Introduction
Eating disorders (EDs) can be enduring with severe conditions associated with significant medical and psychological sequalae, and corresponding psychosocial impairment for individuals and families. Treatment for adolescent eating disorders has progressed significantly over the last 15 years. Family-based treatment (FBT) for anorexia nervosa (AN) was originally developed at the Maudsley Hospital in London, and draws upon psychotherapy techniques from systemic, strategic, narrative and family therapies (Lock and Le Grange, Reference Lock and Le Grange2013). The manualised form of the treatment is the most rigorously evaluated adolescent ED intervention, with several randomised control trials highlighting efficacy of this treatment among cohorts with AN and bulimia nervosa (Le Grange et al., Reference Le Grange, Hughes, Court, Yeo, Crosby and Sawyer2016; Lock et al., Reference Lock, Le Grange, Agras, Moye, Bryson and Jo2010; Madden et al., Reference Madden, Miskovic-Wheatley, Wallis, Kohn, Lock, Le Grange, Jo, Clarke, Rhodes, Hay and Touyz2015). Despite the strong evidence base for FBT, of those who receive FBT for AN, less than half achieve remission (as defined by restoration of healthy weight, ED symptomology within one standard deviation of population means levels, and no ongoing ED behaviours; Le Grange et al., Reference Le Grange, Huryk, Murray, Hughes, Sawyer and Loeb2019), whilst one quarter do not demonstrate any treatment response (as defined by improvements to weight and eating disorder psychopathology; Lock and Le Grange, Reference Lock and Le Grange2019), which highlights the need for alternative treatments and/or adjustments to existing approaches (Lock and Le Grange, Reference Lock and Le Grange2019).
More recently, enhanced cognitive behaviour therapy (CBT-E) has shown promise as an alternate treatment option for adolescents with eating disorders, with growing evidence for its effectiveness in reducing ED psychopathology across transdiagnostic ED samples, as well as on weight regain in young people with AN (Dalle Grave et al., Reference Dalle Grave, Calugi, Doll and Fairburn2013; Dalle Grave et al., Reference Dalle Grave, Calugi, Sartirana and Fairburn2015; Dalle Grave et al., Reference Dalle Grave, Conti and Calugi2020; Fursland and Byrne, Reference Fursland and Byrne2013). It is recommended when family therapy is unacceptable, contraindicated, or ineffective (National Institute for Health and Care Excellence, 2017; Scottish Intercollegiate Guidelines Network, 2022; Wilson et al., Reference Wilson, Withington, Dalle Grave and Dalton2025).
A recent non-randomised effectiveness trial showed similar outcomes between CBT-E and FBT in a group of adolescents with restrictive eating disorders (excluding avoidant and restrictive food intake disorder; Le Grange et al., Reference Le Grange, Eckhardt, Dalle Grave, Crosby, Peterson, Keery, Lesser and Martell2020). Additionally, evidence suggests that CBT-E is effective for those who have previously engaged in FBT but have not achieved full recovery, and that reductions in eating disorder psychopathology and clinical impairment are similar to those who had not previously engaged in FBT (Wilson et al., Reference Wilson, Withington, Dalle Grave and Dalton2025). There were several limitations of both studies that temper the robustness of the results. These included the absence of control groups or randomisation; baseline pre-treatment group differences (e.g. in Le Grange et al. (Reference Le Grange, Eckhardt, Dalle Grave, Crosby, Peterson, Keery, Lesser and Martell2020), participants who chose CBT-E were older and scored higher on measures of ED psychopathology, depression and anxiety scores, whereas in Wilson et al. (Reference Wilson, Withington, Dalle Grave and Dalton2025), those with previous experience of FBT had lower ED psychopathology scores at baseline); substantial missing data, treatment attrition and poor compliance with post-baseline assessment measures; and limited diversity in the samples. However, the findings remain clinically relevant, highlighting CBT-E as a promising alternative that may be offered to individuals for whom FBT has not led to full recovery. The two treatments differ significantly in conceptualisation of the eating disorder, proposed mechanisms of action, role of both young people and parents, and strategies and processes of therapy (Dalle Grave et al., Reference Dalle Grave, Eckhardt, Calugi and Le Grange2019a). These differences may contribute to one treatment being effective where the other has not. For example, young people who are unable to or unwilling to address their ED psychopathology actively (as required in CBT-E) may benefit from their family’s active involvement and support through FBT. Conversely, more individuated or autonomous adolescents, or those with families are unwilling or unable to participate (e.g. due to work commitments), may achieve greater benefits from CBT-E that would not have been possible through FBT. However, it is important to note that there is currently no empirical evidence identifying which individual or family factors moderate treatment response.
With reference to the current paper, transitioning from FBT to CBT-E can present challenges and difficulties for the young person, their parents, and the clinician. This is an important transition to consider for both outgoing FBT therapist and incoming CBT-E therapist, as for this cohort, the change in therapies is often prompted by a suboptimal response to FBT. Therefore, ensuring a ‘good start’ in CBT-E is essential to maximising the likelihood of recovery (Agras et al., Reference Agras, Crow, Halmi, Mitchell, Wilson and Kraemer2000).
The aim of this conceptual paper is to review common challenges encountered when transitioning from FBT to CBT-E and propose strategies to mitigate these difficulties. First, we give an overview of CBT-E for adolescents (Dalle Grave and Calugi, Reference Dalle Grave and Calugi2020). We then highlight common issues encountered when treating young people with CBT-E who have previously engaged in FBT, discuss how they can present a barrier to successful implementation of CBT-E, and describe potential solutions. The barriers and strategies outlined in this paper unless otherwise sourced have come from reflections from the authors’ experience over many years of delivering CBT-E among young people both with and without previous FBT experience. The challenges discussed appear to be more closely associated with restrictive or underweight presentations of eating disorders, as well as certain ego syntonic features observed in patients with binge-eating episodes – such as dietary restraint, excessive exercise, and pre-occupation with shape and weight – which are typically relevant across diagnostic categories. In contrast, we have generally observed fewer transitional difficulties when binge eating is the primary presentation. As a result, this aspect has been discussed less extensively throughout the paper. The core treatment and strategies described are from the treatment manual (Dalle Grave and Calugi, Reference Dalle Grave and Calugi2020). Freely available resources, videos and further information related to the treatment is available at www.cbte.co.
