So, first let’s start with the premise of FBT, or Family Based Therapy. It’s a model designed to support parents in refeeding their starving anorexic teens. The basic idea: The parents decide what the teens should eat, put it in front of them, and the teens eat it.
Of course, it’s not that simple, nowhere near. Teens don’t generally make a habit of doing what it is that their parents tell them. And anorexic teens are particular adverse, since ultimately this means that they have to eat all kinds of foods and quantities of foods that make them extremely uncomfortable and are in direct conflict with what their anorexia is telling them to do.
But there’s this additional confounding factor, especially as a therapist: People often think that FBT strips teens of their autonomy, a hallmark of what many think therapy is supposed to promote. After all, isn’t that what many therapists tout? Finding your voice? Exploring your self? This feels like just the opposite. That I am promoting some form of teen torture, that in allowing -- nay, supporting! -- parents in this endeavor, that I’m also somehow eliminating the rights of the teen. And let’s face it, FBT is not always pretty: Parents can have pretty big face offs with their kids, with kids throwing food, or sobbing on the floor, overtaken by their anorexia and desperate -- desperate -- to not have to eat what they’re given. So, a lot of therapists think that they shouldn’t have to. That the disease is simply a manifestation of a problem with the child’s relationship with the parents and should be treated as that, instead of giving even more power to the parents.
But here’s the way I see it: Imagine you have a three-year old, a really responsible, sweet, listening kid, who always knows to stand next to you when you cross the street. So you let her do just that, and don’t insist that she hold your hand. But if that same sweet three year old suddenly turned a little wild and ran out into traffic, you would rewind the clock (after you calm down, that is.) You would insist that your little sweetie hold your hand again to cross the street until you’re sure -- absolutely sure -- that she understands the importance of the safety issue of staying close. Feeding and eating is really no different. If your teen (or younger child) can’t make good decisions about food and eating, she’s not safe any more, as evidenced -- among other things -- by the high mortality rate of anorexia. And with anorexia, there’s an additional catch: A starved brain actually can’t make good decisions. In fact, the research is pretty clear that a starved brain has a really hard time deciding to feed itself.
So, do I believe in growing autonomy for teens? A resounding ‘Yes”! But I also believe that as parents we sometimes shoulder the burden of setting difficult limits for our kids. For some parents, it’s making the tough decisions about curtailing freedoms when they find their teen has broken house rules and values about the car or drinking or sex. For some, it’s taking away the phone or setting limits around social activities. These limits let kids know that you’re in charge, something that ultimately isn’t punishing (although it certainly can feel that way to both the parent and child) but that allows kids to feel that their world is safe and that they can trust you to be watching out for them. And even though these consequences sometimes feel harsh, they should always be delivered with love and compassion. Really, it’s no different with anorexia: Until parents of kids with this ugly disease can trust that their children can make appropriate food choices, it’s up to them to create the structure that will provide safety and -- ultimately -- healing. Refeeding isn’t a lifetime sentence for a teen; if all goes smoothly, it’s a way station on the track to wellness.