Episode 009

Navigating Family Based Treatment (with Dr. Amy Boyers)

In this episode of The Other Side of the Plate, hosts Laura and Jenni welcome Dr. Amy Boyers, co-founder and president of Galen Hope and a clinical psychologist with over two decades of experience treating eating disorders. Laura and Amy's friendship stretches back to childhood in Miami, making for a warm and candid conversation about family-based treatment (FBT). Dr. Boyers traces the evolution of eating disorder treatment from the "parentectomy" era of the eighties and nineties through the emergence of FBT, explaining the three phases of the manualized protocol while advocating for what she calls "FBT with a twist": adding meal support coaches, dietitians, respite from grandparents, and regular therapy sessions for burnt-out caregivers. She addresses common reasons families stall (inconsistent monitoring, "clean eating" that can't achieve caloric density, reluctance to enforce meaningful consequences) and offers a memorable reframe: when one part of a family system changes, the other parts engage in "change back behaviors" to restore the status quo. Dr. Boyers emphasizes that FBT is only the "gold standard" if it works for your family, and encourages parents to develop a Plan B before they need it.

00:00 Introduction to the Podcast

01:03 Meet Dr. Amy Boyers: From Childhood Friends to Eating Disorder Expert

06:42 What Is FBT? From Maudsley to Lock and Le Grange

13:25 When FBT Isn't the Right Fit: Recognizing Family Dynamics

21:52 Common Reasons Families Stall: "Change Back Behaviors"

27:07 Caloric Density and the "Two Entire Birds" Problem

29:25 Consequences That Signal Commitment

37:00 FBT with a Twist: Adding Coaches, Dietitians, and Therapy

45:02 When to Transition Away from FBT

51:35 The Future of FBT and Treatment

53:57 Advice for Families Starting Their FBT Journey

SUPPORT & RESOURCES

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

FEAST website:

https://feast-ed.org/

Link from Dr. Amy Boyers:

https://www.galenhope.com/eating-disorders/10-foods-for-anorexia-refeeding/

FEAST flyer:

https://feast-ed.org/programs-and-services/

(FEAST webinar August 2025)

When FBT Alone May Not Be Enough: Adding DBT into Treatment

(FEAST webinar slides August 2025)

When FBT Alone May Not Be Enough: Adding DBT into Treatment

(FEAST Webinar-July 2024)

How We Developed FBT and Why it Works

(FEAST webinar December 2025)

Family Based Treatment for Young Adults: Parents as Partners in Recovery

(FEAST webinar slides December 2025)

Family Based Treatment for Young Adults: Parents as Partners in Recovery

Treating Eating Disorders - F.E.A.S.T.

Anorexia Weight Gain: 13 Foods For Anorexia Refeeding

Guest Bio

Dr. Amy Boyers is the co-founder and president of Galen Hope, which is a physician-led program providing eating disorder and mental health treatment for adolescents and adults across a wide range of diagnoses. Galen Hope emphasizes community integration, family support, and fostering a sense of connection and belonging as essential to healing.

She has been in private practice in Miami since 2001, where she provides therapy to adolescents and adults, with a focus on women’s health, eating disorders, anxiety and mood disorders, and behavioral medicine.

After graduating with honors from the University of Pennsylvania, she was awarded a prestigious U.S. Department of Defense psychological research fellowship at the University of Miami, where she completed her masters and doctoral degrees.

Dr. Boyers is adjunct faculty at the University of Miami Counseling Center and has spoken locally and nationally on the topics of eating disorders, stress, trauma, and adolescent development. She has also co-authored several articles in professional journals. She was the founding president of the Miami Chapter of the International Association of Eating Disorders Professionals (IAEDP) and served on the national board.

Episode 009

Navigating Family Based Treatment (with Dr. Amy Boyers)

A conversation with Jenni Gaines, Laura Cohen, and guest Dr. Amy Boyers.

FULL TRANSCRIPT

Host:

Welcome to The Other Side of the Plate, brought to you by FEAST—Families Empowered and Supporting Treatment of Eating Disorders… Together we'll share personal insights, connect you with professionals, and point you toward helpful resources. And as we say at FEAST: We're here because we've been there.

NOTE:

The content contained in this podcast is not a substitute

for professional or medical treatment, and it may not represent

the views and beliefs of FEAST. Always consult a medical

professional for medical advice and treatment recommendations.

Laura:

Hello and welcome back to the Other Side of the Plate. My name is Laura Cohen. I'm here with my co-host Jenni Gaines, and we have a very special guest today, one that is near and dear to my heart. Mainly because—a little fun fact—Amy Boyers is our guest, Dr. Amy Boyers. Amy and I have known each other since the summer before second grade. So we have a lot of history here. I promised her I wouldn't embarrass her, but I can try. We go way, way, way back. So it's really fun.

When I was like, okay, we've got to get Dr. Boyers—I can't even call you Dr. Boyers. That's just weird.

I was really excited to ask Amy personally and professionally to join our podcast because I know that Amy has a lot to offer. On that note, I'm going to tell you a little bit about Amy and then give her the mic.

