Author Archives: Alison Pelz, LD, RD, CDE, LCSW

Text in the bottom left corner reads "Treating Anorexia Nervosa in Teens: The 5 Tenets of FBT" and the rest of the graphic shows a stock photo of a white woman hugging a teenage girl on a couch.

Treating Anorexia Nervosa in Teens: The 5 Tenets of FBT

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You may feel confused, scared, frustrated, and maybe even hopeless if your teen has an eating disorder like anorexia nervosa. You have seen your fun-loving and bright teen change drastically, becoming a shell of their usual self. 

There are many types of treatments for eating disorders that work for teens and their families. Cognitive behavior therapy (CBT), dialectical behavioral therapy (DBT), Family-Based Treatment  (FBT), and Acceptance and Commitment Therapy (ACT) are a few of the common treatment modalities that are used in eating disorder recovery. Additionally, there are different levels of care available for those with eating disorders, such as hospitalization, residential, partial hospitalization, or outpatient treatment.

Looking at all of the treatment options for anorexia nervosa in teens may feel daunting.

In this article, the focus is on family-based treatment (FBT), one type of treatment for eating disorders that is used for treating anorexia nervosa in teens. In particular, this article discusses the nuances of family-based treatment, which are referred to as the “Tenets of FBT”. 

The focus of FBT is to empower you, the parent, to provide nutrition rehabilitation and restore your child back to health with the guidance of a treatment team. FBT is an outpatient treatment that can be used in place of residential treatment or partial hospitalization if your teen is medically stable. That means your teen can stay at home during treatment. 

The tenets of Family-Based Therapy guide me as a clinician, and you as a parent, during eating disorder treatment and recovery. When working with families and teens throughout treatment I refer to these guiding principles frequently.

5 Tenets of Family-Based Treatment for Anorexia Nervosa in teens

Agnostic view of the eating disorder

In FBT, the focus shifts from why your teen developed the eating disorder to treating the eating disorder.

Eating disorders are complex disorders and can develop for a myriad of psychological, biological, social, and medical reasons, and beyond. The parents and the teen are not to blame for the eating disorder. I know it may feel like your teen is choosing their eating disorder because they are restricting food or purging, but they are not.

Additionally, parents don’t cause eating disorders-so let yourself off the hook.

How this is helpful:

It reduces blame, guilt, and shame for the teen, as well as their parents. It focuses on stopping the eating disorder in its tracks, restoring your teen’s health, shortening the length of illness, and preventing the eating disorder from becoming chronic. 

This is similar to if you found out you had cancer. You or your doctor initially wouldn’t spend a lot of time figuring out why you have cancer but rather focus on how to treat the cancer. Treatment for an eating disorder is similar, including for anorexia nervosa in teens.

Externalization of the illness

Externalization of the illness is a tool to understand that the eating disorder is separate from your teen. Although it may appear on the surface that your teen is refusing food, it is the anorexia that causes the food refusal. 

Externalization is commonly utilized in the treatment of OCD, schizophrenia, and other mental health conditions. 

How this is helpful:

This helps families understand how to separate their loved one from their eating disorder which can reduce blame and shame. The spirit of treatment feels more like us (family and teen) vs. the eating disorder, in contrast to parents vs. the teen. FBT helps you call on your years of parental experience and wisdom to help heal your child.  This can often increase parental empowerment leading to more successful nutrition rehabilitation.

An increase in connection between parents and teen is what I have observed when working with families during eating disorder treatment. Increased connection can contribute to improved physical and mental health for the whole family.

The therapist takes a non-authoritarian stance

In traditional adolescent-focused therapy, the therapist works predominantly with the teen, and the therapist is leading the treatment. In contrast, in FBT, the therapist acts more like a coach.

“The therapists are experts on eating disorders and parents are experts on their family and teen,” is something I learned during my training in FBT.  This lends itself to high amounts of collaboration between the therapist and family. Additionally, FBT utilizes the strengths of the teen to help aid in the healing process.

How this helps:

FBT is “not a one size fits all approach” to treating anorexia nervosa in teens. In Family-Based Treatment, the therapist activates the problem-solving skills of the family.

In other words, the therapist is there to help guide you and your child through recovery – but you know your child best and what has helped them with other struggles in the past. This knowledge is essential as you work together toward recovery.

Additionally, FBT appreciates the uniqueness of each family and their teen including culture, gender, abilities, exceptionalities, neurodiversity, religion, and family values to name a few.

Parental empowerment

Simply put, parental empowerment means that parents feel confident about taking care of their children. Some parents have some experience with feeling empowered with things like setting a curfew, boundaries around school work, and expectations around chores, while others might second-guess their parenting choices. FBT is an opportunity for growth in this area.

