Family-based treatment (Maudsley)

1. Introduction

Version followed: Lock & Le Grange, Treatment Manual for Anorexia Nervosa: A Family-Based Approach (FBT-AN). The session structure follows the 3rd edition (Guilford, 2025). Only its table of contents is drawn on; the book itself is not drawn on. Session contents come from the published HSE fidelity checklist and from articles by the manual's authors and their trialists. Two variants are noted where they differ: FBT for adolescent bulimia nervosa (FBT-BN; Le Grange & Lock, 2007) and the Maudsley service model, Family Therapy for Anorexia Nervosa (FT-AN; Eisler, Simic et al., 2016). [source: Guilford ToC; HSE checklist; Rienecke 2017; Eisler et al. 2016]

Family-based treatment (FBT) is an outpatient family therapy for children and adolescents with anorexia nervosa. It grew out of family therapy work at the Maudsley Hospital, London, and Lock and Le Grange later manualised it in the USA. Its core idea of change is this. Starvation keeps the illness going and cripples the young person's own judgement about eating. So the parents, the family's strongest resource and never the cause, temporarily take over all decisions about eating until weight and normal eating are restored. Control is then handed back step by step, and finally normal adolescent development is put back on track. Early weight gain is the main driver of physical and cognitive recovery, so the therapy front-loads behavioural change. [source: Rienecke 2017; Eisler et al. 2016; Lock & Nicholls 2020; div12 FBT-BN page]

2. Framework

Setting and team. FBT-AN is for young people medically stable enough for outpatient care. A lead therapist works alongside medical monitoring (a paediatrician or other physician, plus a nurse in some models) and usually a dietitian at the start. The Maudsley FT-AN service bases medical admission on an overall assessment of physical risk (heart rate, blood pressure, hydration, ECG and electrolytes, refeeding risk), not on weight alone. [source: Fitzpatrick 2012; NHS Lothian leaflet; Eisler et al. 2016] The exact team configuration in the manual itself is not drawn on. [uncertain]

Dose and format. About 20 sessions of 50–60 minutes over 6–12 months. Rienecke's review describes a 10-session/6-month short form and a 20-session/12-month long form. The 2020 adaptive trial protocol used 18 one-hour sessions over 9 months and defined 8 sessions as an adequate dose. Frequency is weekly in Phase I, every 2–3 weeks in Phase II (fortnightly in NHS Lothian; every 2–4 weeks in the trial), and every 4–6 weeks or monthly in Phase III. Sessions are conjoint (whole household, siblings included), opening with a short individual check-in with the adolescent. A separated or parent-focused format is the alternative (see 4.20). [source: Rienecke 2017; Fitzpatrick 2012; NHS Lothian; L'Insalata et al. 2020; Lock & Nicholls 2020]

Phase (3rd ed. sessions)	Goals	Move on when
Pre-treatment: initial evaluation and setting up treatment	Diagnosis, medical stability, agreement on outpatient FBT, team roles	Medically safe for outpatient care; family agrees to attend together
Phase I: weight restoration / refeeding (sessions 1–10)	Engage the family; parents take over all eating decisions (what, how much, when), supervise meals and snacks, curtail exercise, interrupt purging; keep the family's focus on the eating disorder; mobilise siblings as support; reduce criticism	Steady weight gain (roughly 90% of expected body weight in clinical accounts); eating without much struggle; little resistance to parental control; parents confident they could step back in if needed
Phase II: helping the adolescent eat on their own (sessions 11–16)	Keep parental management until the adolescent can eat and gain on their own; negotiate an age-appropriate return of control; begin linking adolescent issues to the illness; keep addressing criticism	Healthy weight is maintained independently, and eating-disorder behaviours have stopped or abated
Phase III: adolescent issues and termination (sessions 17–20)	Establish that the relationship no longer needs the symptom; review adolescent development and model problem-solving; check that the parents are functioning as a couple; plan for future challenges; relapse prevention; ending	Ending

[source: Guilford 3rd ed. ToC; HSE checklist; Rienecke 2017; Fitzpatrick 2012; Aspen & Boutelle 2014; L'Insalata et al. 2020; NHS Lothian] The checklist itself gives no numeric transition thresholds. The 90% figure comes from clinical accounts and case reports, and services differ in the weight metric they use (expected body weight vs. median BMI). [uncertain]

Decision point at session 4. Weight gain by session 4 is the strongest predictor of end-of-treatment remission: about 2.2 kg (2.88%) in Rienecke's summary, and 2.4 kg as used in the adaptive trial. Families below this mark are offered intensive parental coaching (4.17). [source: Rienecke 2017; L'Insalata et al. 2020]

FBT-BN variant. About 20 sessions over about 6 months, in the same three phases. Phase I targets regular eating and the interruption of binge eating and purging, with parents in charge but working more collaboratively with the adolescent, because the illness is usually more ego-dystonic. Phase II starts when acute symptoms have improved and the adolescent eats a regular, varied diet. There is more room to address comorbid problems. [source: div12 FBT-BN page; Rienecke 2017]