Dr. Amy Boyers is the co-founder and president of Galen Hope, which is a physician-led program providing eating disorder and mental health treatment for adolescents and adults across a wide range of diagnoses. It's based in South Florida and they serve clients from across the United States.

Amy is also adjunct faculty at the University of Miami Counseling Center, and she has spoken locally and nationally on the topics of eating disorders, stress, trauma, and adolescent development. I see her all over the place when I'm on Instagram. Amy, welcome.

Amy Boyers:

Thank you.

Laura:

So let's start it off easy. Tell us how you got involved in eating disorder treatment, because I actually don't a hundred percent even know that story.

Amy Boyers:

Sure. It was something that I had always really wanted to get into. I found it fascinating. Growing up in the eighties, there was definitely awareness of eating disorders. There was Steven Levenkron's book The Best Little Girl in the World, and I'm sure that was an afterschool special at some point. I recall some awareness that there were some girls that had eating disorders, but it was very taboo to talk about. I certainly didn't know how you got treatment for that, but I knew I was really interested in it.

When I was doing my internship as part of my PhD, a treatment center opened up in Coral Gables and I decided to pursue that and I worked there. Shortly thereafter I went into private practice and I wound up going into the office space of a therapist who I had shared a case with when I worked at the treatment center.

I called him one day and said, "I'm looking for office space. Do you know anybody?" He was like, "I have office space." And I wound up moving into the office of two men who were two of the first people really in the country to treat eating disorders. They were psychoanalysts and they were brothers, Roy and Eliot Erlichman. Eliot died a while back, and Roy was one of the founders of IAEDP.

I got some additional training with them every week. We would meet and discuss cases, and so for probably eight to ten years, I had weekly psychoanalytic eating disorder training from people who had been doing it for 40, 50 years.

Then I got more integrated into the eating disorder space. I was a consultant for the Oliver-Pyatt Center. That's where I met my co-founder for Galen Hope, Wendy Oliver-Pyatt. She and I created the Clementine program together. One foot in front of the other, one project led to another. Then I approached Wendy one day and said, "I think I have an idea for a treatment center. Would you like to give it a try?" And so here we are all this time later.

Laura:

I remember when my daughter was in treatment, Amy said to me, "Yeah, well I'm opening a treatment center." The timing wasn't right exactly, but it was one of those worlds-colliding moments.

But we haven't really introduced what we're going to talk about today, so I think it's a perfect segue to get into it since you were talking about the eighties. We could probably spend five podcast episodes talking about diet culture and just knowing people who had eating disorders in high school and we didn't know what to do.

And then going into that field and then thinking about what people's experience was in the eighties and the nineties with treatment. Today we're going to talk about FBT, family-based treatment, with a twist. FBT wasn't something that anyone knew about in the eighties and nineties.

Amy Boyers:

I was very new to the field, but when FBT came out, I was an early adopter because it made so much sense to me. Even if FBT isn't something your family can do, there's a lot of principles and the spirit of FBT that I feel really should be present in many ways, even at a higher level of care.

I think we do that really well at Galen Hope. We have something called the Family Integration Model, where it's intentional. It's the expectation of our program that parents are going to be included deeply and they're expected to show up. That's a principle borrowed from FBT for sure.

Laura:

I love that. So what I'm hearing you say is back in the eighties and the nineties, basically the patients would get a "parentectomy." I've heard that before—parents move out of the way, we're removing them. And then comes FBT.

A lot of our listeners may be new to this. We're talking about FBT, but we know what it is. Can you give a brief explanation of what FBT is and also what true FBT looks like in practice?

Amy Boyers:

The first version of family-based treatment really took place in London at Maudsley Hospital. Sometimes you'll hear people use the term "Maudsley"—they'll say, "I did Maudsley." The truth is they are slightly different. What they did at Maudsley Hospital was a little more free-flowing and it was actually a multi-family-based intervention, but they were onto something about really teaching the families how to manage the eating disorder at home.

Then Lock and Le Grange brought that over to the United States and they manualized it and standardized it. That's what FBT is here. Family-based treatment here in the United States is based on a structured, manualized intervention that has lots of research behind it. It was originally developed for families with adolescents with anorexia nervosa, and over the years they've expanded that to working with young adults and other eating disorder diagnoses like bulimia and binge eating disorder.

It's really an intensive model working outpatient with a therapist who's trained in FBT to teach the family how to manage the weight restoration, manage the behaviors at home. There are three phases to the treatment and it develops a developmental model where in the beginning, when the child is more impaired, the parents step in in a more active way. Phase two, they begin to transfer some responsibility for feeding over to the child. Stage three is very short—it's really wrapping up and then transitioning into more traditional psychotherapy.

They say "laser-like focus on weight restoration." It's very behavioral, very nutritionally focused. While you do implement certain psychological tools or interventions, they're all in service of eliminating the eating disorder and blocking the eating disorder.

Unlike traditional family therapy, it doesn't really get into problem dynamics. It's very empowering of the families. It says any family is capable of doing this. It really moves away from that stigmatization that was happening earlier.