One of the tasks of the FBT therapist is to help you harness the skills and confidence that you already have as a parent, and apply them to renourishing your teen. 

How this helps:

Empowered parents can be more effective at renourishing their teen. Since you, as the parent, are in charge of feeding your teen, it reduces distress and second-guessing about what and how much to feed your teen. 

Furthermore, empowered parents provide structure, consistency and boundaries that help children and teens thrive. 

Pragmatic approach

The initial focus of FBT is symptom reduction rather than focusing on why the eating disorder developed. In the case of anorexia nervosa in teens, parents are tasked with the nutrition rehabilitation of their child, similar to the staff at a residential treatment center. This allows the family to stay together during treatment.

How this is helpful:

This approach stops the eating disorder from getting worse, which can lead to medical complications or potentially death. Stopping the eating disorder behaviors will help keep them from becoming habitual for your teen.

One hypothesis for why eating disorders develop is that eating disorders have a function. That is, they are helpful in some way, despite causing physical harm. For example, if someone smokes a cigarette, although the cigarette is physically harmful, it reduces stress for the smoker in the short term. Eating disorders are thought to function in the same way.

In my work, I have witnessed families rally around their teens, and through connection and compassion help their teen develop new skills to manage life stressors so the eating disorder is no longer needed.

Do you have a teen who is struggling with anorexia nervosa? Working with a dietitian  who is experienced in Family-Based Treatment can help. If you are in Texas and interested in working with me, click here to fill out a contact form.

Text in the bottom left corner reads "Levels of Care in Eating Disorder Treatment: How to Choose the Right Option", layered over a stock photo of a Black woman on a couch, talking to a healthcare provider.

Levels of Care in Eating Disorder Treatment: How to Choose the Right Option

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Treatment for eating disorder recovery isn’t a one-size-fits-all approach.

Every person is unique, and not everyone recovers in the exact same way. This is why eating disorder treatment is categorized into different levels of care, depending on what the person in recovery needs.

This post will provide a brief overview of the different levels of care available during eating disorder treatment.

What are levels of care?

Levels of care refer to how much support is needed to reduce eating disorder behaviors during treatment. Several levels of care may be utilized throughout treatment for an eating disorder, based on what is necessary for the person in recovery.

Treatment choices can be overwhelming if you or your teen are newly diagnosed with an eating disorder. Residential, day treatment, or outpatient care – what does this all mean?

Levels of care in eating disorder treatment are selected based on many factors including:

  • Medical: This often is the driving factor in selecting the level of care. If you or your teen are medically compromised more care may be needed.
  • Severity of malnutrition: Different levels of care offer varied amounts of support for nutrition rehabilitation.
  • Co-occurring conditions: Often those with eating disorders have other medical or psychological conditions that also need to be treated.
  • Social support: Social support improves mental and physical health. The different levels of care offer varying levels of social support.
  • “Motivation”: Most of us want to feel better and be healthy. However, change can feel scary, overwhelming and downright impossible at times. Those who feel more stuck in their eating disorder may need more support to feel like change is possible.
  • Access to care: Proximity to treatment, insurance, and specialty care are all considerations. Virtual treatment by clinicians and treatment programs are being utilized to increase access to care.

What are the different levels of care in eating disorder treatment?

In-patient hospital care

In-patient hospital care is used when a person with an eating disorder needs round-the-clock medical care. Since eating disorders have significant medical consequences due to malnutrition and/or purging, medical stabilization may be needed during treatment.

Residential care

In this level of care, round-the-clock care is provided in a therapeutic environment. This allows for intensive psychological treatment and nutrition rehabilitation, while also monitoring medical status. The residential care environment is highly structured and allows for the reduction of eating disorder behaviors.

Partial hospitalization

In a partial hospitalization program, the person attends several hours per day most of the week. Partial hospitalization provides psychological treatment (individual therapy, group therapy, and family therapy) and nutritional therapy, including therapeutic meal support. This level of care is very similar to residential care, just without spending the night. In this level of care, you or your teen may go in several days a week, and each day have a meal or snack at home.

Intensive out-patient (IOP)

This level of care is when you or your teen spend the majority of time at home and engaged in usual activities such as work or school. The person in eating disorder treatment usually has a therapist, dietitian, and doctor and attends several groups per week.

Outpatient

Outpatient care is considered the lowest level of care in eating disorder treatment. In this level of care, you or your teen are spending 2-3 hours a week in treatment with an outpatient treatment team. Oftentimes, outpatient services are utilized first because it allows the person in treatment to stay active in daily activities such as work or school. Outpatient care can be easiest to access because most areas, particularly with telehealth options available, have qualified eating disorder outpatient providers.

