Q: Who are the key members of the FBT team? Is a dietician necessary?

Primary FBT Clinician (a licensed or certified mental health provider, e.g., psychologist, child and adolescent psychiatrist, family therapist). Child & Adolescent psychiatrist to manage coexisting psychiatric conditions, e.g., mood and/or anxiety disorders. General practitioner or pediatrician or adolescent medicine provider to monitor medical stability for outpatient treatment. Nutritionist to participate in the initial assessment and to serve as consultant to the team for special dietary requirements, e.g., vegetarianism, type I DB, etc.

Question 1

High degrees of conflict between the youth and caregiver often develop as the caregiver attempts to monitor and move toward treatment targets. Do you have any recommendations for how to best mitigate and manage this conflict?

Daniel Le Grange · Accepted Answer

The manual of FBT for adolescents with anorexia nervosa provides clear guidelines for the management of such conflict or parental criticism toward the young person.

Lock, J., Le Grange, D. Treatment manual for anorexia nervosa: A family-based approach, 2nd Edition. New York: Guilford Press, 2013.

Recent work has demonstrated the best way to mitigate or manage this conflict is to pursue a separated FBT approach, called parent focused therapy or PFT. In PFT, the key FBT strategies are pursued, but the clinician works exclusively with the parents, while the young person is monitored by a nurse. Findings are quite supportive of the notion that when there is considerable conflict between the young person and their parents or significant parental criticism toward the young person, then the opportunity for a favorable treatment outcome is superior in PFT rather than in conjoint FBT. It is not clear why this separated format is more conducive to allowing the clinician to successfully address and reduce parental criticism. Please see the Allan et al (2018) manuscript showing how critical families in PFT were more likely to reduce this criticism as opposed to critical families in conjoint FBT:

Allan, E., Le Grange, D., Sawyer, S., McLean, L.A., & Hughes, E. (2018). Change in parental expressed emotion during family-based treatment and its relation to outcome in adolescent anorexia nervosa Eur Eat Disord Rev, Jan;26(1):46-52. doi: 10.1002/erv.2564. Epub 2017 Nov 3. PMID: 29105211. DOI: 10.1002/erv.2564.

The Le Grange et al (2021) study shows how we have made informed decisions based on baseline levels of family criticism to recommend PFT rather than conjoint FBT to such families:

Le Grange, D., Pradel, M., Pogos, D., Yeo, M., Hughes, E., Tompson, A., Court, A., Crosby, R.D., & Sawyer, S.M. (2021). Family-based treatment for adolescent anorexia nervosa: outcomes of a stepped-care model. Int J Eat Disord, Oct 22. doi.org/10.1002/eat.23629.

Question 2

How difficult is it for adolescents to recover from anorexia nervosa without family support?

Daniel Le Grange · Accepted Answer

Adolescents can indeed recover from anorexia nervosa without family therapy. However, the percent of adolescents remitted at the end-of-treatment (remission defined as a weight of at least 95% of expected weight for height, age, and sex plus an Eating Disorder Examination Global score within 1SD of community norms) when participating in an individual psychotherapy is significantly less than when the family participates in an eating disorder focused family intervention (i.e., ~25% vs 50%).

Lock, J., & Le Grange, D. (2019). Family-Based Treatment: Where Are We and Where Should We Be Going to Improve Recovery in Child and Adolescent Eating Disorders. Int J Eat Disord, 52, 481-487.

Question 3

What are the key assumptions or principals of Family-Based Treatment for anorexia?

Daniel Le Grange · Accepted Answer

There are five key assumptions or tenets of Family-Based Treatment (FBT). These are (1) the therapist holds an agnostic view of the cause of the illness; (2) the therapist takes a non-authoritarian stance in treatment; (3) parents are empowered to bring about the recovery of their child; (4) the eating disorder is separated from the patient and externalized; and (5) FBT utilizes a pragmatic approach to treatment. See the citation below for more detail:

Rienecke, R.D., & Le Grange, D. (2022). The five tenets of family-based treatment for adolescent eating disorders. J Eat Disord, May 3;10(1):60. doi: 10.1186/s40337-022-00585-y. PMID: 35505444. PMCID: PMC9066936. DOI: 10.1186/s40337-022-00585-y.