In many ways it was a response to feeling pushed out by treatment professionals. There was this big swing when FBT came out that was very anti-establishment treatment. And for good reason, because parents were being demonized. Think about all of that talk about the "enmeshed mother" and that concept, which doesn't even really hold up in the research.

I think FBT was a really necessary development—not only as a tool for families, but for the field. It really brought in an attitude of egalitarianism where parents are treated as experts on their own children and on their own family. The professional has technical skill, but you have to find a way to implement this in a way that's consistent with the way your family operates.

I always found doing it really fun. You get to know these families really well. Everyone does it a little differently. When I did FBT in private practice, I would go into the home and do the meals with the families. That gave me a window into their world that otherwise I wouldn't have. When the child emerges on the other end better, that's a really nice experience to have together because you're all in it together.

Laura:

I remember when I heard what FBT was, I was like, that just makes so much sense. It's essentially tasking the caregivers, the parents, whoever the supports may be, to renourish their child in their home—hopefully not having to go somewhere. To me, I was like, well that does make sense rather than the first thing being "let's get them out of the house." So thank you for that.

Amy Boyers:

Yeah. And there are times where getting someone out of the house might be appropriate. I think that's a complex clinical question and a hard one for anyone to answer—when is that appropriate and when is it not?

Jenni:

That really is a complex question. I think every parent is looking for the right treatment, and it can be hard to decide what that is. There's such a learning curve when your child is diagnosed with an eating disorder. Amy, how do you go about guiding families to decide where to start with treatment, and how do you help them make changes to treatment if that's what's needed?

Amy Boyers:

Anytime I ever worked with a family, I informed them: "Okay, this is what's going on. Your child has an eating disorder. Here's the diagnosis. Here's what I think is going on, and here are your options. Let me go through the pros and cons of all the options for you."

Certainly for a family for whom this is new—these behaviors began recently, this is really the first time you've been working with a mental health professional, or you haven't been working with one very long—I think FBT is a really sensible and reasonable choice. It keeps the family together, it keeps the child at home. But you do need to really understand what that process involves.

I have seen families where it absolutely was not realistic, even though those circumstances were present. It was a fairly new eating disorder. This was a young teen. These were concerned parents who were showing up. But the relationship between the parents and the child was so tumultuous and so tense. This child was unwilling to accept support from her parents, and she was acting out and running away and very, very angry.

She didn't stay in my practice long enough for me to find out why she was so angry. But the anger and the rage was so intense that it was impossible for her to sit in the same room as her parents. They were also feeling like there's no way we can do this. I presented it to them, but they recognized that the relationship was too fragile.

They just weren't in a place where—and that was not really a result of the eating disorder. Sometimes when someone's in the throes of an eating disorder, it completely messes up the relationship with the family. But that wasn't the case here. That predated the eating disorder.

I have seen situations where there may be a parent who's pretty severely impaired in some way. Sometimes the other parent can do it. It depends on the impact that one parent's impairment is having on the whole family system and the finances and all that stuff. So sometimes that can be a problem.

I have seen parents who have their own trauma history and who are just very sensitive to the level of chaos and upset that comes with trying to do refeeding. It triggers them. It overwhelms them. They may have their own responses to conflict that prevent them from being able to do it.

The problem is a lot of people don't always have awareness of that. If you haven't been in therapy yourself, if you haven't recognized that what you've been through is traumatic and that it may be playing out now, that can be a real problem. The low level of awareness that you're having a trauma response every time your child gets dysregulated—and we know that's going to happen.

We know that attempting to implement FBT is going to be so hard. It's going to be upsetting. No amount of explaining that to parents is going to prepare them for that. Some parents are like, "I don't care. Scream away. We are getting this done." And some parents go into a full-on trauma response and then the eating disorder just walks all over them.

If you've done your work, if you have awareness, if you know what your trauma response is and you can manage it, and maybe you have some other support in your life like a husband or wife who can help you through those moments, then you probably will be fine. But if you don't have that awareness, that can be really, really problematic.

I see you nodding along. What are you thinking about, Laura?

Laura:

I totally agree with you. One thing I really like what you were saying is one reason to bring in someone who understands FBT—which hopefully people do. Yes, you can do it on your own and all of that, but I love that you, as the therapist who was trained in FBT, were able to look at the family dynamic and say, "This isn't going to work because..." and there are some other options.

Bringing that professional in is so, so important. Also, sometimes parents think that they can't do it and they're scared to do it and they actually can. Working with the correct team to help manage the caregiver's emotions and their own distress tolerance is huge.

I'm a heck of a lot better caregiver, human, person—more empathetic—from doing FBT and learning all of those skills myself. But definitely having that trained therapist is so, so important because you don't want to give up too soon. And if it's not right, it's not right. And that's okay.

Jenni:

I think that's great for the listeners to hear too, in case they're in one of those situations. If you're told this is the gold standard treatment—FBT, FBT, FBT—and for whatever reason you don't have access to an FBT therapist, it's not good for your family dynamic as Amy explained, or some other reason, there are other options and you don't need to feel like you're missing out on the quote "best option."