Enhanced cognitive behaviour therapy for adolescents
CBT-E is an evidence-based transdiagnostic eating disorder treatment. Originally designed for adults, CBT-E actively involves the patient in addressing, in a personalised and flexible way, the eating disorder psychopathology present in the individual, rather than focusing on the specific ED diagnosis (Fairburn et al., Reference Fairburn, Cooper, Shafran and Wilson2008). CBT-E has been adapted specifically to suit the needs of adolescents. The effectiveness of CBT-E has been demonstrated in recent effectiveness and cohort studies, which have shown significant reductions in ED psychopathology and psychosocial impairment among both underweight and non-underweight young people with EDs, as well as significant increases in BMI centiles in underweight young people (Dalle Grave et al., Reference Dalle Grave, Calugi, Doll and Fairburn2013; Dalle Grave et al., Reference Dalle Grave, Calugi, Sartirana and Fairburn2015; Dalle Grave et al., Reference Dalle Grave, Conti and Calugi2020; Fursland and Byrne, Reference Fursland and Byrne2013, Wilson et al., Reference Wilson, Withington, Dalle Grave and Dalton2025). It is a collaborative individual therapy, which focuses on involving the patient in all stages of treatment including the decision to start therapy, which problems to address during treatment and how to address them. These elements are designed to increase the young person’s sense of control and willingness to engage with the process.
There are four main goals of CBT-E (Dalle Grave et al., Reference Dalle Grave, Eckhardt, Calugi and Le Grange2019a). The first is to actively engage the young person in the process of treatment and the decision to change. The second is to address the eating disorder psychopathology, which includes extreme concerns about weight, shape and eating, dietary restriction and restraint, low weight (if applicable), and other maintenance processes. This requires the young person to understand the mechanisms that maintain their eating disorder, and disrupt them using individualised strategies and procedures, which is the third goal of CBT-E. The strategies and procedures are drawn from modules depending on the needs and maintaining mechanisms of the young person: body image; underweight and undereating; dietary restraint; events and moods changes; and setbacks and mindsets modules. Additional modules are also considered if external maintaining mechanisms are evident, pronounced, and interfering with treatment progress: mood intolerance; clinical perfectionism; interpersonal difficulties; and core low self-esteem. The fourth goal of CBT-E is to help the young person achieve lasting change by future-proofing them with specific strategies to help ‘decentre’ and avoid relapse for any future setbacks that might reactivate the eating disorder mindset.
The structure of CBT-E begins with two assessment sessions aimed at evaluating the young person’s needs, collaboratively drawing a diagram that formulates how their ED is maintained, and engaging them in the decision to start the Step 1 of treatment. If the young person agrees to proceed to trial Step 1 (the extent of the commitment required by the young person at this stage), treatment is implemented with the single therapist across three steps, as shown in Table 1. In Step 1, the young person is seen twice weekly, and the focus is on building a shared understanding of the young person’s eating disorder and the associated maintaining mechanisms outlined in their formulation diagram. This is achieved through the young person engaging in self-monitoring (real-time recording of eating patterns and associated thoughts feelings and behaviours) which is collaboratively reviewed at the start of each session, along with psychoeducation and guided reading. The other main goal of Step 1 is to help the young person decide to change their eating disorder and low weight (if applicable). This is achieved by helping the young person consider how their eating disorder affects them, and the pros and cons of changing in the short and long term. Step 1 can be explained to the young person as a trial phase, after which progress is reviewed, and if willing, the young person decides to progress to Step 2.
Table 1. The treatment structure of CBT-E for adolescents (from Dalle Grave and Calugi, Reference Dalle Grave and Calugi2020)
* One after Step 1 in non-underweight patients, every 4 weeks in underweight patients.
Step 2 is the longest phase of treatment, where young people are provided with individualised strategies designed to address their eating, weight and shape concerns, as well as engaging in weight restoration if applicable. In some patients, the events and associated mood changes influencing eating or other additional maintenance processes are also addressed. In Step 2, most young people are seen weekly, with the exception being underweight young people who are seen twice weekly until weight regain is stable. Step 3 is the final stage of treatment, where young people are seen fortnightly and are equipped with strategies to manage setbacks and maintain/progress the gains that they have achieved throughout treatment.
The length of treatment is variable depending on the mechanisms that need to be addressed throughout treatment. For underweight young people (i.e. BMI centile 3–25th), treatment typically takes between 30 and 40 sessions, whereas for those with a BMI centile above the 25th, treatment lasts for 20 sessions. The default form of treatment is the ‘focused’ form of treatment which addresses only the eating disorder psychopathology. However, for some young people, there are additional maintaining processes (e.g. clinical perfectionism, mood intolerance, low self-esteem, interpersonal difficulties) which present a barrier to treatment. If these are pronounced and appear to both maintain the eating disorder and interfere with CBT-E, the decision is usually made in a review session to address these mechanisms through the ‘broad’ form of CBT-E which includes additional modules targeting these additional maintaining processes.
The parental role in treatment is focused on creating an optimal supporting environment that helps facilitate the young person to engage in treatment and change. Parents are offered a parent-only appointment during the first two weeks of treatment. This session aims to understand any family-related barriers to treatment, explain the psychological model and structure of CBT-E, and highlight the role of the parents and how they can support their young person. This is followed up by joint parent–patient appointments (4–12 times depending on length of treatment) that are held in the last 15–20 minutes of the young person’s individual sessions. Anything that is discussed in the parent-only sessions is previously discussed and agreed to by the young person, and typically focuses on updating the parents on progress, what strategies they are beginning to implement, and what parents can do/not do to support their young person (Dalle Grave et al., Reference Dalle Grave, Eckhardt, Calugi and Le Grange2019a).