Family-based treatment (FBT) is an outpatient treatment for teens. It is particularly effective for teens with anorexia nervosa. FBT can be an option in place of residential care or partial hospitalization, if the person in treatment is medically stable.

How do I know which level of care is right for me?

First, consider your medical needs with your doctor. The more medically compromised the person with the eating disorder is, the higher level care they may need.

If residential treatment is recommended, that doesn’t mean the eating disorder is worse than others. It just means that you need this level of support to get back to health.

If you or your teen are utilizing outpatient care, your treatment team will work with you to help determine the level of support needed.

Many treatment centers provide multiple levels of care residential, partial-hospitalization, and IOP. The treatment center will help determine the level of care needed via an assessment, which is usually free and done over the phone.

It is not unusual to utilize multiple levels of care during the course of recovery.

For example, someone in treatment may start out as an outpatient. If the person in treatment and their treatment team determine that their eating disorder symptoms are not getting better, they may benefit from a more supportive level of care (which is also referred to as a “higher level of care”).

Eating disorders usually don’t go away on their own. They can progressively get worse over time. My hope is that if you, or someone you care about, is suffering with an eating disorder that you make the initial call to get help.

Hi! I’m Alison Pelz, a psychotherapist and registered dietitian in Austin, TX with over 16 years of experience in eating disorder treatment.  If you or someone you care about is struggling with an eating disorder, don’t hesitate to reach out for help. To learn more about eating disorder treatment and levels of care, schedule a consultation with me today.

Are you a clinician? Sign up for my mailing list and get a coupon for 10% off of one of my CE courses!

Book Review: When Your Teen Has an Eating Disorder is a Must-Read

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In the book When Your Teen Has an Eating Disorder: Practical Strategies to Help Your Teen Recover from Anorexia, Bulimia, and Binge Eating, author Dr. Lauren Muhlheim discusses eating disorders and their treatment in great depth.

If you think your child or teen has an eating disorder this is a must read.

Eating disorders can perplex many parents and clinicians alike. Your teen may not be acting like their usual self, and it’s hard to know if this is just normal teenage angst or something more serious. If your teen has an eating disorder, they may have changed greatly right before your eyes: refusing food, feeling anxious around eating, or experiencing changes in mood and energy.

You may have tried several times to talk with them about the importance of eating and try to reassure them that they are not gaining weight. (In fact, they are likely losing weight.) But, your child’s struggles seem to be getting worse not better.

If your teen has not seen a doctor yet about their eating disorder this is the first step to make sure they are medically stable.

This book can help guide you and your family in treatment while establishing an eating disorder treatment team consisting, at minimum, of a doctor and therapist.

About the Book

When Your Teen Has an Eating Disorder discusses the complicated concepts surrounding eating disorders in teens in a non-clinical manner, so it can be more easily understood. The book provides helpful information about eating disorders, an overview of various treatment options, and goes into depth about a unique and well-studied treatment called Family-Based Treatment (FBT).

The author of the book, Dr. Lauren Mulheim, owns a counseling and training center in southern California called Eating Disorder Therapy LA. She uses Family-Based Treatment in her clinic and has been instrumental in training many of the eating disorder therapists in the Los Angeles area and beyond. She is currently serving on the advisory panel of FEAST (an organization providing support to families of those impacted by eating disorders) and is a regular speaker at national eating disorder conferences.

If you are a parent worried about your child and unsure how to help them overcome their eating disorder, or a clinician wanting to learn more about FBT, this book is a must-read. As an eating disorder therapist myself, I recommend this book to all of the families that I work with and to other clinicians. It will be a great resource and provide a glimmer of hope to you on your journey.

What is discussed in When Your Teen Has an Eating Disorder?

When Your Teen Has an Eating Disorder outlines the complexities of eating disorders and the impact that they can have on your teen (and your family’s) life.

A thorough list of the early warning signs of an eating disorder are discussed. These warning signs include:

  • Changes in eating and/or exercise habits
  • Frequent trips to the bathroom
  • Changes in body weight
  • Loss of menstrual cycle
  • Complaining of of feeling cold all of the time
  • Lack of growth
  • Obsessive thoughts about food, body image
  • Changes in overall mood
  • Poorer concentration

Muhlheim highlights the importance of early detection and intervention with trained clinicians, so that the eating disorder can be addressed before it escalates or becomes chronic.

Dr. Muhlheim provides the reader with an excellent explanation of how malnourishment impacts your teen’s ability to understand how the eating disorder is impacting their mind and body. Parents often feel perplexed when their bright, loving child begins to act irrationally around food. Parents will also learn how to separate their child from their illness, one of the basic assumptions of family-based treatment.

