The Importance of Teen Autonomy in Eating Disorder Recovery and Limitations of Family-Based Treatment
I have had the honor of working alongside teens and their families for the past 11 years, as they have navigated the complex road towards eating disorder recovery. I’ve witnessed the profound challenges that teens and their families face as they decide on a treatment approach that best meets their unique needs.
I believe one of the most critical elements in teen therapy alongside their safety, is the respect for their autonomy—something that is often overlooked in traditional models like Family-Based Treatment (FBT). While FBT may be an effective treatment option for some, it is not a one-size-fits-all approach. I am going to break down why I look for alternatives to FBT for teens and their families when considering cultural diversity, teen development, and the unique needs of families.
Understanding Teen Autonomy in Eating Disorder Recovery
Autonomy, the ability to make independent decisions and exercise self-governance, is a crucial developmental milestone for adolescents. During this phase, teens are negotiating their identities, seeking independence, and learning to assert their personal preferences and values. For teens surviving eating disorders, this period of identity formation is often interrupted by a profound internal struggle. Their desire for control becomes deeply intertwined with their relationship to food, body image distress, and self-worth.
In many cases, an eating disorder emerges as a way for teens to cope with overwhelming emotions or situations they feel powerless to change. The eating disorder becomes a survival skill. And we must create alternative ways to manage and cope while asking them to reduce their eating disorder behaviors.
Reclaiming a safer use of autonomy, then, becomes crucial for their healing. Recovery must empower teens, not strip them of further control. An effective therapeutic approach recognizes this need and fosters a sense of agency, allowing teens to take ownership of their recovery journey. Letting them be the captain of the treatment team.
The Shortcomings of FBT: A Focus on Parental Control
Family-Based Treatment (FBT), is often stated to be the “gold standard” for treating adolescent eating disorders, most notably, Low Weight Anorexia Nervosa.
FBT places parents at the center of the recovery process, tasking them with refeeding their child and taking over all food-related decisions for their child.
The core philosophy of FBT is that parents are the best resource for helping their child recover, temporarily taking over all decisions so the child can just focus on refeeding, until the teen is healed enough to do it for themselves.
While FBT has demonstrated success in some cases, it also has notable limitations. One of the main concerns is its lack of focus on teen autonomy. In FBT, teens are often left out of key decisions, which can feel infantilizing and disempowering. For a teenager already struggling with a sense of control, this approach can exacerbate feelings of helplessness or rebellion. The therapeutic relationship between the teen and the therapist, which is crucial in fostering trust and engagement, often takes a backseat in the parent-led approach.
While it is imperative that parents are involved in the recovery process, having the parents play so many roles can also be confusing and stressful on the parent/teen relationship.
Cultural Competency and the Limitations of FBT
Another significant shortcoming of FBT can be its lack of cultural competency. Eating disorders do not discriminate by race, ethnicity, or socioeconomic status, yet much of the research and treatment models, including FBT, have been developed with a narrow cultural lens. In many non-Western cultures, family dynamics, gender roles, and views on food differ significantly from those assumed by the FBT model. There is also not an FBT recommendation for Binge Eating Disorder (BED) which is the most common eating disorder in the US.
Moreover, FBT assumes a certain level of privilege and access to resources, such as time for parents to engage in meal supervision or access to specialized therapists who can provide FBT training. In families where parents are working multiple jobs, dealing with immigration issues, or facing systemic barriers like racism or poverty, the FBT model may be completely impractical. A culturally competent approach to eating disorder treatment must be flexible, recognizing that different families have different needs, values, and constraints.
The Importance of Teen Development in Treatment
Teens are not just small adults, nor are they children—they are in a unique developmental stage that requires specialized care. Adolescents are in the process of developing critical cognitive and emotional skills, including abstract thinking, self-regulation, and the ability to navigate complex social relationships. During this time, they need to practice making decisions, learning from mistakes, and developing a sense of self-efficacy.
By placing parents in control of their child’s recovery, FBT can inadvertently hinder a teen’s developmental process. In therapy, I’ve seen teens become more disengaged and resistant when they feel that their voices are not being heard. In contrast, approaches that emphasize collaborative decision-making—where teens are active participants in their treatment—are more likely to foster long-term recovery and personal growth.
A therapeutic approach that values teen autonomy doesn’t mean allowing the teen to make dangerous or unhealthy choices. Rather, it means providing them with a safe space to explore their emotions, develop coping mechanisms, and engage in decision-making processes that align with their developmental stage. It also means working with families to support the teen’s autonomy and helping parents understand how to balance supporting their child’s independence in a way that promotes recovery.
Alternative Approaches to FBT
While FBT has its place, it’s important for clinicians and families to consider other therapeutic models that emphasize the role of teen autonomy. Approaches such Internal Family Systems (IFS), or Dialectical Behavior Therapy (DBT) allow for a more individualized and developmentally appropriate framework for recovery.
IFS looks at a teen’s internal system as parts and helps to organize and understand the role that each part of them plays. In this framework, the eating disorder is just a part of their whole system and is working to help them cope with something.
DBT teaches emotional regulation and distress tolerance skills, which can be especially helpful for teens who use food to manage overwhelming emotions.
These approaches respect the teen’s developmental stage and promote autonomy while still offering structured support. They also allow for flexibility in family involvement, making it possible to tailor the treatment to the unique dynamics of each family, rather than assuming all families will benefit from the same level of parental control and participation.
Conclusion: Rethinking the Role of Autonomy in Recovery
In eating disorder recovery, teen autonomy isn’t just a ‘nice to have’; it’s crucial. Recovery is a highly personal process, one that upholds developmental needs and cultural values, but also fosters growing autonomy and self-efficacy. While FBT may be appropriate for some families, it isn’t universally appropriate. Families should have choices about the kind of treatment they select for their teens!
Finding the right fit for treatment is about empowering individuals to restructure this distressing and intense time in their lives. It's about providing the support, tools, guidance, and recovery framework they need to eventually reclaim their lives and discover how to truly thrive.
As a teen eating disorder therapist, my role, with the support of their families, is to guide teens toward recovery in the least restrictive setting—one that provides the ideal level of support while fully engaging the teen in their own recovery.