Adjusting to the psychological model
One of the key differences between FBT and CBT-E is the contrasting conceptualisation of the eating disorder (for detailed discussion, see Dalle Grave, Reference Dalle Grave2023; Dalle Grave et al., Reference Dalle Grave, Eckhardt, Calugi and Le Grange2019a) which has subsequent implications for the role of young person and family throughout treatment. FBT takes an atheoretical approach consistent with the disease model, whereby the eating disorder is conceptualised as an illness external to the young person, whose behaviour and experience (e.g. restriction, purging, concerns about eating, weight and shape) are being controlled by the eating disorder. Consequently, the responsibility to regain control of eating falls upon the parents, whose goals in Phase 1 of FBT are to refeed the young person and wrest back control from the eating disorder, that the young person cannot do themselves due to the illness (Dalle Grave et al., Reference Dalle Grave, Eckhardt, Calugi and Le Grange2019a). Parents are vital to this process, and treatment focuses on increasing parental self-efficacy to take back the control over eating that eating disorder symptoms may have disrupted. The young person’s role in treatment is much more passive, especially during Phase 1 of treatment (whilst the ED is still in control), until they have recovered enough to have control of eating returned, at a developmentally appropriate level, which occurs in Phase 2 of FBT (Lock and Le Grange, Reference Lock and Le Grange2013). In the third and final phase of FBT, once healthy weight and eating behaviour has been established, any other issues or problems with adolescent development are addressed (Lock and Le Grange, Reference Lock and Le Grange2013). An advantage of this model is that the agnostic and external view of the eating disorders does not impart blame to the young person or family as to the cause of the eating disorder or associated behaviours (Dalle Grave, Reference Dalle Grave2023). Additionally, it does not rely on the active engagement or ability of the young person to initiate change, instead motivating the resources of the whole family to help the young person recover.
Alternatively, CBT-E takes a psychological conceptualisation of the eating disorders. In this model, the main features of eating disorders (e.g. dietary rules, excessive exercising, binge eating episodes, low weight, etc.) are thought to stem directly or indirectly from a dysfunctional self-evaluation schema overly reliant on excessive control of eating, weight and shape. Instead of externalising the eating disorder, the psychological approach seeks to understand the mechanisms that maintain eating disorder features, and helps the young person make the choice to address them with an individualised set of strategies and procedures. In this treatment, the young person takes an active role in the therapy, working with the CBT-E clinician to understand their eating disorder psychopathology, and learn how to control their behaviour and mindset. Parents, whilst useful in a supporting role, are not essential and do not have the critical role in treatment as in FBT. An advantage of this approach is that it engages the young person and helps them understand the dysfunctional psychological nature of their method of self-evaluation (i.e. overly reliant on controlling eating, weight and shape) and learning strategies to help them change and control their eating disorder mindset both during treatment and into the future (Dalle Grave, Reference Dalle Grave2023).
A significant challenge can arise for young people switching from the externalising model of FBT to the psychological model of CBT-E. Commonly encountered difficulties related to this transition include adapting to seeking a psychological explanation for their problems and taking an active role in treatment.
Seeking a psychological explanation for eating disorder-related difficulties is central to CBT-E treatment. However, coming from FBT the young person may be in the routine of externalising their ED as an illness they have no control over. This can present a barrier to CBT-E, as such a viewpoint does not encourage curiosity into the cognitive and behavioural processes that maintain concerns about eating, weight and shape. This in turn can interfere with the tasks of CBT-E. For example, the young person may have difficulty understanding the point of self-monitoring or making changes to their eating, shape checking or body avoidance. Additionally, it can be a barrier to taking an active role in treatment when the young person still views the eating disorder as an illness that they have no control over. As a result, they may have little motivation to understand and address the eating disorder – an aspect not required in FBT but essential in CBT-E.
Common signs that this may be a barrier
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• Non-completion of homework tasks
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• Use of externalising language from the young person
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• Minimal thoughts/feelings documented in self-monitoring
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• Excessive hopelessness, frustration or pessimism about treatment tasks
Suggested strategies to overcome the barrier
Collaborative personal formulation
Collaboratively drawing a diagram based on the young person’s own words (see Fig. 1) and reported the eating-disorder features/experience is central to CBT-E. This process occurs in initial assessment, start of treatment and throughout, especially if changes to maintaining mechanisms are observed. The formulation helps encourage engagement in treatment by improving understanding of the mechanisms that contribute to the self-perpetuating nature of the ED, and by identifying the goals of treatment. Acting as a ‘road map’ for CBT-E, the formulation empowers patients by promoting a clear understanding of what will be addressed during treatment, helping them feel more in control. It can also be helpful to validate the difficulties involved with change (i.e. due to the interactive nature of the maintaining mechanisms and the rewarding elements that can be associated with dietary restriction and low weight) that differs from a disease/FBT explanation (i.e. you find it difficult to change as you are being controlled by an illness). Validating the functions of the ED may help young people feel understood and open opportunities to learn other more adaptive ways to deal with eating, weight and shape concerns. Continuing to refer to the formulation and editing/adapting if new mechanisms emerge, promotes curiosity within the young person to further understand their ED features. Furthermore, this process increases agency and control as it promotes an understanding of what will be addressed in treatment (Dalle Grave and Calugi, Reference Dalle Grave and Calugi2020).
Figure 1. Example restrictive type formulation using the young person’s own words.
Clear explanation of disease vs CBT-E psychological models of eating disorders
When considering starting treatment, CBT-E is clearly described to the patient and contrast is drawn between the two models and their respective implications for the treatment process (Dalle Grave, Reference Dalle Grave2023). Both models, with different conceptualisations, try to explain why a young person continues to engage in strict dieting or other extreme weight control behaviours and maintains a low weight despite the harm they cause.
