Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

Navigating Phase II

There is a common misconception that Maudsley Family-Based Treatment (FBT) is all about parental control of feeding. While Phase I of FBT does require parents to take control of their ill child’s food intake to help her restore her weight, FBT also encompasses two other very important phases. In Phase II, parents return control over eating to their child as she demonstrates readiness to eat on her own. Phase III involves helping the adolescent return to normal development and establish a healthy identity.

Weight restoration is an essential first step in overcoming AN, but it is only the first step. Equally important is the ability to feed oneself properly and maintain a healthy weight independently. Without the ability to eat independently, opportunities are limited and quality of life is greatly diminished. Recovery from an eating disorder is about more than just restoring a healthy body – it is also about restoring a healthy mind and a fulfilling life.

Phase I tends to be the most tumultuous and draining for the family and the most agonizing for the patient, but the task at hand is very straight-forward: eat more and gain weight.

Phase II, however, is much more ambiguous. Parents and clinicians struggle to determine when a patient is ready to begin Phase II. The patient herself may send mixed signals – she may beg for the freedom to eat lunch in the school cafeteria and go out to dinner with her friends, but yet she is clearly unable to take a single bite of food that isn’t “required” and “supervised.” To outsiders, the patient seems normal – she looks healthy, she acts more or less like a typical teenager (in between mealtimes, at least), but appearances belie the still-raging battle in her head. Still tormented by the anorexic thoughts and compulsions, she feels torn between a wish to return to the safety of emaciation and a desire to dive headlong into the normal life she has been missing.

I use the following benchmarks to help families determine when their child is ready to enter Phase II:

• The patient has been fully weight restored to his/her historic growth curve (per pediatric growth chart percentiles) for at least a few weeks. While the FBT manual (Locke & Le Grange, 2001) recommends beginning Phase II when the patient is at 90% of her ideal body weight, I have found that the vast majority of patients are not ready for any control over their food intake until they achieve 100% of their ideal body weight. In my experience, many patients need to maintain their ideal body weight for a number of months before they are ready to enter Phase II.

• The patient’s metabolism has normalized to the point that she no longer requires a very high-calorie diet. It is hard enough for the patient to feed herself a normal meal – don’t make it even harder by expecting her to serve herself very high calorie meals.

• The patient is no longer engaging in eating disorder behaviors such as restricting, bingeing, purging, or excessive exercise.

• The patient is eating all of the food her parents provide her, in a reasonable amount of time, without much fear or resistance. [NOTE: the patient will still have some anxiety around eating at this point – that is to be expected. The point is that the patient needs to be able to push through that anxiety and eat what she needs without a struggle.]

• The family is no longer operating in “crisis mode.” The parents feel confident that they can help their child defeat the eating disorder, and the child has accepted that her parents have taken charge.

• The patient expresses readiness to assume some control over her eating and confidence that she can feed herself appropriately. [NOTE: Many patients 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 ED’s desire to restrict and lose weight. Therefore, it is a mistake to use the child’s expressed readiness as the sole criteria for entering Phase II. Rather, you want to look for the child’s expressed readiness in addition to the previous criteria.]

Here are some general principles I discuss with families to help them navigate the uneasy waters of Phase II:

• Have a vision.

I like to begin Phase II with a vision of how the patient’s life will look at the end of Phase II. By the end of Phase II, the patient needs to be able eat on her own while maintaining her weight, in an age appropriate way, in the context of her family and her normal life. All patients, regardless of age, will enter Phase II eating in the same way – with parents in control of what, when, and how much they are eating. However, the end goal of Phase II is different for a 10-year-old than for a 16-year-old or a 22-year-old. A good frame of reference in creating your vision for Phase II is to look at the amount of autonomy the patient’s friends have with regards to their eating.

For example, by the end of Phase II, a pre-teen patient should be able to eat lunch with her friends in the cafeteria at school, order from a restaurant menu, select her own after-school snack and eat it without supervision. She should be able to have a few meals and snacks at a friend’s house during a sleep-over, or spend the day away from her parents on a field trip. She should still share meals with her family each day and eat what the family is eating.