The majority of the book really gets to the heart of the matter: What parents really want to know when their child has an eating disorder. You might be asking yourself questions like “What do we do?” or, “How do we improve our child or teens’ health and get them feeling better again?”

This book can help you answer those questions. In it, Mulheim:

  • Outlines the path to help your child or teen heal from their eating disorder using family based treatment (FBT). Parents will then learn what the path to recovery from an eating disorder looks like using Family-Based Treatment.
  • Discusses the three stages of recovery-nutrition rehabilitation, eating independence and relapse prevention-in depth.
  • Provides parents rationale behind each step so parents can feel empowered to help their child.

Discover Practical and Helpful Tools to Help Your Teen in Eating Disorder Recovery

This book is a practical guide that provides effective, concrete strategies for eating disorder treatment, and examples of how to use them.

Muhlheim helps parents become empowered agents of change amid their child’s eating disorder. The book provides general guidelines about what to feed your child and how to structure meal times. It also highlights how to effectively interact with your child at each stage of treatment, and how to be empathetic with them when they are struggling.

Not only does this book share concrete strategies and practical steps, it also covers the challenges that parents might face during treatment. The book details what to do when your child refuses to eat. It also explains how the parents can get support throughout the difficult journey of helping their child get better. This helps parents know about the hard aspects of treatment they should expect beforehand, so that they are prepared.

Muhlheim provides all of this information while also sharing real-life examples throughout the book. The stories within this book help parents feel less alone about what is going on with their child. It also provides them with a realistic picture of what they are facing. These examples make parents feel more confident about applying the practical tools needed for recovery.

It is normal for parents to worry about how treatment will affect their relationship with their teen. When Your Teen Has an Eating Disorder emphasizes the importance of your relationship with your teen in the treatment of their eating disorder.  It talks about how to further develop a family culture of unconditional acceptance and respect and focuses on the importance of trust, empathy, and understanding to support your child in their recovery. Furthermore, it provides the reader with strategies of how to talk to their teen about food and body image during the recovery process.

When Your Teen Has an Eating Disorder is a Great Resource For Parents

Whether your teen is struggling with anorexia, bulimia, or binge eating disorder, this book is helpful for parents. This book will help you if your child is newly diagnosed with an eating disorder, in early stages of treatment, or if your teen has been through several rounds of treatment already.

This book will empower you to support your child’s recovery. If you are seeking treatment for your child, it will give you enough information to decide whether or not Family Based Treatment is right for your family. If you decide that FBT is the best treatment option, this book walks you through how to create a treatment team that will be the best fit for your child and family.

As a therapist and parent, I appreciate how this book (and FBT in general), takes a very non-blaming stance on eating disorders. Parents aren’t faulted for the disorder and the child isn’t isolated from their family. This book recognizes the family-based treatment approach and belief that parents are the experts on their child. It emphasizes how treatment for eating disorders needs to include the family for best results and also the importance of meal support and nutritional rehabilitation for recovery. I highly recommend reading this book!

If you think your teen has an eating disorder please consult their doctor for assessment and medical care as eating disorders can be life threatening. If you are a parent and are interested in family-based treatment for your child in Texas, you can schedule a consultation with me here.

If you are a clinician looking for a book that can help you understand eating disorders and family-based treatment, you can get CEU’s for reading this book by clicking here.

*Please note this book is not a substitute for professional help from a doctor and eating disorder treatment professionals.
Understanding ARFID: More Than Picky Eating

Understanding ARFID: More Than Picky Eating

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Avoidant/Restrictive Food Intake Disorder (ARFID) often remains underrecognized and misunderstood.

Adults who have struggled with Avoidant/Restrictive Food Intake Disorder for most of their life may feel it is impossible for things to be different. Parents who have a child struggling with ARFID have, more often than not, literally tried everything to help their kiddo eat, but nothing seems to be working. ARFID is often equated with picky eating, but it’s actually much more complex than that.

Although ARFID is a newer diagnosis, there is really nothing new about it.

Prior to being added to the DSM-5, it was included in a broader category called “Feeding Disorder.” It was added to the DSM-5 in order to develop better ways to treat it.

Parenting a Child with ARFID

If you are a parent, well meaning doctors may have minimized your child’s selective eating. This can be particularly true if your child is on track with growth. This can be frustrating for a number of reasons. You spend significant time to figure out how to feed your child – and it takes a lot of mental energy and often can feel very limiting to keep dealing with this challenge day after day.

If it’s left unaddressed, ARFID can lead to nutritional deficits, which can impact both physical health and emotional well-being. Early detection of ARFID is important so it doesn’t turn into a life-long struggle. Understanding ARFID is crucial for effective intervention, and a comprehensive treatment strategy tailored to the individual’s specific needs is necessary.

