clinic or hospital? In a country with a national health service, is your allocated clinician suitably specialised? If you feel harm is being done, should you hunt for private treatment or even go solo?

Is your specialist a specialist?

How do you know a therapist will deliver good family therapy? There’s no universal criterion. In the US, there’s a general certification for eating disorder clinicians, but they may be untrained in a family-based approach.[xli] For FBT therapists only those who are ‘certified’ have had extensive (and expensive) training and supervision by Lock or Le Grange’s teams. You’ll find some of them on the FBT training website.[xlii] 

Most clinicians who treat eating disorders have none of the above credentials. They may or may not be excellent. So we must pick up our courage and ask them about their training, experience, and methods. Experienced clinicians tell me that a few days’ training in a family-based approach, or simply reading a manual, is not enough to really understand the approach[xliii] – especially so if they’ve been using older eating disorder treatments for years. Outdated concepts can leak out:

“Our therapists were new to FBT. Early on they gave us an awful ‘why did this happen in your family’ session. While I think it was meant to illuminate, it actually caused us all more worry about what we possibly did wrong to cause our daughter's illness. The day our daughter heard me tell her the illness wasn’t her fault, we really began to move forward.”

Window dressing or ignorance

Any professional will claim to follow evidence-based practice. It may be true, or it may be window-dressing. Clinicians don’t all follow the science.[xliv] One reason is human nature: most humans trust their opinions and suffer from an overconfidence bias. We mean well, but ‘we don’t know what we don’t know’.[xlv] Or, as eating disorder researcher Glenn Waller quipped, ‘There's a lot of evidence that evidence is better than opinion, but a lot of opinion that opinion is better than evidence.’

Another reason is that keeping up to date is expensive and time-consuming. So many treatment providers – including expensive private centres – keep doing what they’ve been doing for the last few years.

The no-brainers

Any adolescent service that isn’t putting specialised family therapy top of their list is only paying lip service to evidence-based treatment. Sure, the website’s photography is gorgeous, but what’s behind the words?

• ‘We offer family therapy to improve how family members relate to each other, resolve conflicts and communicate.’ That’s about fixing the family (and probably blaming parents). What you want is treatment with the family, not of the family.
• ‘Your child will receive intensive psychological and emotional support to understand underlying factors that have contributed to her eating disorder.’ Understanding (or more likely, speculating) doesn’t constitute treatment. Insight usually comes because of nutrition and behavioural work, not the other way around.
• ‘Your child will gain a deeper understanding of herself and insight into the root causes of her eating disorder.’ Ditto
• ‘Eating disorders are symptoms of deep, unresolved issues. You will learn how to confront these issues and the emotions they produce, and your relationship with food will stabilise.’ With extra alarm bells as it doesn’t sound like the person is expected to eat for a while.
• ‘All meals are eaten in a family atmosphere with our highly trained staff.’ Sounds like parents don’t get a seat at the table.
• ‘… blank …’ Nowhere does the website mention eating or weight gain.
• ‘Parents may visit their child between 2 and 3pm on Sundays. Visitation privileges will be withdrawn if the child has not gained the expected daily rate.’ Yes, this still exists. Parents are excluded because considered harmful (‘parentectomy’) or used as a punishment and reward system. The last parents I spoke to who went along with this eventually pulled their child out (a tender eleven-year-old), as there was no progress. She recovered at home.

A checklist to assess a treatment provider

Here are some questions to help you assess whether a therapist can meet your needs. In case you’ve skipped previous chapters and are in a hurry, I indicate the desirable answer in brackets. If an answer is very different, see if the reason makes sense to you. A good clinician will love how well-informed you are rather than be offended. See also the endnotes[xlvi] for more guides on choosing a provider. And if you need to assess an inpatient unit, I’m giving you a checklist further down.

• What treatment will you give my child? [Family therapy/Family-based treatment/FT-AN/FT-BN, in the case of anorexia or bulimia]
• If not a family-based approach, why not? [At this stage, the only valid reason would be if you are unwilling or absolutely unable to take an active role]
• What will be our role (as parents) in treatment? [Initially you’ll take responsibility for meals and for normalising behaviours (phase 1), then cautiously steer your child to regain age-appropriate control (phase 2) and finally help them step back into a full life (phase 3)]
• Will our child have to regain the weight he lost? [Yes, plus more to account for expected growth]
• What is the target weight? [We won’t know until we get signs of a healthy body and improvements in mindset]
• Can we let our child be a little bit thin, since he feels fat and wants to diet? [No, we’re aiming for health and total recovery]
• Can we let our child exercise/purge after meals, as it relieves her anxiety? [No, but I’ll help you help her to manage her feelings]
• He’s used to small meals, so can we reassure him they will stay small? [No, rapid refeeding is best, and I’ll help you make it work]
• Should I be glad that she’s banned junk food? [No food is ‘junk’. We’re aiming for freedom to eat without rules.]
• Will you give us a meal plan? [With FBT: no, but I’ll guide you if you’re unsure.] [Also fine: yes, but only at the beginning, and the plan gives you plenty of flexibility and will evolve.]
• Can my child recover totally? [Yes]
• Did we cause the eating disorder? [No, there are many interlinked causal factors – genetic, biological, environmental – and scientists don’t yet understand causation. But we can successfully treat anyway.]
• How can I stop her being so selfish and manipulative? [We’ll work on unconditional acceptance of your child, as it’s the eating disorder that makes her this way for now.]
• Will parents be included in all sessions? [Yes – parents are central players within the treatment team]
• Will you provide my child with individual therapy for her anorexia/bulimia and why? [FBT: no, unless your child still has difficulties after the eating disorder is addressed.] [Also fine: yes, in conjunction with family therapy, for co-occurring OCD/anxiety, etc.]
• If you’re proposing CBT, why, and can you describe the approach? [See earlier how CBT for eating disorders is the go-to approach for binge-eating disorder. Also how it differs from general CBT.]
• If you propose individual therapy, how will we parents be kept in the loop? How can we inform you of behaviours we see at home? [If the therapist is vague about your involvement, beware of getting disempowered]
• My child is neurodivergent/has OCD/depression/anxiety. How will you address it? [Discuss how this will affect eating disorder treatment. In general, eating disorder treatment comes first.]
• Will you work on giving my child insight and motivation? [No, that would delay the real work.]
• What if my child is in medical danger, or needs psychiatric medication or hospitalisation? [We are a team, each with our specialities, and we work closely with you and each other]
• Will you help me liaise with the school and athletics club? [Yes]
• What support will you give us as parents? [Mealtime coaching or support visits at home would be good, though uncommon. Sessions without your child can be very useful. Sessions with other families can be supportive.]
• Who trained you in a family-based approach? [Ideally, one of the key names in the field, and for longer than the basic 2 days]
• What are your qualifications, experience, ongoing training and supervision?[xlvii] Are you a member of eating disorders associations? Have you published any research? How do you keep yourself up to date? What books or online resources do you rate highly? [If they haven’t studied the FBT or Maudsley service manual, I’m not impressed. Certification in FBT is quite rare, so consider it a bonus.]
• What led you to work in the field of eating disorders? [Looking for a wise, compassionate attitude and commitment to total recovery.]
• Have you ever suffered from an eating disorder yourself, and if so, do you still experience symptoms? [Checking the therapist can stay focused on your child’s recovery]
• How many eating disorder patients have you treated recently? How many completed the whole course of treatment? What were the outcomes after 1 or 2 years? [A tricky one, as very few clinicians collect or publish any data]
• How soon can you see my child? [If a private clinic isn’t in a hurry to see a child who is losing weight, they don’t appreciate the importance of early intervention]

I suggest that, at first, you check out a therapist alone, to protect your child from hearing anything harmful. In my case I also didn’t want my daughter to develop an intolerance to therapists.

You could also visit online forums[xlviii] to ask about other parents’ experiences with a particular treatment centre.

Finally, trust your gut. I would be concerned about the therapist’s effectiveness if I sensed being bossed around, patronised, hurried, judged, excluded, not listened to or not respected. Or if the therapist was evasive or authoritarian, or if it took tremendous perseverance to get answers. On the other hand, I wouldn’t let a warm, compassionate exchange distract me from the other essential requirements.

We’re not looking for perfection. Some help may be better than no help. As long as the therapist doesn’t disempower you in the eyes of your child, there is plenty you can do yourself.

Clinicians who previously had an eating disorder

Many eating disorder clinicians come to the field because of lived experience. Some disclose it if they sense this will benefit their client (for example, by instilling hope).[xlix] Others don’t.

Some peddle the single thing that happened to work for them (such as a spiritual epiphany). They are unaware of evidence-based treatment or haven’t properly studied them. They are sure their way is best. I hear them on podcasts, and it breaks my heart that some parents may choose them before giving gold-standard treatments a chance.

Our children need a strong, courageous expert who will challenge eating disorder behaviours. Someone with a positive attitude to food, exercise and body diversity, and who appreciates the necessity of complete weight recovery. Usually, that means someone who has recovered. But it’s not that black and white. There are therapists who still have occasional personal struggles but are great at their job. Conversely, a clinician who never had an eating disorder may never have detached from diet culture and weight bias.[l] Consider this specialist who told her patient, ‘Don’t worry, it will be easy to maintain your weight. You’ll just make sure you don’t eat too much. That’s what I do’.

Is it wise to ask a clinician if they’ve suffered from an eating disorder and if they’re now recovered? Is it even wiser to check out their attitudes toward weight, food and exercise? Probably. Hard to do within a national health service, where you’re expected to trust whoever you get. Easier when choosing private treatment. This is not about being judgemental and shaming a professional, but about assessing what may or may not help your child.

A recovered therapist may be fantastic, and I know a few of them. Conversely, I don’t think their experience is an essential asset. Any good therapist should have developed both experience and empathy. After all, there’s no need for the podiatrist who treats my mum’s feet to have had foot problems herself.

You can be sure that your child will scrutinise the therapists’ bodies. Many of the professionals who cared for my daughter had very large bodies, and I wondered if that would be an issue for her. Apparently not. What did matter was how they treated her. One of her favourite, most motherly nurses had a generous, cushiony body specially designed for hugging, something that gave my daughter and myself great delight.

Clinicians rich in human qualities

My daughter received meaningful support from various nurses and specialists, irrespective of their training. One of her hospital therapists had a psychoanalytical background, which for me is normally a turn-off. Yet I cannot think of anyone I would want more in times of need: she could make a desiccated twig flourish, such is the power of her empathic manner and the quiet wisdom she embodies.

There was also the nurse on the ward whose hugs were pure therapy. I remember weeping with gratitude when she promised to comfort my little girl on one particularly awful night. And then there was a nursing aide, no more than 25 years old, one of the wisest, kindest, most empathic people I’ve ever met.

It’s no coincidence, I’m sure, that the staff who were wonderful to my husband and me were also the ones my daughter loved the most. Their humanity lit up everything in their path. I believe that their life-affirming influence lives on within my daughter now. It certainly does with me.

When you disagree with your clinicians

Parents who educate themselves can soon become more knowledgeable and up-to-date than a clinician who hasn’t specialised in eating disorders or has limited curiosity. There are big names who have treated teens for decades, and only have a vague, incorrect idea of what family-based treatment is. And there are therapists who say they ‘do FBT’ after just a few hours of introductory training.

