Adults or young adults: treatment for a restrictive eating disorder

Where can I get help on adult treatment for someone with anorexia?

At present my expertise is mostly on children and adolescents, though I do speak to a number of parents of university-age people. Here are starting points for you.

Adults who embraced the strengths of adolescent treatment

For approaches that are similar to the resources I value for youngsters, but made to work for independent adults, I recommend Tabitha Farrar's website, podcasts and discussion groups. You will find quality information and real positive action you and your son or daughter can take.

Also packed with resources is Gwyneth Olwyn's website edinstitute.org.

I love the insightful account from 40-yr old Helly Barnes on 'Reflections on my recovery at 40 – a journey with my parents'. She described how she used her parents' support. Note that Helly now has a book that I highly recommend and review here, a great podcast, and she provides coaching for people with an eating disorder. She wrote to me:

"I am very ED aware and I have great amounts of knowledge about what recovery takes – my parents did not have this and the process for us has involved my having to do a lot of educating of them… which has not been easy – to be that honest, to feel like I am having to keep repeating information about what might help me when the ED is screaming at me not to tell them!. That is where, some sort of education for family members of adult patients by treatment teams would make such a difference – to help the family understand so much more about what restriction in an ED really can look like, what compulsive movement is and how crippling it is, how much food recovery really does take (and not the pathetic meal plan amounts that most ED units use!!).

Emotional support has been the biggest part. This process is such an emotional rollercoaster and the anxiety has been crippling at times.  I have had a full panic attack which luckily mum was here to help me through.  At other times it has just been having someone to comfort me when I have sobbed my heart out….

Ultimately, the type of support that I think would work best for me and perhaps a lot of adults in recovery is a firm stance.  We are all very very hungry but terrified of eating as much as our body desperately wants us to and is crying out for… ultimately we want and need to eat thousands of calories each day (as do kids) and because it is so terrifying, the best support is having that push and that permission to really eat as much as we possibly can and be reassured that it is not just safe to do so, it is right to do so.

Alongside this most adults with an ED have exercise and movement compulsions. We want nothing more than to be able to sit on the sofa and watch Netflix, but for most of us the guilt at doing so is at least as intense, sometimes more so, as the guilt for eating.  Therefore, again… family support where people are reassuring and supporting in resting.

 And even if we push away, scream and shout – stay strong and stay consistent, as inside the shouting and screaming beast is a desperate person, longing to break free of the illness – longing to sit, longing to eat.  We need people we love to help make us feel safe to do that…

I write, speaking for other people with an ED too because I do have contact with a lot of adult ED peers from all over the world and their experiences they share with me are the same as I write here…  "  

Helly Barnes

You can learn lots also from Hannah's account of her journey to recovery in 'Insights from relapse to recovery: what I’ve learned from falling and getting back up again'. Note that throughout, she had meal support from her mother. So don't think that because your child is 18+ they should be pulling themselves away from anorexia through sheer willpower:

"When I graduated from high school, I stayed home for a year, attended community college, and essentially lived in a recovery bubble. My mom supported me through almost every meal, and we had weekly sessions with my therapist."

Hannah

Most of the above is for anorexia, but there are always useful overlaps with other eating disorders involving restriction, fear of weight, over-exercise.

A family-based approach for adults

Indeed there are plenty of adults who recovered with the help of their own parents, and there's been some research on adapting FBT for young adults (referred to as 'Transition Age Youth' in a method called 'FBT-TAY'. I describe the FBT-TAY method here and offer my opinion on its strengths and weaknesses.

From my Bitesize audio collection: “I was desperate for my parents to feed me”:

Everyone can learn a lot from Emily Boring, in her mid-twenties, describing her state of mind when she's been underweight and comparing it with her ease of life and freedom of thought after treatment and weight recovery. I love this piece of hers, as well as her two-part interview on a podcast. If you registered for FEAST of Knowledge 2022 then you'll have access to another excellent talk from her.

From certified FBT therapist Kellie Lavender:

"Working with young adults between 17 and 25 using FBT-TAY has been some of the most gratifying work I have done. I have seen it work. If an older adolescent/young adult agrees to have their loved ones involved, this is a treatment model that can and should be offered as an option."

