Thank you for your feedback. I appreciate your thoughts on this issue.

I am so sorry to hear that you and your family had such an awful time with FBT.

Out of curiosity, what would you have liked your therapist to do differently that would have made treatment more helpful to you? How do you think FBT should be modified or improved in cases like yours? What kind of treatment would have been most effective for you, given your personal and family circumstances?

I am always looking for ways to improve my practice, and researchers are (or at least should be) trying to improve upon existing treatments. You seem to be in a good position to offer insights on this, having been through the process yourself.

1.) “I work with adults. FBT is not applicable to most adults.”

I have actually not seen any evidence of this (outside of the age range of 18-20 which is practically no different from 17-18 anyway).

A case study I HAVE read from the University of Chicago (I believe by Dr. Chen) was a ridiculous piece of literature supporting FBT in young adults.

FBT studies in adolescents have mainly been done for AN. This case series had 4 adults — 3 of which did NOT meet criteria for any clinical eating disorder upon beginning the study — both psychological criteria (EDI scores) and behavioural/physical criteria (not underweight, no b/p, etc.). The ONE individual who was considered anorexic had not achieved remission by the time the study had terminated. If I remember correctly, for the others, their EDI scores remained sub-clinical (as would be expected) and some subthreshold behaviours remained.

Yet the study somehow concluded a 50% recovery rate (from a sample size of 4!!) and made the assumption that FBT could be applicable in adult populations.

My understanding of Cynthia Bulik’s UCAN research was that there were significant modifications from Maudsley FBT to allow for differences between parent/child and spousal relationships — I don’t know if it is 100% fair to call it Maudsley.

I realize there is anecdotal evidence from FEAST, etc. that FBT does work in adults — but I think this highly depends on the adult — the financial dependency upon family, emotional immaturity, etc.

2.) “Some families can’t do it.”

As you said — true. But I take issue with this statement,

“The only real contraindications for FBT in patients under18 are cases in which the patient has been physically or sexually abused by a parent, or both parents are so mentally or physically ill that they are unable to care for their children.”

I’m sorry, but FBT is incredibly stressful for both family and child — especially on the parents who believe that they are solely responsible for their child’s recovery. FBT can quickly exacerbate a mental or physical illness and create turmoil within the family. I speak from my own experience.

My parents are alcoholics — but highly functioning alcoholics. They only drink at night, they hold prestiguous jobs, have won awards, have hobbies — and yet they fall asleep drunk on the couch each night. My mom has an anxiety disorder that in her youth caused a nervous breakdown and my dad lost both his parents to cancer in his early twenties. My sister has cerebral palsy and is physically disabled. My AN strained the balance of our already fragile family.

Our FBT knew nothing of this and I was not about to enlighten him. My parents were NEVER physically abusive or verbally abusive, are WONDERFUL people and only wanted to support me. BUT under FBT things increasingly escalated out of control.

My father didn’t want to lose me as he had lost his parents (even though I was in no physical danger at a BMI of 18 with no medical issues), but weekly sessions with the FBT made him feel like he should be able to help. My resistance and his fear quickly escalated to physical violence (I was punched, dragged out of my bed, food was thrown BY my parents, etc. ) This was a man who had NEVER before been abusive in ANY way.

My mom become antagonist, angry and irrational when she is intoxicated. This did not bode well for rational mealtime behaviour or support — in fact, she often became verbally abusive and blamed me for the stress and my dad’s reaction.

My sister became reclusive, terrified and attempted to stop my parents from this. She could see the insanity and spoke strongly against it.

I wanted to tell my story because this is a family unit that although had problems was functioning, never abusive and had very strong bonds of love/affection. I take issue with the fact that you believe the ONLY time FBT is not appropriate is when things have escalated to such severity (before beginning FBT!) that the child should be in foster care. That is absolutely ridiculous.

As a therapist, I think you fail to appreciate the strain that FBT puts on families with already existing problems. I think the child DESERVES to be treated by parents who are emotionally stable, rational and healthy — I wonder at the quality of the decisions that are made day by day when a mentally ill parent is driven by fear and desperation.

It is not enough to say that the therapist should be able to “sense” these issues. It is not enough to expect a terrified child to explain this to a therapist they barely know. More dangerously, once FBT sessions start up, such concerns are in danger of being dismissed as ED stories and do you REALLY believe the parents are going to admit the truth?

That’s all — besides these points, it was a well written blog post. But I’d encourage you to be careful as to what you say before you post. You are greatly respected by many parents and your words carry great weight.