By the end of Phase II, a high-school age patient should be able to prepare a simple breakfast and lunch for herself when needed, serve herself appropriate portions at dinner, eat a meal on occasion without her parents present (for example, dinner on her own if her parents are out for the evening), and go out to eat with friends. Regular family meals are still important for teenagers so that parents can keep an eye on their child’s eating behavior, even when the teen is eating many of her meals and snacks on her own. A young adult patient who is preparing for independent living should be able to plan her menu, shop for groceries, cook for herself, and eat without parental supervision.

• Take baby steps, go very slowly, and accept that this Phase will take a long time.

In my experience, Phase II usually takes somewhere between 3-12 months, depending on the severity of illness and other individual differences.

• Accept and embrace the fact that Phase II poses an inherent risk.

Like many things in life, giving a recovering anorexic more control over her food intake involves some degree of risk. It is likely that the patient will experience struggles and setbacks during Phase II. Try to learn and grow from these slips, and help her do the same. Keep in mind that you can, to some degree, manage the amount of risk involved by ensuring that the patient is genuinely ready before starting Phase II, monitoring her closely over the course of this phase, and stepping in to help her when needed. I liken this process to helping a baby learn to walk. You wait until she is confident in her crawling. Of course she will stumble and fall, but she will grow stronger each time she pulls herself back up. And you can provide her with a soft, carpeted surface on which to practice her steps.

• Have the patient practice choosing and preparing her food under supervision before she is permitted to eat unsupervised.

I typically start Phase II by having the patient choose and prepare one snack each day under parental supervision. The parents observe the child’s food selection and gently guide her in the right direction if needed. For example, let’s say the child chooses crackers with peanut butter and puts 4 crackers with a thin coating of peanut butter on each one. The parent may say: “That’s an excellent, balanced choice, but it’s not quite enough nutrition. Let’s put three more crackers on the plate and add more peanut butter.”

I usually require a patient to have at least a week of consistent success preparing a meal/snack under supervision before moving on to the next meal/snack.

• Be systematic.

I typically coach patients to proceed through Phase II by giving back control of one meal or snack at a time and allowing the child to gain mastery of each meal/snack before moving on to the next one. For example, the child may begin Phase II by assuming control of her own after-school snack, while parents maintain control of all other meals and snacks.

• Assess progress regularly.

The patient should be weighed weekly during this phase, and family members should keep tabs on her mental state and behavior daily. If she is maintaining her weight within her healthy range, and her mood and behavior around food are good, then it is time to move forward to more independence. If her weight drops, or if she demonstrates an increase in eating disorder behaviors (even in the absence of weight loss), then it is time for parents to take back more control of her food intake.

• Take back control when necessary.

Nearly every patient has a few setbacks during this Phase. It is the parents’ responsibility, with the guidance of their clinician, to take back more control over the patient’s food when she has not been able to manage eating on her own. The step backwards is a temporary measure to help her get back on track, and she will regain control when she demonstrates readiness.

• Some patients need a gentle nudge to move forward.

While many patients are all too eager to take back control over their food intake, some become overly dependent on their parents to feed them and have great difficulty moving forward. This makes sense in light of the nature of AN – being fed by your parents is a passive process which does not involve taking personal responsibility. The “ED voice” quiets down after several months of full nutrition, and the patient is able to eat well without too much guilt when she is being “forced.” The acts of preparing one’s own food, deciding what to order from a restaurant menu, or choosing whether to have a snack when no one is watching – these are all acts of defiance against the “ED voice.” Patients are flooded with anxiety, indecisiveness, and guilt when the time comes to make these choices. It is a scary step for parents and patients alike. Some patients require lots of encouragement to become more independent with their eating. I find that it is often helpful to remind the patient of the benefits of being able to eat independently, such as spending more time with friends and doing other activities away from home. Some younger patients respond well to concrete, short-term rewards for eating independently. For example, a 6th grader who successfully manages her afternoon snack every day for a week without weight loss may be rewarded with a trip to the movies.

• Be realistic.

