FBT and CBT-E for Adolescents with Eating Disorders

Family-based treatment (FBT) is the current leading recommended intervention for adolescents with eating disorders. As this treatment has certain limitations, alternative approaches are needed. The National Institute for Health and Care Excellence (NICE) has recently recommended cognitive behavior therapy (CBT) for eating disorders in children and young people when family therapy is unacceptable, contraindicated, or ineffective. This recommendation was supported by promising results demonstrated by the enhanced version of CBT (CBT-E) adapted for adolescents with eating disorders.

Given the importance of the NICE recommendation, in this post, I describe the main differences (see Table 1 for a summary) and similarities between FBT and CBT-E.

Principal differences between family-based treatment (FBT) and enhanced cognitive behavior therapy (CBT-E)

Source: Riccardo Dalle Grave

Conceptualization of eating disorders

In FBT, the problem or symptoms belong to the entire family, and therapy works to separate the illness from the patient (externalization), enabling parents to temporarily take control of their child or adolescent’s eating.

The initial focus of FBT is the task of weight restoration through the parents’ efforts at home. Once this is achieved the focus gradually shifts toward adolescent issues with the family, and the therapist encourages the family to examine the relationship between adolescent issues, working towards increased personal autonomy for the adolescent, and establishing more appropriate intergenerational boundaries. Toward the end of treatment, the therapist will check with the parents, if appropriate for the age and developmental stage of the children, regarding their needs.

CBT-E, on the other hand, views the illness as belonging to the individual. Cognitive behavioral theory postulates that these patients have a shared but distinctive self-evaluation scheme based on their overvaluation of shape and weight (i.e., judging oneself predominantly or even exclusively in term of shape, weight, and their control) which plays a central role in maintaining all eating disorders. This gives rise, directly or indirectly, to the other clinical features of the disorder, that in turn maintain and intensify, with several mechanisms, the overvaluation of shape and weight.

The clinical “expressions” of the patient’s eating disorder and the mechanisms that act to reinforce them are then addressed by a progressive series of well-specified CBT strategies and procedures designed to help patients to change their behavior and reflect on the consequences of these changes. The ultimate aim is to train patients how to decentre from and overcome their difficulties, and, thus, for them to learn to control their eating-disorder mindset, rather than the mindset controlling them.

Involvement of parents and adolescent

Parents’ involvement in FBT is vitally important for the ultimate success of the treatment. Moreover, in FBT, parents must defer working on other family conflicts or disagreements until the eating-disorder behaviors are resolved.

Source: AdobeStock

Parents’ involvement in CBT-E is useful but not essential. The role of parents is only simply to support the implementation of the one-to-one treatment.

Both treatments pay attention to adolescent development, however, in FBT the adolescent is not viewed as being in control of his/her behavior (the eating disorder controls the adolescent), and this is corrected by improving the parental control over eating in the first phase of the treatment. On the contrary, in CBT-E the adolescent is helped to learn how to control his/her behavior, and parents may be involved in helping the adolescent in pursuing this task.

In FBT, the adolescent is initially not actively involved and plays a more passive role, although his/her role becomes more active in the last phase of the treatment, while in CBT-E the adolescent is encouraged from the beginning to become actively involved in the treatment.

Treatment team

FBT involve a multidisciplinary team, and each member may contribute to its effects. Most prominent is the psychotherapeutic element, focusing on weight restoration, and is delivered by a primary clinician (e.g., child and adolescent psychiatric, psychologist or social worker/family therapist). In the most recent FBT trials, this involved no more than 20 one-hour family sessions over about nine months. Another component is the sessions with a physician with expertise in the medical management of adolescents with anorexia nervosa. These meetings usually start out weekly, before tapering off to monthly or six-weekly, as is clinically indicated. Hospitalization for medical instability should be pursued when indicated.

CBT-E is provided by one therapist (e.g., psychologist or a health professional trained in the treatment) who is substituted when they have to be absent. It is delivered in 20 treatment sessions over 20 weeks (in not underweight patients) and 30 to 40 sessions over 30 to 40 weeks (in underweight patients). The treatment also involves a 90-min assessment session with only the parents and some 15- to 20-min sessions with the patient and parents together. No additional therapeutic input, other than an initial assessment by a physician to check that the patient is suitable for outpatient treatment and reassessment if there were physical concerns (e.g., due to weight loss or frequent purging), is required. Hospitalization for medical instability, as FBT, is recommended when indicated.

Similarities between FBT and CBT-E

Despite several differences, the general strategy of FBT and CBT-E is to address the maintaining mechanism of the eating disorder psychopathology, as opposed to an exploration of any potential causes of the eating disorder psychopathology.

A major focus of both treatments is to help the adolescent patient to normalize body weight and to support the adolescent’s return to a normal developmental trajectory of weight.

Both FBT and CBT-E, although using different procedures, include regular weighing of the patients within each session.

Another possible mechanism of action shared by FBT and CBT-E is how they might indirectly reduce the over-evaluation of shape and weight once the patient has normalized weight: CBT-E helps the patient to enhance the importance of other domains of life (e.g., school, social life, hobbies, etc.), while FBT works toward increased personal autonomy for the adolescent.

Conclusions

The availability of two effective treatments for adolescents with eating disorders now opens the chance to compare them in a randomized controlled trial to compare their effectiveness and whether particular types of patients respond better to one or the other.