Plenty of parents rate their clinicians highly. But they may still strongly disagree with one aspect of the treatment. That happens in a field that is changing rapidly. In this situation, a clinician can feel threatened: they’re the expert on the treatment, and who do you think you are? You’re conscious that you don’t know what you don’t know, so at first you genuinely want a discussion. But the therapist isn’t hearing you, and doesn’t like their authority challenged. You hesitate. Perhaps you go along with their instructions for a while. Eventually, you’ve spent a gazillion hours on research, plus you’re concerned that your child is regressing. Your team says they’re ‘doing FBT’, yet when you speak to parents in another part of the country, with another team who is also ‘doing FBT’, you find striking contradictions.

Make an appointment without your child and discuss the issue. You’re part of the team, and you’re officially an expert on your son or daughter. You may bring research papers, links to conference videos, quotes from respected experts who founded or researched family therapy. I warn you, though, that some parents have found this does not make one jot of difference. The clinicians argue that the evidence we present them with doesn’t apply to our child, or isn’t strong enough, or that their experience points the opposite way. ‘Evidence’ becomes a weapon with which to beat each other up. A clinician may rebuke parents for reading ‘too much’! An issue becomes highly emotional, and rational discourse vanishes.

It may help to keep the three foundations of ‘evidence-based practice’ on the table: the evidence, the clinician’s expertise, and your family’s needs and experience. You’re an expert on the latter. Describe what’s happening at home and use your well-practised skills of compassionate persistence to persist with your request. You can make change more acceptable by ‘agreeing to disagree’ and proposing a trial with a review date.

And sadly, nothing may work. Some parents find that treatment is so ineffective – or even harmful – that they wonder if it’s time to cut their losses and run.

Should you drop unhelpful treatment?

Here's a rule of thumb: if despite your best efforts, you see no progress (e.g. reversing weight loss) after a few weeks of a therapy, it’s time to review. What needs to be tweaked? Or might the method – or the clinician – simply not be the right fit?

One seemingly trivial reason why we stay with a therapist despite poor outcomes is that we want to be nice. Sometimes we feel sorry for them.[li] They mean well and have worked very hard for us. We imagine they’re so vulnerable that we’ll hurt their feelings if we leave. However, being ‘nice’ rarely meets real needs.

Sometimes we put therapists on a pedestal. We fear that if we don’t behave like compliant children, they’ll judge us. It shouldn’t matter what people think of us, but hey, we’re social animals.

Parents’ self-confidence can be so low that they get confused. This happens when clinicians blame them for the illness, diagnose them as over-controlling or codependent, and insist that their child would eat if they backed off. Who to trust? Your spouse may believe that the doctors know best. Perhaps you are indeed entirely wrong. On the other hand, there are many examples of parents’ instincts being validated after moving to a new therapist.

As you toy with the idea of walking away from a treatment provider, you may feel extremely vulnerable, alone, and somewhat reckless. Yet if you sense that a professional is letting your child get worse or is undermining your own work, part of you knows it’s crazy to stay. So what’s holding you back? The possibility that they’re better than nothing? The worry that if they took the huff, they could make it more difficult for you to access other health services? The fear of burning your bridges and being left stranded if your child gets worse?

We certainly felt quite vulnerable whenever, for any reason, a relationship with a therapist came to an end, and it was good to know we could get prompt support again if we needed it. You’ll need to check the situation where you live. Where I am, the safety net of hospital admission remains, irrespective of any treatment you accept or turn down.

If you’re struggling with doubts, seek parent-support groups to help you name your concerns and consider your options. You must make these decisions for yourself, but it helps to learn from other people’s experiences.

No good treatment locally?

If you can’t find a good therapist locally, there are other options.

• Therapists can work by video call.[lii]
• It might be worth travelling far for several days of intensive multifamily therapy.[liii]
• If you’re in the UK and your GP acknowledges that treatment isn’t meeting your needs, they can release funds for treatment elsewhere, either at an NHS centre of excellence or a private clinic.[liv] Of course, do your research to make sure you’re not going from the frying pan into the fire.

Family treatment the DIY way

Finally, some parents bravely go it alone. If that seems daunting, be aware that you’re in good company. You may benefit from reading about the experiences of people who have done this.[lv]

If you’re even considering this move, I’m guessing you’re already extremely well-informed and determined. At the same time, you’re going to need support. At the very least, you’ll need a doctor to monitor your child’s health. In the UK, we can choose our GP, so switch if you’re not happy with the current one. You need someone who’s either well educated in eating disorders or who’s willing to learn.

You’re bound to have all kinds of practical questions: should you let your child choose her flavour of yoghurt? Should you weigh her? Should you let her go for a sleepover? Parents and therapists all over the world share their wisdom online.[lvi]

Here’s from Dr Rebecca Peebles:

“I believe that bad therapy is worse than no therapy. So when I get a call from parents … if they cannot access someone who can work with them and their family in a respectful manner then I guide them to Lauren Muhlheim’s book, Eva Musby’s book, Laura Collins and FEAST and… That’s what I guide them to and I try to empower them to pull themselves up and try to do this more on their own. I know that’s really scary, and I’m not saying it’s ideal but it’s better than working with a crummy therapist who undermines you.”[lvii]

Parent-coaching, home support and day treatment

Your clinician may invite you to bring a ‘family meal’, ‘picnic’ or ‘mini meal’ to a session. Their aim is to witness how it’s going and to model appropriate responses. Nourishment is so crucial that during the refeeding phase, FBT sessions focus on reviewing how meals went – what helped and what didn’t.

What if meals aren’t working? Ask for more help, and keep asking. Some providers – though far too few – can send a professional to your home. This may be to break a deadlock and restart eating, to avoid hospitalisation, or to observe and coach you.[lviii] If that doesn’t work, the next step, ideally, is an intensive day program: for several meals a day, our children get back into the swing of eating, and parents get education and coaching.

Outside the US, these programs are quite rare. Assuming your child is medically stable, you may – like us – have only two options: home or inpatient unit. As home meals were not consistently working, my girl had 11 months of inpatient care and countless family therapy sessions. What a waste of time and resources! We made repeated requests for coaching at home. It took more than a year for this to be granted. With just four lunches at our house, we became competent to feed.

Health service managers take note: I reckon that those visits cost the service a total of six hours. Six hours to make parents competent, versus thousands of hours of therapy and nursing care. If I were king, every family hit by an eating disorder would receive coaching and support at home.

If you need help with feeding or have other needs, check whether carers may be provided through healthcare, social care, psychiatric services or non-profit organisations.[lix] If staff visit your child at home or take her out, she may enjoy the break from you while you get a rest.

There’s another kind of support you might explore if you’re struggling: a ‘recovery coach’. This person may take on some of the work a parent normally does in  family-based treatment, such as supporting a meal or exposure work. You’ll need to check the person’s competence and see how they’ll work with the rest of the team, including yourself. Make sure you don’t disempower yourself in the process.[lx]

Hospitals and eating disorder units

When meals aren’t working at home, your child needs a higher level of care.[lxi] It could be a paediatric (medical) ward if they’re medically unstable. Eating there can provide a bit of a ‘reset’: if youngsters manage to eat with their parents on the ward, the transition back home may work well.

When someone needs intense support – for severe restriction, purging, self-harm or suicidality – then a mental health/psychiatric/eating disorders inpatient unit may be indicated.

When a person simply cannot eat, either type of unit may provide nasogastric (NG) tube feeding. If your child needs this, take heart: they may readily accept it because it nourishes them without guilt. If they fight it, there’s guidance on making NG feeding as gentle as possible.[lxii]

In the UK, parents tend to believe that home is infinitely better than a unit. Meanwhile, many US parents feel bad about keeping their child at home, even when they’re making good progress. So who’s right? Research indicates that home is better… but only if you’re succeeding.[lxiii] At times, a higher level of care is very much needed. After that, the work at home resumes, because no institution can provide complete recovery.[lxiv]

Parents, you’re unlikely to love everything about an inpatient unit, but you can insist on aspects that really matter. Chances are these are listed in published standards that you can quote and insist on.[lxv]

Some autistic youngsters find a ward or inpatient unit especially tough. Nowadays, professionals should be educated in adaptions for particular needs and sensitivities. If you have concerns in that respect, you’re justified in insisting on intense support to treat at home.[lxvi]

The first hurdle in getting your child into hospital might be a waiting list. Another hurdle – shockingly unscientific – comes with units that only admit low-BMI patients.[lxvii] I recall a family blocked in this way. The girl’s outpatient team wanted her admitted fast as she was deteriorating daily. The inpatient unit wouldn’t budge because her BMI was still ‘normal’. They wouldn’t factor in the ongoing weight loss, nor the parents’ heroic but unsuccessful attempts to reverse her medical and mental decline. One of the therapists advised the parents, in confidence, to let the girl restrict so that she’d get admitted sooner rather than later. It’s not acceptable. And if you’re in this situation, know you have every right to advocate for your child.

Why would my child eat in hospital and not at home?

There are many reasons why hospital staff manage to get our children to eat when we can’t. Your child may eat because she respects the authority of strangers, or because she’s embarrassed to make a scene in front of others. Her fear of being tube-fed or detained against her will may outweigh her fear of eating. Unlike us, nurses are not on an emotional rollercoaster 24/7. They have built up many hours of experience with a range of patients; they get coaching, support, teamwork, and sleep. I’m told that despite all this, staff aren’t immune to frustration when a patient isn’t eating, and many are genuinely awed by what we parents do.

Eating disorders inpatient (residential) units

If you have a choice of eating disorder unit, be alert for the old model where the clinic would raise a patient’s weight, sprinkle in some therapy, and discharge with little attention to transitions. The result can be a revolving door situation: weight drops at home and the person needs re-admission. If the unit preaches autonomy and self-responsibility, it leaves parents powerless to support reintegration into everyday life.

Inpatient or ‘residential’ units are increasingly shifting toward a more family-orientated ethos. The trailblazers make parents – as well as the outpatient team – active members of the treatment team, following principles of family-based treatment.[lxviii] Parents support meals within the unit. They take the lead in choosing meals – rather than dieticians negotiating meal plans with the young person (I rant about this in Chapter 6). Home visits are progressively increased – staff may initially come and assist. When your child manages meals over several days at home, you know they’re ready for discharge and that the transition is likely to be successful.

Medical (paediatric) wards

Increasingly, when care at home isn’t working, the first step is a short stay in a medical (paediatric) hospital ward. Many paediatric units now follow protocols (pathways) devised in collaboration with specialist services. The outpatient eating disorder team works with the ward staff and with parents. Parents gain mealtime skills. This way, the child can continue treatment at home as soon as health is stabilised. If all goes well, they’ll never need a higher level of care.

As a first step, I find this so much better than a long admission to a residential unit. Unfortunately, it may only be available if your child is medically unstable.

Tips: when your child is in a paediatric ward or eating disorder unit

My husband and I still remember our amazement and relief when we learned that our daughter, within 20 minutes of admission, had calmly eaten a packet of crisps and drunk a glass of milk. It’s a wonderful feeling, and thank goodness for safety nets provided by competent units.

Services vary. It’s a big worry for parents when hospitals don’t treat them as valuable team members. It means you must constantly be on the ball, informing, requesting, checking and complaining. When your child enters a unit, don’t assume anything. Be vigilant. But also recognise when your kid is in safe hands. It’s OK for things to be ‘good enough’.

Here are some pointers to help you work out how to manage hospital-related issues.

