Eating disorders are severe mental health conditions associated with profound psychosocial and physical impairment. Among adolescents, Family-Based Treatment (FBT) has emerged as a leading intervention, with randomized trials demonstrating its efficacy for disorders such as anorexia nervosa and bulimia nervosa. However, FBT has limitations, with only 40% of adolescents who start the treatment achieving full remission. Moreover, FBT is unsuitable for families lacking available caregivers, those struggling to participate in sessions, or those resistant to a family-based approach.
Enhanced Cognitive Behavioral Therapy (CBT-E), a transdiagnostic and personalized treatment, has been proposed as an alternative and has been recommended for adolescents with eating disorders when FBT is either contraindicated or unacceptable.
FBT and CBT-E differ in their conceptualization of eating disorders and the roles of patients and parents.
In FBT, eating disorders are viewed through a medical or disease model, where symptoms like dietary restriction and concerns about shape and weight are seen as manifestations of the illness. The disorder is considered separate from the individual (a strategy called “externalization”), and parents are crucial in helping the young person regain control by following treatment. This model emphasizes parental active involvement, with the adolescent playing a passive role. An advantage of this approach is that it absolves both the young person and parents of blame, encouraging family-wide support for recovery.
In contrast, CBT-E uses a psychological model, where the eating disorder is not separated by the individual. The overvaluation of shape, weight, and eating control (i.e., a self-evaluation predominantly based on shape, weight, and eating control) is considered the core psychopathology, from which the main cognitive and behavioral symptoms of the disorder emerge. To achieve remission, CBT-E requires the adolescent to understand and challenge these psychologically maintaining mechanisms, actively participating in their treatment. While parents provide vital support, they are not essential to the recovery process, as the individual’s healing remains independent of their direct involvement.
These differences in conceptualization, parent-child involvement, treatment strategies, and mechanisms of action suggest that either treatment may be effective where the other is contraindicated, not accepted, or ineffective. However, there is limited evidence on whether those who don’t recover with one approach are more likely to benefit from the other.
A recent Australian study aimed to assess the effectiveness of CBT-E for two groups: adolescents who discontinued FBT without full recovery and those who received CBT-E as their initial treatment.
Study Overview
The study analyzed 69 adolescents aged 13–17, all diagnosed with eating disorders and treated in a public outpatient clinic in Australia. Participants were divided into two groups:
- No previous FBT Group (n=42): Adolescents who did not engage with FBT, often due to logistical challenges or family constraints.
- Previous FBT Group (n=27): Adolescents who started FBT but discontinued treatment without achieving full recovery.
Both groups underwent a manualized CBT-E intervention comprising 20-40 sessions. Outcome measures included body mass index (BMI) centile, eating disorder psychopathology, and psychosocial functioning.
Key Findings
The findings revealed that both groups experienced significant improvements in eating disorder symptoms and psychosocial functioning following CBT-E treatment. Many participants reached clinically significant improvement thresholds, demonstrating the intervention’s effectiveness.
Notably, adolescents with no prior FBT treatment showed marked increases in body weight, while those in the previous FBT group did not exhibit significant weight changes. This difference is likely attributable to partial weight restoration achieved during earlier FBT sessions, emphasizing the need to consider individual treatment histories when evaluating weight-related outcomes.
Attrition rates for CBT-E were comparable between the two groups, with 60.9% of participants completing the full course of therapy. Interestingly, prior discontinuation of FBT did not appear to reduce the likelihood of completing CBT-E, suggesting that a history of incomplete FBT does not hinder engagement with CBT-E as a subsequent treatment option.
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Implications for Adolescent Eating Disorder Treatment
The findings of this study emphasize that adolescents who respond suboptimally to FBT or do not engage with FBT, often due to logistical challenges or family constraints, can still achieve significant benefits from CBT-E. This supports growing evidence that CBT-E is an effective alternative for those unable or unwilling to engage with FBT.
By highlighting the value of individualized treatment approaches, the study underscores the need for public health policies to expand access to CBT-E as a standard intervention for adolescents with eating disorders.