By Lauren Mulheim, Psy.D., FAED, CEDS-S
2020 was a year of disruption. Among everything else we have had to deal with, every clinician with whom I’ve spoken perceives that the rate of eating disorders has skyrocketed. The National Eating Disorders Association has reported monthly increases of up to 78% in calls to their hotline. Treatment has been harder to access. Social distancing guidelines required treatment centers to adhere to lower censuses, and lengthening wait lists accumulated.
At the same time, pandemic living created ideal conditions for families to start Family-Based Treatment (FBT) for their teens with eating disorders. With schools closed for much of the year and most adults working from home, it had never been more convenient to administer and supervise the meals of their teens with eating disorders. Gone were the days of parents driving to school to eat lunch in their car with their kids.
There is a catch, however. As Katie Grubiak, RDN declared to me in spring 2020, “The pandemic has been great for Phase 1 of FBT, but not so great for Phase 2.”
FBT is a structured treatment administered by parents in the home. In Phase 1, parents take full charge of all meal decisions and supervise every meal as well as activities between meals—if necessary—to prevent over-exercise and purging. In Phase 2, control is gradually handed back to teens in a deliberate fashion.
The exact conditions that have made Phase 1 of FBT during a pandemic so convenient to administer have made it nearly impossible to transition through Phase 2. With everybody sheltering at home together, creating opportunities to grant teens more independence have felt very contrived—for example, is it a normal behavior to send your teen outside to eat lunch with their siblings while you eat inside by yourself?
I have been worried about this for months. One of the things I most appreciate about FBT is the way that control is handed back to the teen gradually through a series of planned experiments. Families with whom I work decide how to craft increasingly challenging situations to allow the teen increasingly greater independence around eating. The first steps are small: maybe they are allowed to choose their own snack, or portion their own plate with parental correction, or eat a meal at a friend’s house (with the friend’s parent confirming the meal was completed). Later steps are more significant: they might eat lunch at school with peers, or go out to buy a snack with a friend, or sleep over at a friend’s house, eating dinner and breakfast there.
This gradual progression gives us a chance to observe and self-correct. We may even take back control if the step does not go smoothly: for instance, if the teen struggles to eat at his friend’s house, we may put in more safeguards before trying this step again in a few weeks. I usually recommend adding only one independent meal at a time and seeing how it goes. We may try introducing packed lunch with friends at school only one day per week at first, and observe and weigh the child before adding additional days. I usually recommend a single overnight at a friend’s house before a longer stay away. And so on.
However, during the pandemic the natural opportunities for parents to work on building independence have not been available. For most of the past year, teens have not been going to school, most restaurants have been closed, and no one has been able to visit friends’ houses for any meaningful length of time. For either those families who have completed FBT but could not formally work through all the aspects of Phase 2 due to the pandemic, or those families who are still in treatment and tempted to rush things along as things open up, there are a number of things to consider.
First: as pandemic restrictions are loosened, I encourage you to maintain oversight for just a little longer. I totally understand that you will be relieved to have your child out of the house and back at school, and you’ll be so eager to be done with the pandemic and the eating disorder altogether—who wouldn’t? However, continued vigilance will pay off in the long run. Don’t assume your teen with an eating disorder will be able to smoothly transition from eating all meals under the watchful eyes of parents at home, to suddenly eating lunches and other meals on their own. If it was this easy, treatments like FBT would never have been developed.
The usual criteria to consider before starting to return control to the teen are that the they are mostly weight restored, meals are going smoothly, purging and exercise are under control, and parents feel confident enough to step back in if there is a stumble along the way. These should be the minimal prerequisites for allowing your teen to eat lunches at school.
If the above criteria are met, I suggest going a step further and talking to your teen about how they feel about having lunches at school and whether they feel ready to eat on their own. Ask who they will sit with, whether their friends eat lunch (you cannot assume that they do), and whether they have enough time to eat the food required for their lunch.
I usually recommend starting with a lunch that is packed at home, even if a later goal is to be able to buy lunch at school. Talk to them about what an “easy” lunch would be. Arrange for them to have a single lunch on their own and see how it goes before relinquishing oversight of all lunches. Continue to weigh your teen weekly to make sure that weight is maintained. Talk and see how each step goes before going the next step.
As things open up, you can identify more situations in which your teen can practice eating with gradually decreased oversight from you. Some other situations in which you can plan to allow your teen to practice independence:
- A snack at a friend’s house
- A visit with a friend to a coffee shop to order a snack that they eat together
- A visit with a friend to a restaurant for a meal
As you give your teen more freedom, she will be exposed to a greater range of settings in which she hasn’t yet practiced recovery skills. You can help by anticipating and simulating these situations with your teen first before you send her to do it alone or with peers.
My biggest advice is not to rush it. As you allow them increased independence continue to watch and observe. So while you may be tempted to let go quickly, especially if your family is eager for a return to normalcy, I encourage you to consider taking things one step at a time.