Amy Boyers:

Yeah. That idea of "gold standard"—it's only the gold standard if it works for you. If it doesn't work for you, then... I feel like that just makes people feel like they're failing when there's so many ways to get there.

I also think that people shouldn't feel pressured to accept any course of treatment in the moment. You're allowed to take these recommendations home with you, do your research, think about it, come back a week later, talk about it some more. You don't have to make that decision right then and there.

Unless there really is medical acuity that's so dangerous that you've got to act now, you can take a minute. I think it's really important to go and do your research. I know FEAST has lots of information available for people who are considering FBT so that you can get a flavor of what it's going to be like for you.

It's no joke. It's a big undertaking and you've got to be ready to set aside a lot of aspects of your life for a while to do this. I think most parents would do it without thinking, because that's the parental instinct—if I can do something to save my child, throw myself in front of a car or bus, whatever, I'll do it.

But there are options out there for everyone. I think we're at a really interesting point in terms of the field. People have lots of access to information—some good and some not as good—but there are also a lot of treatment options now. You should do your homework in really thinking about what's going to work best for your family.

Laura:

What would you say—you touched upon some of this about different families that it may or may not work for, that FBT may not be a good fit. If you had to put it in a nutshell, where would you see the common reasons that families either struggle or stall within FBT? I definitely want to get into other options and other modalities as well.

Amy Boyers:

Look, I think a lot of families are good candidates and I think people should try it. If you're interested in it, you should try it. That's a reasonable choice.

The older the child, especially if they're in their twenties, it can be a little more challenging—especially if that person has lived independently and now the parents are stepping in in a way that's developmentally a little bit back from where they are. That can be really hard for that adult child to accept. I have seen some young adults do it with their parents and it's been great, but if they have been living with a lot of independence and freedom, that's going to be a tough one.

Where I have seen families fall off or stall is in a couple of places.

One is it gets really hard and it's going on for a really long time, and the eating disorder is still finding ways to beat the system, get in there. They're not catching all the behaviors. So the eating disorder is getting emboldened and reinforced because the child's been able to continue to engage in eating disorder behaviors at the same time that the parents are making a concerted effort to beat it back. They've figured out how to sneak around their parents.

Laura:

They're so smart.

Amy Boyers:

Yeah. And so if the parents can't wrap their arms around that and really implement effective consequences for that, I think that can get people stuck. That's where sometimes it can even go further into enabling—when parents struggle to tolerate their child's distress, whether it's because you're asking them to eat and they don't want to, or because you're enforcing rules and expectations in a way that's new and different for the family.

This is serious and parents get down to business and they're not messing around. That may feel really uncomfortable. In any family system, when one part of the system changes the way they operate, the other parts of the system are going to do things to get them to change back. That's human nature. They love that status quo.

And so the child will begin to engage in what I call "change back behaviors." "Go back to being the relaxed parent who let me get away with a lot of things." They want you to go back to that. And they'll escalate certain behaviors until the parent will do it.

That requires a certain amount of awareness. I think that's where having a trained clinician involved is helpful—to point out to you that this pattern is happening.

I have seen people move into stage two too quickly with the returning of responsibility back to the child, and not really watching enough time to make sure that the child really can handle that responsibility of feeding themselves again.

I have seen parents say that they're monitoring every meal and then it turns out they're not, and the kid's throwing breakfast or lunch away. If the parents can't fully commit to making sure that there is monitoring for every meal and snack—that means every meal and snack—because if that kid knows that mom is going to get distracted on her phone or go to her computer and start working while they're eating lunch... they know. "I'll performance-eat breakfast because dad watches that, and then I'm going to toss lunch."

Some people struggle with the consistency of doing it every single time.

I have seen some families who tend to eat more clean, in a more dietetic fashion, struggle with the amount of food that is required. They want to stick with foods that are "healthy foods," and that can be very reinforcing of everything that the eating disorder wants. "You want to give me quinoa and grilled chicken and broccoli every day? Fantastic."

And I'm like, do you want your child to have to eat two entire birds a day? You are never going to get there if you're eating grilled chicken and steamed broccoli. Bring me the ice cream. Please get some chocolate cake out here.

Actually, on my personal website for my private practice, the blog that has the most traffic is the blog that shows foods for weight restoration.

Laura:

Show notes! That's going in the show notes.

Amy Boyers:

And we have one at Galen Hope. We did an updated one. I went to Trader Joe's and I took pictures recently and we posted it on the Galen Hope website too. Because sometimes it just requires you to buy food that normally you might not eat.

If you are a person who grew up in a time like we did, where foods were labeled as good and bad, or if you grew up in a family that really put a lot of emphasis on eating "the right way," where you're putting moral values on foods, it can be hard for you to load up your pantry and your refrigerator with those foods. And that's going to prolong it. There is just no way you're going to get there with those kinds of foods.