Many parents lament that their recovering child no longer goes out for ice cream on a whim or breezes into the kitchen to grab a few cookies or gives herself generous second helpings of her favorite meals. I advise parents that it is unrealistic to expect a recovering anorexic to eat freely or spontaneously. Some people who have recovered from AN are eventually able to eat intuitively, but not until they have been well for at least a year or two.

• Don’t force Phase II into an external timeline.

Don’t rush through this phase just so that the patient can eat lunch with her friends when the school year starts go away to college at the same time as all of her friends. The only timeline that matters is the patient’s recovery timeline, which may or may not be convenient for her (or you). Each person’s recovery moves forward at a different pace.

• Remember that whatever happens is simply feedback, not failure.

Keep in mind that the patient will probably struggle quite a bit at first. Re-learning how to feed oneself properly after a bout of AN is a very difficult task. If a patient is not able to take charge of a meal or snack, that says nothing about her character or her effort or her prognosis for recovery. It simply means that she is not ready for that step yet. Expect the patient to make mistakes, and be there to help her correct them without blame or judgment. Remember that she is doing the best she can.

• Keep things in perspective.

As challenging as Phase II can be, don’t lose sight of how far the patient has come. She is eating well, she is at a healthy weight, she is medically stable, and she is in effective treatment. In the long run, it doesn’t matter whether someone breezes through Phase II or whether it takes over a year – she’s safe, she’s physically healthy, and she will recover eventually.

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13 Responses to Navigating Phase II

  1. gobsmacked says:

    Thank you so much for this post, Dr. Ravin! It is so very relevant to our family. Our daughter has been weight restored for over a year and a half (over six months of which we spent weaning her off a hospital meal plan and working through fear foods), and she is doing very well in so many ways now, but she still needs us to serve her all her food and falls apart on a field trip. We have had to work without a trained FBT, and in some ways, we feel refeeding was a cinch compared to phase two. I think our daughter fits into the mold of having become almost comfortable with her dependency on our feeding her.

    I have a couple of questions.

    You say one requirement to begin phase two is:
    “• The patient is no longer engaging in eating disorder behaviors such as restricting, binging, purging, or excessive exercise.”

    Binging, purgeing, and excessive exercise are easy to see, but if one is putting all one’s child’s food in front of them, and they are eating it all within certain situations, what counts as restricting at this point? My daughter takes less than she should when I ask her to serve herself and argues the point when I push it. She finds excuses to eat less when she’s away from us for a day, even though I packed everything and gave her explicit directions, and it’s like a rolling stone, where she starts with her snack but ends with not eating her dinner. Would this count as restricting still, as in she’s just not ready?

    Another question is that she is unable to talk about her eating disorder at all. She goes into herself or lashes out, and after over two years of doing this, between her actual ED and post refeeding, our family has grown into this. We don’t talk about it. I feel like to be able to move forward with her independence, we need to be able to talk about it, even just enough to say “I know you would like more independence with your meals, here’s what you need to do…” Any thoughts on ways to open up some dialogue with someone who is completely closed off to it?

    Sadly, she doesn’t have a lot of friends or situations where she would like more independence. I think she’s molded herself a bit to our eating schedule. She doesn’t make a lot of plans, and she doesn’t get invited many places. So that makes it difficult to hold up the carrot of independent eating. When something comes up, I turn myself into a pretzel to make it work because it happens so rarely, and if I don’t do the pretzel thing, she goes downhill fast, but because she won’t talk about it, I can’t bring it up during the down times to say let’s work on this so that you can have more independence the next time something comes up.

    Thank you again. This information was sorely needed.

  2. Vicki Hams says:

    Oh boy! A friend (insert “angel”/”Godsend”/”inspirational mum”/) of mine forwarded this link and it couldn’t have come at a better time. Our daughter is WR (just) but completely unable to eat independently and we have felt both frustrated and compelled to try to rush this next step. I’m so grateful for this link as it puts some reality into what to expect and also how to push through it. This phase is so incredibly difficult as our daughter fears any further weight gain with such an irrational force that it is scarey. If we ask her for her choice in snack she will say “whatever has the least amount of calories” and raise one eyebrow at us as if to say “idiots”!! Need to get some stamina back for this bit I think!
    Thank you for this practical guide.

