As described above, FBT is based in several main therapeutic principles for intervening with eating disorders that are applicable across the child and adolescent age range and clinical presentations. To review, these principles include the following: no focus on etiology of the disorder, no blame of parents or affected child for causing the disorder, encouraging parents to be responsible for behavioral change in eating disorder symptoms in their children, and explicit and almost exclusive focus on behavioral change in eating disordered behaviors early in treatment, and deferring of other developmental issues or problems until the eating disorder symptoms have largely abated. The specific therapeutic interventions associated with these principles include:
- empowering parents by education, support, and affirmation;
- separation of the eating disorder from the patient (externalization);
- engendering appropriate levels of anxiety in parents to motivate them to take action; and,
- providing supportive, consultative, and practical reflections about parental efforts to disrupt eating disordered behaviors.
The key tenets of FBT are adhered to and remain relatively uniform for FBT across ages and eating disorder diagnoses (i.e., AN, BN and EDNOS). However, the application of these principles and the interventions associated with them vary somewhat according to developmental stage and primary presenting symptoms. For example, FBT’s flexible adherence in terms of these key tenets is perhaps best demonstrated around the issue of parental empowerment. For AN, parental empowerment will imply that parents take charge of weight restoration with no input from the adolescent on this issue; for BN, parental empowerment implies a much more collaborative arrangement in that the adolescent’s direct cooperation is solicited and encouraged; for EDNOS, parents are also empowered to get a handle on the eating disorder symptoms, but the period of their involvement in this process might be less intensive and time consuming than typically is the case for AN or BN. Put another way, the same skills parents have to master in order to encourage their offspring to eat more than they would wish to (as for AN), are to be employed in supporting regular healthy meals while curtailing binge eating and purging (as for BN). Therefore, it is parental efficacy that is bolstered through FBT and implemented in practice, but tailored toward the adolescent’s specific symptom profile depending on their diagnosis.
There are also some adjustments that therapists employ based on the age of patients. For example, the rationale for parental management of eating and exercise is the same for all ages in AN, but parents of younger adolescents find implementation of parental management more natural and consistent with the developmental age of their child than parents who attempt similar behavioral control with older adolescents. In both instances, however, both patients and their parents are reassured that this is a temporary intervention. In the case of FBT-BN, a further modification of the recommendation of parental control is made. Unlike adolescents with AN where parents are strongly cautioned against negotiating control of eating problems with their son or daughter, in BN, the transfer of parental control over eating and exercise is negotiated with the adolescent. This adjustment reflects several differences between the clinical presentation of adolescents with AN and BN. In AN, the symptoms of severe dieting and over exercise are ego-syntonic, making it unlikely that the adolescent will agree to parental intervention. In contrast, adolescents with BN are secretive and shameful about binge eating and purging making it more likely that they will be motivated to change these behaviors when help is offered and therefore consider accepting parental assistance. In addition, adolescents with BN tend to be exercising more developmental autonomy from parents than those with AN when they present for treatment, often making it a practical necessity to seek their agreement to involve their parents. Finally, adolescents with AN who do not eat and over exercise are easier to detect, but binge eating and purging are secretive behaviors, so in order for parents to help with these behaviors, the adolescent has to be willing to share information about their eating patterns, trigger foods, and periods of high risk for purging.
In FBT- AN, there is a family meal where parents are asked to bring a meal that they believe will help their child gain weight and then to help her eat it. Weight gain is seldom a goal in FBT-BN, so parents are asked to bring a food that the adolescent says will typically trigger a binge and purge episode. The adolescent is asked to eat this food and allow her parents to help her avoid binge eating and purging. In the second stage of FBT-AN, parents gradually transfer control of eating related issues back to adolescent according to what would be expected for the child’s age. Younger adolescents would likely still eat most meals, except lunch, with the family; while older adolescents would spend more time eating away from home. In FBT-BN, this transition to adolescent control of eating is similar in design, but often proceeds more quickly than in adolescent AN because the adolescent with BN is typically somewhat older, more independent, and more socially engaged with peers.
In the later phases of FBT- AN, there is a gradual shift in focus to other adolescent issues that may be affecting the adolescent and the family. Typical issues that might arise are accepting an adult body shape, developing social relationships outside the family, exploring adolescent developmental issues around dating, alcohol and drug use, sexual behaviors, and anticipating leaving home for school or work. In FBT-BN, these adolescent issues tend to arise earlier in treatment because adolescents with BN are often exploring these issues prior to or in the context of BN. On a practical level, adolescents with AN typically spend more time in the first phase of treatment which is focused on weight restoration and parental control, while adolescents with BN spend more time in the other phases of treatment. Both treatments can be delivered in about 6 months, though a subgroup of adolescents with AN who come from non-intact families or who have the highest levels of obsessional thinking appear to need longer treatment (Lock et al., 2007).