Read more from Kellie Lavender on my FBT-TAY page.

Hope for better any-age treatment: Temperament-Based Therapy with Supports

I am excited by Temperament-Based Therapy with Supports (TBT-S), for any age (for children and adolescents, it can work well along with Family-Based Treatment). The person with the eating disorder has support people (parents, friends etc) that they chose to help them throughout the treatment, guided by clinicians. The stance seems to be genuinely respectful and empowering of all those involved. I say more and guide you to the TBT-S manual here.

Is anorexia treatment for children and adolescents different from treatment for adults?

Currently, yes, it's usually very different. And that is a shame. It's not evolved the way adolescent treatment has, and I hope that will change.

For a review of the research on treatment for adults, see Glenn Waller (2016), ‘Recent advances in psychological therapies for eating disorders’

Adult treatment emphasises psychological approaches, getting the patient to be motivated to get well, to gain insight, and to work on their recovery on their own, with weekly outpatient appointments. 

There can be a lack of ambition in getting them to fully recover, possibly because a fair number of adult patients are chronic sufferers.

Often treatment for anorexia stops before the person has reached a normal weight, and people are left to their own devices before they're well enough to take care of themselves.

Sometimes treatment stops because the adult is kicked out for lack of sufficient motivation.

If weekly outpatient appointments don't work, in the US there are partial hospitalisation programs (PHP) and in some countries (including the UK) there are day treatment programs. People get help to eat several meals a day, but are often required to muster some willpower back home alone. Again, they may get kicked out if that fails.

Some adults can be in limbo until they get 'sufficiently' ill to be admitted to an inpatient unit, where there is more robust help to get them to eat, stop exercising and purging, and gain weight. If they can't eat and are very ill, the mental health act kicks in and they are tube-fed — if necessary against their will.

In adult treatment, parents or partners tend to be held at arm's length, on the basis that the patient must have motivation and autonomy and self-responsibility. So the family has to watch helplessly while the person restricts. Then if the person gets worse, a hospital will take away their autonomy and do the very things that the family members could have done months before.

With most adult treatments, if there is any 'family therapy', it looks at the interactions between family members, on the basis that dysfunctional relationships may have caused, or may be maintaining the illness. Workshops for parents tend to be all about managing one's emotions so as to do no harm. Mostly it's about staying out of the way, in a calm and compassionate way, while the person supposedly takes ownership of every difficult meal and behaviour.

When I talk to parents in this situation, they generally feel blamed, disempowered and helpless, and it may become even harder for them to help their child eat at home.

The picture is a lot more positive with children and teens, thanks to research on a totally different concept of family therapy for anorexia. On this site, when I talk of 'family therapy', I refer to an evidence-based approach whereby parents are part of the team and are empowered to take charge of meals and of normalising behaviours. The standards of many countries make this approach either highly recommended or mandatory, as the first approach to try. The beauty of it is that this treatment does not require the child or teen to have motivation or insight, and it addresses the biological aspects of an illness that cannot be healed while the body and brain are malnourished. My book, my 'Bitesize' audio collection, and this website, are designed to help you support your child in this way.

I am confident that family therapy for eating disorders, or some variant of it, could help people beyond their teen years. Exactly how we adapt the treatment is the big question. See my article 'Young adults with anorexia: FBT-TAY family-based treatment for 17-25 year olds'.

An all-age treatment service

Some eating disorder services treat all ages, which means that adults benefit from the best treatment principles used for teens. From a therapist on a video interview I did : "A colleague of mine said, it's brilliant because they actually get better!"

But what about the legal freedoms of an 18+ ?

Treatment providers can make a big deal of the legal rights of a person age 18 and over. The good ones will work around it. Many young adults are still at home, or they're dependent on their parents for money to live away. Older adults may decide to prioritise their recovery, and move in with helpful support people — whether that's their parents or friends. That is the most assertive choice they can make, when most of their life is governed by an eating disorder.

