Table 2 Adaptations in action: multiple family meals

Sarah was a 17-year-old, White, female-identifying patient with anorexia nervosa, restricting subtype. During an 8-week course of home-based FBT, the therapist conducted weekly family meals to scaffold support for the parents in overseeing reintroduction of regular meals and snacks to support Sarah’s return to her premorbid weight trajectory. Initially, Sarah’s mother, Diane, focused on supporting Sarah in taking “one more bite” than intended, which later shifted to 100% meal completion. Shepherd’s pie was a meal that was typically served in Sarah’s home, and one that Sarah had enjoyed prior to the onset of the eating disorder. Before starting FBT, if Sarah had a challenging time with a meal, the meal was typically not presented again in favor of meals that were anticipated to be better tolerated by the eating disorder (e.g., vegetable-based soups and salads). During home-based FBT, Diane instead began to repeatedly present meals that Sarah struggled with and provided support by balancing validation (“I know this is hard for you”) and providing clear instructions to consume the meal (“Please move your plate closer to you”). During the first family meal, Sarah refused to face the table, and the therapist encouraged Diane to provide direct prompts to support Sarah in eating her meal. At this recommendation, Diane prompted Sarah to turn her chair towards the table, place her feet on the floor, and pick up her fork. During this meal, Sarah was able to take three bites of the shepherd’s pie, despite having initially stated that she was not going to touch the meal. Although Diane was hesitant to present this meal again, the therapist encouraged her to try again at the next session. The following week, when the meal was presented again and Sarah became distressed during the meal, the therapist was able to work with Diane to identify additional tools, such as allowing a time-limited break before having Sarah return to the meal. Diane stepped out of the dining room with Sarah and gave her 5 min to use distress tolerance skills before returning to the table. Following this intervention, Sarah was able to complete 50% of the meal. Each family meal involved trying new strategies and reinforcing those that had worked previously to help Sarah complete her meal. The therapist was also able to support Diane in minimizing negotiations with the eating disorder, and in maintaining boundaries (e.g., following through with consequences outlined ahead of time surrounding meal noncompletion) that initially led to an increase in eating disorder pushback (e.g., verbal aggression towards her mother). The therapist was also able to decrease the level of intervention, such that Diane was generally encouraging meal completion of her own volition using previously successful strategies. By the end of home-based FBT, Sarah was consistently completing 100% of her meal during in-session family meals