The essentials for a parent who want immediate answers: what are the main principles of the treatments covered in this book, and how long before you can expect some relief and progress?
This is the whole of Chapter 4 of ‘Anorexia and other eating disorders – how to help your child eat well and be well’. I hope it sets you off on a productive path right away.
The road ahead
Here’s an outline of the main elements of treatment for complete recovery:
- Set up specialist treatment – online if necessary. This means regular sessions with a professional qualified in a family-based approach, and depending on requirements, a psychiatrist, a dietitian, or a psychologist – each specialised in eating disorders. When they can’t access a good provider, some parents manage with self-help and a family doctor (more in Chapter 12).
- In a first phase (see the graphic above), we parents take responsibility for all meals: this is ‘refeeding’ or ‘nutritional rehabilitation’. We get skilled at kind and effective support so that our children manage despite their distress. We don’t wait for them to be motivated to ‘beat’ the eating disorder. Their brain is currently sending highly distorted messages about what feels ‘right’. The general rule is 3 meals and 3 snacks a day. We must provide calories and prevent long gaps between meals.
“I have been made team leader of food”
- Your first priority is rapid weight regain and regular meals: that’s because thinking and mood are disturbed while the body perceives a weight deficit – or whenever there’s a big gap between meals. You may wonder how eating and weight gain are possible when they’re your child’s biggest fear. Paradoxically, fear tends to ease as weight increases, though there’ll be ups and downs along the way.
- At the same time, protect your child from compulsive or excessive exercise (a gentle stroll with you might be fine), and from the use of laxatives, diuretics or vomiting.
- Parents take the lead: these tasks usually only succeed when parents take a strong lead, with skill and compassion. That means the young person, however bright and independent-minded, has little or no involvement in food decisions, shopping, cooking or portioning. This tends to relieve them of the guilt and confusion they feel when they eat or rest. For a while, meal support and supervision interfere with both your life and your child’s (they’ll need help with meals in school, for instance). Yet for almost all families, progress only happens when parents take on this work. I help you with all this in Chapter 6, where I also discuss the less common cases where collaboration works better.
- Your next priority is exposure work to free your child of fears, rigid rules, rituals and distorted beliefs. You’ll bring back the foods and behaviours that you consider ‘normal’ (Chapter 9). Start on that as soon as you can, but not if it gets in the way of your first priorities: weight gain, regular meals, stopping exercise and purging). Make sure you address this work eventually, as weight gain alone rarely fixes behaviours and thoughts.
- Make your child’s life as rich and happy as possible and treat them with compassion. Accept that at first, meals or rest can be hard for them. But avoiding distress will only prolong the misery of the illness.
- Gradually, bring back independence. Look for what your child is able to do for themselves. Can they manage school, with or without meal supervision? Can they return to moderate physical activity? Can you coach them to choose between two snacks? To serve themselves a suitable portion of peas? Of lasagne? The aim is for you to safely step back, with your child managing age-appropriate autonomy and taking pride in their progress. Some call this ‘Phase 2’ and it’s the topic of chapter 10. To succeed, your child will first need coaching and supervision. If it turns out that a challenge was too much, too soon, you’ll treat that as a useful experiment, provide more coaching in easier steps, or go back to the last thing that worked.
- Psychotherapy: for many families, psychological support – usually individual, confidential therapy – is introduced only at this stage. Many children don’t need it. Those who do usually have co-occurring mental health challenges – and sometimes, introducing therapy earlier can also ease the refeeding work.
- Time to consolidate: with time, your child becomes well – they just need time to consolidate. There’s education on relapse prevention, and discharge from treatment. Parents begin enjoying themselves, while keeping some light vigilance, as slip-ups are to be expected.
- Recovered: One day, youngsters and parents realise that time, repetition and the pull of life have done the rest of the healing,[i] because the eating disorder thoughts and compulsions have gone, and a beautiful young soul has recovered.
I haven’t mentioned hospitals. If your child is medically at risk then a short stay in a paediatric ward can provide a reset, and you can then resume treatment at home. With some youngsters the illness is just too powerful, or the parents don’t have sufficient support, so a longer spell in an eating disorder treatment centre is needed (more in Chapter 12). This doesn’t provide a complete cure, but good units make parents part of the team and skill them up to take over as soon as possible.
