How to Know if You’re Ready for Phase Two of FBT

In the realm of eating disorder treatment, Family-Based Treatment (FBT) stands out for it’s efficacy for families grappling with the challenges of supporting a loved one through recovery.

Pioneered by Drs. James Lock and Daniel Le Grange in the 1990s, FBT has since emerged as a leading approach for adolescents with Anorexia Nervosa, Bulimia Nervosa, Avoidant Restrictive Food Intake Disorder (ARFID) and Other Specified Feeding and Eating Disorders (OSFED).

At its core, FBT recognizes the pivotal role of families in the recovery process, acknowledging that eating disorders do not exist in isolation but profoundly impact the family unit as a whole. Unlike traditional individual therapy models, FBT actively involves parents and caregivers as primary agents of change, empowering them to take an active role in guiding their child towards a healthier relationship with food and their body.

Central to the success of FBT is its structured framework, which is divided into three distinct phases. In this blog post, we'll delve into the intricacies of Phase 1 and Phase 2, shedding light on the transition between these crucial stages of treatment.

Phase 1 of FBT is characterized by the establishment of parental control over the adolescent's eating habits. Parents take charge of planning and supervising meals, ensuring adequate nutrition intake, and interrupting harmful behaviors related to the eating disorder. This phase is marked by intensive support and monitoring, with therapists guiding parents through the challenges of navigating resistance and fostering a supportive environment at home.

As families progress through Phase 1, they begin to witness gradual improvements in their child's physical and emotional well-being. With the restoration of weight and stabilization of eating patterns, the focus shifts towards promoting autonomy and self-regulation in Phase 2. This transition represents a pivotal moment in the treatment journey, as families navigate the delicate balance between providing support and allowing their adolescent to take greater ownership of their recovery.

In Phase 2, the emphasis is on gradually transferring control back to the adolescent, empowering them to make independent choices around food and challenging maladaptive thoughts and behaviors. Therapists work closely with families to facilitate this transition, providing guidance and support as adolescents navigate the complexities of self-directed recovery.

By understanding the fundamental principles of Family-Based Treatment and the distinct phases involved in the process, families can approach treatment with clarity and confidence, knowing that they are equipped with the tools and support needed to navigate the journey towards healing and recovery. Stay tuned as we explore the important prerequisites before entering Phase two.

Prerequisites for Phase II FBT:

1.   Medical stability and Weight restoration

Ideally, your teen has been weight restored to Target Goal Weight (TGW)* for at least a few months. At minimum your teen is at 90% of the TGW. The vast majority of adolescents are not ready for autonomy over their food intake until they achieve 100% of their TGW. Further, a weight restoration meal plan is significantly higher and more challenging than one on maintenance.  Research has shown that higher rates of relapse happen when autonomy is transferred over prematurely and the teen is not quite ready to handle it, thus leading to an increase in eating disorder thoughts, urges, and behaviors. Relapse is often coupled with a much harder time getting back to where the teen was in recovery pre-relapse, thus it’s recommended to take a more cautious and conservative approach. It’s better to go slow and be overprepared, then too quickly and underprepared leading to a regression or relapse. In my experience, many teens need to maintain their TGW for a number of weeks and even months before they are ready to enter Phase II.

*TGW, also known as estimated body weight (EBW), is a personalized, estimated target weight range for optimal recovery based on available growth records that take into account normal expected growth in the next 12 months. Additional health information is used to determine medical stability including: vital signs, labs, EKG, menses (if applicable), among other factors. This estimate may be greater than the highest prior weight because weight gain is expected with normal growth and development, even after reaching one’s adult height. TGW estimates will adjust over time, increasing with age and changes in height, or as additional information becomes available that informs the estimate.

2.   Your teen is no longer engaging in eating disorder behaviors such as restricting, bingeing, purging, excessive exercise, negotiation, etc.

It’s expected that your teen will still have eating disorder thoughts and urges, but they are able to externalize their eating disorder enough, and they have a strong enough healthy self to challenge these thoughts and urges, not act on the behaviors. Your teen is eating all of the food provided to them, in a reasonable amount of time, without much fear or resistance. Your teen will still have some anxiety around eating at this point – that is to be expected. The point is that your teen needs to be able to push through the distress and eat what their body requires without a significant struggle. You want to be able to trust that when they are in the driver seat of their decisions, they will be able to listen to their healthy self (eg. The healthy part of their mind rooted in sound judgement and stable emotions) rather than the eating disorder.

3.   Your teen has some intrinsic motivation for recovery.

In FBT, we don’t expect teens to choose recovery themselves, at least not to start. This is because Anorexia Nervosa, among other eating disorders and co-occuring mental health disorders, are ego syntonic. Ego-syntonic refers to instincts or ideas that are acceptable to the self; that are compatible with one's values and ways of thinking. They are consistent with one's fundamental personality and beliefs. In short, the beliefs and values of the eating disorder align with beliefs and values of the person; there’s little to no separation, thus why would a person want to change? This is one of the main reasons that parents assume control of eating and renourishment in the early phases of FBT. At some point, the expectation is that teens developing externalization from their eating disorder—they can separate themselves from it. Through this process, they may begin to realize that it may not be 100% aligned with their values and they may begin to challenge certain beliefs. It usually starts as external motivation, like “I don’t want to have to go to so many medical appointments” or “I don’t want to be supervised anymore”. Eventually, this becomes more internal “I want to be physical healthy so I can play sports” or “I want to have less anxiety and distress around eating and my body”. Once your teen reaches a contemplation or action Stage of Change, you can consider turning over some autonomy.

4.   Your teen is able to tackle food challenges; and rigidity around food decreases.

While they may not want to, your teen is willing and able to tackle hard foods or other stressful things, like not exercising. There’s an understanding that exposure to fear and guilt is a necessary and important part of recovery, and your teen is willing to cooperate with you around these challenges. Over time, there should be less anxiety and guilt and increased food flexibility. Food is no longer labeled as ‘good’ or ‘bad’ or moral. Your teen may even be enjoying food again.

5.   Your teen expresses some readiness to take on more responsibility.

Your teens is able to express a desire to assume some control over their eating and confidence that they can feed themselves appropriately.  Many teens express a desire to regain control over their eating long before they are actually ready. This premature push for independence may be partially motivated by a normal adolescent drive for freedom, but it may also be motivated by the eating disorder’s desire to restrict and lose weight. Therefore, it is a mistake to only base the decision around autonomy on your teen’s expressed readiness. Rather, all of the former criteria need to be met before transitioning to Phase II.

Be consistent. Be empathic. Be firm. Be loving.

Written by Erika Bent, LMFT, LPCC, CEDS-S

March 8, 2024 

 If you are seeking eating disorder treatment or mental health therapy for your adolescent, Cypress Wellness Collective can help. Cypress Wellness Collective is located in the San Francisco Bay Area where they specialize in Family Based Treatment (FBT), therapy, and nutrition counseling for teens and families going through eating disorder recovery. They offer in person and virtual appointments throughout all of California. Call today for your free consultation to see if Cypress Wellness Collective is right for you!