Just food

I was surprised, and annoyed, by a curt comment on a recent blog post. Yes, Laura does think of other things...:

"FBT is not just food."

Annoyed because that's usually the point *I* like to make and having spent so many years repeating myself I was sloppy to leave that unclear. A blog post has to stand alone and out of context so the commenter was right to call me out.

The truth is that FBT/Maudsley is one of my interests but I hold opinions that should not be taken as having anything to do with FBT/Maudsley. I, for example, believe eating disorders are a brain disorder and that the symptoms are set into place by malnourishment for a genetic minority predisposed to do so - but that is not something that necessarily goes along with FBT/Maudsley; FBT is "agnostic" on cause. I believe food is the more important active ingredient of FBT/Maudsley, but that is not a belief shared by all Maudsley proponents. I'm a believer in parent empowerment and alliance as a tool for recovery but I think of that as skilled parenting as much as it is a treatment approach. I believe the LACK of harmful ideas that characterize most approaches to eating disorders is a confounding factor that favors FBT, but again that is not necessary to understanding FBT/Maudsley. It would be a mistake to critique FBT/Maudsley based on my beliefs about the method or my other ideas. Or to hold me up as a standard-bearer. I think Family-Based Maudsley is a great option but not the last word on eating disorder treatment. In fact, I advocate improvements to FBT/Maudsley to address its shortcomings.

But I was also uncomfortable because the comment gets to the nub of the problem that I find so frustrating. In my post I was, clumsily, trying to say that I don't think FBT/Maudsley is the only idea out there we should be looking at but that ALL treatment must be pursued IN ADDITION TO THE FOOD.

All eating disorder treatment should include assertive and non-optional nutritional rehabilitation and the cessation of binging, purging, and compensatory exercise. Any psychological treatment that leaves out concurrent refeeding is, in my opinion, both ethically and medically wrong. FBT is not just food but other approaches should not be going on without the food.

Food is medicine, and not "just" with FBT.


  1. I absolutely agree that non-optional nutritional education and stabilization needs to be a component of successful treatment. And, I think that often the pace of the nutritional component may need to vary based on the individual.

    That said (and I'm not saying you're guilty of this), I also think that that any treatment that focuses much more on "refeeding" than it does on psychological stabilization and healing is also unethical and irresponsible.

  2. I much prefer being agreeable but I have to slightly disagree, or change the question.

    Refeeding DOES address psychological stabilization and healting. If the problem is an eating disorder alone, then refeeding and stopping compensatory behaviors IS the treatment. If there are co-morbid issues or problems that distract from or hold back refeeding/symptom cessation then that of course needs to be dealt with.

    I don't think we can assume that an eating disorder stems from a problem in that person's life. We do need to address any problems that do exist, however, and an eating disorder just makes that more urgent.

  3. I agree with Sayhealth in principle, but strongly disagree with the way "psychological healing" is pursued in practice by most treatment programs. For example, searching for root causes before full nutrition and weight restoration (when patients are delusional and incapable of doing meaningful psychological work).

    As Laura said, presuming that an ED is the result of a problem in a person's life is problematic and not consistent with the latest empirical research on this issue.

    I agree with Laura that "Refeeding DOES address psychological stabilization and healing." However, I disagree with her statement that "If the problem is an eating disorder alone, then refeeding and stopping compensatory behaviors IS the treatment." I would re-word the statment as: "If the problem is an eating disorder (whether alone or with comorbid conditions), refeeding and stopping compensatory behaviors is the essential first step in treatment." Nutritional and medical stabilization, and stopping ED behaviors, is necessary, though not sufficent, for full recovery. Almost all ED patients suffer from anxiety, depression, delays in social-emotional development, or identity issues AS A RESULT of the ED, and in my experience, these issues abate, but do not disappear entirely, with weight restoration and cessation of ED behaviors.

    Also, the experience of an ED is extremely traumatic for the patient and for her family, and most patients and families can benefit tremendously from therapy to help them move forward, resume normal life, and plan for relapse. This is what Maudsley Phase III is about. Refeeding and cessation of behaviors does not address these issues.

    In conclusion, I agree with Sayhealth that failure to address psychological healing is irresponsible and unethical. My observation, however, is that most therapists and treatment programs do a tremendous amount of (incompetent and misguided) work on psychological healing, while neglecting the necessity of full nutrition, achieving optimal weight for optimal health, and helping the patient stay there forever.

  4. Agreed. I withdraw my earlier post and replace it with Dr. Ravin's!

    The eating disorder is the problem, and it needs to be addressed on all fronts. What most treatment does is treat the eating disorder as the result of the problem, instead of the cause of the problem. But an eating disorders is EXTREMELY hard to cope with and the results of it on the patient and the family are enormous and there are usually co-morbid conditions to address that were there before or result from the disease process.

    Then, and this is what makes it all succeed or fail, there is relapse prevention. THAT is of huge importance.

    I should have said that "refeeding and stopping compensatory behaviors is therapeutic in terms of the psychological recovery. But not the only thing needed. If all we do is regain weight the patient isn't going to stay better."

  5. I agree that patients need to be nutritionally and physically healthy to fully benefit from therapy. That's why I think that eating disorders treatment must include that nutritional component, AND they must include a psychological component.

    I absolutely disagree that an "eating disorder alone" can be fully treated with refeeding. Though there are obviously temperamental and biological underpinnings of an eating disorder, there are clearly other factors at work. Not everyone with an "eating disordered temperament" develops an eating disorder. Eating disorders occur much more frequently in women than men, which begs the question of how societal pressures (not just about thinness, but also gendered pressures/oppressions more generally) may impact the development of an eating disorder.

    Also, like Dr. Ravin said, there is also the processing of what it is like to have/live with an eating disorder. An eating disorder can be an incredibly alienating and painful experience, even if one has an "eating disorder alone." I can't help but think that one can also have an eating disorder ALONE. Even if the family is involved, it can be an isolating experience. Then, even after recovery, there is the commitment of living in a way to prevent and guard against relapse. Certainly individual and family therapy can be useful in processing the experience of living with an eating disorder, in addition to uncovering root causes, if that is something that would be helpful to the patient.

  6. Sayhealth, I think we're almost completely in agreement. To clarify what I mean by "only an eating disorder" I'm not saying "only malnourishment." I mean the mental illness that is triggered by malnourishment.

    What most people mean by psychological treatment is to discover and fix problems in that person's life that caused the illness. I believe the illness (or co-morbid issues) causes the problems. I'm for any help, therapy, training, coaching, support, family changes, and lifestyle changes that support not only recovery but a whole and satisfying life!

  7. In other words, re-feeding/symptom interruption doesn't occur in a vacuum and isn't just about the food. I absolutely reject treatment that treats food as the ONLY medicine or people who think that if the patient "just eats" they'll be fine. FBT/Maudsley isn't "just about food" and neither should any treatment be so.


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