Understanding Family Based Treatment. A Short Guide for Family.

Your child has been selected to begin ‘Family Based Treatment’ (FBT), what does this mean?

Recommendation: It is really useful to get a copy of ‘Help Your Teenager Beat an Eating Disorder’ by James Lock and Daniel Le Grange. 2nd edition. This is the parent’s companion to the therapist’s manual.

Systemic family therapy is the most recommended treatment for adolescents with anorexia nervosa, and FBT is the most researched version of this. This approach has a significant body of evidence supporting its effectiveness with young people, and it is considered the leading evidence based approach for treating young people with anorexia nervosa.

This approach requires the parents / family coming together and working together to achieve the goal of restoring normal weight and eating patterns, as a way of banishing the eating disorder from the person. Through empowering parents to regain control of their child’s eating, parents are given the responsibility for weight restoration.

In other words, parents take back control from the eating disorder.

In this treatment, weight restoration precedes psychological change. The theory is that once the person’s weight has been restored to normal, the physical effects of starvation will be reduced, which makes it easier for them to continue normal eating. Should there be further underlying emotional issues which have, or are continuing, to contribute to the eating disorder, or causing the person distress, these are dealt with after FBT has achieved its aim.

The treatment team has chosen to treat your child in this way because

  • international evidence supports its effectiveness in treating eating disorders in young people
  • the treatment team believe that this will give your child the optimal chance of recovering in a timely period which is crucial for this age group
  • The treatment team has the experience, knowledge and expertise in this treatment approach to offer the best opportunity for change to happen

For this approach to be effective, you have to commit to the process and work with the team in helping your child to recover. You are being asked to work collaboratively with the clinician to bring your child through the phases of the treatment. This commitment means that you, your child, and sometimes siblings are asked to come to approximately 20 sessions of treatment, often weekly to begin with.

Overview of Family Based Treatment:

Overview of Family Based Treatment

FBT involves family working through 3 phases of treatment:

Phase Sessions Aim / goal
Phase 1 Session 1-10 Parents to restore their child/adolescent’s weight.
Phase 2 Session 11-16 Parents transfer control back onto the child/adolescent.
Phase 3 Sessions 17-20 Adolescent developmental issues are addressed and treatment is brought to a close.

As you will see, this means that in FBT

  • There is a pre-determined time-scale, and FBT is structured (meaning it has three distinct phases encompassing a beginning, middle and an end).
  • The treating clinician is harnessing, equipping and supporting the parents/family with knowledge and skills to carry out the treatment goals.
  • The parents / family are the key players ensuring the treatment is completed successfully.
  • The goal of FBT is for the child/adolescent to be weight restored, and have normal eating habits by the conclusion of the treatment.

Intervention style of FBT:

The FBT clinician will take an Agnostic view of the illness / eating disorder. The clinician will make no judgement or decision about what the cause of the eating disorder is, and most importantly, the clinician knows that parents are not to blame.

  • There is a Separation of the child / adolescent and the eating disorder.
  • Taking a Pragmatic approach, the clinician’s focus is initially on the symptoms of the eating disorder only.
  • Through Empowering parents to regain control of their child’s eating, parents are given the responsibility for weight restoration.
  • The clinician takes a Non-authoritarian stance

TIPS!

  • Keep Notes! Keep a note of situations / difficulties to ask the clinician about at your next appointment.
  • You know how to feed your child! You have fed and nourished your child since birth. Do not get caught up in wondering about nutrition and calories, etc. Feed your child as if they didn’t have an eating disorder.
  • Remember to trust your gut! Parents often feel incapable of feeding their child, or they have lost confidence in how to parent. Remember how it feels to set rules and boundaries like you would with a toddler.
  • Nobody wins in a power struggle, only the eating disorder! Remember the ‘one more bite’ of the family meal – if you get into a power struggle with your child and their eating disorder, stand firm, but do not allow the eating disorder to push you into an ‘all or nothing position’ at the detriment of the process – if allowing a compromise means ‘one more bite’ then go with that and move on.
  • The clinician and team are there to support you to do the work of the treatment. Use them for support.

