Last updated on August 9th, 2020
The essentials for a parent who wants immediate answers: what are the main principles of the treatments covered in this book, and how long before you can expect some relief?
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
What does treatment look like? Here’s the process that a specialised family therapy team would typically take you through. This book guides you through the many questions you will have along the way:
- Treatment starts with parents making it possible for their child to eat what they need, in spite of the anxiety stirred up by the eating disorder. Regularity matters, and daily caloric needs can be high, so the general rule is 3 meals and 3 snacks a day. This ‘refeeding’ or ‘nutritional rehabilitation’ provides a huge part of the physical and mental healing. Note that we don’t lose precious time trying to build motivation: our children manage meals because we develop new skills to make it bearable for them.
- Your child cannot achieve recovery while underweight, so if they lost weight or did not maintain a normal weight trajectory, the focus is on rapid, full weight restoration. You may wonder how your child can gain a lot of weight when they fear it so much. Weight gain is your friend as it reduces irrationality and anxiety. The general trajectory is that as weight increases, fear of weight gain eases off.
- Meanwhile parents also support their child to normalise behaviours. For instance they guard their child from vomiting, laxatives and compulsive exercise; they gradually serve foods that the eating disorder has forbidden; they facilitate the return to life in all its richness. This behavioural work brings lasting changes to the brain’s perception of what is normal and perfectly fine.
- Parents learn to be firm in order to keep moving towards recovery, while also giving love, kindness, and non-judgement (I call this ‘compassionate persistence’). The best current treatment is hard for our children. It requires them to walk through their version of hell. It makes all the difference that we are walking next to them. We can all bear suffering when we are feeling loved and understood. A parent’s compassion also provides emotional healing, and it models emotional skills that are precious further down the line for resilience and relapse prevention.
- To achieve all this, in a first phase parents normally take charge of all things related to health – everything which the child, in their mental state, cannot do wisely for themselves. With time there is a gradual handover during which parents guide their child to re-learn and practice ‘normal’ behaviours, while keeping in place just the right level of safeguarding. The child recovers age-appropriate autonomy around more and more situations (resuming school, physical activity, eating with friends, going on holiday, leaving for university). By this stage, most of our sons and daughters are really well and they keep the eating disorder at bay by sticking to safe behaviours (such as regular meals and staying within a safe weight zone) – something that becomes increasingly easy. Usually this is when they are safely discharged from treatment, after some education on relapse prevention. Everybody gets on with normal living, though parents, wisely, keep a light level of vigilance. And then one day, children 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.
By now you’ll have got the message about the importance of food and weight. Food is medicine for someone with an eating disorder. The brain is particularly calorie-hungry. People who binge or purge need regular meals in order to gain stability and escape a vicious cycle of obsessive restriction, terrible hunger, eating with guilt or bingeing, followed by another attempt at restriction. Children and teens need to grow and it is never OK for them to lose weight (contrary to what you might infer from media campaigns). Losing weight is especially dangerous for individuals who are vulnerable to an eating disorder because it triggers the thoughts and behaviours. Another big trigger is dipping below a certain weight: for those with a vulnerability it’s crucial to be within a weight range that meets their individual, genetically programmed needs.
As a medicine for an eating disorder, food really sucks. It’s the one thing sufferers fear the most in the world, and they need to swallow the pill not once, but five or six times a day, day after day. Sadly, medical science hasn’t yet come up with anything that is easier for patients or their families.
If you’re wondering how anyone can possibly get a child with anorexia to eat, read on. In Chapter 7 I list general principles, offer some 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’
Food is fuel, but there is an additional reason why it is medicine: it seems the brain needs to relearn what is ‘normal’. For instance, we serve fear foods so as to make them feel ordinary and safe again. Our children often lose the sense of what a normal portion is, what their body is supposed to look like, what it feels like when they have a sufficient level of body fat. Sometimes our children need to remember what it’s like to be happy and carefree. A big treatment principle is that they shed eating-disordered habits by engaging in new behaviours. Their brains need nutrition, exposure, and time, in order to heal and form new, healthy pathways.  Our sons and daughters need help with this, and that’s why weight-restoration should never signal the end of treatment.