It doesn't mean you can't eat them. Actually, that's an exercise that I've done with some people—let's look at how much salmon and quinoa you have to eat in order to calorically meet your needs, and let's do it my way. And it's like this mountain of food. You have to eat so much of these foods. We've got to go for the denser foods.

So some families really struggle with that. That's where I think families get stuck. A lot of it comes down to really implementing consequences consistently when you catch a behavior—implementing appropriate consequences that have meaning to that child.

So if you have a very studious, academically oriented child who refused to eat her dinner last night and threw a fit and did not complete her meal, why are you letting her go to school the next day?

Laura:

Yeah.

Amy Boyers:

In my mind, your brain and your body needs nutrition in order to make it through the day and in order for you to be successful at school. Why are you letting her go to her dance competition? "Well, she practiced for it for the last three months." Yeah, I know. But if you really want her to know that you're serious about her recovery, you need to show her that you're willing to sacrifice even the dance competition or the prom or graduation. That you can go all the way. That you will go nuclear.

That's where a lot of families struggle—in giving up the things that they know are a source of pride and identity for that child.

Laura:

But sure, the parent, right? The parent doesn't want to give that up because it's important for their pride too.

Amy Boyers:

And it's really hard. I'm sure there are parents here who are listening to this and thinking, "That's BS. You don't really understand my child and my child's level of achievement and how special they are and what's at risk and the college applications and the scholarships and all that."

Your child has to survive and has to be healthy enough to be able to do that away from home. If they can't feed themselves and they can't take care of themselves, what good is it? Who cares?

That may sound extreme, but that's the only way that you really can signal to the eating disorder—not to your child, but to the eating disorder—that you are willing to go as far as it takes to get this eating disorder out of your child's life and out of your family.

I think that can be hard. For so many of these families, these kids are so amazing and interesting and talented, and it's very hard to pull them out of these things. Especially with all the pressure that children and families feel around college admissions. Or jobs—they have this great job, this great internship, whatever it may be.

But you have to be willing to say nothing is more important than your recovery. Parents absolutely feel that way. But sometimes their behaviors don't communicate that a hundred percent of the time. Communicating that 90% of the time is not good enough. That 10% of the time that you flex and give in is keeping that door open for the eating disorder.

Laura:

The eating disorder will find anywhere to wiggle in. And it's so hard as a parent. Jenni and I are on the other side of the plate—exactly—and know how hard that is.

Jenni:

I remember for me, one of the hardest things was accepting that my daughter—who you just described, the one that's academic and talented and very high achieving—to look at her trajectory and see it may not be the way we always thought it was going to be. That was my work to do, to learn how to accept that. And it was extremely difficult.

But listening to you talk about all the parts of FBT—I went through it—it sounds overwhelming even now, in the aftermath. But I love FBT because it empowers parents. It's also really intimidating. I think some of us lose our confidence and we may give up too soon.

I wanted to ask you: if our child's progress plateaus—maybe we're not gaining weight as quickly as we want with FBT—or our child's health worsens, maybe their weight goes down and they start having some signals that their health is worse than it was, are there any questions that parents could ask themselves to evaluate or assess whether it's time to move on? Just as an assessment tool for parents who are listening.

Amy Boyers:

Look, plateaus happen. I think that's where having really good communication with the team is important. A plateau isn't necessarily the end of the world, and I would engage the team. "Okay, we are having a plateau. Her weight hasn't budged in four or five weeks." That's not great. That's not great prognostically. Your team should be concerned about that.

But I also think—just for me as a clinician, having seen all different types of therapists do this and being at this point on the more seasoned end of things—this is where it's really important to have a clinician who knows more than just FBT.

You need to work with someone that you think is a really strong therapist who has a lot of wisdom generally, because sometimes you need to step outside of the protocol for a minute. Maybe the parents need to come in and have a session where they just have a good cry with the therapist and they get some support for themselves and we talk about what's been making it hard.

They can release some of those feelings and explore where this is coming from. You do a regular therapy session, not an FBT session, but a real therapy session where they work through some stuff. Sometimes that's enough to get your energy back up. Whatever was blocking you, you make some connections, you realize where your responses are coming from, and you can get back on the saddle and do it again.

I was trained on a million different manualized interventions throughout the course of my career. I think they're great for learning and they teach you a lot of tools as a therapist. But there is something called clinical intuition. There is an art to doing any kind of therapy, and you need to be attuned as a clinician to what is going on with this child, with this family, with these parents.

You sometimes need to listen to yourself. Maybe mom and dad are going through something. Maybe there's another stressor in the family. It's not uncommon for families to come in with an elderly parent, like a grandparent, who's not doing well. At the same time that they are a caregiver for an elderly parent, they are dealing with this crisis with their children.

Sometimes you just need to give the parents a little love. Or sometimes maybe I need to give this kid a couple of just regular psychotherapy sessions so that I can increase her motivation to do this some more. Maybe they're getting burned out.

This is where your judgment as a clinician to address some of these side problems—it's not part of the protocol, you're not supposed to do that—but if I want to get there, and especially for some families going to a treatment center is not financially viable, their insurance doesn't cover it, or there isn't one that is appropriate nearby, or they have to make FBT work... they have to.