Understanding ARFID

Avoidant/Restrictive Food Intake Disorder is not just a simple case of picky eating; it is a complex psychological condition that can cause significant nutritional and reduced quality of life, particularly if it endures into adulthood.

Unlike other eating disorders that are often driven by concerns about weight and body image, ARFID is characterized by an avoidance of food based on sensory sensitivity, lack of interest in eating, depressed appetite, and/or fear of adverse consequences such as choking, throwing-up, or an allergic reaction.

Individuals grappling with ARFID may face a persistent difficulty when it comes to eating sufficient quantities or varieties of food. This can stem from deep-seated anxiety, gastrointestinal discomfort, or past negative associations with food.

Recognizing Avoidant/Restrictive Food Intake Disorder Symptoms

Persistent avoidance of specific foods or food groups or low food intake are characteristic of ARFID. Physical responses such as gagging may coincide with this avoidance of certain foods.

The eating patterns of individuals with ARFID reveal a restrictive intake that fails to meet their physiological needs. Without treatment, ARFID can lead to potential nutritional deficiencies, weight loss, or developmental delays, irrespective of age, gender, or body weight.

Behavioral signs and changes in eating that may indicate ARFID include:

  • Poor appetite
  • Getting full quickly
  • Avoiding eating due to fear of choking
  • Picky eating that often gets worse over time

Avoidant Restrictive Food Intake Disorder (ARFID) is often misinterpreted as a phase among children or as mere pickiness in adults; however, it represents a significant feeding or eating disorder that hinders one’s capacity to consume an adequate variety and volume of food.

Impact of ARFID on Everyday Life

ARFID’s restrictive eating patterns in children can lead to low energy, isolation, and anxiety around meal times. For caregivers, it can be a struggle to know how to feed your child, or  it can take lots of effort to prepare foods that you know they will eat in order to support growth.

For older children and adolescents, ARFID can make socializing, which often happens around food (such as parties, sleep overs, family events or team dinners), anxiety provoking for both the child and parents. The disorder’s consequences radiate outward, often simmering into familial tensions and social rifts, as loved ones grapple with the complexities of ARFID.

Adults with ARFID tend to have a decrease in quality of life. Moreover, the fear of eating outside one’s comfort zone can hinder personal and professional growth, particularly when mealtime activities are involved.

Ultimately, the disorder’s grasp can dampen overall quality of life, exerting a significant emotional toll.

Approaches to Treating ARFID

The main goal of treatment for ARFID is supporting the sufferer with eating enough (and enough variety) to keep their body nourished. For children, treatment works to support growth. Treatment for children, adolescents, and adults can help to improve overall quality of life.

Improved quality of life looks different depending on the individual with ARFID. For some, that may mean eating most food. For others, it may mean expanding the variety of food in order to support quality of life and being nourished.

Avoidant/Restrictive Food Intake Disorder treatment usually focuses on making eating or feeding a priority.

That is, for most folks, increasing the number of times each day they eat meals and snacks. Due to the nature of ARFID, eating often gets put off because it is uncomfortable for the person to eat, or they simply aren’t hungry.

Structured meal planning can be an effective strategy for managing ARFID, as it introduces routine and predictability into the dining experience. By brainstorming menus in advance, individuals and families gain clarity and a sense of control over their food choices.

Having structure and making eating a priority can help make sure people are getting adequate nutrition and reduce meal time stress.

In addressing the dietary concerns that stem from Avoidant/Restrictive Food Intake Disorder, we take a gradual approach to food exposure. Food exposures are designed in collaboration with the client and/or the family in order to personalize care.

Incremental exposure to food means starting with foods that are less anxiety-provoking, building up to a more diverse diet over time. Food-related anxieties are meticulously deconstructed, facilitating the individual’s encounters with previously feared foods in a safe and controlled environment.

Efforts are channeled into ensuring balanced nutritional intake while concurrently addressing emotional and cognitive barriers. Over time, the individual learns to associate eating with safety rather than distress, thus gradually dismantling the cycle of avoidance that characterizes ARFID.

My Approach to ARFID Treatment

When I am working with children with ARFID I work closely with their caregivers. I have learned from my training in Cognitive-Behavioral Therapy for ARFID that I can bring the expertise in eating disorders, and the parents & kiddo bring the expertise on their family, food beliefs, culture, and abilities (to name a few).

With adults with ARFID I use a similar mindset. I bring skills to the table to treat the eating disorder and they bring their expert knowledge of themselves.

Are you concerned that you or your child are dealing with Avoidant/Restrictive Food Intake Disorder? Sign up for a free consultation to learn more about how I can help you and your family.

Can Family-Based Treatment Help My Child Recover from an Eating Disorder

Can Family-Based Treatment Help My Child Recover from an Eating Disorder?