I mentioned how much our children need our uncritical acceptance, our unconditional love and support. This is not empty sentimentality; it’s a key principle that’s been validated in scientific trials.  We parents hold essential keys to the treatment, because families are all about love.
Your love helps your child to trust you so that together, you can tackle seemingly impossible challenges. Besides, have you noticed that anything that has any kind of importance in life comes down to love? If you yourself are presently suffering, you may already have felt how healing and empowering it is when someone hears you, understands you, accepts you.
Love is hard to put into practice in the middle of our daily storms. This is why this book offers emotional tools as well as practical ones. Feel free to jump to Chapter 13 if you feel this is what you need the most right now.
There are no drugs to cure eating disorders. But medication may assist with your child’s anxiety, depression or delusional thoughts, especially at the beginning of treatment, when eating causes such high levels of distress. ]
When does psychotherapy have a role?
You may have noticed that in my treatment outline I haven’t mentioned psychotherapy. That may seem strange, because an eating disorder looks like a psychological problem. We want to talk some logic into our child. Motivate them. Find out what upset caused the eating disorder and fix it. Indeed the illness used to be treated this way but the results were poor. People don’t beat the illness by talking or thinking, and that is understandable now that we know more about the physiological mechanisms which maintain an eating disorder. Family therapy for eating disorders addresses these mechanisms, which is probably why it works so much better.
The method does make space for psychotherapy, but usually at the end of treatment, when the child’s mind is more free to engage. Very often there is no need for psychotherapy because once the eating disorder is beaten, your child is back. The most common psychological issues that made your child so unhappy – depression, anxiety, rigidity, delusional and obsessive thinking, compulsions – recede as the eating disorder loses its hold. When a health service won’t give your child psychotherapy, it’s not to save money, it’s good scientific practice. Having said that, there are exceptions to every rule, and some youngsters do benefit from some psychotherapy input as an adjunct to family therapy: more on this in Chapter 12.
Disorders that ride on an eating disorder’s coat tails
It’s common for eating disorders to be accompanied by conditions (called ‘comorbid’ or ‘co-occurring’ conditions) that your child didn’t suffer from before, such as OCD, anxiety or depression. There are also children who developed an eating disorder after they’d been suffering from other disorders, like anxiety disorders (including OCD), autistic spectrum disorder or attention deficit hyperactivity disorder (ADHD). ] And indeed research is indicating that these conditions share a number of genes. The general rule is to treat the eating disorder as a priority because:
- it presents the greatest risk to health
- as the eating disorder recedes, some of the other problems usually do so as well
- your child probably can’t engage with psychotherapy while his brain is affected by undernourishment
If a clinician suspects that your child has clinical depression, borderline personality disorder (BPD), bipolar disorder (manic depression), OCD or that he is on the autistic spectrum, don’t panic quite yet. Hold the possibility lightly. I know of cases where a clinician did not have the experience to appreciate the aggression, volatility, depression, suicidality, anxiety or rigidity that an eating disorder can create to varying degrees. Often, once the child’s eating disorder is successfully treated, the other diagnostic labels are dropped. 
Family therapy for eating disorders
What I’ve described above is family therapy for eating disorders. There are variations, but the principles are pretty much as outlined. They worked for us, they worked for the many families whose stories I have followed, and most importantly we have scientific evidence for their effectiveness. Briefly for now (I return to this in Chapter 12), when I talk of family therapy in this book I am not talking about general or traditional family therapy, which addresses problematic relationships. For eating disorders, family therapy is simply therapy (i.e. treatment) based within the family. The method mobilises the power of parents to rescue – and then guide – their child.
