“What Is FBT?” Your Family-Based Treatment Questions, Answered
By Alexandra Hayes Robinson
Whether you’re a concerned parent or a clinician trying to provide the best care for your patients, it’s natural to have questions about eating disorder treatment. We’re here to partner with you in navigating the abundance of information out there. Our goal is to set you — and your family — up for success.
We often receive questions about family-based treatment, commonly known as FBT. In this guide, we’ll cover all the frequently asked questions from our community, as well as clarify some common misconceptions.
Let’s dive in!
What is FBT and how is it utilized at ERC?
FBT is a leading evidence-based treatment for eating disorders. It is traditionally an outpatient approach to keeping people with eating disorders in lower levels of care, but at ERC we use an FBT-informed approach in higher levels of care, too. We also integrate emotion-focused family therapy (EFFT) and the use of a multidisciplinary team, including registered dietitians, in our programs.
Primarily for adolescents and young adults, FBT is unique because it involves the patient’s family members (often parents or caregivers) — and it recognizes that families are not to blame for their loved one’s eating disorder. This is a core differentiator between FBT and other treatment philosophies.
“Our team considers ourselves the experts on eating disorders, but the family members are the experts on their loved one, so our goal is to increase parental empowerment,” says Leslee Marcom, PhD, CEDS, senior clinical director at ERC. “We need to work as a team because parents are the primary agents of change when treating eating disorders.”
There are five core tenets to FBT and we utilize all of them in our treatment process at ERC, including in higher levels of care.
- Therapists have an agnostic view of the eating disorder, meaning they don’t try to identify why or how the eating disorder came to be. Instead, they focus on behavior change and teaching the family how to facilitate the process themselves.
- Therapists take a nonauthoritative point of view in the treatment, meaning they don’t claim to be the sole person who can “cure” the patient.
- Parents/caregivers are empowered to play a key role in their loved one’s recovery, rather than be blamed as the reason for their loved one’s eating disorder.
- The eating disorder is viewed as a separate entity from the recovering person, like a monster for them to slay.
- Therapists focus on current eating disorder symptoms, while understanding how co-occurring conditions such as depression and anxiety can impact recovery.
Led by an FBT-trained mental health provider, FBT treatment is typically:
- Eight to ten weeks in length
- Separated into three phases:
- Phase 1: Parents/caregivers take on the responsibility of fostering behavior change and make all eating-related decisions for their loved one. This phase typically occurs in higher levels of care.
- Phase 2: Eating-related responsibilities are gradually handed back over to the recovering person, depending on how old they are. This phase (and the next) typically happens once the patient has returned home.
- Phase 3: Provider conducts an assessment of where the recovering person is now that symptoms have receded — and makes a plan with the family for the future.
Does FBT work?
It does! Research has proven that FBT is a highly effective approach to eating disorder treatment, which is why FBT-informed principles are embedded into everything we do at ERC — from higher levels of care to family education to outpatient FBT treatment.
FAQs about FBT
We’re here to answer them. Below, we’ve rounded up some of the common questions and concerns we hear from folks in our community, along with answers from our expert team.
“How can I be sure if FBT is worth trying for my loved one?”
FBT is worth trying as a first course of treatment if the patient’s symptoms are moderate enough. “The reality is that by the time most parents realize what an emergency they are in, their child’s symptoms are too advanced for FBT,” says Tyler Wooten, MD, psychiatrist and medical director at ERC Pathlight. “Their sweet and pleasing child has been flying under the radar, and they didn’t realize the train had left the station.”
If FBT isn’t the right initial approach for your loved one because they require higher levels of care, it will become available as they progress through treatment. And rest assured, family involvement is a key component of our programming at ERC, so you will always be a part of their treatment process.
Is FBT too much of a time commitment when we’re already strapped for time?”
“The hard truth is that any person’s eating disorder will require time to heal, regardless of their level of care,” Dr. Wooten says. Overcoming this time scarcity mindset often requires a shift in perspective. Dr. Wooten encourages families to identify ways they can get more support. “Do you bring in grandma and grandpa? Do you bring in the favorite family friend that could go eat lunch with them at school? Do you need to take a family medical leave so you can be with your child between every meal and snack?” he says.
And remember: This level of support is just for a finite period. By taking the time to invest in your loved one’s recovery with FBT now, you will get to a place where they can function on their own, with less supervision.
“My loved one doesn’t want to get better. Does that mean we’re not ready for FBT?”
There is a common misconception that motivation to heal is necessary for recovery. But motivation to heal is not a requirement for healing — and FBT is based on this very principle! (We hope this brings you comfort, as we know it can be frightening for families.) “Part of the philosophy of FBT is that it’s not a requirement for the patient to want to get better, but it is a requirement for them to eat their food and to restore, or to not purge,” Dr. Wooten says. “This is a big learning curve for many families.” So to put it simply: Yes! FBT is right for your patient or family even if the child is resisting treatment or hasn’t yet gotten to the point in their recovery where they “want” to get better.
“We can’t believe we didn’t figure out our child’s eating disorder sooner and are ridden with guilt. Will FBT make us feel worse?”
Guilt, surprise and regret are all common feelings when parents first learn of their loved one’s eating disorder. But know this: The eating disorder is not your fault, and we can work through these feelings together to better support your loved one.
“I recently worked with one set of parents who were filled with guilt, thinking they should have ‘caught’ their 16-year-old’s eating disorder sooner, and, using an FBT-informed approach, I worked with them to relieve the guilt and focus on symptom reduction and behavioral interventions,” Dr. Marcom shares. “We externalized the eating disorder, which helped them manage their emotions that came up when they were frustrated. Over time, with practice, education and confidence increases, they were able to support their daughter and effectively help her step down levels of care.”
“We’re already in family therapy. Do we need FBT, too?”
Family therapy and FBT are not the same type of treatment, though their names are very similar. For one, a family therapist may not be trained in FBT principles, and may not be trained in eating disorder treatment at all. Another key difference: Family therapy is for people of all ages, whereas FBT is typically used with children and adolescents. That said, family therapy can be used in conjunction with FBT, and oftentimes is! At ERC, we encourage EFFT for families in our programs, regardless of whether they are practicing FBT.
“Is my child is too old for FBT?”
While FBT is mostly for children or early adolescents, it can be effective for young adults in their late teens and early twenties, too. In FBT, the family shows their loved one that they can’t have the life they want and their eating disorder at the same time. This could mean the patient can’t go to soccer practice, have sleepovers with friends or go away to summer camp. This reinforcement shows the patient that they must choose and ultimately helps them “slay their monster.” But as a child gets older and gains autonomy, it’s harder for the family to create that buy-in, making FBT more difficult to implement, Dr. Wooten explains.
“Is FBT required at ERC?”
Yes and no: Not all families need to practice FBT at home, but ERC does work with all patients in an FBT-informed way. In fact, there is no treatment plan at ERC that works without family involvement. For example, “When kids come to higher levels of care, we operate as if they are in Phase 1 of FBT in that their parents are filling out their menus and choosing their food options,” Dr. Marcom explains.
Then, as a patient moves down the levels of care, we pull the family in closer and closer using an FBT-informed approach. That’s why when a patient in higher levels of care steps down into a partial hospitalization program, the next step in their treatment is to eat meals and snacks with their family. “Pretty soon, they're going to have breakfast passes and then dinner passes,” Dr. Wooten explains, and all families will have had “meal education” to prepare for this phase. “Families have really been learning FBT since admission. It’s the philosophy behind all the family education that we do here.”
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