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If you are a parent or caregiver, desperate to help your child who is struggling with an eating disorder, family-based treatment may be the solution you are searching for.

Often, families come into my office worried sick about their child.

Their child might have lost a lot of weight or been acting “sneaky” around food. Maybe their child has been over-exercising, using laxatives, or throwing up after eating.

Or, they might be worried because their child only eats a small number of foods, or eats a lot of food at once.  

Or maybe your child has become an extremely “picky eater”.

On top of that, parents are often terrified because they have heard doctors mention hospitalization and many therapists have turned them away. When they do research online, things look bleak. 

No matter their child’s symptoms, when families first come in they are often frantic, frustrated, and feeling powerless. They don’t know what to do. 

If you find yourself in a similar boat today, you’re not alone. I have worked with countless families who walk into my office feeling this way. Sadly, there’s a lot of blame put on the parents. All they want for their child is to get better and live a happy life without the constant obsession with food. 

Many parents have been seeking help for a while. Unfortunately, they have found no real results. They often receive criticism, but no real guidance on how to help their child get better, or well-meaning doctors say they will grow out of it and that it’s just a phase.

I’m here to give you hope.

After years as a therapist and registered dietitian, I’ve seen the positive results that come from family-based treatment where parents are properly equipped and supported to be part of the solution their child needs.

Why Choose Family-Based Treatment?

Family-based treatment (FBT) for eating disorders is an evidence-based treatment for disorders like anorexia, bulimia, binge eating disorder, and even ARFID (i.e. extreme selective eating).

Unlike many other treatments that put the responsibility on the identified patient or the person with the eating disorder, FBT includes the parents. Instead of seeing the parents as part of the cause of the eating disorder, they are seen as part of the solution.

We use your expert knowledge of your child to help your child get better.

This method of treatment makes sense to parents. If your child had cancer or some other serious medical condition, you, as the parents, would be highly involved in treatments including appointments, physical therapy, and all the steps to recovery.

It shouldn’t be any different for treating eating disorders.

Eating disorders are an epidemic in our country. According to the NIH, for teens between the ages of 13 and 18, the lifetime occurrence of anorexia, bulimia, and binge eating disorder is 2.7%. These disorders are twice as common among girls than boys. They also tend to be more common the older the teen gets.

When it comes to ARFID or avoidant/restrictive food intake disorder, the prevalence is between 5 and 22%, with about 2% reaching the need for help. ARFID also tends to happen with anxiety disorders and neurodivergence. Effective, evidence-based treatment for eating disorders is important and necessary.

How Effective is Family-Based Treatment?

Family-based treatment has been used in the United Kingdom for many years. It has proven to be more effective than other forms of eating disorder treatment.

With a 75% success rate, teens receiving FBT also recover faster than with other treatments. The research also shows that teens are doing better after engaging in FBT than in other treatments.

How Does Family-Based Treatment Work?

In family-based treatment, a clinician guides the parents in empathizing with the child while also holding boundaries around eating, food, and other eating disorder behaviors like binge eating and laxative use.

The therapist coaches the parent on how to teach their child to eat again. The goal is for the child to eventually have age-appropriate responsibility with food intake and eating habits, once the child has reduced their eating disorder symptoms and is stabilized. They also want to encourage an appropriate relationship with food and their body image.

Family-based treatment usually lasts around 20 sessions and happens in three stages.

During the first stage, the parents are responsible for preparing and serving food as well as insisting that it gets eaten. They are pretty much doing what a nurse during inpatient treatment would do. There is no room for negotiation around food or other eating disorder behaviors like purging, misusing exercise, or laxatives.

The second and third phases include slowly giving responsibility for food and exercise back to the child.

During the second phase, the child may return to more normal activities while being supervised by their parents for any signs of relapse.

During the third stage, the child begins to transition back on track with their developmental stage of eating.

What Makes FBT Different?

Family-based treatment is quite different from the standard eating disorder treatment. 

First of all, at its core, FBT does not blame the child’s parents (or the child) for the eating disorder. One of the core beliefs of family-based treatment is that no one in the family is to blame. Really, the focus is on getting the child well instead of placing blame.

In other treatments, the person with the eating disorder is treated on their own outside of the family system, but with FBT, the parents, child, and sometimes even the siblings, are involved in treatment. 

The parents’ care and motivation to help their child are used to make some major changes in the family’s life, especially around food. Their unique expertise on their child is used to help them get better, and parents are taught how to interact with their child around food, and other eating disorder behaviors.

This allows the family to overcome the eating disorder, together. 

Another difference with FBT is the focus on food, nutrition, and eating disorder behavior rehabilitation. FBT believes that a lot of the symptoms of the eating disorder will disappear when the child is better nourished and no longer using other eating disorder behaviors. So they first focus on nutrition, feeding, and decreasing the other eating disorder behaviors. 