Some treatment providers find it weird and inappropriate to have parents of an adult in a caring role. Yet that's only with mental health. With cancer or a stroke, I doubt that clinicians push parents away.

So the attitude should be that for a while, with this very difficult illness, your child needs your intensive support, and it's appropriate and feasible to give it. More on this in Chapter 12 of my book.

Frustratingly, some professionals seem to be so worried about breaching privacy laws that they might as well be begging the young person to refuse treatment: ‘OK Morgan, we would 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 are free to walk away any time.’ I hope that documents such as those compiled below, more can have the tools to involve parents.

Standards and recommendations on involving carers [Click]

Your country may have legal rights or guidance regarding the involvement of carers (parents, family members).

This Australian document may help you get your head around the issues, wherever you are in the world, and whether you're a parent or clinician. See page 20 in particular. A practical guide for working with carers of people with a mental illness

In the UK, the NICE guidelines make it clear that parents must be involved with the care of their child or adolescent. With adults it's not so easy to find specific standards. It's not always clear whether they're just referring to children, and there's a lot of '"as appropritate". There is clarity here, though:

1.11.7 When a person is admitted to inpatient care for medical stabilisation, specialist eating disorder or liaison psychiatry services should: keep the person's family members or carers involved

1.11.8 Inpatient or day patient services should collaborate with other teams (including the community team) and the person's family members or carers (as appropriate), to help with treatment and transition.

1.11.11 Develop a care plan for each person with an eating disorder who is admitted to inpatient care. The care plan should:
be developed in collaboration with the person, their family members or carers (as appropriate), and the community-based eating disorder service

This 2021 report from the Department of Health and Social Care, 'SHARE: consent, confidentiality and information sharing in mental healthcare and suicide prevention" has much that could help you. For instance:

"Practitioners must consider the wellbeing of families, friends and carers and their potential ability to contribute to positive service user outcomes."

For Scotland, see the Mental Welfare Commission for Scotland's good practice guide (2024): "Carers, consent and confidentiality"

Readers, feel free to add resources from your country, in the comments at the bottom of this page.

How to get my independent child to accept help?

If your child is 18+ it may seem impossible to get them to accept treatment, and even more impossible to bring them home and take your meal support if they are independent.

Occasionally I help the parent of an adult to prepare for difficult conversations, using principles of compassionate communication. I remember one mother who was astounded how quickly her 22-year old accepted her help — she had assumed everything was hopeless.

Some people will tell you to use any leverage you have, for instance stopping your child's money if they're financially dependent. Or making them move out, if they're still at home but refusing treatment.

If you think it might work, fine. But it's risky. I'm remembering a young adult who simply moved to her (flaky) friend's sofa. Another who got money from an aunt, who didn't understand the severity of an eating disorder.

So as a safer first step, I'd recommend finessing your communication. Be ready for many conversations to nurture your connection.

For help with great communication — how to be compassionate while also firm in your requests — see Chapter 13 of my book or listen to my Bitesize audios.

I also love the suggestions in section 6 of the FEAST guide written by therapist Ephrat Lipton, 'Using leverage'. I'm more cautious than she is about how leverage (like withholding a phone) can backfire (see Chapter 14 of my book) but section 6 of the guide is not about leverage: it has good tips for using your relationship capital, when your child is independent. (A tip, though, as I explain in Chapter 13, that little word 'but', which you'll see in that guide, could water down your message of empathy!)

In the UK: the NICE guidelines for adult treatment methods

If you're in the UK, check out my page on what's in the NICE guidelines for adults (18+).

Briefly: for adults with anorexia they recommend just three approaches:

• CBT for eating disorders (which I describe here)

• Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)

• Specialist Supportive Clinical Management (SSCM)

• If none of those three are acceptable or effective, the next best option is eating-disorder-focused focal psychodynamic therapy (FPT).

There is not enough research for a family-based approach or for Temperament-Based Therapy with Supports (TBT-S) to feature in these recommendations.

For bulimia and for binge-eating disorder in adults, NICE recommends a guided self-help programme, possibly with brief supportive sessions, and if after four weeks this proves unacceptable, contraindicate or ineffective, then CBT is to be offered.