• Some treatment units still believe in punitive or highly regimented approaches, so do your research.
• Your child will be surrounded by others with eating disorders or other mental illnesses. Ask what measures are in place to prevent patients from sharing weight-loss or self-injury tips with each other. How are children shielded from other children’s distressing behaviour?

In our case, when another child with anorexia joined the ward, the two were never left alone. When any child had a violent outburst, nurses swiftly ushered everyone into another room. Despite these precautions, my daughter did learn more than I’d have liked about the traumatic lives of other children. And I didn’t love how she copied some of the other kids’ raucous style. Yet none of it stuck. And being exposed to distress wasn’t all bad – she developed a lot of kindness and understanding for human vulnerability.

• Ask the unit what their aims and discharge criteria are (safety? medical stabilisation? weight recovery? some level of mental recovery?)
• We saw in Chapter 6 how weight gain should be rapid. If meals or calories fed by NG tube aren’t providing that, ask why?
• If your child is at risk of self-harm or suicide, what measures are in place? Where necessary, the unit must provide 24/7 one-on-one supervision.
• If tube-feeding under restraint is needed, do staff follow the latest guidance to save a life while minimising distress?[lxix]
• If your child is autistic, discuss accommodations (e.g. a busy dining room might be the worst place for them to manage a meal)[lxx]
• Even if the unit isn’t perfect, consider the whole picture. Is your child safe and gaining weight? Use the time and space to recover and to get yourself ready to take over again.
• You will fight some things, and you will accept others. You can’t sweat the small stuff. Once your child is back home, you can stage-manage a clear takeover, refusing to be bound by how the hospital did things.
• The unit may introduce systems you disagree with. In hindsight, I am appalled that my 11-year-old had weekly meal-planning sessions with a dietitian. Negotiations gradually led to fewer calories and a failure to expand her range. What a waste, given she’d managed a packet of crisps within 20 minutes of admission!
• The hospital should work to give you the competence and confidence to feed your child at home as soon as possible. And to rebuild your relationship. You should have practice on the ward, and your child should come home for increasingly long spells.
• Things might have been a lot faster for us if the health service had supported us with meals at home. It might have saved my daughter from such a long residential stay – or even prevented admission. When she’d been an inpatient for a few weeks, the staff helped us feed her in the ward, but all we had during home visits was phone support. Contrast this with another family’s experience: a nurse accompanied the young girl home until the family got the hang of meals. If a meal failed, the nurse took the child back to the ward, reinforcing the ‘food is medicine’ message.
• It grieves me when home visits are conditional on the child managing all their food or gaining weight. In their effort to incentivise, these units punish the child, disempower parents and delay a crucial part of treatment.
• We live close to the hospital and don’t have other children, so daily visits were easy. For others, long journeys mean days of only phone contact, or one parent staying locally while other cares for the family.
• Nowadays, most admissions are shorter than my daughter’s, and it helps that you have far more knowledge than I did. Still, some youngsters are hit particularly hard, especially when co-occurring mental health conditions are involved. Take heart: from parents I’ve supported, I’ve seen a difficult initial start give way to rapid improvements and full recovery.
• I’m so grateful that our hospital cared for our daughter while her opposition to us was extreme. If she’d been discharged before we could feed her, she’d have been in a revolving door of decline and re-admission.

Parents have all kinds of emotions when their child goes into hospital – worry, grief, frustration. My own feelings weren’t always what you might expect.

• When hospitalisation was first discussed, I was horrified. Then I realized it might be a place where my daughter would feel safe and well cared for – and it was.
• The speed of decline was terrifying. It was becoming hard to get her to drink. Suddenly, we were pushing for an earlier admission. We believed the hospital would save her life, and it did.
• We saw right away that she would feel well cared for. The staff acted like real human beings. Our daughter thought the place looked wonderful (to us, it was old, shabby and rather depressing). This was what she wanted. As a result, we could drive away without feeling torn, worried or guilty.
• Unlike my daughter, many children resist hospital. At first, some plead to be taken home. Others withdraw, feeling abandoned. Treat yourself with kindness while things are hard.
• I felt relieved and very grateful at the start. My mother thought I’d be a wreck, but I wasn’t. I refused to feel guilty about not feeling guilty. Competent, kind professionals were rescuing my girl. We were lucky.
• I was also relieved that my personal hell was over. I still had to deal with rejection and hate every day or two when I visited, but that was fine. I allowed myself to enjoy some much-needed peace of mind.
• Some parents, like me, take advantage of respite (in between numerous meetings and visits), while others fret. Some have to deal with multiple concerns about the hospital. Conversely, some feel guilty because they suddenly hardly have anything to do. If this is you, treat yourself with as much kindness as you would treat a loved one. Use the time to recuperate. Your child needs you to be very well, so that you can advocate for them now and resume the hard work when they’re discharged. Rest. Have fun. And if anyone asks you how you’re doing, tell them what they want to hear: that you’re sick with guilt and worry.
• I used the time to read and learn. Where necessary I advocated for her.
• Some days my husband visited straight from work, and my time at home could feel disconcertingly long. Most days, though, there were hospital meetings. Our work suffered, though not irreparably. I turned down any jobs that required me to be bright-eyed and bushy-tailed. There are situations where tears are not OK.
• If you cry a lot, you’re in good company. I cried because I missed my daughter. I cried when I drove away from the ward and she’d not talked to me. I cried when someone treated me with kindness. I cried and fumed and pondered and planned when I disagreed with aspects of her treatment. It’s stressful to clash with clinicians… and it happens. My wish for you is that your child’s hospital has such a strong reputation that you can relax.

Most of you won’t face hospitalisation as long as we did. So I’d like to quote a mother whose child, aged 13, was cared for at the Center for Treatment of Eating Disorders, Children's Hospital Minneapolis. It sounds like heaven.

“The program follows Maudsley meticulously. They do not believe in residential treatment for adolescents/teens UNLESS the patient is medically unstable, and then only for the briefest period possible.

During the entire three week period in the hospital, I was encouraged to be present as much as possible. We had family meals beginning after seven days, ramping up to twice per day as we neared the date for her discharge. We got LOTS of support from the team to help us understand both the theory and the practical means for implementation. I felt very little hesitation about going home, and they made me feel as if my husband and I were competent to handle the refeeding process at home.

[…]While hospitalized, there was minimal interaction with other inpatients, and always supervised. It was very well done. They had a TON of diversionary activities throughout each day, which made the stay more pleasant for my daughter (arts and crafts, music therapy, physical therapy, yoga, television shows produced in house, etc). She loved it.

The nurses were, without exception, kind and generous. Also, well trained in Maudsley, and deferential to parent decisions. I really felt like an important member of the team.”

Nine weeks after her daughter returned home for Family-Based Treatment, this mum wrote:

“Things are going VERY well with my daughter. The ED monster hasn't shown itself in any ugly way in several weeks now. We get little glimpses (requests for one kind of food over another), but nothing that has caused me so much as to raise an eyebrow.”

On my site: Can hospital equip you for family-based treatment? A parent’s inspirational account[lxxi]

Hospital accident and emergency units

If you have urgent concerns about your child’s health, take them to your out-of-hours GP service or your accident & emergency unit. This can be reassuring and helpful, especially if the eating disorders team have provided instructions for the emergency staff. Sometimes this speeds up admission to a medical ward. Be warned, though: staff don’t have specialised eating disorder knowledge. To avoid being sent home after hours of waiting with: ‘She’s fine. Just make sure she gets a sandwich when you get home,’ and to make sure the right tests are done, bring the guidance listed in the endnotes.[lxxii]

Parents and clinicians in partnership

When clinicians stand on a pedestal, competent parents cannot contribute to problem-solving and can easily become powerless victims. I hear of professionals who intimidate, blame, and refuse to discuss options. Even their team members don’t dare oppose them. Parents tell me they fear upsetting or angering the clinician, worried their child might receive worse treatment. We really need teamwork and respectful relationships.

“Our treatment team didn't get everything right but they were really open to feedback.”

Here’s a trivial example of how even a lovely clinician can inadvertently create distance. Some of our professionals called us ‘Mum’ and ‘Dad’. Seeing my husband addressed as Dad was hilarious, but it drove him crazy. ‘Take a seat, Dad. How was your week, Mum?’ Grrr!

Experts are there to contribute their valuable expertise. Some FBT therapists consider themselves consultants to the parents – that’s how much they value our role. Sometimes we’re exhausted and devoid of imagination, wanting professionals to tell us exactly what to do. At other times, we’re glad to take the lead because we know our child better than anyone else, and we’ve got the hang of this illness. Clinicians have the challenging job of tracking where we’re at and what we need. For that, we must talk openly and trust they can handle what we have to say.

“I told them they could/should give us more advice and feedback (a kind of coaching) without being afraid they were being too directive.”

Sometimes clinicians seem to lose momentum. They’re human! I supported parents whose daughter had been ill for several years. After all this time, the therapists seemed to just be going through the motions. But they were re-energised when they saw the child achieved new milestones.

The Nonviolent Communication framework outlined in Chapter 13 can help you sort out what’s going on in your head and give you the poise to request what you want. Even a small change – such as telling the clinician what isn’t working for you – can make all the difference. Therapists may also be ready to adjust how they do things. Whatever they learn from you will shape how they work with future patients. Openness and collaboration can do wonders.

Tell your clinicians about this book

If you’ve read this far, I’m guessing you’ve found some tips you want to try. I recommend being open about this with your clinicians for the sake of teamwork. Any disagreements are better out in the open. Nobody likes to be told how to do their job, so it’s about showing how this book – or the Bitesize audio collection – is providing some of the ‘how’ of what the professionals are asking you to do. Ask, ‘I’d like to try this idea. What do you think? Could you have a quick look and let us know?’[lxxiii]

Plan ahead to make sessions fruitful

During therapy sessions, we tend to let clinicians take the lead. But sometimes the hour passes quickly, and the issues most important to us haven’t been addressed. Clinicians are not mind readers, so it’s rational – and not disrespectful – to list, right from the start, the topics we need help with. If you have a partner, plan those, show that you two are a team, and expect your clinicians to work in partnership with you.

More family therapy without children, please

Standard FBT sessions usually involve the whole family together in a room (‘conjoint’). But there’s an equally successful variant (‘separated’ or ‘parent-focused’) where parents meet with the therapist separately.[lxxiv]

With our best therapist, I had a weekly phone call to brief her about the week’s progress and difficulties, and to plan the coming days. This kept family meetings upbeat and spared my daughter shame or guilt. It protected her from discussions about upcoming challenges, which tended to raise her anxiety and resistance.

If you ever feel your therapist is barking up the wrong tree (especially when moving a child towards independence), perhaps that’s because there are things they need to hear from you without your child present.

Whether a family does better with conjoint or parent-focused sessions may depend on the parents’ ability to care for their child, and how much the child can collaborate.[lxxv] If your child engages with the therapist, the conjoint approach can be wonderfully supportive. If your child wriggles and squirms, lies, clams up, or makes rude comments, try some parent-focused sessions.

Parents with their own troubles

Given that eating disorders have a significant genetic component, it’s to be expected that many parents have suffered from one themselves. As I explained in Chapter 5, family-based treatment proceeds just the same.

For any of us, caring for a troubled child can re-awaken emotions from our own childhood. We may notice we’re returning to a young place of hurt, fear or anger. If we can access resources, our current challenges can be a springboard to finding resources that will provide healing and growth for ourselves.

