Family Based Treatment for Eating Disorders (FBT-ED)

Core Components

Family-Based Treatment (FBT), also known as Maudsley method or Maudsley approach, is a manualised intervention for the treatment of child/ adolescent eating disorders, including anorexia nervosa, bulimia nervosa, and other specified feeding or eating disorder (OSFED). FBT aims to restore adolescents to health by using parents as the agents for change, and as the best resource for recovery in the therapeutic process. Hence, it relies on the core capacity of parents to feed their child(ren) and assist in recovery from the eating disorder.

FBT adopts an agonistic view and makes no assumptions about the underlying causes of the eating disorder. For this reason, its primary focus is on weight restoration rather than on the psychological aspects that are associated with the disorder. FBT also recognises the eating disorder as an external illness that is separate from the adolescent. Hence, it recognises that the child’s behaviours, thoughts, and feelings (as it relates to food) are not within their control, but are driven by the eating disorder. This in turn helps parents to remain firm when faced with significant resistance, to stay compassionate, and to avoid criticism of their child/ adolescent. 

FBT is typically delivered in three phases, over a period of 6-12 months;

• Phase 1: This phase involves giving parents full control as it relates to re-feeding their child for the purpose of rapidly restoring them to physical health. To achieve this, the therapist equips patents with the knowledge, tools and skills they need to make decisions regarding the type, quantities, and frequency of feeding, and interrupt problematic eating disorder behaviours (e.g. over-exercising, binging and purging).
• Phase 2: This phase is initiated when steady weight gain is achieved, and the signs eating disorder are starting to recede (including control of eating disorder behaviours and easier feeding). In phase 2, the child is given gradual control of their eating in an age-developmentally appropriate manner. A gradual approach to handing over control is adopted in order to reduce chances of reverting to eating disorder behaviours. Parental oversight is in place, and parents are able to reassert control if required.
• Phase 3: As the child/adolescent establishes an age-appropriate level of independence as it relates to eating, the focus of treatment shifts. FBT now focuses on ensuring the family is back on track with normal family life. It also focuses on identifying the developmental challenges that the child will face, as well as the strategies that can be used to address these challenges without resorting to eating disorder behaviours as a coping mechanism.

FBT facilitates the child’s recovery in their own environment and with support from their parents, as opposed to in inpatient or residential treatment programmes.

Fidelity

Fidelity can be enhanced by practitioner training and practitioner adherence to FBT treatment manual. Recorded sessions can be rated for treatment fidelity using validated FBT fidelity measures (1). Regular external and peer supervision can enhance fidelity to treatment.

Modifiable Components

FBT is typically delivered as an outpatient intervention to children and adolescents who live at home with family. However, it can be delivered as part of residential or partial hospitalisation programmes. FBT is available for the treatment of Anorexia Nervosa (AN) and has been adapted for use in the treatment of Bulimia Nervosa (BN) (focused on disrupting patterns of binge eating and purging). FBT has also been adapted for use in the treatment of other eating and weight disorders, including prodromal presentations of AN, Paediatric Obesity (PO), and Avoidant/Restrictive Food-Intake Disorder (ARFID). FBT can be delivered face-to-face or remotely (e.g. via video-conferencing or guided self-help). FBT can be adapted for individuals with neurodevelopmental conditions such as autism. This involves retaining the core elements of FBT and incorporating adaptations based on a robust assessment and formulation of neurodevelopmental needs and preferences. The PEACE Pathway (2) offers structured guidance for adapting FBT for autistic people with eating disorders.

Multifamily Therapy (MFT): MFT shares a conceptual focus with FBT, because MFT also identifies family as the agent of change in recovery from the eating disorder. However, MFT is a more intensive intervention that is delivered in group format. This delivery format is intended to help reduce the isolation and stigma families may feel. Group delivery also enhances mutual support, solidarity, and stimulates new perspectives for the families. MFT consists of a four-day intensive multi-family workshop involving 5-7 families, 5-8 follow-up sessions delivered over 6–9 months, and with individual family sessions delivered between follow-up sessions if needed. The total length of treatment for MFT for each family is typically 12-months. 

Support for Organisation / Practice

Implementation Support

Implementation in NHS Scotland CAMHS services including training of supervisors has been supported by The Training Institute for Child and Adolescent Eating Disorders, (Train2Treat4ED), which is a specialist training institute offering evidence-based education for clinicians treating child and adolescent eating disorders. Based in the United States, the institute provides internationally accessible training, including Family-Based Treatment (FBT).  The institute also offers a global network of certified clinicians. Train2Treat4ED Official Website.

All FBT trainees in Scotland who undertake the NES training at the advanced levels are allocated individual FBT certified supervisors.  Continued support and monitoring of progress is provided by NES staff throughout the training.  Scotland now have an FBT network of practitioners who meet to provide ongoing CPD support.