Maudsley FT-AN variant. Four phases: (1) engagement, (2) helping the family manage the eating disorder, (3) individual and family development, with a shift of responsibility for eating to the young person, and (4) ending. It adds systemic formulation, more individual work, and multi-family therapy. Its service data were a median of about 17 family sessions plus about 10 individual sessions over 11 months, which the authors state is not a protocol. [source: Eisler et al. 2016] Phase-transition detail in FT-AN is not drawn on here. [uncertain]

3. Guiding principles

Agnostic about cause. The therapist does not search for, or imply, a cause. In practice, redirect "why did this happen?" to "what will get her better?", and blame no one. [source: Rienecke 2017; div12]
Parents are not to blame; the family is the resource. Treatment is "with the family as opposed to treatment of the family" (Eisler et al. 2016). In practice, say explicitly that the parents did not cause the illness and that they are the best people to treat it. [source: Eisler et al. 2016; Lock & Nicholls 2020]
Externalisation. The illness and the young person are not the same. In practice, talk about what the anorexia demands rather than what the child wants, and let the young person choose their own words for it. [source: Rienecke 2017; Eisler et al. 2016]
Parental empowerment. Parents are the main agents of change and already know how to feed their child. In practice, express confidence in them, and coach their strategies instead of supplying a plan. [source: Rienecke 2017; L'Insalata et al. 2020]
Non-authoritarian therapist stance. The therapist is the expert on the illness and treats the parents as the experts on their family (Maudsley: "non-expert in the family"). In practice, do not prescribe an exact refeeding plan; ask what they will do and help them refine it. Watch that your expertise does not breed dependency. [source: Rienecke 2017; Eisler et al. 2016]
Pragmatic, symptom-focused, especially early. Phase I keeps an unwavering focus on eating and weight, and secondary problems such as low mood wait. In practice, keep steering each discussion back to food, eating and weight until these are resolved. [source: Rienecke 2017; HSE checklist; Lock & Nicholls 2020]
Urgency and seriousness. The family must grasp that this is a life-threatening illness that needs action now. In practice, Session 1 deliberately raises appropriate anxiety (4.7). [source: HSE checklist; Fitzpatrick 2012]
Non-critical acceptance, modelled by the therapist. Parental criticism and hostility predict poor outcome, and warmth predicts good outcome. In practice, model warmth towards the adolescent and interrupt criticism every time it appears. [source: Rienecke 2017; Lock & Nicholls 2020]
United parental team. Refeeding needs both parents (or all carers) acting consistently. In practice, get decisions made jointly, out loud, in session. [source: HSE checklist; Fitzpatrick 2012]
Siblings support, parents treat. Siblings comfort, distract and side with the patient, and carry no responsibility for eating. In practice, give siblings an explicit, different job. [source: Rienecke 2017; div12; Lock & Nicholls 2020]
Transparency about weight. The young person is weighed every session and the result is shared. In practice, never skip weighing to spare anyone's anxiety (yours included). [source: Rienecke 2017; NHS Lothian]
Respect adolescent development throughout. Parents control eating, while the young person keeps age-appropriate autonomy elsewhere (friends, school), and control of eating returns in age-appropriate steps. [source: div12; Rienecke 2017]
Flexible fidelity. Rigid adherence to the manual does not track outcome, and an alliance in trouble calls for widening the frame, not repeating the standard interventions harder. In practice, use supervision and adapt deliberately. [source: Eisler et al. 2016; Rienecke 2017]

4. Intervention inventory

Interventions follow the order of the treatment. All example language is my own wording, labelled (illustrative), unless shown in quotes with a source. The manual's own scripts are not drawn on.

4.1 Initial evaluation and setting up treatment (pre-Phase I)

Purpose / when: Before Session 1. Confirm the diagnosis and that the young person is safe for outpatient care, set up medical monitoring, and agree that the whole household will attend. [source: Guilford 3rd ed. ToC (chapter 3); Eisler et al. 2016; NHS Lothian]
Steps: (1) Arrange a medical assessment (vital signs, hydration, ECG and bloods as indicated) with the physician, who sets criteria for medical admission. (2) Screen for self-harm and safeguarding concerns. Maudsley FT-AN also meets the parents and the young person separately during assessment. (3) Explain the FBT model, the phases, and that everyone who lives at home attends. (4) Agree who weighs, who sees the medical results, and how the team communicates. (5) Arrange an early dietetic contact if your service uses one (it does in Lothian and the Maudsley). [source: Eisler et al. 2016; NHS Lothian; Rienecke 2017] Steps 3–4 as a sequence are [synthesis].
Example language (illustrative): "This treatment asks a lot of you as a family for a few months. You'll all come together each week, and for now you as parents will be in charge of every meal."
Watch for: Medical instability. That is a medical decision, and FBT is outpatient treatment that cannot be fully reproduced on a ward. Also watch for a parent who plans not to attend. Address it before starting. [source: Rienecke 2017; Eisler et al. 2016]