  3. Wendy says:

    So glad that you’ve put this in writing with rationale. As you know from working with us, for those with AN for longer time, their thoughts are more ingrained and the slow and steady approach with consolidating each gain is what worked for my Y/A D. Her ED behaviors were automatic and hard to change.

    I think that all parents knowing that it’s best to wait till their child is accurately and fully WR will bring the best outcome.

    And that navigating Phase II is a trial and error period with one change at a time. It helps families to realize that this is not a speedy process for many, and that small slips can be seen as feedback.

    There is nothing wrong with helping to get your child back on track when they are showing they need that intervention.
    What really helped my D was to identify her ED thoughts/behaviors so that she could eventually monitor herself and see where she struggles.

    And for her to know that being honest is what will help her battle those ED thoughts – rather than obeying them.

  4. Carrie says:

    It took me several years to progress all the way through Phase II. I started off living at home, then taking control of most meals, then I moved out and had to figure out grocery shopping (which I still do with my mom most of the time) and meal prep. Not that I haven’t had slips–even rather significant ones–during that time, but I’m glad and proud to say that I’ve finally figured it out.

    I’m adding this to my “must reads” on my blog. It’s brilliant.

  5. Eva Musby says:

    Thank you! Your posts are always so informative. Will you write one on Phase 3 now? I think most of us get discharged from treatment before that, so it’s a bit of a mystery to me what’s involved.

  6. Dr. Ravin says:

    Gobsmacked,

    The criterion for entering Phase II which is “no longer engaging in ED behaviors” simply means that restricting, bingeing, purging, and over exercise are no longer occurring BECAUSE the parents have successfully gotten these symptoms under control. In Phase I, with the way I coach families, the patient would not have an opportunity to restrict because all meals and snacks are supervised. So “no restricting” in this context simply means that all food served is being eaten without significant resistance (no trips to the ER, etc).

    Your daughter sounds like a kid who needs a nudge to move forward. However, it is hard to nudge someone who isn’t motivated by anything. There must be something she wants to do – spend time with friends, go on a trip, go away to college, do an activity – something to provide an incentive for her to start eating on her own.

    With regards to not talking about ED, this is not uncommon. My opinion is that it isn’t important in early recovery for a young patient to be able to discuss or even acknowledge ED. However, it will be important for her to become fluent in the language of ED before she lives independently so that she can manage her symptoms on her own. If she is still not ready to talk about it when it comes time for college, I would recommend keeping her home until she has shown better insight and maturity.

  7. gobsmacked says:

    Thank you so much Dr. Ravin. That makes sense. It will take some working to find something she wants to do that requires more independence. I am not sure if this is because of who she is or because of how our family has shaped itself around ED. When she wants to do something social, we bend over backwards to make it happen, because she doesn’t do it that often. If we made her being social dependent on certain behaviors, my guess is she’d just choose not to do those things, which is a problem in its own right. But we will examine this and see what we can come up with. I appreciate your response.

  8. Chartreuse says:

    Thanks for a fabulous post — I’m a psychiatry trainee and we get such mixed messages about how to treat eating disorders, particularly in the form of minimizing the importance of residual symptoms and minimizing the importance of full nutrition/weight restoration. Reading your blog helps me find a better way of working with families and patients.

  9. Mary Jeane says:

    Dr. Ravin – You wrote ” However, it will be important for her to become fluent in the language of ED before she lives independently so that she can manage her symptoms on her own. If she is still not ready to talk about it when it comes time for college, I would recommend keeping her home until she has shown better insight and maturity.”

    Our daughter has been recovering for 3 1/2 years (w/r since April 2009). She is in charge of her food with supervision from us. She is still not ready to talk about her illness and becomes extremely agitated any time we do. We have tried 3 different therapists and she will not talk. I think she would have with the last one but she would not accept our insurance. This is my biggest fear with her going away to college (potentially in one year) — that if she does not have any insight or maturity she will not be able to manage her illness. Any suggestions for moving her forward in talking about her illness?