Start-up Costs

There are no costs for CAMHS clinicians who have been selected by their service for an NHS Education for Scotland (NES) training and supervision place.  NES has commissioned FBT training places from introductory to advanced supervisor level training fromTrain2treat4ed, which are open to CAMHS clinicians from across Scotland. Clinicians who achieve supervisor status can certify their supervisees and are listed in the Train2Treat4ED directory of certified therapists.  Out with these NES funded places training costs are listed on the  Train2Treat4ED Official Website.

Building Staff Competency

Qualifications Required

To undertake FBT training you must be a registered mental health professional such as a family therapist, mental health nurse, psychologist, or psychiatrist. 

Training Requirements

Train2Treat to Training Pathway to Certified Practitioner level includes:

Introductory Workshops

• Duration: 1.5-day delivered as online/virtual group training
• Purpose: Provides foundational knowledge in FBT principles and methods
• Requirement: Must be completed before progressing to advanced training

Advanced Certified level training Individual Training

• Minimum Requirement: 25 hours of personalised training with a Train2Treat4ED approved supervisor.
• Format: Can be completed virtually on TEAMS or in-person

Supervisor level certification includes

• Minimum Requirement: 25 hours of personalised training with a Train2Treat4ED approved supervisor.

Format: Can be completed virtually on TEAMS or in-person

Supervision Requirements

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). There is additional training available listed above that specifically supports FBT supervision skills. 

Theory of Change

FBT has its roots in elements of behavioural therapy, narrative therapy, and structural family therapy. It is centred on the theory that restoration of child/ adolescent weight is required to facilitate normal thinking and functioning. FBT therefore focuses on re-feeding (with parents as the agents of change), and the restoration of weight, as opposed to the psychological factors associated with the eating disorder.

MFT shares the same conceptual principles as FBT. However, MFT draws on the therapeutic benefits of groups to address the sense of isolation that can arise in single-family therapy. MFT therefore maximises the resources, strengths, and adaptive coping strategies of group of patients and their families, as they work together as ‘co-therapists’ with the MFT therapist to address the problem and promote recovery.

Values

Family-Based Treatment (FBT) is a manualised intervention for the treatment of child/ adolescent eating disorders. FBT aims to restore child/adolescents to health by using parents as the agents for change, and as the best resource for recovery in the therapeutic process. FBT has its roots in elements of behavioural therapy, narrative therapy, and structural family therapy.

• Does the eating disorder focus of FBT align with the requirements of your organisation?

Priorities

The primary focus of FBT is on weight restoration rather than on the psychological aspects that are associated with the disorder. FBT therefore relies on the core capacity of parents to feed their child(ren) and assist recovery from the eating disorder. FBT facilitates the child’s recovery in their own environment and with support from their parents, as opposed to in inpatient or residential treatment programmes.

• Is your organisation looking to deliver an intervention in which parents play a key role in the treatment process?
• Should re-feeding and weight restoration be the key priorities for the intended intervention, as opposed to the psychological factors associated with the eating disorder?

Existing Initiatives

• Does your service currently deliver interventions to treat eating disorders?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

Family therapies for eating disorders can be delivered by mental health practitioners including psychologists, psychiatrists, dieticians, social workers, and family therapists. Groups can be facilitated by one therapist and two co-therapists. Practitioner training prior to intervention delivery enhances programme fidelity.

• Does your service have qualified practitioners who are available and interested in learning and delivering family therapies?

Technology Support

FBT can be delivered without access to technology but access to video platforms for remote delivery can be useful, as is access to methods of recording sessions for fidelity monitoring.

• Will FBT be delivered in-person or remotely?
• Does your service have the technology to support FBT remote delivery?
• Can your practitioners access technology to record sessions for supervision?

Administrative Support

FBT is typically delivered as an outpatient intervention but may also be delivered as part of residential or partial hospitalisation programmes. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.

• In what setting will FBT be delivered?
• Does your service have a venue to deliver FBT sessions?
• Can administrative supports for FBT delivery be provided?

Comparable Population

Family-Based Treatment (FBT) is a manualised intervention for the treatment of child/ adolescent eating disorders. Research studies have included adolescents and young adults, aged 12-21 years, with anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified.

• Is this comparable to the population your organisation would like to serve?

Desired Outcome

Family therapies are associated with significant improvements across several eating disorder outcomes. Significant improvements have been reported at post-treatment (e.g. remission, eating disorder scores), at 6-12 months follow-up (e.g. remission), and up to 54-months follow-up (e.g. BMI and menstrual status).

• Is delivering family therapies for the treatment of eating disorders a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?