Family-Based Treatment for Anorexia Requires Expertise, Family Buy-In

“The article from [Dr] Couturier et al. adds qualitative input that can aid specialists who work in treatment of eating disorders to coordinate care and better communicate with therapists,” Dr Serrano said. “In addition, it is important to recognize that FBT requires unique training and continued guidance from FBT experts. This dictates the efficacy and ultimately health outcomes of patients with anorexia.”

Dr Couturier’s team analyzed 35 audio recordings from clinical consultations over 2 years and identified 10 main themes among the 8 therapists who participated from 4 clinical sites. Those themes closely align “with many of the central tenets of FBT, including how to help parents align their supportive approach during the refeeding process and how to help parents assume control of eating disordered behaviors.” Those 10 themes include the following, which can guide clinicians who conduct consultations with therapists on their team:

  • Encouraging parental meal time supervision
  • Discussing the role of mothers
  • How to align parents
  • Ensuring parental buy-in
  • When to transition to phase 2
  • Weighing the patient and the patients’ knowledge of their weight
  • The role of siblings in FBT sessions
  • How best to manage patient comorbidities
  • The role of the father in FBT
  • How best to manage the family meal

Family Buy-In Essential for Successful Management

Several of the themes identified in Dr Couturier’s paper deal with family buy-in and coordination of family members’ roles during FBT and the early recovery process. That buy-in therefore becomes the first major step in beginning a comprehensive treatment process.

“Family buy-in is heavily dependent on their understanding of the disease and the psychological and neurobiological components that drive the disease,” Dr Marshall told Psychiatry Advisor. “Family recognition of anorexia as a serious illness, much like poorly controlled diabetes or hypertension, is important to building a case for FBT.”

Building that case often starts with psychoeducation about the severity of the eating disorder as a “life-threatening, biologically-based illness with the highest mortality rate of any psychiatric illness,” Dr Pieper told Psychiatry Advisor. To convey the seriousness of the disease, the family often needs to understand how the various organ systems of the body are affected and how the brain is altered by the disease.

Different families may require different approaches to wrap their heads around that seriousness, but depersonalizing it may help a lot of struggling parents, Marshall added.

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“Many times, helping families to externalize the eating disorder — in other words, recognizing the eating disorder as a separate entity from their child — can be helpful in diverting negative emotions toward the illness and not the child,” Dr Marshall told Psychiatry Advisor.

It’s not until much later in the treatment process that control over food and eating behaviors can gradually be transferred from the family to the patient, Pieper explained. Initially, “food is medicine.” Providers focus on prescriptive meal plans with specified amounts of calories and nutrients so that the body can begin healing and the brain can be psychologically repaired enough that the patient can focus more clearly on therapy.

“When a patient is starved, they’re not really processing well, and their body’s signals are way out of whack,” Pieper said. Eventually, the goal is to transition patients to an intuitive eating approach in which they become more attuned to the body’s signals of hunger and fullness. Eating moves from a prescriptive approach to a more flexible one without “good” or “bad” foods.

The mechanisms of the disease may differ from one patient to the next, however, and it will require more research to understand how treatment can be further individualized.

“This is an exciting time in understanding the neurobiology involved in the development of anorexia,” Dr Serrano stated. “As more is understood, more patient-specific treatment modalities will become the standard of care.”

Disclosure: The study was funded by the Canadian Institutes of Health Research. One author of the study receives royalties from Guilford Press and Oxford Press. No other authors or sources have disclosures to report.


Couturier J, Lock J, Kimber M, et al. Themes arising in clinical consultation for therapists implementing family-based treatment for adolescents with anorexia nervosa: a qualitative study. J Eat Disord. 2017;5:28.