The most recent review of treatments was done by England’s health service: family therapy came out a clear leader for anorexia and bulimia.  There are similar recommendations world-wide.  For instance, the Canadian Paediatric Society writes:
“The evidence to date indicates that Family-Based Treatment (FBT) is the most effective treatment for children and teenagers with anorexia. A key component of the FBT model is that the parents are given the responsibility to return their child to physical health and ensure full weight restoration.” 
If you have a child or adolescent with anorexia or bulimia (or an atypical version of those), your therapist should be offering family therapy and doing their utmost to make it work for you. There are therapists who built their reputation years ago using older methods, who still don’t use family therapy. I cannot understand that. I recommend you go elsewhere to maximise your child’s chances of a full and swift recovery.
How long before my child is well again?
Our family therapist said she expected nothing less than full recovery. Our children need hope and so do we. Treatment is a lot more effective than it used to be, and when I talk to parents whose child was ill for a long time, I usually find that the care is poles apart from what is recommended, nowadays. The depressing recovery statistics refer to old treatments. Figures vary enormously across studies and results depend on the definition given to ‘recovery’ and on the type of treatment (lots more in Chapter 12). In addition, our children vary in how severely the illness hits them and they vary in how quickly the treatment brings them relief.
“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.”
Let me try and give you some indicators so you can form realistic expectations if your child is suffering from anorexia. Children who are underweight need your intense support for at least as long as it takes to get them weight-restored. You can estimate how long that will be if you plan on 0.5 to 1 kg per week of weight gain (this is the expected norm at home, and a hospital should go faster). With every meal eaten, 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. You may have more and more delightful moments when you feel that your kid is back. There can be day-to-day or week-to-week fluctuations, so if you have bad times, step back and see where you are in the overall picture.
Eventually your child will reach a weight that seems to suit them (usually several kilos higher than their pre-anorexia weight), and many (but not all) of us see a big improvement in our child’s mood and thinking.
The next stage of treatment is to repeatedly guide your child to practice normal behaviours (through ‘exposure’) and to engage in normal life. This phase is all too often rushed or even missed out, and too many youngsters go downhill again. The brain and body need time to heal before a person’s recovery is secure. For instance it can take over a year for normal hunger cues to return. And it takes a lot of repetition before fears go and our children become flexible, relaxed and autonomous again.
Life will seem more normal when visits to therapists end. This typically happens 6 to 12 months after the start of family therapy, the recommended treatment for adolescents. Studies indicate 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, it took between 2 and 48 months for them to achieve full recovery. 
In short, after weight-restoration your work will continue as you steer your child towards normality – typically 6 months of active exposure work, easing off into some more months or years where we are just vigilant.
Our children vary in how the illness hits them. Some need a lot of support for many years and their parents say that if they’d known this from the start, they could have been more patient, more resilient. But for most of us, improvements come sooner. A big push is required at the start, and as time goes on, we settle into whatever level of support our child needs. After a year or two, for most of us life feels increasingly normal, though I consider it wise to maintain some level of vigilance until our children are in their mid-twenties and their brains have fully matured.
Here are factors that usually support faster improvement and better outcomes in the case of anorexia: 
- Your child is treated according to the principles I outlined earlier in this chapter (food, no purging, compassionate family support, consolidating normal behaviours).
- Treatment starts as early as possible. Right away, your child gains weight at a fast rate.
- Recovery may proceed quicker if your child didn’t have other mental health disorders prior to the onset of the eating disorder.
- may seem particularly tragic when the illness hits a very young child, but this makes treatment easier and increases the chances of a 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 your child against relapses.
instance, Hildebrandt, T., Bacow, T., Markella, M. and Loeb, K.L., ‘Anxiety in
anorexia nervosa and its management using family-based treatment’, Eur Eat Disord Rev. (January 2012) vol.