The above outline, like much of this book, is in line with a family-based approach. Professional institutions worldwide recommend this as the top child and adolescent treatment. However, if you’re absolutely certain it’s not for you, don’t give up! Jump over to Chapter 12 where I introduce you to other valid treatments.
Food for weight restoration and stability
Food is an essential medicine in the first stage of treatment. If your child has lost weight or failed to grow, they need to catch up. People who binge or purge need regular meals to gain stability and escape the vicious cycle of obsessive restriction, intense hunger, eating with guilt or bingeing, followed by another attempt at restriction.
For those vulnerable to an eating disorder, ‘weight suppression’[i] is very likely to trigger an onset or relapse. That means youngsters must not lose weight and must keep gaining weight for growth. Your priority is now rapid weight recovery. If you’re wondering how much to aim for and what to do if your child previously had a high BMI, I explain this in Chapter 6.
As a medicine for an eating disorder, food really sucks. It’s a distressing pill for people to swallow not once, but five or six times a day. Sadly, medical science hasn’t yet come up with anything easier. Take heart: meals usually get easier as weight increases. The brain is especially calorie-hungry, and you should see mood and thinking improve with nutrition.
If you’re wondering how you can possibly get your child to eat, read on. In Chapter 7, I share general principles and practical dos and don’ts. Then in Chapter 8, you can be a fly on the wall and witness an entire mealtime session. And in Chapters 13 to 15 I give you emotional tools to help you support your child meal after meal.
Train the brain: practice ‘normal’ with exposure work
Food is medicine because it’s much-needed fuel. It’s also because the brain needs to relearn what is ‘normal’. For instance, when we repeatedly serve a fear food it starts to feel ordinary and safe again. Our children often lose their sense of what a normal portion is, what their body is meant to look like, and what it feels like when they have enough body fat. Sometimes they need to rediscover what it’s like to be happy and carefree. They shed eating-disordered habits by engaging in new behaviours. Their brains need nutrition, repeated exposure, and time to heal and form new, healthy pathways.
Our children need help with this, and that’s why weight-restoration should never be seen as the end of treatment.
Unconditional love
Every step of this treatment calls upon your ability to give unconditional love and support. This is not empty sentimentality; the evidence is that criticism and hostility from parents impede progress. We parents hold essential keys to the treatment because families are all about love.Your love helps your child trust you, so together you can face challenges that may seem impossible. Suffering is far more bearable when we feel loved and understood. And if you worry that your child isn’t yet receiving psychotherapy, know that your compassion provides emotional healing. You’re also modelling emotional skills your child will one day use for themselves. With your own suffering, you’ll recognise how healing and empowering it is when someone hears you, understands you, and accepts you.
Love is hard to put into practice in the middle of daily storms. That’s why I offer emotional tools alongside practical ones. Jump to Chapter 13 if you feel this is what you need the most right now.
When does psychotherapy have a role?
In a family-based approach, the young person normally doesn’t receive individual psychotherapy. Parents worry about this. When we’re new, we assume that there are psychological fixes that will make our children ‘come to their senses’ and motivate them to eat again. We hope that therapy for bullying, divorce, or bereavement will restore the ability to eat. But this is putting the cart before the horse. Mental changes follow physical recovery and behavioural work – not the other way around. Even if your child has moments of insight, they will likely lose all willpower at the next mealtime. The work is done bite by bite.
“Knowing that he didn’t need to have insight at the beginning or want to get better was a huge relief to me. It helped lift the sense of despair early on.”
If your child didn’t have any psychological issues before the eating disorder, they may not need any psychotherapy. The issues that make them so unhappy now – depression, anxiety, rigidity, delusional and obsessive thinking, compulsions – tend to diminish with nourishment. They recede further with behavioural work that makes ‘normal’ feel normal again. And then time, plus a good life, provide the final magic. When a health service doesn’t yet provide psychotherapy, it’s not to save money; it’s good scientific practice.
That said, clinicians are becoming more flexible in assessing each child’s needs. In Chapter 12, I explain more to help you consider whether your child – especially if they face other mental health challenges – might benefit from one‑on‑one therapy now or later. What is certain is that the feeding work must continue regardless.
Medication
There are approved medicines for bulimia and binge eating disorder. For anorexia, no drugs provide a cure. But some medications have been approved to help ease the anxiety, depression, delusional thoughts, or self-harm that can accompany anorexia, especially if mealtimes are particularly tough. It’s the role of psychiatrists to assess and keep reviewing.