Parents want advice

This bit is mostly for clinicians. For parents, the message is: if you need advice, keep asking for it. Be specific.

Clinicians, I see harm being done at two ends of a spectrum. Some professionals issue directives in a dogmatic, no-room-for-discussion way. That discounts the expertise the parent has on their child (and perhaps the learning gained through hours of research).

At the other end, some FBT materials promote a creed that the professional must not give any advice. This comes from a commendable philosophy of empowering parents as experts on their children, with the therapist adopting a consultative, non-authoritarian stance. Yet one unintended outcome is that it can feel patronising. As though the professional is withholding knowledge, patiently and benevolently waiting for us to find our feet – like under-developed toddlers who can only learn through our mistakes. Meanwhile, our children suffer even more than necessary.

“We were in this big circle of parents and young people, and this woman started speaking of her daughter as ‘selfish’. We shifted uncomfortably in our seats. I glanced at the therapists, wondering why they weren’t saying something. Someone changed the subject. So I spoke up. The woman listened and it was like she’d seen the light. Her daughter teared up in relief. At break time, one of the therapists thanked me for intervening. It was surreal.”

If our children had a heart condition, specialists would answer our questions. With eating disorders, we want to work towards rapid recovery through your expertise and your experience – not by trial and error. This illness is far too serious for weeks to pass before we hear mealtime tips, or before we realise we should have supervised school meals.

“I don't think every family has to start from scratch and re-invent the wheel. Sometimes I think Maudsley professionals get so wound up in not being directive that they end up not being supportive enough. We felt at times that they knew what we were doing wrong during meals but had to let us work it out rather than coach and give feedback. This left us feeling that we were experimenting on our child, and that we were being tested (how long would it take us to finally find a way of supporting meals which worked?).”

Of course, advice-giving is an art. If parents don’t ask obvious questions like ‘How can I get my child to eat?’ then they’re probably too upset to cope with the answer. That may be a reason for a therapist to hold back.

Or perhaps the reason for evasiveness is a lot simpler:

“We’d ask the therapist for tips, and she’d say we were perfectly capable of feeding our daughter and that we’d find our own way. That made us feel even more incompetent, because we were failing big time. Then one day it occurred to me she probably didn’t have a clue herself. If so, I wish she’d told us straight.”

Despite this philosophy of letting parents find their own solutions, the main experts in a family-based approach are directing people to my resources. They seem happy for parents to hear more ‘how-tos’ from me than in therapy sessions. Maybe it’s because family therapy for eating disorders values parent-to-parent support.

Clinicians visibly empowering the parents

After the terrible old days of ‘parentectomies’, it’s a relief that enlightened therapists now make parents part of the treatment team. Our need to feel competent and empowered is fundamental. If this need isn’t met, we turn into doormats or behave like bulls in a china shop. Empowerment also helps us make decisions on the fly. We can’t run to the therapist whenever we hit a new variation on a problem. We may never feel totally competent, but we can at least aim for ‘good enough’.

Beyond how we feel about ourselves, it’s also vital that parents are empowered in their children’s eyes. How else can we get them to trust us more than they trust their disordered internal talk? Our first instinct may be to lean on the expert’s authority, but that can quickly lead to triangulation: ‘The therapist said that I didn’t have to wear a hat and gloves if it’s not cold outside.’ Imagine waiting a week for an appointment to resolve that one!

I noticed our specialist very deliberately handing power over to us. In one phone call, I told her of my desire to ditch the meal plan we’d inherited from the hospital. She validated that with enthusiasm. So I asked how she’d raise it at our next appointment. I knew it would be a massive blow to my daughter, and I expected the therapist to weigh in with her professional authority. No such luck. If I had hoped to hide behind an expert and be shielded from my daughter’s reaction, I was sorely disappointed. ‘YOU will tell her,’ she said. ‘You and your husband are the people most competent to care for her.’

After a while my daughter began complaining on the drives to appointments: ‘She’s nice but I don’t need her. YOU know how to look after me.’

Success!

Your clinical team: is everyone on the same page?

At one stage, around 20 people seemed to have an interest in my daughter’s care – hospital and outpatient staff, eating disorder experts, and even school team members. That meant 20 people around the table at hospital review meetings every few months.

It’s an amazing feeling to see so many rooting for your child, puzzling over how best to help her, celebrating her progress. And to have them all give us, the parents, genuine consideration. The link between clinicians and school, for instance, was beautifully handled. Our daughter’s education never fell behind.

But having many experts also means multiple appointments, with your child pulled out of class or deprived of fun several times a week. Can you spare her from unnecessary sessions, keeping only those that are truly useful?

Most importantly, is everyone singing from the same hymn sheet? If psychiatrists, nurses, therapists, counsellors, social workers, teachers and coaches are not well integrated, they may pull in opposite directions – and your child is stuck in the middle.

Take one example: your eating disorders specialist wants you to take responsibility for meals. Yet there’s also a dietitian negotiating meal plans with your underweight daughter, a doctor announcing she doesn’t need weight gain, a psychologist fixated on adolescent independence, a counsellor advising low-fat foods to avoid anxiety, a something-or-another therapist shaming her for refusing dinner, and a psychiatrist pressing for one-on-one sessions to explore the reasons why, deep down, she uses her eating disorder as a defence mechanism. See the problem?

Each expert believes they’re competent, experienced and up-to-date. Some tell me they despair at their colleagues’ methods, but hierarchy and politics make it hard to tell a parent, ‘You’re right, and my colleague/my boss is wrong.’

It grieves me to see a child pulled in all directions and parents left with confusing messages, while experts stay diplomatically silent. But what can be done? This is yet one more thing that falls on parents. Keep asking questions. Don’t be afraid to put some noses out of joint. Find out about people’s training and what models they hold of the illness. Be your child’s best advocate. Make your choices.

One mother who read a draft of this book told me, ‘Cut that last bit out. You don’t have any choices.’ But she made important choices, over and over, striving to make the best of a disjointed and ineffective treatment team.

“I arranged meetings with all professionals involved to get them on the same page. I threatened that otherwise I would write to the hospital board.”

Eventually, she and her husband dismissed everyone except the family doctor and successfully took over their daughter’s care.

Individual psychotherapy: precautions

Is your child about to get some individual psychotherapy? Psychotherapy (often shortened to ‘therapy’) refers to any kind of psychological care. Some psychotherapists (often shortened to ‘therapists’) are qualified clinical psychologists, others have completed a counselling or coaching course, and others still have no recognised qualifications.

As mentioned earlier, individual psychotherapy may be a fruitful adjunct to family therapy. To avoid harm, I suggest that you first establish how information will flow. Make sure you’re not excluded from important decisions, and that your parental authority is not overridden.

Because it’s individual therapy, the client is the child – not the child-parent unit. Therapists aim to give the client privacy from their parents, with a confidentiality agreement in place. You will mostly be sitting in the waiting room.

Think carefully about the pros and cons. When it works, parents are glad their child has a private space to express themselves, heal, or learn new ways of handling life’s challenges. Everyone is on the same page, and the therapist understands your role in supporting your child most hours of the day at home.

But when a child bitterly resists sessions, and the parents lack a communication channel with the therapist, they have no idea if it’s worth persevering.

Check that the therapist won’t jeopardise the work you’re doing at home. Some regard family-based treatment as a shocking infringement on a young person’s independence. They see you as over-controlling or codependent. Their view is a person must take full responsibility for their recovery, which means that parents must back off. For some, autonomy is the overriding task of adolescence, and they set about this with little regard for the loving parent-child bond. Some make unilateral decisions based on what your child says, in a naïve belief that he always tells the truth.

A therapist may take it as read that your child wants a ‘private space’ away from you. Even FBT therapists make excuses to be alone with your child – presumably checking for abuse. It can be excruciating for our children. When you’re present in therapy, not only can you make it easier for your child to express themselves, but you can help them apply learnings to daily life. That’s more effective than nagging them to fill in worksheets. The whole family can benefit from learning tools such as ACT (acceptance and commitment therapy) or DBT (dialectic behaviour therapy). And treatment for OCD requires a lot of practice in everyday situations.

If a therapist sees you as nothing more than a taxi driver, I recommend you meet them alone to check their expertise, qualifications, beliefs and methods. You are, after all, your child’s advocate. The therapist’s style and approach must make sense to you. Agree on two-way communication (I discuss confidentiality below). How will you update them about symptoms or behaviours? How will you warn them if your child’s mood plummets or if new pressures arise at school, with friends, or after a bereavement?

Conversely, what will the therapist share with you? Some reveal information only if your child is actively suicidal. Others agree to report if your child misses a session or drops below a weight threshold. Some invite you to join in ten minutes at the end of each hour or for a longer monthly review, after agreeing with your child what can be shared.

Discuss with the therapist where their decision-making stops. For instance, if you’re challenging your son’s avoidance of short sleeves, it’s counterproductive if the therapist tells him to make his own clothing decisions.

When my daughter was seventeen, and hoped to complement our work with CBT, we discovered how easily we could get overruled. Despite sending growth charts and explaining her ongoing difficulties, the therapist—trained by the best and part of an FBT team—listened to my bright, bubbly girl for four sessions and then decreed she was well, could stop weight gain, join a gym, and end therapy. It took time to undo the damage.

It’s not OK for your child to come home – and these are real examples – saying, ‘She told me I’m old enough to make my own food choices.’ Or ‘She worked out my BMI and I don’t need to gain any more weight.’ Or ‘She thinks you’re over-protective and I should stop telling you things.’

If you haven’t set up the rules of teamwork, you could quickly become disempowered and unable to support your child in the long term.

Here’s a real and all-too-typical example. I know of a 15-year-old whose parents quickly and successfully restored her to a healthy weight. The clinical team skipped the following phases of family-based treatment (Chapter 10) and moved her to individual therapy. There, the therapist decreed the girl was old enough to make her own food choices. Her parents sat helplessly while she ate tiny, obsessively-prepared meals alone in her bedroom. They sent the therapist lists of symptoms and asked for joint sessions, but received only bland reassurances: ‘Don’t worry, things take time. Your daughter needs to learn to take responsibility’. When the girl became medically unstable and couldn’t eat, it was a hospital that had to ‘take responsibility’.

I’m frustrated by the wasted opportunities when parents are excluded. I moved heaven and earth for my daughter to see an EMDR therapist after she was discharged from hospital and mentally better. Her dieting had been triggered by a bullying incident, and emotionally she equated thinness with safety. I really hoped that trauma therapy could help reset her beliefs.

Well, she took great pride in taking the therapist for a ride. She’d come home and laugh at the woman’s credulity. She did want help, though, and was happy for me to join the sessions as an intermediary – a translator of sorts. I knew enough about EMDR to know what the therapist needed to know. Frustratingly, her professional opinion was that my presence would be weird. It isn’t. EMDR with very young children is routinely done with the help of a parent. And so we lost our chance to give my daughter resilience against future bullying. Had we succeeded, perhaps she’d have refrained from dieting years later when a comparable situation arose.

More on my website: Eating disorders: understand where psychotherapists are coming from[lxxvi]

Confidentiality

When evaluating treatment providers, ask about their stance on confidentiality. In individual therapy, it’s crucial. Mental health laws are poorly designed for illnesses like eating disorders, which usually involve anosognosia, but a skilled clinician will work to find solutions.[lxxvii] Sadly it’s common for parents to be given a blunt: ‘Your son doesn’t want to speak to you. He doesn’t want you to know anything about his weight or his lab results. Sorry and goodbye.’ Depending on where you live, this can start as early as age twelve.