    I so appreciate your knowledge!

  10. Dr. Ravin says:

    Mary Jeane,

    While you can make your child eat more and gain weight, you can’t make her have insight or motivation. Those things come from within. However, you can encourage her to develop insight by talking with her about the illness (which you have tried) and by having her in therapy (which you have also tried).

    I strongly recommend that patients live at home until they have demonstrated the insight and motivation to maintain their remission independently. Of course, a patient needs to be able to talk about her illness and demonstrate an understanding of what she needs to do to stay well in order for me to have confidence that she can manage on her own.

    My recommendation to you would be to sit down and have a talk with your daughter now about what criteria you require her to meet in order for her to live independently. If she won’t talk, that’s fine, just as long as she listens. Let her know that, as things are now, she is not nearly ready to live on her own. Let her know that you will need to see much more insight from her in order to consider allowing her to live independently. Be specific about what this would entail – for example, conversations with you and her father about managing ED and preventing relapse, seeing a therapist and actually talking about managing her illness, etc. I would recommend encouraging her to apply to local schools in case she is not well enough to go away next year. If she really wants to go away, use that as a motivator to get her to demonstrate insight. Let her apply to the faraway schools of her dreams (but NOT early admission, which is a binding decision) and by the time spring rolls around, you will have a better idea of whether she will be ready to go away, and her final choice of college will be contingent upon her readiness.

    It is unclear to me from your description whether your daughter lacks insight or whether she simply doesn’t wish to talk about her illness. If it is the former, you will have a much harder time getting her to come around. If it is the latter, then it is simply a matter of providing incentives for her to open up. It may be humiliating or upsetting for her to talk about her illness, and up until now there has been no real need for her to do so. What you need to do now is help her understand that the rewards of insight (a full, independent life) are worth the discomfort of opening up about her illness.

  11. Iris says:

    Thank you for your posts, Dr. Ravin. I rely on them for guidance that is so important to help my daughter recover. You state that phase 2 is entered once all ED behaviors are stopped. My daughter has been weight restored for 7 months . We had three meals and one snack with her for six of those months, but haven’t been successful in stopping binges which occur once every week or 10 days. Our team had us move to independent lunches,which we did a month ago. The weight has held steady, but so have the binges. Do you have any suggestions of how to help her with this? Her binges take the form of hungry days where she eats throughout the day, but with no intense out of control eating. She is actually quite engaging on these days, although at some point in the day she will start trying to hide that she’s eating yet again.

  12. Dr. Ravin says:

    Iris,

    What you describe as “bingeing” in your daughter sounds to me more like grazing. Some ED sufferers have what I call a “permission valve,” which is usually turned off (meaning they eat restrictively or according to rigid rules) but which gets turned on periodically, and while it is on they have “permission” from ED to eat whatever and whenever they want. The permission valve is dangerous because it often leads to a dysregulated cycle of restrict / over-eat / restrict / overeat. It can also very easily cause AN to morph into a binge / purge cycle.

    While grazing is not necessarily a bad thing, it can be problematic for ED sufferers, who usually need quite a bit of structure to keep their eating regulated and nourish themselves properly. Also, if you are posting this question on my blog, I imagine that you and/or your daughter see it as a problem.

    I would recommend viewing your daughter’s binges as symptoms, just like restricting, which she needs you to step in and help her stop. She may be ashamed and she may resist your help, but it sure sounds to me like she needs it.

    The best way to stop grazing is to serve three balanced, satisfying meals with plenty of protein and fat, along with three nutritious snacks in between. She may need support from family members or friends to distract her between eating times and help her refrain from grazing.

  13. gold price says:

    When an individual with AN restricts his/her food intake, he/she may also begin to develop negative evaluations about his/herself and distortions about food and exercise (e.g., self-doubt, overvaluing weight, perfectionism). Oftentimes, weight loss becomes reinforcing and can reduce anxiety caused by the negative self-evaluations. Overtime, dramatic weight loss occurs, leading to medical complications and continued cognitive distortions. For example, a patient with AN may not recognize that his/her low-weight is unhealthy and may actually find his/her low weight desirable.

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