Night-vision cameras, heavy whipping cream, and “magic plates”: The fascinating world of Family-Based-Therapy (FBT) for anorexia

I think it was back in 2009 that I first stumbled upon the Around the Dinner Table online forum or what my best friend and I cleverly call the “Maudsley Mom Forum.” At the time I was already aware that Family-Based Therapy (FBT; also referred to as the Maudsley Method) existed. However, this was the first time I saw it “live” in action and it was actually quite terrifying.

When your kid asks, “Dad, what’s in this shake?” you’re going to need a story. And the story can’t be “about 75% heavy cream, 20% heavy syrup, and some other stuff for flavor.” The truth won’t fly. So give some thought to your alibi before you are asked to come up with an answer. It goes without saying that the kid can’t be in the kitchen when you are making a shake.

Make vegetarian chili and then dump a bunch of olive oil into it. 100 kcal per Tbsp is the oil. It is a good oil, tastes great, requires no explanation. Dump it into anything. What they eat is not the issue. The total kcals is. We don’t care how the kcals come in but they have to come in. Shakes, oils, Boost, HWC, whatever. It is all the same.

These are just a few selected posts from the “High calorie suggestions” thread that dates back to 2005 and is still going strong today. It’s pretty much what it looks like– a bunch of highly involved concerned parents of children and adolescents with anorexia trading tips on how to trick their little ones into packing on the pounds. Because recovery from anorexia is a simple matter of stuffing a person with food, right? Oh boy.

Here’s a brief description of FBT from the Around the Dinner Table forum:

Family Based Therapy (FBT) is a home-based treatment approach that today remains the only treatment proven effective in controlled trials for anorexia nervosa in adolescents.  FBT takes an agnostic view of cause of the eating disorder but instead places initial focus on re-feeding and full weight restoration to promote recovery. All family members are considered an essential part of treatment. FBT has been successfully adapted and utilized with adults of all ages. FBT does not focus on psychological therapies, though family therapy and individual therapies may be employed after full weight restoration is achieved.

From that description, it doesn’t sound so bad. And it is true that FBT has shown some promising results for children and adolescents with anorexia. However, I can guarantee you that the parents sneaking butter and heaving whipping cream into every ounce of their child’s food are not the ones seeing those promising results.

FBT abides by the principle that anorexia is a biological disease that can be fully cured through proper nutrition and weight restoration. There is no need to go searching for any “underlying cause” because it was nothing any one could have controlled. A person with anorexia is suffering from malnutrition and can’t benefit at all from therapy anyway until fully weight-restored. To treat anorexia, parents needs to stop everything they’re doing and devote their entire life for the next 6-12 months to their sick child. There’s no need to see a dietitian or to worry about meal plans or any of that because the goal should simply be on feeding the child. And what parent doesn’t know how to feed their own child? That’s like, a mother’s instinct, right?  Once the child reaches an appropriate weight, she will be back to her normal old self again. And if she isn’t, you just aren’t feeding enough! More food! Higher weight! Food is medicine!

I’ll admit it’s easy for me to get carried away with my sarcasm here, but there are aspects of FBT that I like. Obviously malnutrition affects the brain and certain symptoms like starvation-induced depression and obsessive thinking are alleviated somewhat with proper nutrition. It’s also true that some people truly aren’t capable of engaging in therapy when they are profoundly malnourished. And yes, having the support of a parent can be crucial for young sufferers.

The problem I have with FBT (that was an even bigger problem in its early days) is when people take it to extremes or overstate its effectiveness. Lying to a kid about what you’re putting in her food is always wrong. You think your kid is afraid of food now? Just wait until she finds out that 200 calorie homemade yogurt you’ve been giving her is actually 1300 calories of heavy cream and lard. Dismissing all potential environmental influences of your kid’s eating disorder is also wrong. Accepting that the way she was brought up may have contributed to her distorted beliefs about food and her body is not the same as admitting to being a bad parent. If you’ve been feeding her 5,000 cals/day for the past year and she still hasn’t “gotten rid of the evil ED” despite now being in the overweight BMI range, feeding her even more is not the answer.

I know FBT does “work” for some kids, usually kids who are diagnosed very early into their disorder who have parents who are truly equipped to deliver FBT in a reasonable way. This leaves a lot of people still suffering despite the hardcore FBTers making it seem like they’ve made some kind of miraculous headway in ED treatment. Not every family has the luxury of having one or both parents devote the majority of their waking hours to feeding and monitoring their child. Both parents may work long hours, if there are two parents. Even parents who do have the time, many are not be cut out for that kind of intensive work with their child. Not to mention, many children themselves are not cut out for that kind of treatment. Many end up resenting their parents and plummeting deeper into their ED as a result. And I’m sorry, I don’t care what anyone says, FBT does not work for adults. I mean, I know there have been a few rare cases where an adult with anorexia happens to have this really special (weird?) relationship with her parents and is totally okay putting her life on hold and being somewhat force-fed by mommy and daddy, but this is clearly not the norm.

I’ll admit I used to spend way too much time perusing the Around the Dinner Table forum out of sheer curiosity and morbid fascination. My friend and I would send each other links to particularly outlandish posts asking, “Can you believe this?
magicplateAre they for real??” Yes, they were for real. One clever dad getting all excited over his new “night-vision” hidden camera to catch his daughter sneaking out to exercise at night. And don’t even get me started on the “Magic Plate…”

I sometimes wonder how things may have been different for me if I was given true reasonable FBT as a newly diagnosed 12 year-old. Maybe all I needed was gobs of hidden oil infused into my food and another 20 lbs? Heh… doubtful. I can’t seriously picture either one of my parents having any luck sneaking crap into my food or convincing me to eat off some headache-inducing “Magic Plate.”

To reiterate, I am not completely anti-FBT. It has its place when delivered in a reasonable way. And actually, it was my discovery of Around the Dinner Table seven years ago that initially got me fired up about some very important issues in the world of eating disorder research. I plan on expanding on this topic in my next blog post, so stay turned!

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