Your child's increasing wellbeing: a visual guide
You’ll be wondering how and when your child’s mental state will get fixed. Here’s the big picture.
The first major improvements in mood come with weight gain, regular meals and interrupting harmful behaviours, such as over-exercise and purging. As we introduce other work – exposure, coaching for independence, and perhaps psychotherapy – progress continues: we generally see improvements in mood (depression, anxiety, self-loathing), fears, rituals (body-checking, measuring portions) and attachment to eating disorder behaviours (over-exercise, purging, restricting).
Thoughts and beliefs also improve: you’ll see less of (‘carbs are bad’) and fewer obsessive thoughts (‘Am I fat? Did I eat too much?’). It’s quite a transformational journey, and many of us have seen our children emerge wiser, more insightful, and better resourced than their peers.
While the graphic above shows the big picture, progress is rarely linear. Every child has ups and downs across different areas. This week’s weighing freaked them out and meals are hard again. At the same time, they’re more like their old self, engaging with you and with friends. Body image is often the last thing to return to ‘normal’: indeed time is one of the healing factors.
While this graphic is only one example of someone’s journey, if you’re seeing zero progress, that’s a sign you need more help from your professionals.
What is this method called?
There are variants of this method, and they’re so similar that we parents don’t need to worry about which we’re getting. As an umbrella term, I’ll use the words ‘family therapy’ or ‘family-based approach’.
Occasionally I’ll refer to specific manuals[i] or publications: ‘family-based treatment’ (FBT) or ‘family therapy for eating disorders’ or ‘anorexia/bulimia-focused family therapy (FT-AN or FT-BN)’. I won’t use the word ‘Maudsley’ as it gets confused with the very different ‘New Maudsley Method’, which isn’t validated for young people (more in Chapter 12). You’ll want to know that what I write is in line with approved methods, so jump back to the first few pages or visit my website[ii] to see how experts in these methods recommend my resources.
Choose a family-based approach first
If your child or adolescent has anorexia or bulimia (including so-called ‘atypical’ versions), any therapist following the science should begin with a family-based approach before considering any other method. This is the recommendation of professional organisations worldwide.
“Of all treatments examined, Family-Based Treatment (FBT), in which parents are placed in charge of the refeeding process, had the most evidence to support its use in children and adolescents with Anorexia Nervosa.”
Other methods can be useful later, as adjuncts.
Nowadays, most treatment providers claim to deliver ‘evidence-based’ treatment and ‘family therapy’. But are they? Check that their ‘family therapy’ is not about ‘fixing’ the family. It should be about valuing and making good use of wonderful parents:
“Treatment with the family as opposed to treatment of the family”
In Chapter 12, I provide a checklist to help you choose good treatment. As a quick guide, any of the following indicate that a method is not family-based:
- It relies mainly on individual sessions between your child and the therapist
- The focus from the start is on motivating your child or having them take responsibility for their recovery
- There’s an emphasis on searching for ‘underlying causes’
- Parents are to stand back or only make gentle suggestions
- Parents are seen as part of the problem rather than a precious resource
- Clinicians aren’t aiming for full recovery
- Clinicians aren’t committed to full weight restoration
A family-based approach may not work for you, and there are individual therapies that have a relatively good evidence base – but only as a second choice (more in Chapter 12). For now, put simply: your child needs you, and your skilled support will make all the difference. A great treatment team will lead the way – and I hope this book helps you too.
One size fits all?
While your child’s is most likely to make rapid progress with a family-based approach, should the method be followed to the letter? No method works perfectly for everyone, and we don’t always know why. Research has identified essential ingredients of FBT – such as rapid weight gain – but we still don’t know whether other elements are optional, or if leaving them out might even work better. If you suspect that some aspects are not helping your child, have a conversation with your treatment team.
Your clinicians’ level of expertise matters. What training do they have in the family-based method? Do they have experience with a wide range of patients, including those who are neurodivergent and those with a co-occurring disorder? Are they willing to problem-solve alongside you, or do they stick rigidly to protocols? Are the opposite protocols being used elsewhere – and if so, who’s right? Within the UK’s national health service, I see major differences in goal weights, whether to weigh open or blind, whether meal plans are provided, and so on.
A rule of thumb is that the less experienced the clinician, the more they should consult the treatment manual (just as an inexperienced cook is wise to stick to recipes). Basically, we ‘don’t know what we don’t know’, especially when we don’t keep up with the field. Some of dogmas we hold firmly today may be overturned tomorrow’s research.