I have worked with families that have no other choice for a variety of reasons. If we have to make it work, then it's my job to figure out how do I get all these people to stay motivated and engaged and psychologically healthy throughout the process. FBT does not provide you tools for that. You've got to read the room and see what's going on with your people and give them the help they need.

Laura:

So since we're talking—you're going to be talking right now to caregivers—what would you say to a caregiver for whom FBT isn't working? Lord willing, they've got a therapist that has different modalities. Could you explain a couple of other options, a couple other modalities? Because our listeners may not know. They may only hear about FBT and nothing else. What other things would you think would be helpful to introduce to caregivers?

Amy Boyers:

Okay. Well, I've done it a lot of different ways. First of all, we all know there are higher levels of care, there are treatment centers. I always, even with my FBT families, told them: "Listen, we're going to give this maybe four to eight weeks to work. If it doesn't work, we are not going to do this forever. And you need to have a plan B. What is your plan B?"

That is not me expressing a lack of faith in them. It's really appropriate. We're going to try to make this work. If we can't get traction, we need to move on quickly because otherwise you're going to get stuck here—and we will talk about that, I guess.

But what's your plan B? I have added dietitians. The original FBT did not involve even a dietitian. I almost always included the dietitian because I think parents just need that additional education around what your child needs.

And then there are higher levels of care. Exploring: Is there a program nearby? Do you know someone that went to a program? There are organizations that will refer you to programs. You can call your insurance, talk to your pediatrician. A lot of times pediatricians are aware of programs that they've had some success with. There are lots of different programs. There are virtual programs. I know that there's a lot of conversation in FEAST—giving each other tips and support and just ideas of how to do it.

Laura:

I love when you said sometimes the support or the patient just needs a regular old cry-vent-session therapy session. Both are different. One week we can be more therapeutic. One week we can just vent. And how helpful that can be too.

Jenni:

That was all FBT with the twist—everything you just described. Because when you're the parent, you're looking at the manualized FBT. If we don't have a therapist that is trained in all these other modalities, is aware of all these other modalities, we're just laser-focused on FBT.

All of the different ways that they could continue with—like you called it—the spirit of FBT at the beginning. I think that's going to open up a lot of possibilities for the listeners. Because I know for me, I did feel a lot of times like I was doing it wrong.

Hearing you talk about creative ways to use your intuition—but caregivers can also use their intuition to make adjustments that will fit your child. Because as you said at the beginning, we're the experts on our kids. I think stepping into that responsibility is just a little bit daunting.

Amy Boyers:

Yeah.

Jenni:

But it will be helpful to hear there are other options.

Amy Boyers:

Yeah. I think hearing FBT is a relief in certain ways, and then it's also like, "Oh my God, what if I can't do it? Now I've doubly failed because my kid has an eating disorder. So of course now I'm a failure as a parent, and now I tried to help them and that didn't work, so I must be a double failure now."

To be honest, there are a lot of people out there that say they do FBT who are not formally trained in it. They're doing something that might resemble FBT, but check to make sure that the people you're working with have actual training. Actual training. Not that they just read a book or went to a two-hour workshop—the training is real.

Just because you're talking to parents about how to refeed their child, that is not FBT. FBT is a specific thing. I did many, many hours of training to do it. I did follow-up training on it.

There's actually some very interesting literature out there. The literature on FBT now incorporates a lot of these twists that are actually being done out in the world. I really like that they're showing how adding certain things—like a meal support coach and other types of coaching—improves outcomes. And adding groups and things like that.

But also, make sure that what you're getting is the real deal, because then the parents are stuck with this feeling like, "I just did something wrong." And it's like, no. If you went to a doctor and you needed medication A and they gave you B and then you didn't get better, is that your fault that you didn't get better?

It's meant to be done in a particular way. I think it's fine to riff and get creative, but you need to do it for the right reasons. You can't just be sloppy about it. It works according to the protocol that was developed. If you're going to add services or mix it up in some way, you need to have a very coherent clinical understanding of why you're doing that. And so does the family.

"Okay, you all are struggling with cooking all these meals all the time. Let's get some prepared meals. Can Grandma cook? Yeah, Grandma loves to cook."

I mean, this is Miami, so we work with a lot of Cuban grandmothers who love to cook for the family and who do it anyway. Or do Mom and Dad need a respite? Can we bring Grandma in so that we can train Grandma on how to do some meal support also, so Mom and Dad can take a break because they're starting to lose it?

There's lots of ways to get creative with the family that way.

Laura:

I think about supporting—I went through this in our own house—you don't get a lot of support outside the house. Someone gets a diagnosis of cancer, God forbid, or anything else, everyone's got a meal train and they're doing this and that. With an eating disorder, you don't get that.

When you were saying that—bring the abuela in, bring the grandma in—if you have anyone that's asking "How can I help?"—I know a lot of people do not—have them make a meal, have them do a meal train to help. That would help so much because you get so sick of cooking. Finding a community that can help you do some of that, that just sparked in my mind.

