Why Your Teen Probably Won’t Want to Do FBT, and Why You Should Feel Free to Do It Anyway

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Lauren Muhlheim, Psy.D., FAED, CEDS-S

Editor’s note: Family Based Treatment (FBT) is one of many effective, evidence-based treatments for eating disorders. Treatment is not a one-size-fits-all approach; it should be tailored to the individual and will vary according to both the severities of the disorder and the patient’s particular problems, needs, and strengths. Click here to learn more about the various levels of care and methodologies.

When I consult with parents who are considering treatment for their teen with an eating disorder, I advise that there are many things to consider. There are several different types of treatments. Family-based treatment (FBT) is an evidence-based treatment, with the best research support for the treatment of teens, and it requires parents to play an active role. I recognize that FBT is a big commitment for families, and I don’t judge parents who do not feel up for the challenge.

I am an FBT enthusiast. I love doing FBT with families. At the same time, I fully admit that FBT is not for every family. It requires a degree of time commitment, active management, and capacity to tolerate distress that may not be practical for every family.

The weakest reason I get for rejecting FBT is that the teen does not want to do it. In my opinion, the child’s perspective should have no bearing on whether you decide to use an effective, research-supported treatment to help them.

Imagine that your child had cancer and the most successful treatment for that cancer was a course of chemotherapy that would make the child uncomfortable and sick. If your child told you he didn’t want to have that treatment, wouldn’t you insist anyway? There are child decisions and adult decisions, and I believe that choosing the treatment your child receives for a life-threatening illness is an adult decision.

When I work with families, informed consent dictates that at the beginning of treatment I lay out what FBT will entail. When I describe that all meals must be supervised; that you should go to school to have lunches with your child; that sports should be curtailed; that sleepovers and other outings with friends will need to wait; that your child may require supervision between meals and in the bathroom as well; and that weight gain should be one to two pounds per week until your teen returns to their recovery weight—your teen (and their eating disorder) hears me.

Their eating disorder is understandably extremely threatened by the description of this approach and may dig in and resist. Further, no teen is excited by this level of supervision; barely any are willing to sign on to such a program! And why would they want to? Teens prize their independence and privacy. Most don’t see their eating disorder as a life-threatening illness, which is a symptom of the eating disorder. This blinds the teen to the very existence of the disease. I don’t expect any teen to ever willingly agree to FBT. You shouldn’t expect them to either—but that should not stop you from undertaking a treatment that is in their best interest.

I hear people say that it’s cruel, unusual, or controlling to insist that a starving child eat and to firmly steer them through the healing process. I reject this opinion. Administering medicine in the form of food to your starving child is an act of love and compassion. Choosing to not do FBT is choosing to not take the strongest possible stance and assert your role as a key member of your child’s treatment team.

Here’s a common response from the family’s perspective. The mother (not a patient of mine) commented:

Of course, she didn’t want to do FBT—she was a 99% independent 17-year old with a car and a job and a college acceptance letter. Luckily, our pediatrician was emphatic that this was life or death and that FBT was the treatment with the most evidence for its effectiveness. It was a huge switch in parenting style for me, and while it was terrifying at times, it worked, and I got my feisty, fierce, full-of-life girl back.

From the teen (now a young adult):

I don’t really remember a lot from the beginning of FBT because I was badly malnourished and what I do know is that there is just no way I could have chosen to eat; it had to be my parents taking charge because I couldn’t. I am so grateful they did what they had to and gave me my future back.

As you decide which type of treatment to pursue for your child, I encourage you to consider what you think is in the best interest of your teen and their future health. That is your job as the parent. Fortunately, FBT is a treatment that you can pursue without their agreement. The alternatives are often less effective.

Lauren Muhlheim, Psy.D., FAED, CEDS is a psychologist and eating disorder specialist who provides evidence-based treatment for eating disorders in the outpatient setting. She directs Eating Disorder Therapy LA in Los Angeles and is able to provide teletherapy in California and New York. She is active in several professional organizations and presents nationally to parents, professionals, and trainees. She is the author of When your Teen Has an Eating Disorder: Practical Strategies to Help Your Teen Overcome Anorexia, Bulimia, and Binge Eating, published by New Harbinger Publications in September 2018.