From the authors of the Maudsley service manual:
“The differences between the manuals […] act as a further reminder, that our knowledge of how treatments work is still very limited and that in applying manuals to practice, therapists need to understand the concepts that underpin the interventions. They also highlight, that families vary and that what may suit one family well may be a poorer fit for another family and that clinical flexibility and respect for the families’ own view must not be lost when treatment is informed by a therapy manual.”
Daniel Le Grange, co-author of the FBT manual, worries when we ‘see the manual and its guidance with a bit too much rigidity’ and wants us to retain ‘an appropriate sense of fluidity’:
“I believe rules are made so that you know when to set them aside […] We should never be rigid, it should never be. ‘Oh everyone has to go this way. Probably most people will go this way […] but there are always exceptions”
In this book, I aim to highlight what usually works best, as well as variations that might be great for some – and terrible for others. I find the adaptations made by parents of autistic youngsters particularly instructive.
“Our 11-year old son seemed different –actively suicidal, with school a huge contributor to massive anxiety. I felt a great deal of anxiety and despair as we tried to implement the tools of family-based therapy but saw complete failure repeatedly. The phrases you suggest for mealtimes just made him madder, sarcastic. What helped was to be kind, calm and confident, remove stressors, and to involve him in some of the meal preparation.”
There are many everyday questions without scientific answers. How long should we persist with a difficult meal? How much rudeness should we tolerate? Will rewards help or hinder? It’s OK, though, because you’re the expert on your child: run small experiments, and you’ll know what works best.
When to treat co-occurring conditions
Eating disorders are often accompanied by what’s called ‘comorbid’ or ‘co-occurring’ conditions, which they share genetic links with. The most common are anxiety disorders (including OCD), neurodivergence including autism and attention deficit hyperactivity disorder (ADHD), and depression. Some youngsters may later be diagnosed with depression, borderline personality disorder (BPD), or bipolar disorder (formerly called manic depression). Some co-occurring conditions were present long before the eating disorder and they worsen with undernutrition. But it’s also common for them to appear only as temporary effects of starvation: hunger and malnourishment are conducive to aggression, volatility, depression, suicidality, anxiety or rigidity.
Unless a person is at significant risk of suicide or serious self-harm, and unless the co-occurring condition makes eating disorder treatment impossible, the general rule is to treat the eating disorder as a priority because:
- it poses the greatest risk to health.
- as the eating disorder recedes, many of the other problems usually ease too.
- psychological treatment for a co-occurring condition may be ineffective while your child is malnourished.
There are plenty of exceptions to the general rule, so do seek out specialists who can advise you.
Adapting for autism spectrum disorder (ASD)
Many youngsters with an eating disorder are also autistic (this now includes the former diagnosis of Asperger’s). Whereas ASD is part of the child’s makeup, expect the eating disorder to be treated. Some parents wish autism had been diagnosed earlier, because they’d uiooadapted the treatment. But it’s tricky to diagnose autism while malnutrition causes anxiety, rigidity, rituals and disrupts appetite. Conversely, ASD is sometimes revealed precisely because malnutrition tends to intensify autistic characteristics.
Some parents report that their child’s love of rules makes refeeding and rapid weight gain easier. Others say their child can only eat if given some autonomy over meals – though parents must still steer choices to ensure portions are large enough. Progress may be slower, but some report that this approach has eventually freed their child from the illness.
Autism presents in such varied forms that there is no unique, correct way of modifying the eating disorder treatment. You and your clinical team will need to assess, experiment and adapt. You’re not alone though: others have been contributing their know-how – see my website for more.
On this website: Eating disorder treatment for your autistic child or teen
Expect full recovery
Our family therapist said she expected ‘nothing less than full recovery’. You need to know that this illness is treatable. Your child only sees a dark tunnel of low mood and isolation, and you’re the one holding the candle of hope. My daughter only gave me one piece of advice as I wrote this book: ‘Make sure they know they will recover.’
You may have come across depressing statistics on recovery: these reflect outdated treatments and don’t apply to you. A family-based approach is very different and more effective (more in Chapter 12).
People recover at any age, even after decades of substandard treatment. Sometimes a slow start is followed by rapid progress. Don’t let anyone tell your child they’ll have to live forever with their eating disorder. I have followed families where the illness was very severe and complicated, with several years of tube feeding in eating disorder units, and the young person is now recovered and thriving.