The disease (externalising) model of FBT is described which will be familiar to the patient, whereby the adolescent is thought to have no control of their illness and thus requires external help to regain control. This is contrasted with the psychological model of CBT-E which seeks to regain control by developing an understanding of the maintaining mechanisms and making a choice to actively address them. It is important the young person understands that in CBT-E they will never be asked to change something that they do not see as a problem, and that it does not involve prescriptive or coercive techniques. However, treatment will require an active effort of the young person to understand the nature of their problems, evaluate the pros and cons of change, and actively work towards addressing those changes.
Empathising and reorienting to psychological model when required
When it becomes evident that the young person is having difficulty adapting to the psychological model and/or taking an active role in treatment, it is important to address this in an empathic and non-judgemental way. It can be important to highlight that the CBT-E clinician can appreciate how difficult it is to adapt to CBT-E given their previous experience where they had a much more passive role and did not have the same requirements to engage as actively throughout treatment. Adopting a non-judgemental but encouraging approach as often as required can be useful to help the young person continue to take an active role in treatment and engage with the therapy.
Use of the Eating Problems Checklist (EPCL)
The EPCL (Dalle Grave et al., Reference Dalle Grave, Sartirana, Milanese, El Ghoch, Brocco, Pellicone and Calugi2019b) can be a particularly useful tool with young people transitioning from FBT. The EPCL is a weekly self-report measure that captures the key features of the young person with ED. It is reviewed with the young person and therapist weekly, and can be used to update their personal formulation, draw attention to changes in psychopathology brought about by implementing strategies (e.g. reduced body pre-occupation as a result of reduced body checking), and draw attention to how much of an active role the patient is playing in treatment by asking how many ‘days of change’ they had per week (i.e. days where they tried their best to implement the treatment procedures). Regularly reviewing this gives the clinician an opportunity to reinforce changes achieved, attribute changes to the efforts that the client has been making and connecting use of strategies with reductions in psychopathology, ultimately reinforcing the psychological approach. It can be an opportunity to discuss what has enabled the patient to make consistent changes and identify any barriers to progress. The use of the ECPL in this way is particularly helpful for young people adjusting from FBT to CBT-E.
Minimising eating disorder features
Adolescents transitioning from FBT to CBT-E may be inclined to minimise weight and shape concerns and episodes of dietary restriction and other extreme weight control behaviours. This tendency may stem from previous experiences in FBT, where disclosure of eating disorder behaviours may have led to aversely perceived increased external control or consequences that were perceived negatively by the adolescent, especially early in FBT, before the treatment has had a chance to improve family unity and attachments.
In FBT, it is assumed that adolescents with an eating disorder will minimise their symptoms, in part due to a conscious effort to keep clinicians and family members from fully understanding their behaviours so that they will be able to continue engaging in them (Le Grange, Reference Le Grange1999). Consequently, the FBT therapist fosters the use of externalisation when supporting parents to uncover secretive eating disorder behaviours, through statements such as, ‘it is anorexia nervosa that makes her hide food’ (Le Grange, Reference Le Grange1999). In Phase 1 of FBT, parents are charged with supporting their child to achieve 0.5–1 kg of weight gain each week, and this early focus on weight gain has been shown to be a mediator of successful treatment outcome (Le Grange et al., Reference Le Grange, Accurso, Lock, Agras and Bryson2014). However, this can be upsetting for adolescents with an eating disorder and may lead to secretive behaviors aimed at preventing weight gain (e.g. hiding food, falsifying weights, excessively exercising). Within the FBT model, adolescents may learn to anticipate parental and FBT-therapist efforts aimed at uncovering these behaviours, which can in turn lead to heightened secrecy. For those transitioning from FBT, it is our experience that it is most commonly restrictive behaviours and weight and shape concerns that are minimised, with minimisation of binge-eating episodes also an issue in CBT-E, but less common in this subgroup.
CBT-E therapists inform patients that they will never be judged for their eating behaviours. Instead, the focus of the treatment is on collaboratively understanding and addressing the primary psychological mechanisms maintaining their eating disorder. Patients are encouraged to openly discuss their eating disorder thoughts and behaviours, using self-monitoring in the real-time to develop insight into their patterns of behaviour and eating disorder mindset. However, those transitioning from FBT to CBT-E may hesitate to disclose certain behaviours, fearing negative consequences based on their FBT experience. For example, an adolescent might be reluctant to reveal to the CBT-E clinician that they are discarding their lunch at school, fearing that this information will be shared with a parent, who may then be encouraged to increase food intake after school. In this way, minimising eating disorder features presents a critical barrier to treatment success, as it does not allow the clinician or patient to investigate their attitudes and behaviours, understanding how it may interact in maintaining the eating disorder or consider if it is a problem they seek to change. This barrier is most evident in Step 1, where the goals of treatment are to come to a shared understanding of the maintaining mechanisms of their eating problems and begin to decide if they wish to engage in change.
Common signs that this may be a barrier
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• Lack of psychopathology evident in self-monitoring
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• Low scores on the eating disorders examination (EPCL)
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• Conflicting accounts from the parents observed in parent-only sessions
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• Unexpected weight gain or loss with no corresponding mechanisms identified through self-monitoring
Suggested strategies to overcome the barrier
Emphasising the individual approach and choice involved with treatment
To build trust, CBT-E clinicians should clarify that they operate on behalf of the adolescent and that parental involvement will only occur in ways that the young person finds acceptable; critically, reiterating to the adolescent that CBT-E is a therapy that they choose to engage with, and the clinician will never ask them to address something that they do not see as a problem. It is important to convey to the young person that the clinician would never judge them for choosing not to address their problems, especially given the positive perceived function the eating disorder serves, whilst at the same time emphasising that the goals of treatment at this stage (Step 1) are to come to shared understanding of the eating problem so that the young person can make an informed decision about progressing to Step 2. The consequence of not engaging in treatment may be discussed when helping the young person weight the pros and cons of change. At this stage, specific alternative treatment or management options may also be presented to ensure the young person does not feel coerced into choosing CBT-E or believe that refusal will automatically lead to deterioration.
