Table 3 Adaptations in action: Clinician assistance meal planning and grocery shopping; cultural tailoring to address racial and ethnic diversity and financial challenges

Mia was a 15-year-old, Latina, female-identifying patient with anorexia nervosa, binge/purge subtype. Her parents divorced when she was a toddler, and her mother, Marisol, retained primary custody of Mia and her brother (age 12) throughout their lives. Her father had returned to his native country shortly after the divorce and had very little contact with the family since that time. From the start of treatment, Marisol expressed concerns about participating in home-based FBT as a single parent living on a single income. In particular, she described worrying that presenting foods that Mia would refuse to eat, or might purge afterwards, felt like “taking food out of [younger brother’s] mouth.” The therapist examined the family’s food supply and helped Marisol set weekly goals and menus that fit within their budget and their family’s cultural food preferences. During Phase I, the therapist would occasionally grocery shop for the family (using a list generated collaboratively with Marisol) to help alleviate caregiver burden. This enabled the therapist to generate a running list of food items that were both energy dense and low cost that Marisol could use to plan meals each week. To validate the family’s financial concerns while avoiding negotiation with the eating disorder, the therapist and Marisol collaboratively agreed that Marisol would serve at least 1–2 meals per week consisting of a food item the family (including Mia) had typically enjoyed before the onset of the eating disorder. The family gradually moved from presenting food items individually (so that any food Mia didn’t eat could be saved for a later meal) to serving multi-ingredient meals with the expectation that Mia would eat all the food she was served. As Mia transitioned to Phase II and became more involved in selecting meal and snack options, the therapist had the opportunity to accompany Mia and Marisol to the grocery store. During this outing, the therapist witnessed Mia experiencing intense anxiety (described by her as “paralysis”) when choosing between two different food options, one a more palatable, energy dense item, and the other a lower-calorie version. The therapist worked with Marisol to quickly generate and implement a plan for how to support Mia in the moment. Marisol coached Mia to put the items down and use relaxation techniques (e.g., diaphragmatic breathing) until her emotional distress returned to a tolerable level. The family then returned to the food items and Marisol instructed Mia to choose the first thing that came to mind without being filtered by her eating disorder. By the end of home-based FBT, Marisol was routinely completing her meals and had tried a favorite food item (beef empanadas) that she hadn’t eaten since before the onset of her eating disorder