When a 12-year-old has diabetes, are doctors as determined to withhold blood test results from parents?

A clinician may not be allowed to share information until your child gives written consent. A reluctant youngster may be more willing to do that if they know they can set an end date and withdraw consent at any time.

In individual therapy, your child’s confidentiality is protected, except where there are indications of danger or risk to her or others. Before sharing this information with you, the therapist would normally discuss with her who needs to know and how to tell them.

Glenn Waller’s manual for CBT therapists gives this example:[lxxviii] an underweight 15-year-old disclosed in therapy that she was secretly vomiting at home. Given the level of risk, the therapist decided others needed to know, and together they discussed how and when to tell the parents.

Good therapists know that a child can’t get effective support at home if information about restricting or self-harming behaviours is withheld. They know collaboration with parents benefits everyone. They take a sensible, compassionate approach to confidentiality, working to secure your child’s agreement to involve you. Rather than making you ‘the other’, they nurture the power of your connection.

A precious tool you have is that confidentiality rules only apply in one direction. You’re allowed – and it would be wise – to tell your child’s therapist about any worrying behaviours you observe. Every clinician has a duty to listen, even if all they say back is ‘Thanks. Goodbye’. Here is some authoritative guidance:

“From the legal point of view, confidentiality and lack of patient consent does not prevent clinicians from receiving third party information from families; patient consent is only necessary for providing confidential patient information.”[lxxix]

When you do share information with a therapist, first have a compassionate conversation with your child, if you can. That way, information flows in all directions. If you don’t feel able to do this, the therapist should advise on the next steps.

We had mostly good experiences around confidentiality. For example, in one family session our daughter revealed that something was seriously troubling her, but she refused to give details. We were delighted to learn that her favourite young nurse was on duty that night and that our daughter was willing to speak to her. The following morning, this wonderful nurse phoned me to assure me that the whole issue had been dealt with and that my daughter was now quite at ease. To this day I don’t know what it was about, and I’m not worried about it.

It's far easier for us parents to let go of the need for information when we trust that professionals are doing an excellent job – at least as good as we would ourselves. It’s easier still when treatment fully involves parents, so confidentiality never becomes an issue.

Old enough to refuse treatment

“Turning 18 can put pressure on a child. Services suddenly want to refer her to the adult services. Friends and classmates start to move away from home, giving her the feeling she should do the same.”

Many parents fear that the day their child turns 18, he’ll suddenly refuse to sit at the dinner table. In practice, many young people continue to accept their parents’ care, even if they fight individual meals.[lxxx] Just as my 10-year-old could have run away every morning before breakfast, 18-year-olds don’t automatically walk off simply because they have the legal right. And remember, the research on FBT was done on youngsters aged 12 to 18 inclusive. I encourage parents to be assertive in their caring role, regardless of age,[lxxxi] though I appreciate it’s not always easy.

Your country’s mental health laws will determine if your child can refuse treatment, whether you retain any decision-making power, and whether you have a right to information at all. Laws do protect very ill people, allowing detention and enforced treatment against their will. Yet some young people avoid treatment by keeping their weight very low, but not low enough to be sectioned.

This is a dreadful situation because anosognosia is part of the illness. Even when people do recognise they need help, the fear of eating and gaining weight can stop them from willingly undergoing treatment.

Clinicians may be legally bound to act according to your child’s wishes, even when they know – and you know – this hinders treatment. They may not be allowed to tube-feed, to keep a person in hospital, or to share information with parents. In some countries these issues kick in as early as age 12. Frustratingly, some professionals seem so worried about breaching privacy laws that effectively encourage refusal: ‘OK Morgan, we’d like to give you a supplement when you can’t finish a meal, but it’s your right to refuse. You’re over-16, you’ve not been sectioned, and you’re free to walk away any time.’

Because of mental health laws, your child’s weight may plummet, he may discharge himself, and clinicians may not be allowed to inform you. Parents can be on tenterhooks, hoping their child will voluntarily accept hospitalisation – or if he’s accepted treatment, won’t suddenly change his mind.

Sometimes the problem lies less with the law than with provider policies. A clinician may prioritise autonomy, while we prioritise nourishment, progress and safety. When clinicians see parents as part of the problem rather than part of the solution, everyone suffers.

I have friends whose 18-year-old willingly entrusted her care to her parents by granting them power of attorney. Yet local eating disorder services would only treat if she checked herself in of her own accord. This was too hard – she needed her parents to carry the burden of decision-making. This story ends well: she eventually got better at home, without therapists, supported by her parents.

To understand the laws in your country,[lxxxii] search the internet for ‘mental health law’, ‘detaining orders’, ‘section under the Mental Health Act’, ‘impaired decision-making ability’ and ‘compulsory treatment’ and ‘citizen’s advice’. Depending on where you live, guardianship or power of attorney[lxxxiii] may offer solutions.

You have a great powerful lever on your child: money (assuming your child depends on you financially). I know of parents who’ve used the money lever to get their child to accept treatment or come home for a period of refeeding.

Threats, however, always carry risk (Chapter 14). If you tell your child she can only live in your house if she accepts treatment, she may set up camp on the sofas of various friends. They’re unlikely to help her eat, or protect her from drink, drugs or self-harm. (As for sex, be aware that young anorexic women do become pregnant – the absence of periods is not reliable contraception.[lxxxiv]) The picture need not be bleak, though: your young adult may storm out of your house but accept care from an aunt, an your ex, of a heroic boyfriend or girlfriend. She may also return home because ultimately that’s where she feels secure.

You have one huge asset: your relationship. Your child may fight you much of the time, but she’s mostly fighting internal conflicts. While she is in distress you can bet she longs to lean on you and receive your care, love and guidance. See my website for some good stories and links.

On my site: Adults or young adults: treatment for a restrictive eating disorder[lxxxv]

Therapy, coaching and emotional support for parents

It’s ironic that while some of our children endure ineffective psychotherapy, the people who badly need psychological support – the parents – are reduced to taxi duty. In my ideal world, every parent would be offered individual support (counselling, coaching, or psychotherapy) alongside group support.[lxxxvi] I believe this is reasonably standard if your child or your spouse is being treated for cancer.

Most of us, however, have to hunt for support and pay for it. My own search began when I found myself regularly bursting into tears in the most inappropriate places, leading to a pathological attachment to my sunglasses. For the first time in my life I caught myself toying with fantasies of self-harm. Back then, I could withstand my child’s resistance without showing my reactions, but it came at a cost. Inside, I was a pressure cooker of emotions.

And yet, I also feel powerful. I wasn’t a depressed wreck. I was on a hero’s journey, with an all-important destination. I was limping but I wasn’t broken. All I wanted were trusted companions to bandage me up and apply healing ointments so I could continue my mission. In short, I was like every parent who cares for an ill child. Acts of parental heroism[lxxxvii] unfold across the planet, day in and day out.

If you’re not familiar with therapists, counsellors or coaches, what follows may help you find the support you need.

Therapists who help you flourish

There are gazillions of schools, models and methods for one-on-one psychotherapy. Some focus on early childhood, and others on the present or future. Some rely on talking, others emphasize behaviour change, and still others work somatically – through the body and emotions. Some aim to make you less miserable, others to help you flourish. Some are evidence-based, and some are not. Whatever the method, what probably matters most is that you feel the person across the Kleenex box genuinely cares for you in all your humanity. (That tip is for you. A therapist for your child also needs to be highly specialised.)

PhDs and top qualifications don’t guarantee a great therapist. However, if you are suffering from trauma, depression or anxiety it’s wise to seek someone with solid experience, training and supervision. Women, do also explore help for peri/menopause.^[lxxxviii]

If the cost of a therapist is a stretch, note that a couple of sessions could make you strong again, after which you only need occasional top-ups. Also, many psychotherapists adjust their rates to suit your financial situation. You may also decide, as I did, to view therapy support as ‘things that come along with the illness and become a priority’.

* Peri/menopause: why mothers of eating disorder teens are swimming through molasses’ *

How to choose the right person for you

You’ll only know if a therapist is good for you after you’ve given them a trial run – though their websites and social media can help with an initial impression.[lxxxix] Don’t get stuck with someone like the first therapist I was assigned. She held a cold professional distance, and her only tool seemed to be psychoanalytical digging into my childhood. What I needed were ways to draw out my strengths – so I could show up for my daughter, meal after meal, day after day. I left after one session and paid for better help elsewhere.

Notice what’s going on for you during the first session or two. Do you feel heard and supported? Are you treated as an equal, with respect for your shared humanity? Do you feel calmer? Does your body get a sense of relief? Do you feel more energised and able to keep going? If so, you’ve struck gold. Never mind the method – you’ve got yourself the therapist you need.

If sessions make you worse, the failure is not yours. Would you keep taking your car to a garage, week after week, if it continued to gurgle and splutter?

A word of caution: if your therapist doesn’t know much about eating disorders, they may be shocked and judgemental about your child’s behaviours. You’re trying to grow unconditional acceptance for your child, not more judgement, so be ready to educate your therapist if necessary.

With my second therapist, I stopped crying after one session.[xc] By the fourth, I said a fond goodbye. I felt well again and sensed I’d received what she had to give me – and for that I’m most grateful.

What was the magic? Good listening and reflecting skills, of course. For the first time, I had someone’s full, compassionate attention – and that was a balm. She also introduced me to the fight-flight concepts I share in this book. She noted my strengths and reflected back a picture of an OK person who could make things happen.

Meanwhile, my knowledge of Nonviolent Communication was starting to come together, and I was gathering tools for my wellbeing (I share these in Chapter 15). Whenever I was stuck, a session with a Nonviolent Communication trainer would help me move on.

With my daughter’s relapse I wanted support again. This time I chose a therapist highly qualified in emotional freedom technique (EFT).[xci] I stayed with her for her human qualities – and because I saw immediate results that lasted. Not only did I get a boost whenever I needed it, but my overall resilience and wellbeing shot up.

I hope that you’re receiving some lovely emotional support, and if not, that you will seek it out and find it.

Endnotes / References

Click to expand the endnotes

[i] We have data from randomised controlled trials of FBT, but when you’re choosing a therapist or centre, it’s nearly impossible to have data on the percentage of patients they successfully treated. For a rare and informative exception, see Dr Sarah Ravin’s series of blogs where she publishes and discusses her results: blog.drsarahravin.com/depression/a-preview-of-my-treatment-outcome-research

[ii] My page ‘How to choose excellent treatment in the USA’ anorexiafamily.com/find-eating-disorder-treatment-usa I also compiled worldwide resources on anorexiafamily.com/international-eating-disorder-help

[iii] European countries have a marked psychoanalytical legacy. I interview parents from Switzerland on youtu.be/ehZ_SelFGwI Forbidding parental visits until a certain weight is reached is common in French hospitals.

[iv] Thomas Insel, MD, Director of the National Institute of Mental Health, November 2010, no longer online.

[v] TBT-S: anorexiafamily.com/temperament-based-therapy-with-supports-tbt-s
EFFT: anorexiafamily.com/psychotherapy-eating-disorders-anorexia#efft

[vi] More on New Maudsley: anorexiafamily.com/mealtime-management-support-fbt-family-based-treatment

[vii] How ‘New Maudsley’ differs from a family-based approach: anorexiafamily.com/mealtime-management-support-fbt-family-based-treatment. In the UK, some NHS clinicians and the BEAT charity weave in New Maudsley concepts without acknowledging how they may conflict with family‑based treatment, leaving parents unaware of the mismatch.