Empathise with any previous negative experiences of self-disclosure
The clinician should empathise with any previous negative experiences of self-disclosure, where the young person has perceived themselves to be punished, judged or blamed for self-disclosing eating disorder features. Demonstrating an understanding of why they are reluctant to be open about their eating disorder features in this context is important, as well as revisiting the first suggested strategy for this barrier, as well as the differences in medical vs CBT-E psychological approaches previously described.
Responding to disclosure of eating disorder features previously minimised
When adolescents disclose secretive eating disorder behaviours, the clinician should handle this information confidentially (with obvious exceptions for risk and safety concerns) to further strengthen therapeutic trust and rapport. It is also essential for the clinician to empathise with the perceived positive functions of the adolescent’s eating disorder behaviours, reinforcing that these behaviours ‘make sense’ within their current system of self-evaluation. Such an approach helps the adolescent feel understood and reduces feelings of judgement and encourages more disclosure which can help both patient and clinician understand the behaviours and implement strategies for lasting change.
Differing approaches for weight restoration and determining target healthy weight
Another key difference between FBT and CBT-E which has implications for those transitioning into CBT-E are the differing expectations regarding weight restoration. In FBT, in the first phase of treatment the young people is not involved in the decision to regain weight, and they are prescribed to reach at least 95% of expected body weight in the first phase of treatment (Lock and Le Grange, Reference Lock and Le Grange2013). In CBT-E, the young person is actively involved in the decision to pursue weight regain and is supported in working towards a ‘minimum individualised healthy weight’. This target is determined on a case-by-case basis using five key criteria, ensuring that the weight goal is both clinically appropriate and personally meaningful. A young person is considered to have reached a minimum healthy weight when their weight: (1) does not contribute to the maintenance of the eating disorder; (2) can be maintained without extreme weight control behaviours; (3) does not contribute to the effects of being underweight (i.e. starvation syndrome symptoms), (4) promotes physical health and development, and (5) allows the young person to engage in a social life (Dalle Grave and Calugi, Reference Dalle Grave and Calugi2020). This generally corresponds to a BMI over 19.0 in young people aged 16 and older. For individuals under 16 years of age, it typically aligns with a BMI ‘above’ the 25th percentile for age in females and ‘above’ the 10th percentile for age in males (Dalle Grave and Calugi, Reference Dalle Grave and Calugi2020). This approach allows the target minimum healthy weight to be personalised based on an individual’s biological set point, which tends to be higher in young people who had a higher body weight prior to the onset of the eating disorder.
Young people transitioning from FBT to CBT-E typically welcome the move away from a specific prescribed weight (it is made clear to low weight patients that weight regain will be required to achieve recovery, but it is their decision to do this or not). They seem to respond well to the approach of working towards an individualised healthier weight range which frees them from the eating disorder mindset and its effects. However, there can be difficulties for the young person and family when making this transition from FBT to CBT-E. Some young people struggle with the uncertainty surrounding moving towards a potentially less defined weight goal. For example, young people who are more rigid in their thinking style may find it hard to let go of a weight goal which has become internalised and fixated upon, which can lead to inflexibility if their minimum health weight according to CBT-E criteria is less certain and must be ‘discovered over time’ with reference to the five criteria discussed, as opposed to a goal weight that may be more clearly defined in FBT.
Common signs that this may be a barrier for young people
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• Fixation on specific weight numbers being ‘good’ or ‘bad’
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• Over-interpreting implications of single weight readings rather than weight trends
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• Over-reliance on weight as sole indicator for recovery
Suggested strategies to overcome the barrier
Psychoeducation regarding weight, weight fluctuations and healthy weight criteria
Psychoeducation included providing education regarding set point theory (discussed at an age appropriate level, although for detailed discussion see Müller et al., Reference Müller, Geisler, Heymsfield and Bosy-Westphal2018) and the notion of ‘finding your true healthy weight range’. Psychoeducation around natural fluctuations in weight is a core aspect of CBT-E when introducing the regular collaborative weighing procedure, which highlights the importance of not over-interpreting any one reading, interpreting trends in weight over time, and, and the importance of working towards a weight range (or around 3 kg) rather than a specific weight. It can be helpful to regularly check-in with young people about their experience of starvation syndrome symptoms (using the Starvation Syndrome Symptom Inventory; Calugi et al., Reference Calugi, Miniati, Milanese, Sartirana, El Ghoch and Dalle Grave2017), and to refer back to the five criteria indicative of a minimum healthy weight to provide a gauge as to whether they are at a healthy weight for them. This approach fosters curiosity within the young person as to their current symptoms and the role of their weight in maintaining or resolving symptoms related to recovery.
Parental difficulties with differing approaches to weight restoration and healthy weight range
Parents may also find it difficult to accept a lower and potentially less clearly defined weight goal than what they were previously working towards in FBT. These concerns are understandable considering that a core focus of FBT is heightening parental anxiety regarding anorexia nervosa to take on the task of weight restoration (Lock and Le Grange, Reference Lock and Le Grange2013).