Understanding each stage in more detail.

Starting well is the most important time.

Phase 1 (Session 1-10): Re-feeding your child.

Session 1: This will be a long session, usually taking two hours (most other sessions will list an hour, 50 minutes together and approx 10 minutes for the child / adolescent alone).

Overall Aims that begin in Session 1 of phase 1:

  • To engage your family in the treatment process
  • To obtain a history of how the eating disorder is affecting your family
  • To obtain information about how your family functions (i.e. coalitions, authority structure, conflicts, food preparation, etc.)
  • To reduce parental feelings of blame

These are achieved by: 

  • The clinician will share very serious information with you and your child about the gravity of the situation and how dangerous and life threatening an eating disorder is. The aim is to get everyone on the same page about the importance of working together.
  • The clinician will begin the process of separating out the thoughts and behaviours of your child from those of the eating disorder.
  • You will be asked to start refeeding your child.

Session 2. The Family Meal.

Aims:

  • To understand what is problematic and difficult for you when you try to refeed your child.
  • To help guide you on how to manage at home and achieve success at feeding your child.
  • To understand your family processes and dynamics during meal eating.

Helpful strategies will be employed to bolster your confidence to taking on the task of refeeding at home.

Aims for the remainder of phase 1:

  • Externalise the eating disorder
  • Ensure your family remain focused on the eating disorder (and getting rid of its symptoms)
  • Help you as parents to take charge of re-feeding your child
  • Mobilise other family supports, such as sibling support

Note: Your child/adolescent will be weighed at the beginning of each session, and asked if s/he needs to talk about any issue in particular.

Phase 2 (sessions 11-16): Negotiations for a new pattern of relationships.

As your child/adolescent’s mood starts to change during phase 1, the clinician will begin to think about introducing phase 2 aims and strategies.

The clinician will consider the following aspects when assessing your child’s readiness for phase 2:

  • Has your child’s weight reached a minimum of 90% of normal body weight?
  • Can your child eat without significant struggle?
  • Are you as parents demonstrating an ability to manage the illness?

(Think of the analogy of learning to drive. At first the person drives under supervision, and as they learn and become more capable, they begin to drive independently).

Aims:

  • To maintain your management of the eating disorder symptoms until your child shows evidence that s/he is able to eat well and gain weight independently
  • To return the food and weight control to your child and help him/her to eat independently
  • To explore the relationship between your child’s developmental issues and the eating disorder

During phase 2, there will be a continued effort to modify family criticism of the patient by externalising the disorder from them. The clinician will continue to highlight the difference between your child’s own ideas and needs, and those of the eating disorder.

Note: Psychological recovery lags behind (approximately 12 months behind) physical recovery. If the person doesn’t have the disordered behaviours that support the disordered thoughts, the thoughts rarely linger.

Phase 3 (Session 17-20): Adolescent issues and ending treatment.

Phase 3 sessions are monthly, and the focus of this phase is on addressing adolescent issues.

The clinician will consider the following aspects when assessing your child’s readiness for phase 3:

  • Is their weight greater than 90% of recommended normal weight?
  • Have the eating disorder symptoms dissipated? (the behaviours and thoughts, although some weight and shape concerns may remain)

Goals of phase 3 include:

  • Restoration of your parent-child relationship in accordance with remission of the eating disorder
  • Review adolescent issues with the family and model problem solving
  • Involve your family in the review of issues
  • Checking how much you are doing as a couple
  • Delineate and explore adolescent themes
  • Plan for future issues
  • End the treatment.

Ending Treatment: For many patients, FBT is the best first approach to treating their eating disorder. In some complex cases, other forms of individual or group family treatments may be offered. These are also very effective and you can read more about them in the fact sheet: Family Treatments for Eating Disorders.

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