4.2 Weighing at the start of every session (individual check-in)

Purpose / when: Every session, in every phase. It tracks progress, acts as repeated exposure to weight for the adolescent, and shows that the therapist can tolerate the young person's anxiety. [source: Rienecke 2017; Lock & Nicholls 2020]
Steps: (1) Meet the adolescent alone for about the first 10 minutes. (2) Weigh them, ideally in a consistent way (same scale, similar clothing; the conditions are [synthesis]). (3) Ask briefly how the week went and how they feel about the number. In Phase I this meeting may be brief and is mostly about weight and their reaction to it. (4) Plot the weight on a chart. (5) Bring the adolescent and chart into the family session, and share and discuss the weight with everyone. [source: Lock & Nicholls 2020; NHS Lothian; HSE checklist] The weight chart as an object is common practice. The manual's exact charting procedure is not drawn on. [uncertain]
Example language (illustrative): "Let's do the weight first, like every week. What's it like to see that number? I'll show the chart to everyone in a moment. Is there anything you'd like me to say, or not say?"
Watch for: Skipping or delegating weighing to avoid conflict. Rienecke argues this signals that the therapist cannot handle the patient's anxiety. Watch also for water-loading or hidden weights. If you suspect them, raise it with the medical team and the parents [synthesis]. [source: Rienecke 2017]

4.3 Grave, sincere greeting (Session 1)

Purpose / when: The first minutes of Session 1. It sets the tone that this is serious and that the therapist is warm. [source: HSE checklist]
Steps: (1) Greet each family member by name, including siblings. (2) Keep your manner warm but sober, with no small talk that minimises the problem. (3) Weigh the adolescent first (4.2). [source: HSE checklist; Lock & Nicholls 2020] Steps 1–2 detail is [synthesis].
Example language (illustrative): "Thank you all for coming. I know it took real effort to get everyone here. We're meeting because your daughter has a serious illness, and I want to help you take it on."
Watch for: The family relaxing too early, or the therapist slipping into social chat that weakens the intense scene that follows. [synthesis]

4.4 Engaging history-taking (Session 1)

Purpose / when: Session 1, and again at the family meal. It engages every family member, gathers how the anorexia developed and how it has affected each person, assesses family functioning (alliances, authority structure, conflicts), and identifies what the parents have tried and what helped. [source: HSE checklist; Fitzpatrick 2012]
Steps: (1) Ask each person in turn, siblings included, when they first noticed changes. (2) Trace how the illness developed and what it has done to family life (meals, holidays, conflict). (3) Ask what the parents have tried and what worked even briefly. (4) Notice who speaks for whom, where alliances sit, and how decisions get made. (5) Use the history to show where the anorexia is operating, as distinct from the young person's own interests (it feeds 4.5). [source: HSE checklist; Fitzpatrick 2012]
Example language (illustrative): "Ben, as her brother, what's changed at home since this started?" / "When things went a bit better for a day or two, what were you doing differently?"
Watch for: History-taking that drifts into causes. Keep it agnostic (principle 1). Watch for one parent answering for everyone, and redirect. [source: Rienecke 2017; synthesis]

4.5 Separating the illness from the patient (externalisation)

Purpose / when: Introduced in Session 1 and maintained through every phase. It reduces blame and criticism and lets parents oppose the illness without opposing their child. [source: HSE checklist; Rienecke 2017; Fitzpatrick 2012]
Steps: (1) Collect examples from the history of the young person "operating under the influence of AN" (Fitzpatrick 2012), set against their own interests and qualities. (2) Name the illness as something that has taken hold of them. (3) Invite the young person to name it in their own words if they reject the term "anorexia". (4) When parents criticise, translate it back: the behaviour belongs to the illness. (5) In Phase II, use it to tell the adolescent's own ideas and needs apart from the illness's. (6) In FT-AN, use externalisation more cautiously and later. Some young people experience it as dismissing their views. [source: Eisler et al. 2016; HSE checklist; Fitzpatrick 2012] Some therapists use an empty-chair or object to represent the illness. This is not drawn from a source, and it is not part of the inventory. [uncertain]
Example language (illustrative): "When she hides food, that isn't the daughter you know choosing to deceive you. That's the anorexia protecting itself." / To the adolescent: "What would you call the voice that argues with you at meals?"
Watch for: The adolescent feeling unheard or caricatured. Ask them, adjust the wording, and give their own views time in individual minutes. It is working when parental criticism drops and parents can stay firm without anger. [source: Eisler et al. 2016; Rienecke 2017]

4.6 Psychoeducation about starvation and risk

Purpose / when: Sessions 1–2 and repeated as needed. It explains why refeeding is urgent, what starvation does to body, mood and thinking (which accounts for much of the behaviour), and why outpatient family refeeding is preferred to admission where safe. [source: Eisler et al. 2016]
Steps: (1) Link the young person's current physical signs (from the medical review) to starvation. (2) Explain how starvation narrows thinking and increases rigidity, obsessionality and distress around food. (3) Explain why recovery of thinking follows weight gain. (4) Set out the disadvantages of admission and the role of the family at home. (5) Check understanding with each family member. [source: Eisler et al. 2016] Sequence is [synthesis].
Example language (illustrative): "A starved brain can't think its way out of anorexia. Food is the medicine first, and the arguments get easier as the brain is fed."
Watch for: Lecturing that loses the adolescent. Keep it brief, specific to this young person, and tied to the next step. [synthesis]

