Family-based therapy for treating eating disorders

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Family-based therapy (FBT) is a type of group therapy used in the treatment of eating disorders that involves members of a family or household, including spouses, children, parents, siblings, and even close friends. FBT is administered by a health care professional—typically a psychologist, clinical social worker, or mental health therapist—over the course of multiple sessions.

There are several reasons why people might benefit from family-based therapy. FBT is helpful when dealing with issues that stem from unbalanced group dynamics within the household. It’s also a useful way to deal with something that affects the family as a whole, such as mourning a loved one. 

But family therapy can also be helpful in cases where one family member is struggling with eating disorders or addiction. While patients in these situations often continue their individual therapy sessions, the family therapy dynamic can help create a healthier home environment and stronger support system for the patient, while allowing other members of the family to air their grievances and concerns.

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How to treat eating disorders through family-based therapy (FBT)

The idea behind family-based therapy is that it allows those struggling with eating disorders to get healthier while surrounded by their support system. In recent years, it has become the leading treatment for adolescents with eating disorders. (1)

Treating eating disorders through FBT is actually a more recent practice. Previously, it was believed that family—and, primarily, mothers—were the root cause of many eating disorders, with patients better off leaving to receive treatment at separate facilities. (2)

That idea has since been disproven, thanks to newer findings attributing malnutrition, rather than family attitudes, as the major cause of ongoing symptoms. (3) In addition, parents of children struggling with eating disorders were found to be valuable resources, rather than sources of harm.

In 2010, the Academy for Eating Disorders released a report supporting both of these views, further paving the way for family-based therapy to be used for treating eating disorders. (3) 

Family-based therapy focuses on the condition as an external factor that needs to be explored. Parents or spouses are assured the condition is separate from the patient and the patient is not in control of the disorder. So they can’t just choose to end it, as they didn’t choose to develop it.

Similarly, parents, spouses, and other family members are not blamed for the condition. Indeed, family members are considered sources of love and healing in FBT, rather than sources of harm or obstacles to recovery.

Through family-based therapy, everyone commits, together, to the goal of helping the patient get healthy. This group effort creates a stronger bond between family members, building a safer space for recovery and giving all parties a deeper understanding of what needs to be done to sustain the change.

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What to expect

Family-based therapy is typically a short-term, goal-oriented version of therapy. It can involve the entire household or just a few key members and is almost always delivered in an outpatient setting.

Everyone sees and speaks to the same therapist, together hashing out any potential issues and developing a plan to facilitate healing. 

When used to treat anorexia nervosa, for example, FBT often takes on three distinct phases: (1)

  • Phase 1: Establish what normal eating will look like for an individual and for their body type. This is typically done by giving parents or a spouse control over when, what and how much food the patient eats, while tasking them with monitoring the patient’s physical activity levels and other previously unhealthy habits.
  • Phase 2: Begin giving the patient more control over their own diet. This phase is entered into gradually, and only after the patient is steadily approaching a healthier weight. Eventually, the patient will take back full responsibility of feeding themselves.
  • Phase 3: Prepare for the future. This could include anything from identifying upcoming challenges to exploring healthier coping mechanisms for the patient.

The therapist may evaluate progress through talk-therapy or ask the family to eat a meal at the office, in order to observe the dynamics in play first-hand.

The therapist may also address other aspects of the family dynamic that could perpetuate an eating disorder, including over-criticizing or shaming. If the patient struggles with bulimia nervosa (BN), extra steps may be taken to address the secrecy and shame involved with binging and purging.

Types of family therapies

Like many therapies, FBT represents more of a broad set of ideas. The general viewpoints and concepts behind family based therapy provide the basis for a number of more specific branches of FBT, including:

  • Conjoint Family Therapy (CFT): In CFT sessions, all members of the family (or all participating members) are seen by the same therapist at the same time. This is the most common arrangement for more traditional or stable families.
  • Separated Family Therapy (SFT): This type of FBT involves members or units of the family seeing the same therapist, but during different sessions. Typically, the arrangement includes one session for the patient, and another for the parents. This is more typically used with more hostile or volatile family dynamics.
  • Maudsley Family Therapy (MFT): The basis of modern family-based therapy, this method was the first to include parents in eating disorder discussions, viewing them as both helpful to the situation and crucial to recovery.

The type of family-based therapy a patient receives may depend on any number of factors.

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Effectiveness in treating eating disorders

Eating disorders of all types affect nearly 9% of the total population. (4) And while family-based therapy is a more recent attempt to solve the problem, some studies show it may be particularly effective in helping some of the most vulnerable groups struggling with eating disorders.

What are the benefits

With significant supporting evidence, family-based therapy has come to be viewed as more effective than having a patient recover in a separate facility, only to be sent home to an unchanged environment. (3) The method allows the patient and their family to make healthier adjustments together, learning and building a stronger support system all at once. 