Often, parents think that their child has to be “motivated” for treatment to be effective. One of the differences with FBT is that the child does not need to be motivated to change to get better. The motivation to make change happen starts with the parents. 

What are the Benefits of Family-Based Treatment?

Family-based treatment has benefits for both the family as a whole and the child, including: 

  • The child or teen usually gets better faster than any other treatment, making it one of the quickest ways to help your child and family heal.
  • Parents are involved in the child’s treatment, allowing them to be the child’s primary support instead of feeling powerless and at fault.
  • This is a good replacement for inpatient treatment or partial hospitalization, allowing your child to stay home.
  • FBT is an evidence-based approach, so you know you are doing the best you can for your child.

Now that you know how FBT can help, let’s look at who it can help.

Who is FBT for?

FBT has been shown to be effective for kids, teens, and young adults. showing signs of eating disorders.

It has been used to help kids and teens who are struggling with anorexia, bulimia, binge eating disorder, as well as avoidant restrictive food intake disorder (ARFID).

In the cases of binge eating disorder and bulimia, the family is taught to help feed their child adequately and supportively interrupt binge eating, purging, laxative use, and misuse of exercise. 

FBT works both for teens who have been to inpatient multiple times and still struggle to let go of the symptoms, and for teens who have just started to engage in eating disorder behaviors, and any child in between.

FBT is not just for teens, however. It can also be used with children and young adults still living at home. FBT can be used in all different types of families or caregiving situations (like grandparent caregivers and single-parent households).

Who Should Not Do FBT?

FBT is often used instead of hospitalization. If the child is underweight and does not have any other reason to be medically supervised, FBT can be a great option rather than hospitalization.

However, if your child or teen needs to be medically supervised for another reason, then hospitalization is recommended.

In the same way, if the child needs to be supervised for other psychiatric illnesses, then this is also a situation where FBT is not going to help until the child is stable psychologically. Family-based treatment may also not be a good option if the child has experienced certain types of trauma.

What Happens During Family-Based Treatment?

Family-based treatment may last around 20 sessions. At each session, you can expect your child or teen to check in with the therapist for mental health support.

After this, the therapist will meet with the parents and child for coaching around nutrition and other eating disorder behaviors. The coaching isn’t just about what to eat but also about how to talk to your child about eating and other eating disorder behaviors, including how to express empathy without giving in.

Unlike other eating disorder treatments where the therapist just meets with the child, most of the time, the FBT therapist meets with the caregivers and child.

Family-Based Treatment is Worth the Hard Work

Family-based treatment can be very intense for the whole family. In the beginning, you will be very involved in your child’s day-to-day life, as well as your child’s nutritional rehab, but the hard work will be worth it when your child learns to eat and regains their health again.

Not only does family-based treatment help your child stay home, as hospitalizations can last weeks or months, but it also helps to heal your whole family from the disruption that the eating disorder has caused.

While it can be hard to find family-based treatment, don’t give up! Finding someone who is trained to do family-based treatment can make the difference for your child.

At the minimum, when you are seeking FBT you will need to at least start with a medical doctor and a therapist.  If your team includes a dietitian, initially they will only meet with the parents and not the child.

As a therapist who is also a dietitian, I can help you understand what is going on from both angles. If you are in Texas and interested in working with me, click here to fill out a contact form. I would love to support you and your child on your journey to health.

"When Your Loved One Doesn’t Want to Get Better Understanding Anosognosia in Anorexia Nervosa" in white text on a light purple background in the bottom left corner of the graphic. The rest is a stock photo of a white woman sitting on a couch next to a teenage girl, looking concerned. White text in the top left corner reads "www.alisonpelz.com Helping people make peace with food & their bodies."

When Your Loved One Doesn’t Want to Get Better: Understanding Anosognosia in Anorexia Nervosa

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Anorexia nervosa is an eating disorder characterized by severe food restriction, an intense fear of weight gain, and body image disturbance. Anorexia nervosa affects many individuals of all genders, ages, and identities worldwide. 

The consequences of anorexia nervosa can be devastating, both physically and psychologically. However, one of the most challenging aspects of this disorder, particularly for family members and caregivers (and even clinicians!), is the phenomenon known as anosognosia.

What is Anosognosia?

Anosognosia, stemming from the Greek words “nosos” (disease) and “gnosis” (knowledge), refers to a lack of awareness of one’s illness. Anosognosia often can feel and look like denial. 

Denial is a defense mechanism and psychological response to avoid dealing with anxiety or other uncomfortable feelings. In contrast, anosognosia in mental health conditions is better described as a lack of awareness of their own condition.