Your child is not a statistic. They have you, with your loving, smart support. Whatever the duration of the journey, expect to see them regain complete freedom. In the process, you’ll all grow closer, stronger and wiser. Sure, some things are not in our control. So we focus on what we have the power to do. We cannot control how many apples a tree will produce, but we can provide the conditions for it to flourish.
On this website: Expect full recovery (not just ‘remission’) from an eating disorder
How long before my child is well again?
The illness hits our children in different ways: some recovery journeys are relatively straightforward, while others take longer. Most parents report that treatment lasted longer than they’d expected, and want you to know: ‘This is a marathon, not a sprint’. For me, a marathon implies constant struggle, whereas with time, things often become easier – routine almost. If you’ve only just begun treatment, you might be going through the hardest part right now.
“Just 4 weeks ago I would scarcely have believed that we would be where we are now. It’s amazing how quickly he improved once we worked out how to help him. That included reducing this anxiety (by taking him out of school), simplifying his life and giving love and support all the time, whilst controlling our own behaviours. His psychological symptoms are abating (apart from the OCD) just as you said they would as his weight goes back up.”
Some youngsters progress fast after a difficult start. If you can’t get your child to eat, or if after 2 or 3 weeks you have little hope of driving weight gain, insist on more help. You might be offered meal support at home, a week in a paediatric unit, access to day treatment, or a lengthier stay in an eating disorder unit (more in Chapter 12).
Let me give you some indicators to help you form realistic expectations – this is for anorexia. The period of weight gain requires your intense support. Your child will need to catch up on the weight they should never have lost if they’d stayed on their growth curve, plus possibly more. With the recommended weight gain of 0.5 to 1 kg per week, you can do the maths. With every meal eaten and every kilo gained, our children tend to get better physically and mentally. They manage to eat without too much cajoling… and you, too, gain confidence. The crisis is over. Increasingly, there’ll be delightful moments when you feel, ‘My kid is back!’
“Last night, when I picked up my girl, I had forgotten to bring the snack for the ride home. She said, ‘But Dad, I'm hungry.’ Just matter-of-fact. So matter-of-fact that I didn't realize she had said them until a few minutes ago, nearly 12 hours later.
I have waited for those two words, ‘I'm hungry.’ I have not heard them since I don't know when.
ED took another hit last night. And my girl took another step. I am joyful.”
There can be day-to-day or week-to-week fluctuations, so if you have bad times, gain perspective by zooming out to the bigger picture.
Eventually your child will reach the weight their body needs, and many (though not all) parents see a big improvement (but not complete recovery) in their mood and thinking.
As I explained at the start of this chapter, the next tasks your child will need you for are behavioural changes (extinguishing fears), followed by coaching for independence (Phase 2).How long this takes varies greatly – I tend to think around six months, with decreasing intensity. Expect to support or supervise certain areas until your child is able to handle them wisely. Gradually, though, they’ll ease back into normal life, and you’ll allow yourself more freedom too.
Another way to view the timescale is that life will seem more normal when therapy sessions end. This typically happens 6 to 12 months after the start of family-based treatment. Studies show that fewer than half of patients have fully recovered by then, so expect your role to continue quite a bit longer. Therapist Sarah Ravin reports that of the anorexia patients who completed treatment with her, full recovery took between 2 and 48 months.[i]
A year or two after treatment begins, life feels increasingly normal for most of us. I consider it wise to maintain some low-level vigilance until our children reach their mid-twenties, when their brains have fully matured.
Here are factors that usually support faster improvement and better outcomes in anorexia:
- Treatment follows a family-based approach (nutrition, no purging, compassionate family support, consolidating normal behaviours).
- Treatment starts as early as possible, aiming for rapid weight gain from the start.
- Recovery may proceed quicker if your child has no other mental health disorders before the onset of the eating disorder.
- My unscientific observation: often, progress is often much faster with excellent clinicians and well-informed parents.
- Although it may seem particularly tragic when the illness hits a very young child, this often makes treatment easier and increases the chances of swift recovery.
- If time is on your side (i.e. if there’s no pressure for your child to leave home), you have a better chance of future-proofing them against relapse.
The book contains numerous endnotes with links, relevant to this text.
* Next: Chapter 5 – What parents need to know about the causes of eating disorders *
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