Family Based Therapy (FBT)

What is FBT?

Family Based Therapy (FBT) involves the whole family in helping their child or teen reach long-term recovery from an eating disorder. FBT prescribes family sessions with a therapist initially once a week but decreases over the course of treatment. Because the parents are empowered to be a part of the treatment team, the treatment is much more intensive than is typically possible in outpatient treatment. FBT often provides a level of care that is similar to residential or partial hospitalization programs (PHP).

FBT differs significantly from traditional treatments for adolescent eating disorders. Earlier approaches to eating disorders suggested that parents caused eating disorders in their children but now FBT is at the forefront of the research that demonstrates families are not a detriment, but often an integral part of the solution to their child’s eating disorder.

Principles of FBT

FBT has five core principles:

• Agnostic view of illness: FBT takes an agnostic view of the eating disorder, meaning we do not try to analyze why the eating disorder developed but focus on the symptoms instead.
• Initial symptom focus: FBT prioritizes full nutrition and prevention of eating disorder behaviors.
• Parent empowerment: Caregivers provide full nutrition by taking charge of their child’s meals. They also help prevent behaviors such as purging and exercise.
• Non-authoritarian stance: The therapist actively collaborates with the parents because they are not expected to be the experts on their child’s treatment.
• Externalization of illness: It is emphasized that the eating disorder and the child are not one and the same. The eating disorder has “taken over” when it comes to issues of food, eating, shape, and weight, and in those instances, it is driving the child’s thoughts, feelings, and behaviors. Parents must know that their child is not in control of the disorder, and just as they did not choose to develop the disorder, they cannot choose to stop the disordered eating behavior(s). Externalization serves several purposes, one of which is to reduce parental criticism, which has been shown to negatively impact the treatment outcome.

FBT has three distinct phases:

Phase 1: Full parental control. Parents are fully in charge of meals helping their child to reestablish regular patterns of eating and interrupting eating disorder behaviors. If weight restoration is needed, a specific weight goal is set. Parents help the child or teen to reincorporate foods they once feared or restricted.

Phase 2: A gradual return of control to the adolescent. This phase usually begins once most weight has been restored, when meals are going more smoothly, and when behaviors are mostly under control. We gradually give the teen more independence over their eating in an age-appropriate manner. In this phase, the adolescent may begin to have some meals or snacks independently from the parent or begin to eat with different people and in different settings and incorporates all “fear foods”. 

Phase 3: Establishing autonomy. In Phase 3, the therapist and family review adolescent development, and the therapist ensures that the family is back on track with normal family life. The family identifies upcoming developmental challenges that the adolescent must face and identifies how to help the young person navigate these challenges without reverting to the eating disorder as a way to cope.