Anosognosia can affect individuals struggling with bipolar, schizophrenia, eating disorders, and other psychological disorders. 

In anorexia nervosa, individuals may minimize the severity of their condition. They may adamantly believe they are not sick, or that their behaviors are justified, making it incredibly difficult for them to recognize the need for treatment. It can feel like your loved one is being “difficult” and in teenagers it can be especially confusing because during adolescence it is normal for teens to be contrary or contradictory. 

Anosognosia causes a person to be unable to achieve one or more of the following:

  • Accept that they have an illness or disorder.
  • See the signs and symptoms of their condition.
  • Connect their feelings and personal experiences back to that condition. 
  • Understand and agree that the condition is serious and needs treatment.

One of the most dangerous aspects of anosognosia in anorexia nervosa is the individual struggling with insight when the condition becomes life-threatening.

This lack of awareness around a loved one’s illness can further complicate the treatment plan and, many times, prevent treatment from occurring altogether. 

Parents frequently ask me if they should wait for their child to want to recover.

My answer is always no, because I know that anosognosia is most likely operating, and because the devastating effects eating disorders have.

Let’s face it – no teen really wants the devastating effects of an eating disorder. Contrary to popular belief, no one chooses to have an eating disorder.

How Anosognosia May be Affecting You

It’s already difficult enough to observe as a family member or loved one suffers from Anorexia nervosa, but anosognosia can make it incredibly distressing and frustrating. Despite your pleas, watching as your loved one deteriorates physically and emotionally, while they remain unaware of the severity of their condition, can evoke feelings of helplessness and despair.

To best help your loved one, you must recognize that anosognosia is not a choice but rather a symptom of the disorder. 

It is deeply rooted in neurological and psychological mechanisms impairing the individual’s ability to perceive reality accurately. This is completely out of their control, and without professional help,they may be unable to leave behind their problematic and highly dangerous behaviors.

The Role of Brain Connection in Anosognosia

Research suggests that anosognosia in anorexia nervosa may have an anatomical basis. 

Brain imaging studies indicate abnormalities in brain structure and function. According to a study published in the European Eating Disorder Review, up to 80% of individuals with anorexia exhibit some degree of anosognosia.

Malnutrition, a hallmark of anorexia, can lead to significant changes in brain chemistry and structure. This potentially contributes to the development of anosognosia. These neurological alterations can impair the individual’s ability to recognize their illness and hinder their motivation to seek help. This perpetuates the cycle of disordered eating behaviors.

The good news is with nutrition rehabilitation, anosognosia diminishes. 

Navigating Treatment and Recovery

Supporting a loved one with anorexia nervosa requires patience, empathy, and a comprehensive understanding of the disorder. Here are some ways you can help your loved one on their journey to recovery:

Show Compassion and Understanding

When you are speaking to your loved one about their eating disorder, it’s important to approach the conversation with compassion. You want to validate their experiences and avoid judgments, criticism, and shaming.

Encourage Professional Help

Although it may be difficult for someone with an eating disorder to want to receive treatment, it is still important for you to encourage it. Most success is found in early intervention. When the illness is treated, early on, there are often better outcomes than for those struggling without help for years.

Educate Yourself

One of the best things you can do to support your loved one if they are struggling with anorexia and/or anosognosia is to educate yourself on the facts. This should include the common signs and symptoms, possible treatment options, and debunked myths. This information is powerful in helping you better advocate for your loved one and their well-being.

Foster Open Communication

Create a safe and supportive environment where your loved one feels comfortable discussing their thoughts and feelings. Encourage open communication and active listening, allowing them to express themselves without fear of judgment or criticism.

Practice Self-Care

Supporting a loved one with an eating disorder can be emotionally and physically draining. Take care of yourself and prioritize your own well-being, seeking support from friends, family, or mental health professionals if needed.

Be Aware of Triggers

One of the most important things to keep in mind is that even those deep into recovery can and will experience triggers. You can avoid adding to these by educating yourself on avoiding phrases and conversations, such as calorie counts or weight loss.

Expert Eating Disorder Treatment

If you think that a family member, child, or friend of yours is struggling with an eating disorder, it is important to consult a professional. With proper treatment, individuals can overcome their eating disorder and live a healthier life, both physically and mentally.

I am Alison Pelz, a psychotherapist and registered dietitian with over 16 years of experience. I specialize in treating eating disorders in Austin, TX. 

If you or someone you care about is struggling with an eating disorder, don’t hesitate to reach out for help. To learn more about expert eating disorder treatment and schedule a consultation with me today. I am here to help you and your loved ones reclaim their lives and break through the chains of disordered eating.

Are you a clinician? Sign up for my mailing list and CE course!

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