4.7 Orchestrating an intense scene (Session 1)

Purpose / when: Session 1, after the history. It raises the parents' concern to the level the illness warrants (including the risk of death and the difficulty of recovery) so that they mobilise. [source: HSE checklist; Fitzpatrick 2012]
Steps: (1) Summarise the medical findings plainly. (2) Describe what untreated anorexia can lead to, including chronic illness and death, without exaggeration. (3) Stress that recovery is hard and needs a determined, united effort. (4) Hold the silence and let the seriousness register. (5) Pair it immediately with hope: the parents can do this, with your help (leading into 4.8). [source: HSE checklist; Fitzpatrick 2012] Steps 4–5 detail is [synthesis].
Example language (illustrative): "Anorexia has the highest death rate of any psychiatric illness in young people. If it continues, it can take years of her life or her life itself. I'm telling you this because I'm also confident you can stop it."
Watch for: Anxiety that tips into blame, panic or hopelessness. Repeat that no one caused this and that parents are the solution. With an adolescent who is frightened by the content, acknowledge it directly in their individual time [synthesis]. It is working when the parents leave with urgency and resolve, not despair. [source: Rienecke 2017; synthesis]

4.8 Charging the parents with refeeding (Session 1)

Purpose / when: The end of Session 1. It hands the parents responsibility for restoring their child's weight, and sets up the family meal. [source: HSE checklist; Fitzpatrick 2012]
Steps: (1) Tell the parents that, for now, they decide what, how much and when their child eats. (2) Explain that they will supervise meals and snacks, limit physical activity, and prevent compensatory behaviour (purging). (3) Frame it as temporary and as caring, not controlling (the FT-AN framing). (4) Assign the family meal: bring a meal to Session 2 that you think your child needs to eat to recover. Fitzpatrick's wording is "bring a meal you feel your starving child needs to eat to overcome AN". (5) Give no further meal-preparation instruction before Session 2. (6) Assign siblings their supportive role (4.11). [source: Rienecke 2017; NHS Lothian; Eisler et al. 2016; Fitzpatrick 2012]
Example language (illustrative): "For the next while, you two will decide what goes on her plate and make sure it gets eaten. That's what nurses would do in hospital, and you can do it at home. Next week, bring the meal you believe she needs to start getting well."
Watch for: Parents asking for a menu. Return the decision to them (non-authoritarian stance) while confirming that you will help them refine it. Also watch for one parent agreeing and the other withdrawing. [source: Rienecke 2017; synthesis]

4.9 The family meal (Session 2)

Purpose / when: Session 2. It lets the therapist assess family structure and eating processes, and gives the parents a first experience of success: getting the adolescent to eat more than they intended. [source: HSE checklist; Rienecke 2017; Fitzpatrick 2012]
Steps: (1) Weigh first (4.2). (2) The family brings and serves the meal they chose. The therapist does not eat. (3) Observe and continue the history: who prepares, who serves, how food is discussed, and how the patient is engaged. (4) Partway through, coach the parents to get the adolescent to eat at least one more mouthful than she is willing to. Alternatively, help the parents work out together how they will refeed. (5) Coach tactics as needed: sit the parents closer to the adolescent, present a united, calm and persistent stance, selectively ignore non-nourishing behaviour (bargaining, stalling, dissecting food), and praise eating. (6) Align the patient with her siblings for support. (7) Close by naming what the parents did that worked. [source: HSE checklist; Fitzpatrick 2012; Rienecke 2017] Fitzpatrick (2012) also describes the therapist giving direct guidance on meal types, energy density, amounts and frequency. This is more directive than the non-authoritarian stance in other sources. [uncertain]
Example language (illustrative): To the parents: "She's stopped. What do you two want her to do next? … Sit closer. Tell her calmly, together, what she needs to eat, and keep saying it." / To siblings: "You can't make her eat, but you can sit with her and help her get through it."
Watch for: Parents who give up after one refusal, or who get into a debate with the illness. Coach short, repeated, united statements. Watch for escalating distress. Stay calm and slow the pace, and keep the parents in charge rather than taking over yourself [synthesis]. It is working when the extra mouthful is eaten because of the parents' persistence, which gives them evidence that they can do it. [source: Rienecke 2017; Fitzpatrick 2012]

4.10 Directing and redirecting to food, eating and weight (rest of Phase I)

Purpose / when: Phase I sessions 3–10. It keeps the family focused on the eating disorder until the concerns about eating and weight are relieved. [source: HSE checklist; Rienecke 2017]
Steps: (1) Open from the weight result: what happened this week at each meal and snack? (2) Go through specific meals (who served, what was eaten, where it got stuck). (3) When the talk drifts to school, mood or other conflicts, acknowledge it briefly, then bring it back to eating. (4) Defer non-urgent comorbid problems (low mood, and PTSD per Lock & Nicholls) unless they are a risk issue. [source: HSE checklist; Rienecke 2017; Lock & Nicholls 2020]
Example language (illustrative): "That fight about her phone matters, and we'll come back to things like that later. Right now, tell me about Tuesday's dinner, when the weight stalled."
Watch for: Risk issues (self-harm, suicidality) always override this focus. Assess them in the standard way. [synthesis] It is working when sessions are mostly about practical meal problem-solving and the weight curve rises.