Denial is also a prominent component of eating disorders, present in more than 80% of patients in one 2006 study. (5) And the malnutrition involved in many eating disorders only makes this condition more pronounced. Here, too, FBT has been found helpful in the early phases of recovery, handing responsibility for the patient’s diet to loved ones struggling with AN, for example.

In particular, FBT has been found to be helpful for adolescents struggling with eating disorders – especially anorexia nervosa. (1) This has been a welcome finding, as nearly 13% of adolescents will develop an eating disorder by age 20. (1) And the number of teenagers suffering from eating disorders was also reportedly on the rise in 2021. (6)

What are the limitations

FBT as a form of treatment for eating disorders can be very effective, as it may unify the family toward the directed path of healing. However, it is far from the only treatment option available for an eating disorder. While effective in many cases, family-based therapy is not for everyone.

FBT can be very difficult because the struggles around eating can escalate conflict in the family, or put the onus on the family to be more like a clinician to the patient, rather than a loved one. This can often backfire, especially in cases where patients may engage in self-induced vomiting, over-exercising, or other forms of self-destructive behavior. Expecting the family to have to manage these behaviors can be incredibly taxing on both the patient and the family. 

The method may also not work in cases of particularly abusive or hostile families. While separated family therapy techniques have been developed to help ease this problem, uncooperative parents or other family members could also pose a major setback in this scenario. 

Efficacy of family therapy in healing eating disorders

While many clinical trials involving FBT as an eating disorder treatment have been relatively small, results have been encouraging.

One 2010 study (7) saw as many as 66% of its 121 patients recover from AN by the end of a course of family-based therapy. After a five-year follow-up, that number increased to as much as 90%.

Another 2015 review (8) compared the results of FBT treatment for bulimia nervosa (BN) to cognitive behavioral therapy (CBT)—which has widely been accepted as the leading evidence-based treatment for BN. According to the study, family-based therapy was essentially as successful as CBT in eliminating binging and purging behavior, but patients undergoing FBT got to that level nearly six months faster than those using cognitive behavioral therapy techniques.

Still, the science of recovery is very much a living thing. More data is always needed to refine processes and achieve better results. And while these outcomes are encouraging, they hopefully represent just the beginning of family-based therapy’s potential.

How Within Health utilizes FBT

At Within Health, we incorporate whatever aspects of FBT make sense for that individual patient, and their family. For example, a family may be able to provide meal support alongside our care partners, or in addition to our care partners, and if this doesn’t escalate conflict, we may in fact rely on family members to fill in some of the treatment gaps if they are willing to do so and if the patient would be receptive to such an intervention. We are very careful about considering what the best modalities are for helping each individual complete meals and based on each circumstance we will make this determination.

At Within Health, we believe there are many aspects that are useful from FBT, but our program is not limited to the practices of FBT. Call our team today if you would like to learn more about how Within Health uses FBT, or our other treatment modalities when it comes to our patients’ recovery from eating disorders.

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Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Rienecke, R. (2017). Family-based treatment of eating disorders in adolescents: Current insights. Adolescent Health, Medicine and Therapeutics, Volume 8, 69–79. https://doi.org/10.2147/ahmt.s115775
  2. Treasure, J., & Cardi, V. (2017). Anorexia nervosa, theory and treatment: Where are we 35 years on from Hilde Bruch's foundation lecture? European Eating Disorders Review, 25(3), 139–147. https://doi.org/10.1002/erv.2511
  3. Le Grange, D., Lock, J., Loeb, K., & Nicholls, D. (2009). Academy for Eating Disorders Position Paper: The role of the family in eating disorders. International Journal of Eating Disorders. https://doi.org/10.1002/eat.20751
  4. Report: Economic costs of eating disorders. STRIPED. (2021, September 27). Retrieved February 25, 2022, from https://www.hsph.harvard.edu/striped/report-economic-costs-of-eating-disorders/
  5. Vandereycken, W. (2006). Denial of illness in anorexia nervosa—a conceptual review: Part 1 diagnostic significance and assessment. European Eating Disorders Review, 14(5), 341–351. https://doi.org/10.1002/erv.721
  6. Damour, L. (2021, April 28). Eating disorders in teens have 'exploded' in the pandemic. The New York Times. Retrieved February 25, 2022, from https://www.nytimes.com/2021/04/28/well/family/teens-eating-disorders.html
  7. Lock, J., Le Grange, D., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67(10), 1025. https://doi.org/10.1001/archgenpsychiatry.2010.128
  8. Le Grange, D., Lock, J., Agras, W. S., Bryson, S. W., & Jo, B. (2015). Randomized clinical trial of family-based treatment and cognitive-behavioral therapy for adolescent bulimia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry, 54(11). https://doi.org/10.1016/j.jaac.2015.08.008

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