Amy Boyers:

This could be really challenging for families who don't cook.

Laura:

Oh yeah.

Amy Boyers:

And that's okay. You don't actually have to cook. I worked with a family that did it all via takeout. Literally even breakfast.

Laura:

Yeah. And Trader Joe's, Aldi. There are so many options. I know finances can obviously be a huge thing, but there are options. Being creative.

Amy Boyers:

Yeah, for sure. And it's exhausting.

I think that these conversations of "Is this really working?"—these are conversations you need to have. Trust that your team will tell you it's not working. You need to know: What is my plan B? What is my plan C?

What I do find sometimes is that the meals all fall on one parent. That can really be problematic. Oftentimes just by making sure both parents are present, even for most of the meals—maybe not every single one, but if both parents can commit to maybe always being together for half of the meals—that makes a huge difference. Because the one parent who's really doing a hundred percent of the meals, they get burnt out and they need to rely on the support from the other parent. Sometimes just making a simple change like that can make a huge difference.

Jenni:

It's so good to talk about all the different ways that this can go. I think it normalizes just how much this is not a straight path. We always hear "it's not linear," but this is really helping to illustrate it can go in so many ways and that doesn't mean it's not working.

It can sometimes help to just walk through what maybe it looked like for someone. So I was wondering if you would share an example of a situation where you'd recommend that the family continues doing FBT, but that you do some of these twists with it.

Amy Boyers:

I have a family—and believe it or not, I'm still in touch with them. Every year they send me a picture of their daughter who's doing well. She graduated college now.

This family had a very interesting immigration story. They were recent arrivals in the United States. Daughter developed an eating disorder. Both parents fully participated. We brought in some meal support coaches for them because the kid was getting so dysregulated. When the meal support coach was there, it calmed things down and they got the food in. With the help of the coach for that first week or two—we just did it for the first week or two—they actually came to Miami, stayed in a hotel, we had a coach work with them so that they really felt confident in doing it.

I did the first meal and the kid was like, whoa. You know how it is—demon child. But having the coach there helped calm things down, gave them the confidence to keep going. They developed that confidence with the coach to then go back home and do it. They gave themselves time. They did maybe 15 meals with a coach so that by the time they went back, they were really feeling like, "I got it." And I think you do.

The meal support coach has done this for like a decade. She worked in a treatment center. She's seen this a million times. Watching someone throw a fit and spit out their food and cry did not ruffle her feathers. She's not emotional about it. It's not her kid.

That was really helpful for the family—to be able to ride that storm with someone a bunch of times before you do it on your own. Not everybody can afford a meal support coach, but that can be really helpful. That's a way we mixed it up a little bit.

Jenni:

That's a great example. Thanks for sharing that.

I'm going to go with the opposite question maybe, and I'm putting you on the spot a little bit—coming up with an example of a situation where you would recommend that they transition to a different treatment approach away from FBT.

Amy Boyers:

Yeah. I definitely had cases where the FBT wasn't working, where the kid just—and again, this is another family I'm still in touch with—the child's eating disorder was not caught for a long time because she was very tall and she was an athlete, and they thought she had a heart problem.

It was being treated like a medical issue, but it was because she was restricting and underweight and playing a lot of sports. Her mom is the nicest woman, so sweet, but really had a hard time saying no, really had a hard time laying down the law with the eating disorder. This kid knew exactly how to push her mom's buttons.

So we're going, we're going, we're going. Her weight's not getting better, her weight's going down. Finally, I always bring the child in first and have a meeting with them. She said to me that she knew she was manipulating her mother, and it was making her angry.

I said, "Do you think you need to go to a higher level of care?"

And she said, "I need you to tell my mom I need to go to a higher level of care." She said, "My mom can't do this."

This was not a mom who was not trying. She's extremely likable—sweet, polite, lovely. The father became a puddle every time he talked about the eating disorder. All he would do was cry.

So this kid—but again, part of that is that I built a relationship with that child where she was able to say it's true. I kept saying to them, "I don't think she has a heart problem. I think this is a nutrition problem." She does not have a heart problem anymore. She went to college. She's getting a degree in counseling now.

But she knew it. The mom was so frustrated because I was like, "Look, she's not eating as much as you think she is. Her weight continues to go down. We've been at this two, three months and we're spinning our wheels here."

In most cases where FBT didn't work out, we had a systematic plan to refer the person to a higher level of care with a place worked out. Sort of like, "If we don't get this together, we're going to be going to a higher level of care." Sometimes that increases the motivation of everybody to make it work. And sometimes it doesn't work.

I'm always blown by families who've been doing it for two years straight. I know it happens for a lot of different reasons, but if you've been doing FBT nonstop for 12, 16, 19 months—time to reconsider for sure.

Laura:

That makes perfect sense. On that note, where do you see the future—with your little crystal ball, Dr. Boyers—the future of FBT and treatment? Where do you see this going maybe five years from now, ten years from now? We had that shift back in the eighties—getting the parents out and then bringing them back in. Where do you see the trajectory going in the future?