4.11 Mobilising siblings and aligning the patient with them

Purpose / when: The family meal and the rest of Phase I, and ongoing. It gives the patient support from peers inside the family and keeps siblings out of the parents' refeeding role. [source: HSE checklist; Rienecke 2017; Lock & Nicholls 2020]
Steps: (1) State explicitly that siblings are not responsible for eating or for reporting on it. (2) Ask siblings how they can support the patient: company after meals, distraction with games or videos, sympathy. (3) Help the family evaluate how the siblings' efforts are going. (4) Address sibling criticism or teasing like parental criticism (4.13). [source: HSE checklist; Lock & Nicholls 2020; Rienecke 2017]
Example language (illustrative): "Your job isn't to watch her plate. It's to be her brother. What could you do after dinner that would take her mind off it?"
Watch for: Siblings who become informants, or who are neglected or resentful. Give them space in the session to say how it is for them. [synthesis]

4.12 Coaching the parental team in refeeding

Purpose / when: All of Phase I. It helps the parents take full charge of eating, consistently and together, and solve the practical obstacles. [source: HSE checklist; Rienecke 2017; Fitzpatrick 2012; NHS Lothian]
Steps: (1) Review the week's meals and snacks against the parents' own plan. (2) Problem-solve each obstacle together (supervision gaps, school lunches, refusals, hidden food, exercise). (3) Make sure the parents agree on the decisions and take turns. (4) Arrange supervision of all meals and snacks. Parents are strongly encouraged to do this and may take leave to be at home; some young people need time off school during Phase I. (5) Agree how activity will be curtailed and how purging or bathroom use after meals will be prevented. (6) Bring in the dietitian when weight stalls or activity increases. (7) Praise specific successes. [source: Fitzpatrick 2012; NHS Lothian; Eisler et al. 2016; Rienecke 2017] Avoid calorie counting in front of the adolescent, and leave quantities to parents with dietetic input. [synthesis]
Example language (illustrative): "You've each been doing different breakfasts, and she's noticed. What will you agree on so it's the same whoever is there?"
Watch for: Coercion that becomes physical force. The aim is insistence through the parental relationship, "not 'force feeding'" (Fitzpatrick 2012). Watch for parental exhaustion, and help the parents divide the work and use their own support. It is working when the weight rises steadily and meals take less effort. [source: Fitzpatrick 2012; synthesis]

4.13 Addressing parental and sibling criticism

Purpose / when: Whenever criticism appears, in every phase. Criticism and hostility (high expressed emotion) predict poorer outcome. [source: HSE checklist; Rienecke 2017]
Steps: (1) Notice critical or hostile remarks in session as they happen. (2) Interrupt gently and reframe the behaviour as the illness (4.5). (3) Acknowledge the parent's frustration and fear behind it. (4) Model a warm, non-critical stance towards the adolescent yourself. (5) If criticism stays high, consider separated sessions (4.20). [source: Rienecke 2017; Fitzpatrick 2012; Lock & Nicholls 2020]
Example language (illustrative): "I can hear how worn down you are. Let's be clear that the lying is the anorexia's doing. She needs you angry at the illness, not at her."
Watch for: The adolescent shutting down after critical exchanges, which is an early sign the format needs changing. [synthesis]

4.14 Helping parents tolerate outbursts without giving in

Purpose / when: Phase I, when refeeding provokes distress, anger or bargaining. [source: Lock & Nicholls 2020]
Steps: (1) Predict the outbursts in advance as the illness reacting to food. (2) Help the parents agree a calm, brief and consistent response: stay at the table, repeat the expectation, and do not argue content. (3) Help them not react to the outbursts and not give in. (4) Review in session how it went and what helped the adolescent settle. [source: Lock & Nicholls 2020] Steps 2 and 4 detail is [synthesis].
Example language (illustrative): "When she shouts that she hates you, you can say, 'I know this is hard. You still need to finish,' and then say nothing else."
Watch for: Outbursts that include self-harm or threats to life. Those need risk assessment and a safety plan, not just tolerance. [synthesis]

4.15 Behavioural disruption of rituals and perfectionism

Purpose / when: Phase I. It targets ritualised eating, calorie counting and excessive self-weighing, and addresses perfectionism behaviourally. [source: Lock & Nicholls 2020]
Steps: (1) Identify the rituals with the family (cutting food tiny, fixed order, timing, checking labels, weighing at home). (2) Agree with the parents how they will interrupt each one: varied foods, normal pace, removing the home scales, not discussing numbers. (3) Review in session. [source: Lock & Nicholls 2020] Steps detail is [synthesis].
Example language (illustrative): "The anorexia likes things exactly the same. What could change at dinner this week to loosen its grip?"
Watch for: Persistent perfectionism or social anxiety after FBT ends. Consider separate treatment then, and add cognitive remediation alongside FBT for persistent cognitive inflexibility. [source: Lock & Nicholls 2020]