[viii] See for instance, Beverley Mattocks’ account in Please Eat (amzn.to/2W16VQt). The ‘rock bottom’ principle has been popularised by accounts from recovered addicts, but we should not generalise to eating disorders

[ix] See notes in Chapter 4

[x] This is according to England’s NICE guidance. Similar in many other countries.

[xi] FBT manual, James Lock and Daniel Le Grange: amzn.to/3jZKpPW) For parents: Lock & Le Grange, Help your teenager beat an eating disorder (amzn.to/3iPT6gC) Also principles and vignettes in Family-Based Treatment for Eating Disorder Piece by Piece by Lock, Whyte, Matheson, Datta (amzn.to/49SHlP9)

[xii] Minimum 4-day training (which sounds very little to me) given to experienced therapists in many UK eating disorder teams (though Scotland is mostly FBT-trained).

[xiii] Ivan Eisler, Mima Simic, Esther Blessit, Liz Dodge and team (2016), Maudsley service manual for child and adolescent eating disorders mccaed.slam.nhs.uk/wp-content/uploads/2019/11/Maudsley-Service-Manual-for-Child-and-Adolescent-Eating-Disorders-July-2016.pdf

[xiv] From what parents tell me or write on forums, some find multi-family incredibly helpful, while others say it wasn’t for them. In the US, five-day intensive multi-family therapy program at the University of California, San Diego (eatingdisorders.ucsd.edu) was developed with Ivan Eisler’s input. It differs from the UK approach and generally gets a big thumbs up from parents.

From Eisler, I., ‘The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa.’ In J Family Therapy (2005) 27 doi.org/10.1111/j.1467-6427.2005.00303.x Includes a highly-readable description of the therapy. Also this, showing better outcomes when families receive multifamily therapy as well as single family therapy: Eisler, I., Simic, M., Hodsoll, J. et al. A pragmatic randomised multi-centre trial of multifamily and single family therapy for adolescent anorexia nervosa. BMC Psychiatry 16, 422 (2016). doi.org/10.1186/s12888-016-1129-6

[xv] Agras, S. W., Lock, J., Brandt, H., Bryson, S. W., Dodge, E., Halmi, K.A., Jo, B., Johnson, C., Kaye, W., Wilfley, D., Woodside, B., ‘Comparison of 2 Family Therapies for Adolescent Anorexia Nervosa. A Randomized Parallel Trial.’ In JAMA Psychiatry (2014), 71(11) doi.org/10.1001/jamapsychiatry.2014.1025 There were 78 adolescents receiving FBT and 80 receiving systemic family therapy with ‘no specific emphasis on normalisation of eating or weight, although if the family raises this issue, the therapist will help them address it.’ I imagine most families would be extremely concerned about the adolescent’s eating and weight, and therefore there may be quite a lot of crossover between the two approaches. Both treatments led to similar rates of recovery at end of treatment and at 12-month follow-up. But there were differences in other outcomes: systemic family therapy was better for adolescents who had obsessive-compulsive symptoms as well as anorexia, and FBT was better at reducing hospitalisation (median number of days 8.3 days versus 21.0 days), possibly because patients put on weight faster in the initial 8 weeks of treatment. Both types of treatment lasted 9 months. The systemic family therapy took a ‘non-pathologising, positive view of the family system, and the current difficulties they are struggling with’ and recognised that ‘the family themselves will be in the best position to generate suitable solutions’. All the therapists worked in specialist eating disorder services and had an average of 6 years of experience in treating adolescent anorexia.

Fisher, CA, Skocic, S, Rutherford, KA, Hetrick, SE. Family therapy approaches for anorexia nervosa. Cochrane Database of Systematic Reviews 2019, Issue 5. doi.org/10.1002/14651858.CD004780.pub4 The conclusion is there’s insufficient evidence to determine if ‘family therapy’ presents any advantage over psychological or educational interventions. This is not surprising as all kinds of family therapy are lumped together.

[xvi] Treasure, J., Smith, G. and Crane, A., ‘Skills-based Learning for Caring for a Loved One with an Eating Disorder: The New Maudsley Method’ (amzn.to/2VXpGUM)

[xvii] anorexiafamily.com/mealtime-management-support-fbt-family-based-treatment

[xviii] Prior to the research conducted on FBT, ‘the evidence’ for anorexia treatment was ‘weak’, the literature ‘sparse and inconclusive’, according to Bulik, C. M., Berkman, N., Kimberly, A. et al, ‘Anorexia nervosa: a systematic review of randomized clinical trials’ in Int. J. Eat. Disord. (2007), vol. 40, pp. 310–20, doi.org/10.1002/eat.20367

Some figures for patients not treated with FBT are available from Strober, M., Freeman, R. and Morrell, W., ‘The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study’ in Int. J. Eat. Disord. (December 1997), vol. 22, no. 4, pp. 339–60, ncbi.nlm.nih.gov/pubmed/9356884

Here’s an overview from this paper: Other review studies reported that 32 percent to 68 percent of people who’d had anorexia as youngsters had, some years later, a ‘good outcome’. Mortality, including suicide, was 1.8 percent to 14.1 percent. Strober’s study followed adolescents treated in one intensive inpatient unit, which provided weight-restoration, individual and family therapy. Ten to 15 years later, none of the 95 patients died. There was a ‘good outcome’ in 86 percent of patients, and 76 percent of patients made a ‘full recovery’. But it took a long time to get them there: 57 to 79 months, depending on the definition of recovery.

[xix] For a systematic review of all previous studies on a family-based approach, see Austin, A., Anderson, A. ., Lee, J., Vander Steen, H., Savard, C., Bergmann, C., Singh, M., Devoe, D., Gorrell, S., Patten, S., Le Grange, D. and Dimitropoulos, G. (2024), Efficacy of Eating Disorder Focused Family Therapy for Adolescents With Anorexia Nervosa: A Systematic Review and Meta-Analysis. Int J Eat Disord. doi.org/10.1002/eat.24252 You’ll see some rather lukewarm conclusions, because the studies are of varying quality, using different criteria.

More reader-friendly is this earlier summary of the research: Rienecke, Renee D. ‘Family-based treatment of eating disorders in adolescents: current insights’ in Adol health, med and therapeutics (Jun 2017), vol. 8, pp. 69-79 pdfs.semanticscholar.org/d3d1/65e737dceeda802a134bd86c37b2ffda6ddf.pdf

Were all these studies done with ‘easy’ patients? It seems not, in the largest study (the 2010 one), 26 percent of the participants had co-morbid psychiatric disorders, and 45 percent had previously been hospitalised.

[xx] So how successful can you expect FBT to be? First, we need to define success. Since 2010 the trials have set a high bar for ‘full remission’ (close to what most of us consider to be ‘full recovery’). An adolescent needs to be weight-restored (or very close) and their behaviours and thinking must be similar to those of youngsters without an eating disorder. With the bar set this high, average outcomes from various studies show full remission in 34 percent of participants at the end of treatment. With the passage of time, more tend to recover, so the total figure a year after end of treatment is 40 percent of participants.

Although we all want ‘full remission’, note that results are far better for ‘partial remission’ (reaching at least 85 percent of median body mass index): 89 percent of participants recovered to this level by the end of treatment.

On the whole, the effect of the treatment seems to stick, and youngsters continue to improve after discharged from treatment – presumably thanks to time or life or parents knowing what to do: five years after the end of FBT treatment, 80 to 85 percent of youngsters no longer met diagnostic criteria.

Before you lose heart over the low figures at ‘end of treatment’, please note that in these studies the treatment time was one year or less. That gives plenty of time for weight restoration and for improvements in thinking and behaviours, but we parents know from experience that it takes longer to get complete freedom from the eating disorder, whatever the method used. Note also that these statistics are for FBT conducted as per the manual. I think skilled and very experienced therapists can do better by modifying details to suit the individual.

I can think of another reason why the FBT statistics might be so low. I wonder if for half of the patients, weight gain was halted before they were weight-restored. Everyone’s goal weight was set as 95% of the median BMI, and by definition, half of a population is above the median, and half is below. Many parents report increased success when they seek an individualised target that reflects their child’s needs (I explained this in Chapter 6).

FBT trials relate to patients treated within three years of diagnosis. If your child or young adult has been ill for much longer, there is no research, so you can decide whether to use a family-based approach or direct your child towards individual therapy. Personally I think that if your child has never had your active support in treatment, there is plenty of hope that things will improve when you do start.

How about results from The Maudsley Centre for Child and Adolescent Eating Disorders? Ivan Eisler tells me that with a range of modalities (outpatient, day care and close links with the inpatient unit), 80% of patients were discharged without any need for further eating disorders treatment (most are simply discharged, while around 14% go on to CAMHS (Child and Adolescent Mental Health Service) to be treated for other problems like anxiety or depression). Could one consider these patients to have achieved full remission, as in published studies? ‘We would be cautious in saying that they are all recovered as there is often a time lag between weight/eating recovery and cognitive recovery. There are certainly a proportion of people we discharge who remain troubled for some time by eating disorder thoughts, but the great majority continue to improve in this area post treatment and very few relapse (around 5-10%).’  How long before patients are discharged? ‘Around 25% need 6 months or less, another 25% need 18 months, and a very small proportion need 2 years or more of outpatient treatment.’

[xxi] FBT and under-12s: Lock J., Le Grange, D., Forsberg, S. and Hewell, K., ‘Is family therapy useful for treating children with anorexia nervosa? Results of a case series’ in J. Am. Acad. Child Adolesc. Psychiatry (November 2006), vol. 45, no. 11, pp. 1323-8, doi.org/10.1097/01.chi.0000233208.43427.4c
Many FBT studies focus on 12- to 18-year-olds, but results are similar with 9 to 13-year-olds, according to a study of 32 children with anorexia: Lock J., Le Grange, D., Forsberg, S. and Hewell, K., ‘Is family therapy useful for treating children with anorexia nervosa? Results of a case series’ in J. Am. Acad. Child Adolesc. Psychiatry (November 2006), vol. 45, no. 11, pp. 1323-8, ncbi.nlm.nih.gov/pubmed/17075354

[xxii] ‘Young adults with anorexia: FBT-TAY’ anorexiafamily.com/family-based-treatment-young-adult

[xxiii] I explain TBT-S on anorexiafamily.com/temperament-based-therapy-with-supports-tbt-s The main book is Temperament-Based Therapy with Support for Anorexia Nervosa by Laura Hill and Christina Wierenga (amzn.to/39J4GIt)

[xxiv] anorexiafamily.com/treatment-adult-anorexia-eating-disorder

[xxv] 'Randomized clinical trial of family-based treatment and cognitive-behavioral therapy for adolescent bulimia nervosa.' Daniel Le Grange, James Lock, W. Stewart Agras, Susan W. Bryson, Booil Jo. J Am Academy of Child & Adol Psych, 2015, 54(11) p886-894 doi.org/10.1016/j.jaac.2015.08.008 For a summary of this research, read Dr L Muhlheim (2015): 'For teens with bulimia, family based treatment is recommended' eatingdisordertherapyla.com/for-teens-with-bulimia-family-based-treatment-is-recommended