20, no. 1, pp. 1–16, http://www.ncbi.nlm.nih.gov/pubmed/22223393
For these concepts put in practice for adults, see Tabitha Farrar’s book ‘Rehabilitate, rewire, recover!’ https://amzn.to/2Gpxnrk
 Family-Based Treatment (FBT), an approach validated in randomised controlled trials, relies heavily on unconditional acceptance from parents. One study indicates that the higher the ‘expressed emotion’ (hostility, criticisms) from fathers, the lower the chances of recovery: 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, http://tinyurl.com/z7rwsgr
 Dr Julie O’Toole provides a good introduction to the role of medicines like Olanzapine, Prozac or Zoloft. ‘Directly observed therapy, baby bird style, swish and swallow twice’ (13 May 2011) on https://www.kartiniclinic.com/blog/post/directly-observed-therapy-baby-bird-style-swish-and-swallow-twice/ and on Let’s Feast Blog (23 May 2014): ‘Medication’ letsfeast.feast-ed.org/2014/05/guest-post-by-dr-julie-otoole.html and an entire chapter in Dr Julie O’Toole’s Give Food a Chance (https://amzn.to/2CivYS6).
 Nice guidelines (May 2017): nice.org.uk/guidance/ng69 I explain them on anorexiafamily.com/nice-guidelines-adolescent-eating-disorder-ng69
Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. https://www.ranzcp.org/Files/Resources/Publications/CPG/Clinician/Eating-Disorders-CPG.aspx
The National Institute of Mental Health highlights the greater effectiveness of Family-Based Treatment (also named the Maudsley approach) in ‘How are eating disorders treated?’, http://tinyurl.com/83frh8o. They write: ‘In a therapy called the Maudsley approach, parents of adolescents with anorexia nervosa assume responsibility for feeding their child. This approach appears to be very effective in helping people gain weight and improve eating habits and moods. Shown to be effective in case studies and clinical trials … for treating eating disorders in younger, nonchronic patients.’
From the American Academy of Pediatrics:
Rosen, D. S. and the Committee on Adolescence, ‘Identification and Management of Eating Disorders in Children and Adolescents’, Pediatrics, Official Journal of the American Academy of Pediatrics (2010) vol. 126, p. 1240, http://pediatrics.aappublications.org/content/126/6/1240.full.pdf . They write: ‘Family-based interventions, nevertheless, remain an effective and evidence-based treatment strategy for adolescent AN in both open trials and randomized controlled studies … Unfortunately, family-based treatment by experienced providers is not available in all communities. Nevertheless, the essential principles of family-based treatment can still be encouraged by community providers in their work with patients and families.’
 Canadian Paediatric Society. Position Statement. ‘Family-based treatment of children and adolescents with anorexia nervosa: Guidelines for the community physician’ (Posted 1 January 2010, reaffirmed 30 January 2013). Findlay, S., Pinzon, J., Taddeo, D., and Katzman, D. K. (Canadian Paediatric Society, Adolescent Health Committee), Paediatric Child Health (2010) vol. 15, no. 1, pp. 31–5, http://www.cps.ca/documents/position/anorexia-nervosa-family-based-treatment
 Dr Sarah Ravin reports on end of treatment outcomes with her own eating-disorder patients: http://www.blog.drsarahravin.com/eating-disorders/end-of-treatment-outcomes-for-patients-with-anorexia-nervosa/
 For more on this, see Lock, J., ‘Evaluation of family treatment models for eating disorders’, Curr Opin Psychiatry (2011), vol. 24, no. 4, pp. 274–279. http://www.medscape.com/viewarticle/744675
 Ravin, S., ‘Defeating the Monster: Helping Little Girls Overcome Anorexia Nervosa’. http://www.blog.drsarahravin.com/eating-disorders/defeating-the-monster-helping-little-girls-overcome-anorexia-nervosa/
Evidence that being at the younger end of the 12 to 18 range is a predictor of successful weight gain: 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 (September 24, 2014) http://archpsyc.jamanetwork.com/article.aspx?articleID=1910336