4.16 Early-response review (Session 4)

Purpose / when: At session 4, to decide whether to add intensive parental coaching. [source: Rienecke 2017; L'Insalata et al. 2020]
Steps: (1) Compare the session 4 weight with the session 1 weight. (2) Below the early-response threshold (about 2.2–2.4 kg in the trials), name it openly with the family and offer IPC (4.17). (3) If the threshold is met, continue standard FBT. [source: Rienecke 2017; L'Insalata et al. 2020] Sharing the result openly follows the transparency principle. [synthesis]
Example language (illustrative): "Families who see this much gain by now usually do well. You're not there yet, so I want to add some extra sessions to work out what's getting in the way."
Watch for: The threshold is a research criterion. Use it as a prompt to intensify treatment, not as a prognosis to give the family. [synthesis]

4.17 Intensive parental coaching (IPC), three added sessions

Purpose / when: After session 4, for early non-responders. It boosts the parents' self-efficacy through intensive coaching at mealtimes, and is included in the 3rd edition (chapter 9). [source: L'Insalata et al. 2020; Rienecke 2017; Guilford 3rd ed. ToC]
Steps: (1) IPC session 1 (family): Present the insufficient weight gain as a crisis, and re-energise the family to make definite behavioural changes. (2) IPC session 2 (parents alone): Identify what the parents see as the barriers to refeeding (fear of the child's distress, disagreement between them, logistics, their own beliefs). (3) IPC session 3 (second family meal): Coach the parents directly on the specific barriers identified. (4) Resume standard FBT. [source: L'Insalata et al. 2020; Rienecke 2017] The barrier examples in step 2 are [synthesis].
Example language (illustrative): Parents alone: "What happens inside you when she cries at the table? What do you find yourself doing then?"
Watch for: Mealtime coaching that makes the barrier concrete. It is working when there is a clear behavioural change at home and the weight rises within the next few weeks. Evidence for IPC is from small samples. [uncertain]

4.18 Phase II: negotiating the return of control over eating

Purpose / when: Phase II, once the Phase I criteria are met. It returns eating and activity to the adolescent in age-appropriate steps, gradually enough to protect against relapse. [source: Rienecke 2017; HSE checklist; Fitzpatrick 2012; Lock & Nicholls 2020]
Steps: (1) Keep parental management until the adolescent shows they can eat well and keep gaining on their own. (2) Negotiate the steps with the parents and adolescent together. (3) Sequence the steps, for example: the adolescent plates food while parents monitor and may add if they judge it inadequate; then serves independently; then one meal or snack is eaten unsupervised (school lunch); then socialised eating (friends, restaurants, takeaways, parties) and less meal structure. (4) The adolescent joins the problem-solving about diet and activity, including a gradual, agreed return to sport. (5) After each step, review the weight and behaviour, and step back to parental control if it slips. (6) Keep addressing criticism around the handover. [source: Rienecke 2017; Fitzpatrick 2012; Lock & Nicholls 2020; HSE checklist] Step 5 (stepping back) is implied by the requirement that parents feel able to resume refeeding, and its procedure is [synthesis].
Example language (illustrative): "You've shown you can do dinners. What would you like to take back next, and what would tell your parents it's going well?"
Watch for: Handing control back too fast because of parental fatigue, or because the adolescent's push for autonomy is driven by the illness. Use the weight chart and observed behaviour, not promises. [synthesis]

4.19 Phase II: linking adolescent issues to the illness and separating the adolescent's own ideas

Purpose / when: Phase II. It starts examining how adolescent developmental issues relate to the anorexia, and tells the adolescent's genuine wishes apart from the illness's demands. [source: HSE checklist]
Steps: (1) Invite the family to notice which developmental issues were in play as the illness developed (school transitions, peers, puberty). (2) When the adolescent states a preference about food or activity, explore with them whether it is their own wish or the illness. (3) Keep this tied to the handover rather than causes. [source: HSE checklist] Steps 2–3 detail is [synthesis].
Example language (illustrative): "Wanting to go to the party is you. Wanting to skip the pizza there, who's talking then?"
Watch for: The talk sliding into causes or blame. Stay agnostic. [source: Rienecke 2017]