Another difference in the approaches is that whereas weight restoration is the primary target of Phase 1 of FBT, it is not until Step 2 of CBT-E that weight restoration is addressed, with the initial focus on engaging the young person in treatment and change. Furthermore, the young person must make an autonomous decision to pursue weight restoration before the weight restoration process is undertaken. Parents transitioning from FBT can struggle with the fact that weight restoration is not prioritised in the first step of treatment. This could be attributable to residual heightened anxiety associated with FBT, as well as their prior experience of Phase 1 of FBT being associated with pressure for a rapid weight restoration. Although one of the most common reasons for transitioning from FBT to CBT-E is inadequate weight gain during the early phase of treatment, this is often compounded by parental conflict or difficulty in effectively supporting the adolescent’s weight recovery. Some parents can also feel anxious that the young person themselves is responsible for deciding to make the decision to restore weight, particularly if the young person has been opposed to this notion previously during FBT, and may be highly ambivalent about this in the early phases of CBT-E. This can interfere with CBT-E, in that anxious parents may pressure or encourage the young person to regain weight prior to the young person making the decision for themselves in Step 1 of CBT-E. This interferes with the young person’s autonomy to be in control of treatment direction, which is a vital aspect of the treatment. It may also result in subsequent ambivalence about weight restoration, increasing relapse risk. Additionally, parental anxiety can interfere with the young person’s ability to engage with the tasks of CBT-E. For example, parents may pressure young people to eat more than they have planned, undermining the regular planned eating strategy.
Common signs that this may be a barrier for parents
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• Self-monitoring showing deviations from regular planned eating that are influenced by parents (e.g. pressured to have another serving of dinner)
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• Self-monitoring showing excessive comments from parents with regard to what the young person has planned to eat or how much
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• Young person reports receiving parental pressure to increase intake, or tries to influence meal planning in an unwelcome manner
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• The use of compensatory behaviours evident in monitoring, following instances where parents have influenced food choices
Suggested strategies to overcome the barrier
Initial parent-only session and follow-up
The importance of the parent-only session is paramount, where comprehensive education to parents regarding CBT-E theory and the structure of the treatment is provided. The specific reasons for transferring the young person from FBT to CBT-E treatment can be carefully reiterated. Ideally, these have been previously explained within the termination process of FBT with support of the FBT therapist, and will vary from case to case (e.g. change in parent availability, lack of improvement with the treatment). The differences between the approaches are emphasised, and the empirical support for CBT-E as a second-line treatment can be explained (Dalle Grave et al., Reference Dalle Grave, Calugi, Doll and Fairburn2013; Dalle Grave et al., Reference Dalle Grave, Calugi, Sartirana and Fairburn2015; Dalle Grave et al., Reference Dalle Grave, Conti and Calugi2020; Fursland and Byrne, Reference Fursland and Byrne2013, Wilson et al., Reference Wilson, Withington, Dalle Grave and Dalton2025). This promotes hope and confidence in the new treatment direction and allays concerns about any apparent discrepancies in psychoeducation delivered between FBT and CBT-E clinicians.
It is important for the clinician to empathise with any concerns the parents have, and/or difficulties that they may have in transitioning between the approaches and validate their concerns. If parents have concerns about the immediate need for weight restoration, parents are reassured that a major focus of the first stage of treatment is to help their young person see the need for weight regain, and to agree to embark on this process, and reassure them that their young person will be closely monitored for their medical safety during this period. In this way, parents are more likely to feel reassured about the treatment processes and the young person’s safety, which can allow them to step back and allow the treatment to progress unhindered. The importance of their role in facilitating appropriate medical monitoring of the young person should be emphasised, where available and appropriate.
Parents are also involved in joint sessions throughout treatment including during the weight restoration module, and this may be of particular importance for parents transitioning from FBT. During this stage, it is important for the clinician to provide information regarding the CBT-E approach to working towards a minimum healthy weight. In addition, in these cases it can be particularly helpful for the CBT-E clinician to collaborate with the young person to give the parents very clear tasks to support the young person to implement their plan. In this way, parents are able to feel more involved and aware of the processes at this stage of treatment, and clarify their roles in how they can support their young person to recover.
Use of the parents’ guide to CBT-E
Parents can also be referred to, or provided with, a copy of the parents’ guide to CBT-E (Dalle Grave and el Khazen, Reference Dalle Grave and el Khazen2021), a resource designed for parents to help support their young person as they progress through CBT-E. Having this resource can consolidate the information provided in parent-only or joint sessions, and provide reassurance as to the structure of CBT-E and parents’ role in creating an optimal family environment for their young person to succeed.
Collaborative handover between FBT and CBT-E therapist
It is our experience that a different therapist delivers CBT-E from their FBT clinician. While maintaining the same therapist can offer benefits such as continuity and a strong therapeutic alliance with the parents, transitioning to a new therapist may facilitate a shift in the conceptualisation of the eating disorder and support changes in the roles of the patient, parents, and therapist within the treatment process. During this transition, we have found it helpful for the FBT clinician to ‘pass the torch’ to the CBT-E clinician, by expressing support and confidence in CBT-E, and encouraging the young person and the family to embrace the new approach and potential changes. Parents in particular, may be reassured to know that CBT-E has the support of their FBT therapist who they may know and trust, and give them confidence in the new approach. This collaborative handover can also provide a space for questions about both models, and provides the opportunity for the treating team to demonstrate unity in support of both, as well as highlighting progress and gains achieved through FBT (which would be particularly important if the young person transitioned back to FBT). Of course, it may not always be possible to have a different therapist deliver CBT-E, in which case a handover is redundant, and focusing on other strategies discussed in this paper of particular importance.
Other difficulties parents find with transitioning to CBT-E from FBT
In addition to the points raised above, another common difficulty that parents encounter when transitioning from FBT to CBT-E is supporting the regular planned eating procedure. This procedure is introduced in CBT-E and is vital to the process, whereby the young person independently (supported with example menus) creates an eating plan of three meals and two or three snacks for the following day. The procedure initially focuses on ‘when’ to eat rather than ‘what’ or ‘how much’. This is in stark contrast to the parental control over mealtimes in Phase 1 of FBT. Young people may leave FBT at varying points within the course of therapy, and often arrive in CBT-E with regular eating established, but with strict parental control. Parental anxiety about weight loss is common, upon learning that the young person should now have control over these decisions. Some parents hand this responsibility over to the young person with a sense of relief, whilst others struggle to relinquish even minor control. This can present a barrier to the young person successfully engaging in the regular planned eating procedure, and undermine their autonomy in making treatment decisions. Alternatively, in some cases parents fully relinquish all control and involvement in treatment, particularly if they have found FBT highly challenging. This can leave the young person inadequately supported through CBT-E. Parents can also accidentally hinder progress if they are unaware of their young person’s current agreed-upon treatment tasks and the young person’s bespoke ideas and suggestions for parental support. For families who are already eating together during FBT, this positive pattern is encouraged to continue throughout the transition to CBT-E, as shared meals promote family cohesion, provide support, and model healthy eating behaviours. Consideration and sensitivity to developmental and cultural norms are advised when considering implementing the regular planned eating procedure and the role of the family and culture in the same.