Amy Boyers:

I think there has been much more of a coming together. There was a time where FBT families really didn't trust treatment centers. I think now there's much more of a recognition of the contribution of FBT to the field generally, and of really bringing families in.

I see a lot of FBT-based programs that incorporate traditional components of residential treatment centers too. There's a recognition that sometimes people just need a little bit of everything. I don't think FBT is going anywhere, and I don't think treatment centers are going anywhere.

What we're starting to see now is a little more creativity in the field around reaching populations that haven't always gotten particularly good quality care. There's better access now with virtual programs. There are people coming up with a lot of different types of services that give people more freedom and choice.

But with that being said, I will say: just because you have the ability to pay for some kind of concierge, very individualized treatment doesn't mean it's better.

Laura:

Exactly. What do we say at the beginning, right? What's the best treatment for your kid?

Amy Boyers:

Right. Just because you can buy it and control it and tell people how to deliver it doesn't mean that you're getting the best care. You really want to work with people who have ethics and guidelines and who will say no to you if they think that something you're asking them to do is not in the best interest of your loved one.

Jenni:

That makes a lot of sense. Would you be able to, Amy, just as we're wrapping up this episode—there might be some parents that are in the middle of FBT and they're recognizing all these things that we're talking about. But maybe someone's right now trying to decide if they want to do FBT. What advice would you give the ones who are maybe about to start their FBT journey?

Amy Boyers:

First of all, I would talk to whatever therapist you're working with and ask them: "Do you have a family that you could recommend that I speak to?" Because I did that all the time. And I matched families that I thought were more similar to one another.

So I would try to find—if it was two working parents, I would try to find another family with two working parents, because the experience if one parent is at home and able to really do the work is going to be different than two parents who both have to work. How do you navigate that?

I always tried to match them up. So ask someone who knows you and other families: "Can you have me talk to a family that you think I could relate to, who did this with you, so that I can learn more about it?"

Sometimes I even had other families come into the session to talk to the families about their experience. I did that sometimes when they got stuck. I would bring the patient and their parents in to meet with another patient and parents. The parents would talk, and then the two patients would talk to one another. If one was recovered and one was struggling, I would bring them in because they were feeling very alone.

You want to work with someone who does this a lot, who can do stuff like that for you.

What would help them consider FBT? I think you have to be very honest with yourself. This is a big undertaking and you have to know yourself. You have to know what your strengths and weaknesses are. Nobody else is going to do that. You can't just do it because you were told to. You have to do it because you in your heart believe that this is the best way for your child and your family to heal, and you have to be fully committed.

If that doesn't feel right to you, that's fine. That's great. Let's explore options that are more appropriate for you, that are going to allow you to be the best you can be in supporting your child.

"Yes, I want to be involved in my child's care, but I don't think I can handle this for whatever reason." People have lots of reasons. "Maybe it's just this moment in time in my life. Maybe it's me. I know me. Maybe there are other stressors going on that I have to be aware of."

Whatever it may be: How involved can I be in my child's care? How much am I going to be able to participate in treatment—not just visit your kid, but participate in treatment? How do I feel when I'm talking to them?

There are lots of ways to get there. But I think at the end of the day, it's being very quiet with yourself and being so, so, so honest, and really listening to yourself.

You can start and give it a try. And you can also stop. It's not going to be the end of the world if it doesn't work. And you might surprise yourself. It might not be as bad as you think it is.

Laura:

And you can do it and you can have setbacks and get right back on the saddle again. We're definitely capable of more than we think we can do. And it doesn't need to be perfect.

Amy Boyers:

No, it's not going to be. It's really messy in the beginning. Very, very hard. It takes a long time.

I always tell parents: you're having to do what an entire team of people do in a treatment center, all by yourself. And we all went to school for this and you didn't. So it's going to take a while to get the knowledge and the skills to deal with it.

But it sends a very strong message to your child and to the eating disorder that I am willing to roll up my sleeves and show up for this. That this is going to end. This is not going to stay this way.

Jenni:

Yeah. That's a really powerful way to end this episode. Amy, Laura and I really want to give you a huge thank you for being here and sharing all of your wisdom with us, your insights with our listeners. We're really, really grateful that you spent this time with us and shared your work with us. Thank you.

Amy Boyers:

That was fun. Thank you so much. I'm so glad. I hope it's helpful to people, and I hope it's some good food for thought, as they say.

Jenni:

It definitely will be. Thank you.

Our next episode, we'll be joined by Hannah Hickinbotham from the UK, who is going to share her powerful and inspirational journey with an eating disorder. She's bringing the perspective of someone who's recovered, so I know all of the caregivers will find her story informative and hopeful. We hope you'll join us. Thank you.

Laura Outro:

Thank you for joining us at the Other Side of the Plate. If today's episode gave you hope or guidance, we invite you to explore more resources and peer support at feasted.org. Remember, you are never alone. For more conversations of hope and help for families facing eating disorders, please join us for our next episode.