Family-based treatment
The seminal uncontrolled family treatment study was conducted by Minuchin and colleagues15 in the late 1970s. Using a structural family therapy approach in which family members were helped to change their relationship patterns to promote better communication, resolve conflicts, and support appropriate independence, the investigators found that about 80% of their patients improved and maintained improvement over time. Inspired by these findings and informed by their experience with a long-term inpatient service for adolescent eating disorders, Dare and Eisler,16 at the Maudsley Hospital in London, developed a specific form of FBT that aimed to put parents in charge of weight restoration in their malnourished children.16 They identified several key treatment strategies:

• Increase parental anxiety about the disorder to encourage them to take definitive action to change disordered eating and to promote weight gain.
• Reduce parental guilt for having caused the disorder to increase their sense of competence.
• Empower parents to be in charge of decision making about how best to correct disordered eating and restore weight.
• Educate parents through expert consultation about anorexia nervosa rather than explicit advice giving or meal planning.
• Externalize anorexia nervosa and define it as a disease state to allow parents to take on the challenging behaviors as they would do for any other medical disease.

The usual FBT model is structured into about 20 whole-family 50-minute sessions that take place during the course of a year. The treatment initially targets weight restoration above all other considerations. At every session, the patient's weight progress is illustrated to the parents and their efforts to try to promote normal eating and weight gain praised. Families typically struggle in the initial sessions to change their family routines to ensure that the patient's eating is the central priority. This often means that one or both (if there are 2) parents take leave from work to refeed their child for several weeks, just as they might do for a child with any other serious medical illness.

Parents often must confront their differences in how to approach the problem of getting their child to eat, but they usually find that when they agree on a strategy it is more successful. There is also a family meal held early in treatment during which the therapist observes and coaches the parents in how to be consistent in their requests and insistent in adherence, while also constraining their frustration with what appears to be defiance and disobedience.

If the patient has siblings, they are asked to refrain from helping with weight restoration or meal time regimens, but they are asked to recognize how difficult this is for their sister or brother with anorexia nervosa and to try to find ways to support them during this period. For older siblings this might mean talking to them, playing games with them, or watching a video to distract them. Younger siblings sometimes make cards or drawings or help their sibling with household chores. The idea is to use the whole family as a resource to help confront, change, and ultimately move beyond the problem that anorexia nervosa is causing for all of them.

The second part of treatment begins when the adolescent with anorexia nervosa has gained weight and is eating without conflict under parental supervision. The aim of this part of treatment is to ask the parents to promote age-appropriate activities and eating behaviors for the adolescent. In a typical case, parents hand over control of eating gradually to see how their child manages this challenge. There is usually a learning curve for the adolescent, but the enjoyment of being with friends and the reduced worry and conflict in the family typically help to make this phase go smoothly.

The final part of treatment examines adolescent issues and how the family's role has changed as a result of having struggled with anorexia nervosa. In this part of the treatment, the family focuses on what they have learned in therapy by taking on the difficult problem of anorexia nervosa; examining the effects of this struggle on their family, both good and bad; and anticipating future issues they may face, particularly family changes as a result of increased adolescent autonomy.
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