Common signs that this may be a barrier
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• Frustration/helplessness/hopelessness about control over treatment decisions.
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• Young people struggling to implement treatment strategies due to barriers that may be overcome with increased parental support (e.g., needing support from parents to drive and pay for food shopping to plan foods for the week).
Suggested strategies to overcome the barrier
Gradual return of control of eating to the young person
A strategy may be employed involving taking an ‘experimental approach’ and beginning with one independently planned meal at a time, typically commencing with a morning snack and then gradually increasing to all meals. This serves as an implicit exposure task for parents, and a method for progressing safely whilst medical monitoring is ongoing, with anxiety reduction typically following. It is the exception rather than the rule that this strategy is utilised, as typically full control lies with the young person initially as per standard CBT-E procedure. If anxiety continues to pose a barrier to CBT-E, parents are encouraged to obtain their own individual treatment for anxiety.
Encouragement of parents to maintain appropriate support
If the young person is finding that they desire increased parental support through CBT-E, parents are encouraged to remain involved in treatment in accordance with CBT-E guidelines, as they can be of great assistance (Dalle Grave and Calugi Reference Dalle Grave and Calugi2020). Parents are advised that parental input can be vital in creating an optimal recovery environment and supporting implementation of the individual’s treatment efforts.
Challenges with transitioning from FBT to CBT-E within the multi-disciplinary team setting
In the treatment of adolescent eating disorders, it is recommended the patient’s treatment is monitored using a multi-disciplinary team (MDT) approach due to the medical, nutritional, and psychological complications of eating disorders (Joy et al., Reference Joy, Wilson and Varechok2003). As such, a young person’s treating team may consist of medical specialists (e.g. psychiatrists, general practitioners), nurse consultants, dietitians, and allied health (e.g. psychologists, social workers) all who may have distinct roles, and may have different backgrounds in training and treatment orientation. There are many obvious advantages to having different skill sets involved in the treatment of eating disorders, arguably the most crucial being monitoring medical stability during treatment, which is beyond the scope of practice for CBT-E clinicians from non-medical backgrounds. However, especially for young people transitioning from FBT to CBT-E, the multi-disciplinary milieu can present challenges for the MDT in maintaining an approach consistent with the psychological model, whilst also maintaining the patient’s medical and nutritional stability (Dalle Grave et al., Reference Dalle Grave, Eckhardt, Calugi and Le Grange2019a). Primarily, these challenges occur in the context of the different theoretical models which underlie FBT and CBT-E and the strategies involved within each modality. In an ideal world, all the clinicians involved in the young person’s care would be trained in CBT-E, but this is not always possible. Often, the main medical monitoring of the patient is outsourced to their regular general practitioner, which may have varying degrees of experience treating eating disorders. As FBT is the most well-evaluated treatment of adolescent with eating disorders (Lock and Le Grange, Reference Lock and Le Grange2019), and owing to the young person’s history of FBT, GPs or other clinicians may be familiar with this treatment orientation and can inadvertently impede CBT-E treatment through a few common ways. The three most common difficulties we observe within the MDT during transition from FBT to CBT-E are related to the regular planned eating procedure of CBT-E, measurement of progress, and consistent use of language.
Regular planned eating
Young people with eating disorders frequently present as medically compromised as a result of inadequate intake or other eating behaviours, and as such there is often a sense of urgency and anxiety among the MDT members to increase regularity and adequacy of oral intake, especially when a young person does not yet see their eating disorder as a problem or demonstrate willingness to increase their intake. In FBT, this anxiety may be in part mitigated by parental control over increasing food intake during Phase 1 of FBT, which is different from the initial stages of CBT-E as previously outlined.
Problems can arise during the transition from FBT to CBT-E, often by well-meaning clinicians in the young person’s care, who may often give advice based on FBT principles especially when feeling anxious about inadequate intake. This can present a barrier to CBT-E, when the young person and/or family unit are receiving mixed messages from the treating team, which then results in therapy being neither truly FBT nor CBT-E. Alternate treatment strategies are also contraindicative to the collaborative nature of CBT-E where patients are encouraged to be autonomous in taking control over their eating disorder mindset and implementing change, and undermines their sense of control during treatment.
Common signs that this may be a barrier
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• Deviations from regular planned eating that have been advised/influenced by other treating clinicians
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• Confusion evident from the young person about what the treatment strategies are (e.g. individual vs parental involvement)
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• Frustration/helplessness/hopelessness about control over treatment decisions
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• Parents reporting mixed messages from the team
Suggested strategies to overcome the barrier
Increased collaboration
Addressing this issue requires increased collaboration and communication from the CBT-E clinician with the MDT. As MDT input is vital (to ensure the patient is healthy enough to continue out-patient CBT-E), providing information to clinicians not familiar with CBT-E about the transition, specific information about the process and goals of each step of CBT-E, as well as suggestions of how to support the young person and family can help reduce the potential impact of this problem.