Question 4

Who are the key members of the FBT team? Is a dietician necessary?

Daniel Le Grange · Accepted Answer

Primary FBT Clinician (a licensed or certified mental health provider, e.g., psychologist, child and adolescent psychiatrist, family therapist).
Child & Adolescent psychiatrist to manage coexisting psychiatric conditions, e.g., mood and/or anxiety disorders.
General practitioner or pediatrician or adolescent medicine provider to monitor medical stability for outpatient treatment.
Nutritionist to participate in the initial assessment and to serve as consultant to the team for special dietary requirements, e.g., vegetarianism, type I DB, etc.

Question 5

How do you approach the situation where the adolescent with restricted eating is also vegan? Can weight and health be restored on a vegan diet and are there situations where veganism is an actual manifestation of the eating disorder?

Daniel Le Grange · Accepted Answer

Yes, an adolescent can be weight restored on a vegan diet. That said, the task of weight recovery is significantly more arduous and complicated under these circumstances. If there are no medical reasons to follow a vegan diet, then it might be best to temporarily suspend such a diet until after recovery from the eating disorder. And yes, veganism or vegetarianism can be a manifestation of the eating disorder, and the clinician will most likely consider this to be the case if the change to such a diet was undertaken around the time of the onset of the eating disorder.

Question 6

Can you explain how exposure and response prevention applies in the context of anorexia and Family-Based Treatment (FBT)?

Daniel Le Grange · Accepted Answer

While FBT is considered theoretically agnostic, it nevertheless borrows pragmatic interventions from other theoretical approaches or therapeutic modalities. One can argue that encouraging parents to present the adolescent with the types and amounts of regular food that will rapidly reverse weight loss, which will include many of the young person’s ‘feared foods’, while creating an empathic environment at home in which the adolescent cannot escape not eating, is akin to what cognitive-behavioral or behavioral clinicians will call exposure and response prevention (ERP). However, FBT following a pragmatic approach to treatment will more than likely describe this process as “helping the parents do what nurses would have done had the young person been admitted to a specialist inpatient unit for eating disorders” rather than ERP.

Question 7

Where can I find training to become certified in Family-Based Treatment for anorexia nervosa?

Daniel Le Grange · Accepted Answer

The Training Institute for Child and Adolescent Eating Disorders (www.train2treat4ed.com)

Question 8

How does Family-Based Treatment (FBT) compare to Enhanced Cognitive Behavioral Therapy (CBT-E) and when would parents choose one over the other?

Daniel Le Grange · Accepted Answer

This exact question was carefully addressed in our non-randomized effectiveness trial comparing FBT and CBT-E in a sample of largely DSM-5 restrictive eating disorders. The Dalle Grave et al. (2019) manuscript clearly outlines the differences between these two treatments: FBT of course being a family intervention and CBT-E an individual psychotherapy with limited parental engagement.

In the treatment study, we presented these two evidence-based treatments to about 100 families explaining what is expected of them, and that the young person should choose one treatment over the other. About half the families opted to receive FBT while the other half opted for CBT-E. Perhaps the clearest defining baseline characteristic that differentiated the two treatment groups is that parents with a younger adolescent seem to favor FBT while those with an older adolescent favored CBT-E.

Question 9

Is atypical anorexia treated in the same way as when the teen is medically underweight?

Daniel Le Grange · Accepted Answer

Largely yes, as a great number of adolescents with atypical anorexia nervosa present with a similar psychiatric profile and similar medical complications as those with anorexia nervosa. The main difference, although, not limited to, is probably treatment weight goal/range. Whereas most young people with anorexia nervosa, when weight restored, will probably be around the 35th – 65th BMI percentile, for atypical anorexia nervosa, weight recovery will most likely be >65th BMI percentile. Therefore, FBT has been adapted for young people with atypical anorexia nervosa with the main difference being the magnitude and rapidity with which the clinician would promote weight recovery, and weight recovery typically at much higher numbers than is the case in anorexia nervosa.

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