[xxvi] The FBT manual: Lock, J., Le Grange, D., Agras, W. S. and Dare, C., Treatment Manual for Anorexia Nervosa: A Family-Based Approach (amzn.to/3jZKpPW)
For an overview of what FBT is (and is not): Rienecke, R.D., Le Grange, D. The five tenets of family-based treatment for adolescent eating disorders. J Eat Disord 10, 60 (2022). doi.org/10.1186/s40337-022-00585-y or watch Le Grange (2024): ‘How we developed FBT, and why it works’ on youtube.com/watch?v=jgZjpPMHcbk
Maudsley’s manual is more general: Ivan Eisler, Mima Simic, Esther Blessit, Liz Dodge and team (2016), Maudsley service manual for child and adolescent eating disorders mccaed.slam.nhs.uk/wp-content/uploads/2019/11/Maudsley-Service-Manual-for-Child-and-Adolescent-Eating-Disorders-July-2016.pdf

[xxvii] Contrary to what many of us parents observe, a study shows FBT working with half the dose: 20 to 24 sessions over a year are no better than 10 sessions over 6 months (but patients with significant obsessive-compulsive disorder symptoms fare better with the longer dose): Lock, J., Agras, W. S., Bryson, S. and Kraemer, H., ‘A comparison of short- and long-term family therapy for adolescent anorexia nervosa’ in J. Am. Acad. Child Adolesc. Psychiatry (2005), vol. 44, pp. 632–9, doi.org/10.1097/01.chi.0000161647.82775.0a

[xxviii] Dr Sarah Ravin on Phase 3: blog.drsarahravin.com/eating-disorders/navigating-phase-iii

[xxix] From NICE guidance nice.org.uk/guidance/ng69 which I present in anorexiafamily.com/nice-guidelines-adolescent-eating-disorder-ng69  

[xxx] I have outlined CBT methods and materials on anorexiafamily.com/CBT If you’re using CBT or considering it, I recommend you read the manual – starting with this one, written for parents: ‘Cognitive Behaviour Therapy for Eating Disorders in Young People. A parents’ guide’ by Dalle Grave and el Khazen amzn.to/40629Q3

For a comparison with FBT: Le Grange, D., Eckhardt, S., Dalle Grave, R., Crosby, R. D., Peterson, C. B., Keery, H., Lesser, J., et al. (2020). ‘Enhanced cognitive-behavior therapy and family-based treatment for adolescents with an eating disorder: a non-randomized effectiveness trial’ in Psychological Medicine, 1–11. doi.org/10.1017/s0033291720004407 One conclusion is that while CBT-E produces outcomes similar to FBT’s in the long term (for those who actually complete the CBT), FBT is the first port of call for youngsters with anorexia.

[xxxi] The manual is ‘Adolescent-Focused Therapy for Anorexia Nervosa’ by James Lock (amzn.to/3gKNXEO)

[xxxii] Lock, L., Le Grange, D., Agras, W.S., Moye, A., Bryson, S.W., and Jo, B., ‘Randomized Clinical Trial Comparing Family-Based Treatment to Adolescent Focused Individual Therapy for Adolescents with Anorexia’ in Arch. Gen. Psychiatry (October 2010), 67(10), pp. 1025-1032, doi.org/10.1001/archgenpsychiatry.2010.128

Half the adolescents were given FBT, while the other half were given the most promising type of individual psychotherapy available at the time: AFT.

The two approaches had similar results by the end of a year’s treatment, but FBT proved to be superior at 6- and 12-month follow-up.

Four years after end of treatment, among 79 adolescents who had been symptom-free a year after completing either FBT or AFT, only one in each group had a relapse. Le Grange, D., Lock, J., Accurso, E. C., Agras, W. S., Darcy, A., Forsberg, S., Bryson, S. W., ‘Relapse From Remission at Two- to Four-Year Follow-Up in Two Treatments for Adolescent Anorexia Nervosa’ in Journal of the American Academy of Child & Adolescent Psychiatry (25 August 2014) doi.org/10.1016/j.jaac.2014.07.014

[xxxiii] https://anorexiafamily.com/CBT

[xxxiv] https://anorexiafamily.com/fbt-v-aft-adolescent-focused-therapy-anorexia

[xxxv] https://anorexiafamily.com/aft-adolescent-focused-therapy-anorexia-afp-an

[xxxvi] Official guidance for England: NICE (2017): nice.org.uk/guidance/ng69/chapter/Recommendations

[xxxvii] From Jangled, writing on the Around the Dinner Table forum.

[xxxviii] Gorrell, S., Simic, M., Le Grange, D. (2023). Toward the Integration of Family Therapy and Family-Based Treatment for Eating Disorders doi.org/10.1007/978-3-030-97416-9_59-1 From the book: Eating Disorders, Robinson, P., et al. (2025) Springer. amzn.to/3ykNcyC

Also Simic, M., Stewart, C. S., Konstantellou, A., Hodsoll, J., Eisler, I., & Baudinet, J. (2022). From efficacy to effectiveness: Child and adolescent eating disorder treatments in the real world (part 1)—Treatment course and outcomes. Journal of Eating Disorders, 10(1), 27. doi.org/10.1186/s40337-022-00553-6

[xxxix] feast-ed.org/treating-suicidality-in-eating-disorders-how-dbt-skills-help-families-navigate-suicide-and-self-injury and Le Grange addressing this question 47mn into youtu.be/jgZjpPMHcbk?si=Qr-Nz-m2WmIL25F0&t=2820

[xl] anorexiafamily.com/failing-therapy-eating-disorders-anorexia

[xli] Is Your Eating Disorder “Specialist” Really a Specialist? by Alli Spotts-De Lazzer and Lauren Muhlheim kantorlaw.net/blog/2019/march/is-your-eating-disorder-specialist-really-a-spec

[xlii] Train2treat4ed lists certified FBT therapists: train2treat4ed.com/certified-therapists They may not all be there because they have to pay to be on the site. I attempt to list those who are available to treat via video call on anorexiafamily.com/certified-fbt-therapists-family-based-treatment-who-skype.

[xliii] Even after a year of training and weekly supervision, when 210 FBT therapy tapes were audited, therapists did not show more than a moderate level of fidelity to the FBT approach. Lock, L., Le Grange, D., Agras, W.S., Moye, A., Bryson, S.W., and Jo, B., ‘Randomized Clinical Trial Comparing Family-Based Treatment to Adolescent Focused Individual Therapy for Adolescents with Anorexia’ in Arch. Gen. Psychiatry (October 2010), 67(10), pp. 1025-1032, doi.org/10.1001/archgenpsychiatry.2010.128 The team are working on improving dissemination.

[xliv] Glenn Waller (2016), ‘Treatment Protocols for Eating Disorders: Clinicians’ Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions’ F1000 Research doi.org/10.1007/s11920-016-0679-0
In ‘Show Me the Science’ Dr Sarah Ravin’s explains how, in the world of psychology, it is quite common to find resistance to evidence-based practices. And also, how working to a manual still allows a therapist plenty of room to customise treatment to each unique patient: blog.drsarahravin.com/depression/show-me-the-science/

[xlv] This is ‘unconscious incompetence’, one of four stages of competence wikipedia.org/wiki/Four_stages_of_competence

[xlvi] Dr Sarah Ravin on ‘Red Flags: How to Spot Ineffective Eating Disorder Treatment’ blog.drsarahravin.com/eating-disorders/red-flags-how-to-spot-ineffective-eating-disorder-treatment

Alli Spotts-De Lazzer & Lauren Muhlheim on ‘Is Your Eating Disorder “Specialist” Really a Specialist?’: kantorlaw.net/blog/2019/march/is-your-eating-disorder-specialist-really-a-spec

FEAST of Knowledge 2020: questions to ask youtu.be/4mxOTrWijLQ?t=1595

The NAMI Handbook (2007) Choosing the right treatment: what families need to know about evidence-based practices  on Page 11 ‘How to talk with providers’ aacap.org/App_Themes/AACAP/docs/member_resources/toolbox_for_clinical_practice_and_outcomes/sources/NAMI_Handbook.pdf

[xlvii] There is no standard training path, and you cannot assume anything. Some therapists have treated eating disorders for decades using older psychological models, and it takes more than a two-day introductory course for them to master the family-based approach. In countries without a national health service, training can be just about anything! In England, recently, the NHS overhauled eating disorder treatment for youngsters. Specialist teams were trained up fast, and all therapists must have regular supervision. Overall, the improvements have been fantastic. But there is no standard for training of therapists or supervisors. Some of these people may be treating your child or running multifamily groups after just two days’ training from the team at the Maudsley’s children and adolescents service. A few have had a day’s introduction to FBT when James Lock visits the UK. Some have had a few hours from Janet Treasure’s team on ‘New Maudsley’, after which they tell parents to be dolphins and incorrectly claim to be ‘doing FBT’. Many don’t know the difference between all these approaches and are ignorant of the manuals.
Scotland invites Lock in regularly for training in FBT. Some therapists are going through hundreds of hours of supervision from Lock’s team to become certified, while others treat patients after a two-day course. Others are generalist mental health professionals with no eating-disorder specialisation.

[xlviii] I list online groups here: anorexiafamily.com/parent-support-groups-eating-disorders

[xlix] A good piece by therapists Carolyn Costin and Alli Spotts-De Lazzer: ‘To tell or not to tell: therapists with a personal history of an eating disorder’ edcatalogue.com/tell-not-tell

[l] I recommend ‘When Eating Disorder Providers Are Steeped in Diet Culture’ by Lauren Muhlheim eatingdisordertherapyla.com/when-eating-disorder-providers-are-steeped-in-diet-culture My own page: ‘How to overcome weight bias and fat phobia’ anorexiafamily.com/fat-bias-fatphobia-haes

[li] Perhaps we sense that our clinicians don’t have much fun: Warren, C. S., Schafer, K. J., Crowley, M. E. and Olivardia, R., ‘A qualitative analysis of job burnout in eating disorder treatment providers.’ in Eat. Disord. (May 2012), vol. 20, no. 3, pp. 175–95, doi.org/10.1080/10640266.2012.668476

[lii] My incomplete list of certified FBT therapists who do telemedicine: anorexiafamily.com/certified-fbt-therapists-family-based-treatment-who-skype

[liii] Among others: five-day intensive multi-family therapy program at the University of California, San Diego (eatingdisorders.ucsd.edu) and Terra Towne runs a 5-day program in California with Stephanie Knatz Peck (terratownepsychotherapy.com/5-day-intensive-program)

[liv] The Maudsley hospital in south London provides a national eating disorders service (outpatient and daypatient ‘intensive treatment programme’) for children and adolescents (mccaed.slam.nhs.uk). They work closely with the inpatient unit at King’s College hospital.
In north London, Great Ormond Street Hospital for Children has a Feeding and Eating Disorders Service. Both these London units accept referrals from CAMHS clinicians or consultant paediatricians anywhere in the UK and can give treatment or just a second opinion.

In Scotland, CAMHS can refer under-12s to the inpatient psychiatric unit (which has eating disorders expertise) at the Royal Hospital for Children in Glasgow.

[lv] Laura Collins’ memoir ‘Eating With Your Anorexic’ (amzn.to/3iNEuOP) on how her daughter was treated within the family, using principles of FBT. Harriet Brown, in ‘Brave Girl Eating‘ (amzn.to/37LlSZm), tells the story of her daughter’s journey to recovery at home, also along FBT principles. The book includes useful and accessible accounts of the scientific knowledge about anorexia.