Measuring progress and associated feedback
Potential problems can arise within the MDT or service when inconsistent metrics of progress are applied. In FBT, weight restoration is prioritised within the first step of treatment which can mean medical staff and FBT-informed clinicians may primarily focus on weight restoration as a measure of progress in accordance with the FBT model and evidence suggesting that early weight regain is a predictor of recovery (Le Grange et al., Reference Le Grange, Accurso, Lock, Agras and Bryson2014). In CBT-E, weight restoration is addressed within Step 2 where the young person makes an informed decision about pursuing weight restoration. This difference is potentially highlighted in the findings of Le Grange et al. (Reference Le Grange, Eckhardt, Dalle Grave, Crosby, Peterson, Keery, Lesser and Martell2020) who observed in a non-randomised effectiveness trial that the slope of weight regain was more rapid in FBT compared with CBT-E. However, at follow-up, these differences were no longer significant.
The differences in treatment targets at different stages, and associated expected progress working towards the same, can present a problem when transitioning from FBT to CBT-E. In FBT, if a patient is not gaining weight at an appropriate rate, they may be seen as not progressing adequately, and this is cause for concern due it being a predictor of poorer outcome (Le Grange et al., Reference Le Grange, Accurso, Lock, Agras and Bryson2014). Alternatively, in CBT-E early progress may be judged more by early engagement in the therapeutic alliance, the CBT-E strategies (e.g. regular planned eating, self-monitoring, completing homework tasks), and deciding to change rather than weight gain. Such differences are important, as this may have implications if treatment continuation/discontinuation based of FBT parameters are being applied at a service level. Additionally, if negative progress feedback is given to the client based on FBT metrics, this can be discouraging to the young person and family, especially if they have been engaging all that has been asked of them in CBT-E to that point.
Common signs that this may be a barrier
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• Confusion/frustration from the young person and their family regarding perceived negative feedback on progress despite active engagement in CBT-E.
Suggested strategies to overcome the barrier
Increased collaboration
Such discrepancies can be avoided with open discussions between the MDT, and treatment progress carefully distinguished between the therapies during the transitions, alongside comprehensive education to the team regarding the differences between the therapies, goals and expected rate of progress in CBT-E.
Consistency with psychological vs medical language
A further challenge for the MDT involved with patients who have transitioned from FBT to CBT-E relates to the clinical language and guidance provided. During FBT, externalising language is crucial to enable parents to take action over their child’s eating to facilitate weight restoration and recovery, whilst absolving the family unit of any blame or judgement as the cause of ED-related behaviours. However, once engaged with CBT-E, continued use of externalising language by the MDT can cause confusion for the young person and family during CBT-E and can hinder the patient from taking control over the cognitive and behavioural mechanisms which maintain their eating disorder mindset.
Common signs that this may be a barrier
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• Ongoing use of externalising language from the young person and/or parents
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• Difficulty attributing eating disorder behaviours and attitudes to psychological processes as opposed to symptoms of an illness
Suggested strategies to overcome the barrier
Increase collaboration and joint reviews
This challenge can be addressed by facilitating joint consultations with the patient and treating team during treatment, such as joint medical reviews and dietetic consultations, which provides opportunities for CBT-E clinicians to reinforce language that aligns with the psychological model of CBT-E. This further enhances communication and collaboration within the MDT. Additionally, having open discussions about the implications of continued FBT-informed language occurring while the patient is in CBT-E, and correcting such language in real-time can raise awareness within the MDT about factors which may hinder the patient’s recovery.
Conclusions
The paper provides a comprehensive guide for transitioning adolescents with eating disorders from FBT to CBT-E. It emphasises the distinct conceptual differences between these two approaches and identifies the challenges encountered by young patients, their families, and clinicians during the transition. Key obstacles include adapting to the psychological model, meeting weight restoration expectations, and achieving alignment within the MDT. The paper highlights the importance of clear communication, psychoeducation, and collaborative formulation as essential strategies for actively engaging adolescents in CBT-E. Practical solutions are also proposed to address these challenges, such as reducing symptom under-reporting, fostering patient autonomy, and educating parents and the MDT to align with CBT-E’s psychological framework. Ongoing research is needed to further refine these practices and enhance the transition from FBT to CBT-E, ensuring the best possible outcomes for young individuals with eating disorders. In particular, qualitative research capturing the voices and experiences of young people and families who have made this transition may help to further understand how we can enhance both FBT and CBT-E, and the transition between the two. Additionally, future research discussing and refining the transition from CBT-E to FBT when CBT-E has not achieved full remission would be a valuable addition to the field, and continue to advance our understanding of how to optimise treatments for young people experiencing eating disorders.
Key practice points
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(1) CBT-E can be effectively delivered among those who have previously engaged in FBT but not achieved full recovery.
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(2) Distinguishing the two treatments and underlying models is critical in helping the young person adjust and engage with the psychological model.
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(3) Similarly, having parents and the multi-disciplinary team aligned with the goals and model of CBT-E is essential to both support success in CBT-E and prevent barriers that get in the way.
Data availability statement
Data availability is not applicable to this article as no new data were created or analysed in this study.
Acknowledgements
The authors would like to acknowledge and thank the young people and families that have informed this paper. The authors would also like to thank Victoria Brown for her review and suggestions to the manuscript.
Author contributions
Daniel Wilson: Conceptualization (lead), Writing - original draft (equal), Writing - review & editing (lead); Renee Calligeros: Writing - original draft (equal); Rachel Reavley: Writing - original draft (equal); Kyle Cumner: Writing - original draft (equal); Riccardo Dalle Grave: Supervision (equal), Writing - original draft (equal); Simona Calugi: Writing - original draft (equal); Melanie Dalton: Supervision (equal), Writing - original draft (equal), Writing - review & editing (supporting).
Financial support
D.W. is supported by a Queensland Health Clinical Research Fellowship. The funder has no role in the conceptualisation, design, data collection, analysis, decision to publish, or preparation of the manuscript.
Competing interests
R.D.G. receives royalties from Guilford Press, Routledge, Springer and Positive Press. S.C. receives royalties from Guilford Press, Springer and Positive Press.
Ethical standards
Ethical approval for this study was not required as the article is based on clinical experience.
Open access
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