Family-Based Therapy (FBT) / Maudsley Approach

Family-based therapy, or FBT for short, is an outpatient treatment primarily used for anorexia nervosa in children and adolescents. It owes its other name, the Maudsley Approach, to the Maudsley Hospital in London, where Christopher Dare and his colleagues developed it in the 1980s. U.S. researchers James Lock and Daniel Le Grange later summarized the approach in a treatment manual that is now used internationally.

The basic idea is that, in the case of an acute eating disorder, an adolescent is often unable to control their eating behavior on their own. In FBT, parents are not viewed as the cause of the illness, but rather as the most important resource for recovery. They are guided by the therapist to temporarily take over their child’s nutrition at home. Siblings are also involved, usually to provide support for the affected child. A course of treatment typically consists of about 15 to 20 sessions over the course of about a year.

FBT proceeds in three sequential phases.

• Phase 1—Refeeding and Weight Gain: At the beginning, the parents are responsible for meals. The therapist coaches them on how to support their child during meals in a way that is both kind and clear. A common analogy for this is “the clinic at home.” This phase is usually the most challenging for the family.
• Phase 2—Handing Responsibility Back: As weight increases steadily and the family’s mood stabilizes, parents gradually hand control over eating back to the adolescent, in a manner appropriate for their age.
• Phase 3 – Normal Adolescent Development: As soon as the child is largely able to maintain their weight on their own (a good benchmark is about 95 percent of the target weight), other issues come to the forefront: independence, friendships, and separation from the parents.

The German S3 guideline on the diagnosis and treatment of eating disorders (AWMF Registry No. 051-026) identifies family therapy approaches such as FBT as the first-line treatment for anorexia nervosa in children and adolescents. Such recommendations in an S3 guideline are based on the highest level of evidence, including, among other things, randomized controlled trials.

In comparative studies, FBT performed better for young patients than individual therapy focused solely on the child, particularly when the illness had not been present for very long (less than about three years). Some of the adolescents returned to a healthy weight by the end of treatment, and the results remained stable during follow-up examinations over several years. FBT is thus one of the systemic, family-based approaches considered particularly promising for younger patients. There is no guarantee of a cure, and the course of the condition varies from child to child.

For parents, FBT involves a lot of hands-on work, especially at the dinner table. In the first phase, they plan and supervise every meal, often several times a day. The therapist is not a passive observer but provides concrete guidance, discusses difficult situations, and builds the parents’ confidence in their own role.

An important component is separating the child from the illness. The eating disorder is described as something that gives the child instructions, which the family collectively opposes. This helps ensure that conflicts at the table are not experienced as arguments with the child. How parents support weight regain during the refeeding phase is a central topic of the initial sessions. FBT requires time, good communication between parents, and patience, because setbacks are a natural part of the process.

In German-speaking countries, there are currently few therapists specifically trained in FBT. Many clinics and private practices work with adapted family therapy approaches that follow the same basic principles.

An eating disorder requires professional intervention early on, because being underweight can take a serious toll on an adolescent’s body. The first places to turn to are pediatric and adolescent medical practices, as well as specialized outpatient clinics and hospitals for child and adolescent psychiatry. There, they will assess whether family-based treatment is appropriate or whether inpatient or day treatment is necessary at first.

Rückenwind Parents, we’re here to support you with coaching on issues related to daily life, stress, and family. The assessment, diagnosis, and selection of the appropriate therapy should be handled exclusively by a child and adolescent psychiatrist (KJP) or a medical or psychotherapeutic specialist.