4.20 Format variants: separated/parent-focused FBT, short vs long FBT, multi-family therapy, FBT-BN

Purpose / when: Choose or switch format when the standard conjoint format fits poorly. [source: Rienecke 2017; Fitzpatrick 2012; Lock & Nicholls 2020; div12]
Steps:
- Parent-focused treatment (PFT) / separated FBT. A nurse sees the adolescent briefly at the start for weight and medical checks; the therapist then meets the parents alone, and there is no family meal. In separated therapy the adolescent and the parents are seen separately. It is best for families with high criticism, and is also an option where a parent is grieving or there are significant family problems. [source: Rienecke 2017; Fitzpatrick 2012; Lock & Nicholls 2020]
- Short vs long FBT. The 10-session/6-month and 20-session/12-month forms. The longer form helped families who were not intact and adolescents with marked eating-related obsessive-compulsive features. [source: Rienecke 2017]
- Multi-family therapy (MFT). In the format described by Rienecke, 5–7 families first meet a "graduate family". A 4-day intensive follows, then 5–8 follow-up sessions over 6–9 months, with single-family sessions added as needed. Simic and Eisler have published a separate MFT manual, which is not drawn on here. [source: Rienecke 2017] MFT activity content is [uncertain].
- FBT-BN. Parents take charge of regular eating and prevent binges and purges. The work is more collaborative with the adolescent, and parents use firmer authority when medical risk requires it. The adolescent keeps age-appropriate independence elsewhere. Work actively on shame and secrecy around binge eating and purging, and on parental criticism. [source: div12; Rienecke 2017]
Example language (illustrative): FBT-BN: "Bulimia thrives on secrecy. Your parents' job is to make the secret unnecessary, by being around after meals and helping you keep eating regularly."
Watch for: PFT removes the family meal and the conjoint enactment. Compensate with detailed parental review of meals. [synthesis] Related adaptations exist (for ARFID, prodromal AN and young adults (FBT-Y), and family-based partial hospital programmes). They are beyond this guide. [source: Rienecke 2017]

4.21 Individual time with the adolescent (all phases; expanded in Phase III and FT-AN)

Purpose / when: The brief individual check-in every session (4.2), with more individual work later. FT-AN advises a greater individual focus with high criticism or hostility, older teenagers, lack of progress, or comorbidity. [source: Lock & Nicholls 2020; Eisler et al. 2016]
Steps: (1) Phase I: keep it short and mainly about weight and the adolescent's reactions. (2) Phases II–III: widen it to motivation, identity, peers and the adolescent's own goals. (3) Agree with the adolescent what will be brought back to the family. [source: Lock & Nicholls 2020; Eisler et al. 2016] Step 3 is [synthesis].
Example language (illustrative): "This part is your time. What do you want me to understand that's hard to say in front of your parents?"
Watch for: Confidentiality limits around risk. State them at the start. [synthesis]

4.22 Phase III: reviewing adolescent development and modelling problem-solving

Purpose / when: Phase III, once the adolescent eats independently and keeps a healthy weight. It establishes that the parent–adolescent relationship no longer needs the symptom, and gets development back on track. [source: HSE checklist; Rienecke 2017; Lock & Nicholls 2020]
Steps: (1) Review the adolescent themes with the whole family: autonomy, peers, dating and sexuality, school and future, and individuation from the parents. (2) Pick one or two live issues and model problem-solving them in session. (3) Check how much the parents are doing as a couple (their relationship and activities beyond the illness). (4) Help the family identify upcoming challenges and plan how to meet them without the eating disorder as a coping strategy. [source: HSE checklist; Rienecke 2017; Lock & Nicholls 2020]
Example language (illustrative): "Next year brings exams and a summer job. Let's work out how you three will handle the stress, so food doesn't become the way it shows up." / To the parents: "When did you last do something just as a couple?"
Watch for: Families who want to keep sessions going as general family therapy. Phase III is brief (about 3 sessions over 3 months in Fitzpatrick's account). Refer onward for separate problems. [source: Fitzpatrick 2012; Lock & Nicholls 2020]

4.23 Relapse prevention and termination

Purpose / when: The final Phase III sessions (FT-AN Phase 4). It consolidates gains and prepares the family for the end of treatment. [source: HSE checklist; Eisler et al. 2016; NHS Lothian]
Steps: (1) Review the journey with the family and identify the turning points. (2) Agree the early warning signs of relapse for this young person. (3) Agree who will take responsibility, and how, if difficulties return: parents resuming meal oversight, and contacting the service. (4) Address anxieties about discharge. (5) Plan any follow-up medical monitoring. (6) End by crediting the family's work. [source: Eisler et al. 2016; HSE checklist] Steps 2 and 5 detail is [synthesis].
Example language (illustrative): "If you saw skipped snacks and more exercise again, what would you do in the first week?"
Watch for: Abrupt endings. Space the final sessions out. Watch for unmonitored transitions (moves, new school, leaving home), where the case report saw weight fall once monitoring stopped. [source: Aspen & Boutelle 2014; synthesis]

4.24 Fidelity, supervision and certification

What is required: You do not need certification to practise FBT. To be listed as a certified FBT therapist with the Training Institute for Child and Adolescent Eating Disorders (founded by Lock and Le Grange), you need: (1) a 1.5-day introductory workshop; (2) at least 25 hours of individual training with Institute faculty, including case reviews, role plays and video or audio analysis; and (3) licensure or registration for independent practice. An annual advanced workshop is optional. The page does not state renewal rules or a required number of cases. [source: train2treat4ed certification page] Trial therapists had a 2-day workshop and weekly supervision, with fidelity rated on 20% of sessions. Session-by-session checklists exist for audit, such as the HSE FBT activity log and fidelity checklist. [source: L'Insalata et al. 2020; HSE checklist] Whether certification is needed to use the FBT name commercially is [uncertain].
Practical use: Self-rate each session against the phase task list, and bring "no" items to supervision with the reason and a proposed solution, as the HSE checklist asks. [source: HSE checklist]