[lvi] I list online forums here, while warning you to ignore bad advice: anorexiafamily.com/parent-support-groups-eating-disorders

[lvii] Rebecca Peebles (9mn57 in): youtu.be/WiC4cd4uI9U?t=597

[lviii] Usually it’s a nurse on the mental health team, with variable expertise. See also on my website:  ‘A game-changer: the eating disorder team that’s home with you all day… and saves millions’ on anorexiafamily.com/coast-eating-disorder-home-support and ‘Professionals who help people with an eating disorder to eat at home’ anorexiafamily.com/professional-home-meal-support-eating-disorder
There’s evidence that ‘adaptive FBT’ works: parents get intensive coaching for meal support skills, starting at week five, if there’s been insufficient weight gain (less than 4 pounds/2 kilos by week four – some call it ‘the 4 in 4 response’). Le Grange, D., Pradel, M., Pogos, D., Yeo, M., Hughes, E. K., Tompson, A., Court, A., Crosby, R. D., & Sawyer, S. M. (2021). Family-based treatment for adolescent anorexia nervosa: Outcomes of a stepped-care model. Int J Eating Dis https://doi.org/10.1002/eat.23629

[lix] I compiled worldwide resources on anorexiafamily.com/international-eating-disorder-help

[lx] Anyone can become a recovery coach, so choose with care. For a starting point, see those trained by Carolyn Costin carolyn-costin.com/interns-and-coaches

[lxi] In the US, eating disorder units may offer a continuum of care: outpatient (OP), intensive outpatient (IOP), day treatment, partial hospitalisation (PHP) and inpatient (IP) or residential. In the UK only a few Trusts have a day unit or offer a home team to support you with some meals. See my website for official standards and guides to help you advocate for what you need in your country: anorexiafamily.com/international-eating-disorder-help

[lxii] NG tube feeding: parents’ questions – on my website anorexiafamily.com/ng-tube-feeding-anorexia

[lxiii] Gowers, S. G., Clark, A., Roberts, C., Griffiths, A., Edwards, V., Bryan, C., Smethurst, N., Byford, S., & Barrett, B. (2007). Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised controlled trial. The British journal of psychiatry, 191, 427–435. doi.org/10.1192/bjp.bp.107.036764
Also Madden, S., Miskovic-Wheatley, J., Wallis, A., Kohn, M., Lock, J., Le Grange, D., Jo, B., Clarke, S., Rhodes, P., Hay, P., & Touyz, S. (2015). A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents. Psychological medicine, 45(2), 415–427. doi.org/10.1017/S0033291714001573
Also Herpertz-Dahlmann, B., Schwarte, R., Krei, M., Egberts, K., Warnke, A., Wewetzer, C., Pfeiffer, E., Fleischhaker, C., Scherag, A., Holtkamp, K., Hagenah, U., Bühren, K., Konrad, K., Schmidt, U., Schade-Brittinger, C., Timmesfeld, N., & Dempfle, A. (2014). Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa. Lancet (London, England), 383(9924), 1222–1229. doi.org/10.1016/S0140-6736(13)62411-3

[lxiv] It’s interesting to note, from Dr Sarah Ravin’s experience, that ‘Hospitalization during treatment with me was not related to treatment completion or treatment outcome, regardless of diagnosis.’ In other words, if you’re treating your child with FBT, a spell in hospital may be necessary, but after that, FBT is just as likely to succeed. blog.drsarahravin.com/eating-disorders/a-comparison-of-treatment-outcomes-an-bn-and-ednos

A study following youngsters after an intensive inpatient program: Strober, M., Freeman, R. and Morrell, W., ‘The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study’ in Int. J. Eat. Disord. (December 1997), vol. 22, no. 4, pp. 339–60, pubmed.ncbi.nlm.nih.gov/9356884

[lxv] I list standards for various countries in anorexiafamily.com/international-eating-disorder-help

[lxvi] anorexiafamily.com/autism-eating-disorder-tips and peacepathway.org

[lxvii] Weight suppression is just as much of a risk as a low BMI: anorexiafamily.com/weight-suppression-target-atypical-anorexia

[lxviii] Stuart B. Murray, Leslie K. Anderson, Roxanne Rockwell, Scott Griffiths, Daniel Le Grange, Walter H. Kaye, ‘Adapting Family-Based Treatment for Adolescent Anorexia Nervosa Across Higher Levels of Patient Care’. Eating Dis: Journal of Treatment & Prevention (2015) 23(4) doi.org/10.1080/10640266.2015.1042317 Also on my website: ‘Can hospital quip you for FBT? A parent’s inspirational account’: anorexiafamily.com/erc-denver-hospital-inpatient-residential-php-fbt

[lxix] Links to publications on my site: NG tube feeding: parents’ questions: anorexiafamily.com/ng-tube-feeding-anorexia

[lxx] anorexiafamily.com/autism-eating-disorder-tips and peacepathway.org

[lxxi] anorexiafamily.com/erc-denver-hospital-inpatient-residential-php-fbt

[lxxii] Risk assessment, physical examination and LOTS more on Medical Emergencies in Eating Disorders (MEED), Royal College of Psychiatrists, UK, for all ages: tinyurl.com/muv44e9u.

For the US and worldwide: Academy for Eating Disorders (AED) Guide to Medical Care, aedweb.org/resources/publications and The American Psychiatric Association Practice Guideline For The Treatment Of Patients With Eating Disorders, Fourth Edition, 2023 doi.org/10.1176/appi.books.9780890424865.eatingdisorder02

[lxxiii] Advice from clinician Xavier Amador in I am not sick and I don’t need help! How to Help Someone with Mental Illness Accept Treatment (amzn.to/3HBBy33).

[lxxiv] Daniel Le Grange, Elizabeth K. Hughes, Andrew Court, Michele Yeo, Ross D. Crosby, Susan M. Sawyer, ‘Randomized Clinical Trial of Parent-Focused Treatment and Family-Based Treatment for Adolescent Anorexia Nervosa’ in J Am Academy Child & Ado Psych (2016), vol. 55, no. 8, pp. 683–692 doi.org/10.1016/j.jaac.2016.05.007
and Le Grange, D., Pradel, M., Pogos, D., Yeo, M., Hughes, E. K., Tompson, A., Court, A., Crosby, R. D., & Sawyer, S. M. (2021). Family-based treatment for adolescent anorexia nervosa: Outcomes of a stepped-care model. International Journal of Eating Disorders, 54( 11), 1989– 1997. doi.org/10.1002/eat.23629

[lxxv] Dr Sarah Ravin (2016). Parent-focused treatment: an attractive alternative to FBT. blog.drsarahravin.com/eating-disorders/parent-focused-treatment-an-attractive-alternative-to-fbt

[lxxvi] anorexiafamily.com/psychotherapy-eating-disorders-insight-underlying-cause

[lxxvii] From Medical Emergencies in Eating Disorders (MEED), Royal College of Psychiatrists, UK, for all ages: tinyurl.com/muv44e9u : ‘Where family members are important to the ongoing support of patients to be able to engage in and benefit from treatment, every effort should be made to persuade patients to allow appropriate communication so they can carry out this task’  

[lxxviii] Waller, G., Cordery, H., Costorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., Russel, K. (2007) ‘Cognitive Behavioral Therapy for Eating Disorders: A Comprehensive Treatment Guide’ (amzn.to/3AJLOkC)

[lxxix] Medical Emergencies in Eating Disorders (MEED), Royal College of Psychiatrists, UK, for all ages: tinyurl.com/muv44e9u
Also Amador, X., I am not sick and I don’t need help! How to Help Someone with Mental Illness Accept Treatment (amzn.to/2I1p5Z0).
Also DesertDweller’s blog relating to caring for an adult, in particular desertdwellergettingon.blogspot.com/2010/10/being-parent-of-adult-loved-one-with.html and desertdwellergettingon.blogspot.co.uk/2014/11/what-about-hipaa-and-how-to-overcome.html

[lxxx] Insightful account from a 40-year-old: feast-ed.org/reflections-on-my-recovery-at-40-a-journey-with-my-parents

[lxxxi] Adults: anorexiafamily.com/treatment-adult-anorexia-eating-disorder Young adults with anorexia: family-based treatment for 17-25 year-olds: anorexiafamily.com/family-based-treatment-young-adult

[lxxxii] On confidentiality and parent-involvement, I list standards for various countries on anorexiafamily.com/treatment-adult-anorexia-eating-disorder Look up laws in your country on my site: anorexiafamily.com/international-eating-disorder-help
For the UK, good info from Medical Emergencies in Eating Disorders (MEED), Royal College of Psychiatrists for all ages: tinyurl.com/muv44e9u

[lxxxiii] In the UK, I think that Lasting Power of Attorney sets the bar too high to be much use: it only kicks in when the person is judged to not have the mental capacity to make decisions for themselves.

[lxxxiv] Bulik, C., ‘The complex dance of genes and environment in eating disorders’. An insightful one-hour lecture on YouTube youtube.com/watch?v=zi2xXEz0JOg Warning: several images of skeletal people, which I could do without.

[lxxxv] anorexiafamily.com/treatment-adult-anorexia-eating-disorder

[lxxxvi] See anorexiafamily.com for my workshops and my individual support

[lxxxvii] My video ‘The hero’s journey: resilience and wellbeing for parents’ youtu.be/HZgqolG3HeU

[lxxxviii] On my site: ‘Peri/menopause: why mothers of eating disorder teens are swimming through molasses’ anorexiafamily.com/menopause-perimenopause-eating-disorder-care-teen-fbt

[lxxxix] Dr Sarah Ravin’s tips: blog.drsarahravin.com/psychotherapy/how-to-choose-a-therapist

[xc] She trained in the ‘Human Givens’ approach www.hgi.org.uk

[xci] Odet Beauvoisin, certified advanced practitioner of EFT eftkinesiology.co.uk She can treat by video call. There is a lot of research on EFT, including some randomised controlled studies – though not enough for EFT to feature in national recommendations (eftuniverse.com/research-and-studies/eft-research#review). I like how the technique dovetails with mindfulness and connection to physical sensations.

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More on my website:

* Psychotherapies that might be on offer to your child or yourself *

This includes:

• Positive psychology
• Nonviolent Communication (NVC) as a psychotherapy
• Acceptance and commitment therapy (ACT)
• Cognitive behaviour therapy (CBT)
• Dialectical behaviour therapy (DBT)
• Emotion-focused family therapy (EFFT)
• Psychodynamic therapies
• Eye-movement desensitisation and reprocessing (EMDR)
• Emotional freedom technique (EFT, or ‘tapping’)
• Cognitive remediation therapy (CRT)
• Repetitive transcranial magnetic stimulation (rTMS)

Also:

* Three routes out of post-traumatic stress disorder (PTSD) *

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Onwards

* Next: Chapter 13: Powerful tools for well-being and compassionate connection *

* Go to Table of Contents *

* International: eating disorder help across the world * for links to treatment and support in various countries

* ‘How to choose excellent eating disorder treatment in the USA’ *

* Eating disorders in England (and tips for Wales, Northern Ireland and Scotland *

* What’s the best eating disorder treatment for children and young people? The UK’s NICE guidelines *

* Recommended eating disorder treatment for adults: the UK’s NICE guidelines *