Family-Based Treatment (FBT)
What is FBT?
Family-Based Treatment (FBT) is an evidence-based therapeutic approach that involves the entire family in the process of treating an adolescent’s eating disorder. Rather than placing blame on parents, FBT empowers them as the most critical element in their child’s recovery. Under the guidance of a therapist trained in FBT, parents take on the primary role in re-nourishing their child, ensuring they receive the necessary nutrition and support to heal from the effects of the eating disorder.
FBT is typically conducted on an outpatient basis and requires fewer treatment providers than other approaches to eating disorder care. The core treatment team usually consists of a therapist and a medical provider. In some cases, a dietitian may be involved to provide additional guidance in supporting the child’s nutritional needs.
FBT is grounded in five core principles:
1. Agnostic View of the Cause – We do not focus on the cause of the eating disorder but instead concentrate on empowering the family to move forward with treatment.
2. Non-Authoritarian Stance – Our therapists serve as guides, supporting the family in their efforts while allowing parents to take primary responsibility for their child’s recovery.
3. Parental Empowerment – Parents are seen as the key agents of change in their child’s recovery process.
4. Externalization of the Eating Disorder – The eating disorder is viewed as separate from the child, allowing the family to unite against the illness rather than blaming or criticizing the child.
5. Pragmatic, Here-and-Now Focus – FBT focuses on practical, immediate steps for re-nourishing the child and restoring health, rather than delving into past causes of the illness.
Key Tenets of Family-Based Treatment (FBT)
Phases of FBT
FBT is divided into three distinct phases, each designed to progressively return control of eating to the child as their health improves.
Phase 1:
The primary focus of Phase 1 is re-nourishing the child. Traditionally, this involves weight restoration, particularly when treating anorexia nervosa, but in some cases, biomarkers other than weight may serve as the primary goal for recovery. Weekly therapy sessions include the entire family, and parents assume complete responsibility for meal planning and ensuring that all meals and snacks are eaten. We typically observe one family meal in the office, providing parents with real-time strategies to help their child eat successfully, which they can then implement at home. This phase provides parents with the necessary tools to effectively support their child’s nutritional rehabilitation.
Phase 2:
Once the child has regained most or all of the necessary weight and meals are being eaten with less resistance, parents gradually return some of the responsibility for eating to their child. This phase focuses on reintroducing flexibility in eating and allowing the child to practice eating independently in various settings. While setbacks may occur, practicing food independence is a key step in the recovery process.
Phase 3:
In the final phase, the focus shifts from managing the eating disorder to addressing broader developmental and psychological needs. As the eating disorder recedes, therapy often begins to center around more typical adolescent concerns, such as school, peer relationships, or negotiating curfews. An indicator that the child has entered Phase 3 is when these everyday issues become the focus of sessions. We also work with the family to address any developmental delays or mental health concerns that were previously overshadowed by the eating disorder. As sessions become less frequent, relapse prevention is emphasized, and the family prepares for discharge.
Does FBT work?
FBT has been proven to be the most effective treatment for adolescents struggling with eating disorders for less than three years. It is highly successful in treating anorexia nervosa, bulimia nervosa, and OSFED (Other Specified Feeding or Eating Disorder), and has shown promising results for those with ARFID (Avoidant/Restrictive Food Intake Disorder). Although primarily developed for adolescents, FBT can also be adapted for young adults, particularly those transitioning to independence, such as college students.
We understand that each family brings a unique situation to treatment. One of the benefits of FBT is that it can be tailored to fit each family’s unique needs.
Typically, we involve the caregivers who are most often feeding the child in FBT, whether that be a single parent, blended family, or even grandparents. We understand that FBT can require significant time and adjustment, especially for parents with demanding schedules. Some families designate a primary caregiver to manage re-nourishment, while others share responsibilities and may even take time off from work.
Regardless of the approach, it’s essential that the caregiver receives support from others during this process. It is even possible to include siblings who are able to attend sessions, as it is important for each family member to understand the process and what role they may play in it.
The responsibility of feeding a child can feel overwhelming for parents and caregivers, especially in Phase 1 of FBT. Part of the role of the therapist is to help you identify ways to seek out resources, build resilience, and practice caring for yourself during this difficult phase. You may also feel distanced from your child during this phase, as the primary focus is on re-nourishment and less on emotional connection—this is completely normal.
At this stage, the process is more about following a prescribed meal plan to restore your child’s health. Keep in mind that by focusing on this critical step, you are potentially saving your child’s life. As they become physically healthier, there will be plenty of time to rebuild closeness. We will work to strengthen the bond with your child in therapy once a solid foundation of re-nourishment has been established. Additionally, your therapist will spend one-on-one time with your child each session to ensure they feel heard and understood.
Your child may resist treatment at times, especially when the eating disorder has taken a strong hold. We encourage parents to stay the course with renourishment even when the child is fighting. It is common to think you are making it worse as you bear witness to how severe the eating disorder actually is.
We often compare the struggle to re-nourish your child to undergoing treatment for cancer: the treatment you are providing may be unpleasant, but without it, your child’s life is at risk. Encouraging your child to undergo this difficult and unpleasant process is crucial to saving their life. It’s not a choice to avoid because it’s hard—just as you wouldn’t excuse them from chemotherapy simply because it’s uncomfortable.
At RWT, we recognize the severity of eating disorders and provide families with compassionate support and a toolbox of resources to ensure they can do everything in their power to rescue their child from this life-threatening condition
Family-Based Treatment (FBT) is a structured, empowering approach that allows families to work together to combat eating disorders. Through three distinct phases, parents play a critical role in their child’s recovery, with the support of a trained therapist.
As FBT progresses, the focus shifts to returning normalcy and independence to the child, ensuring long-term recovery and development. If you have any questions or would like to learn more about how we approach FBT at Reflect Wholeness Therapy, please don’t hesitate to reach out.
Citations:
• Rienecke, R.D., Le Grange, D. The five tenets of family-based treatment for adolescent eating disorders. J Eat Disord 10, 60 (2022).
• Chen EY, Weissman JA, Zeffiro TA, et al. Family-Based Therapy for Young Adults with Anorexia Nervosa Restores Weight. Int J Eat Disord. 2016;49(7):701-7.