5. Handling problems

Weight not rising by session 4 (early non-response). Use the session 4 review and IPC (4.16–4.17): name the crisis, meet the parents alone to find the barriers, then hold a second coached family meal. [source: L'Insalata et al. 2020; Rienecke 2017] If the weight is still flat after IPC, review medical status and the case with the team, consider the dietitian, PFT or the longer format, and discuss a higher level of care. [synthesis]
Adolescent refuses to attend or eat. Parents use their authority over privileges, with the medically indicated alternative (hospital) made clear. In the group-home case the caregivers gave an ultimatum of treatment or hospital, and the young person chose treatment. [source: Aspen & Boutelle 2014] Frame this as the parents' decision, explained calmly, never as a punishment. [synthesis]
Resistance and outbursts at meals. Prepare the parents to tolerate them without reacting or giving in (4.14). Use externalisation to keep anger aimed at the illness. Selectively ignore non-nourishing behaviour, and praise eating. [source: Lock & Nicholls 2020; Fitzpatrick 2012]
Parental overwhelm, exhaustion or self-doubt. Remind the parents of their competence and of the successes they have had. Divide tasks between carers, and enlist extended family or work leave. Consider parent-to-parent consultation or therapist-guided online parent groups, which parents found helpful though they did not change weight. [source: Fitzpatrick 2012; Rienecke 2017] Screen the carers' own mental health and refer as needed. [synthesis]
Non-adherence (meals unsupervised, plan dropped). Go through the week meal by meal without blame. Find the specific gap (work hours, school, a dissenting parent) and problem-solve logistics: packed meals with notes, spreading intake across the day, involving school staff. [source: Aspen & Boutelle 2014; HSE checklist] If one parent disagrees, hold a parents-only segment to reach a joint plan. [synthesis]
High criticism or hostility. Interrupt and reframe every time (4.13). Move to separated or parent-focused sessions. FT-AN adds early work on emotions and attachment ruptures at a slower, more cautious pace, to avoid alienating the young person or increasing guilt. [source: Rienecke 2017; Fitzpatrick 2012; Eisler et al. 2016]
Alliance rupture with the adolescent. FT-AN warns that pressing on with the standard interventions can make things worse. Broaden the frame (attachment, CBT or DBT ideas), add individual time, and use supervision. [source: Eisler et al. 2016] Acknowledge the rupture openly in individual time, and repair before pushing on. [synthesis]
Therapist anxiety and drift. Therapists often skip weighing or soften Phase I, and few practise fully to the manual. Use the checklist and supervision, and remember that your firmness models the parents' firmness. [source: Rienecke 2017]
Medical deterioration. Follow the physician's admission criteria (multi-system risk, not weight alone). After admission, re-engage the parents early so that FBT continues afterwards. [source: Eisler et al. 2016; synthesis]
Self-harm or suicidality. Assess at intake and whenever it appears, using standard risk assessment, and make a safety plan with the parents that includes lethal-means counselling (securing medicines and other means at home). It overrides the Phase I focus on food and weight. [synthesis; Eisler et al. 2016 lists self-harm screening at assessment]
Comorbidity (depression, OCD, anxiety, trauma). Usually defer it until the anorexia is largely resolved. Medication may help comorbidity that predates the anorexia, and cognitive remediation can be added for cognitive rigidity without disrupting FBT. Refer for stand-alone treatment of persistent perfectionism or social anxiety afterwards. [source: Lock & Nicholls 2020; Rienecke 2017] FBT-BN allows more early attention to comorbidity. [source: Rienecke 2017]
Separated, single-parent or non-standard families. Use the long format for families that are not intact. In the case report, group-home staff acted as the "parents", with logistics adapted and the phase timing changed pragmatically. FT-AN addresses separated and reconstituted families in Phase 3, but that content is not drawn on here. [source: Rienecke 2017; Aspen & Boutelle 2014; Eisler et al. 2016; uncertain] For separated parents, aim for a shared plan and consistent rules in both homes, holding joint or parallel sessions if needed. [synthesis]
Bereaved or unwell parent. Expect treatment to take longer, and consider a parent-only format. [source: Lock & Nicholls 2020]
Premature handover in Phase II. If the weight drops or behaviours return after a step, go back to the previous level of parental control and slow the sequence. [synthesis, consistent with Phase I criteria in Fitzpatrick 2012]
Relapse after discharge or a change of setting. Arrange monitoring before transitions, and give families an agreed plan to resume oversight and recontact the service. [source: Aspen & Boutelle 2014; Eisler et al. 2016; synthesis]
Cultural fit of parental control. Discuss the family's own norms about food, authority and adolescent autonomy, and adapt how the parents take charge without dropping the principle. [synthesis; Eisler et al. 2016 lists cultural context among therapist considerations]

Sources

Sources

Further reading (not drawn on)

Lock J, Le Grange D (2025). Treatment Manual for Anorexia Nervosa: A Family-Based Approach, 3rd ed. New York: Guilford Press. (Earlier editions: 2001, 2013.)
Le Grange D, Lock J (2007). Treating Bulimia in Adolescents: A Family-Based Approach. New York: Guilford Press.
Simic M, Eisler I, et al. Multi-Family Therapy for Anorexia Nervosa: A Treatment Manual. Routledge.

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