Table 2 Themes and representative quotes

Theme 1: Lack of family time or resources to adhere to FBT model

“Yeah, you can do it if you don’t have to work outside the home for 10 h a day in order to make ends meet, then you can easily shop for, cook and present and supervise three meals and three snacks a day for your child.”

Nurse practitioner, specialty eating disorders clinic

Subtheme 1a: Engaging in FBT while working-full time is impractical for many caregivers, but quitting a job or taking a leave of absence may not be possible.

“It’s harder to get them good care. I think, you know, because of their support systems in a lot of ways, and their resources. And not because we’re asking them to pay for things but because if they’re…a parent is working, and unable to really supervise and bring them places, that creates a large barrier.”

Physician, community health clinic

“But yeah, to actually be able to sit and do meal support, a lot of times our parents are working full time at least and so the kids are going to school, school, in that situation, those kids probably aren’t going to schools that have a lot of extra support to deal with them.”

Therapist, community mental health clinic

Subtheme 1b: Obtaining the amount of food necessary to refeed an adolescent with anorexia nervosa is a source of significant financial stress.

“Financial insecurity. So parents that really depend on food stamps or government assistance and maybe they can’t afford Ensure. Maybe they can’t afford the supplements that their child is choosing to eat.”

Social worker, specialty eating disorders clinic

“Yeah, so a lot of times our population were coming from lower socioeconomic status. So that was interesting to see they didn’t always have the means of getting the food that they needed, and that just always brought up a bunch of stressors within the family in general.”

Therapist, community mental health clinic

Theme 2: Psychosocial barriers unrelated to FBT model that interfere with implementation

Subtheme 2a: Psychiatric comorbidity

“And sometimes the sad truth is that we have to address the major mental illness or the behavioral problems. Sometimes like before we can make a whole lot of progress with the eating disorder. Except they go hand in hand because if you have a starving brain then you have a poorly emotionally regulated brain.”

Nurse practitioner, specialty eating disorders clinic

“Well so one thing that I think I see a fair amount of is…difficult home situations, not great support, and behavioral concerns that are contributory. So for example, a patient who is eloping and taking high risk behaviors and using drugs and doing other things, that’s contributing to her really poor nutrition and maybe body image too but body image is not the driving force, and they don’t really have a great support system at home to get them into the treatment that they need. That happens a fair amount with my patient population.”

Physician, community health clinic

Subtheme 2b: Lack of outpatient FBT providers in the community

“I think there was a lack of step down for our population. I think in Rhode Island there’s not a ton of like, lower level of care eating disorder treatment so I think alright you’re working through FBT and now you’re ready to go to outpatient, and there wasn’t always the continuity there.”

Therapist, community mental health clinic

Theme 3: Organizational barriers to implementation

“Some [providers] are not always so willing to do [FBT], and then maybe you have to make sure that everyone working in on that team understands that too, not just family but like the psychiatrist, the, if there’s a dietician involved, if you’re on a team, making sure that they, the other therapists on that team, and everything is really understanding of [FBT]… yes this is hard but we just have to get through this hump, instead of kind of pushing like “oh this shouldn’t happen, this treatment’s not working so you should try something else.””

Therapist, community mental health clinic

“We’re checking in [with the team] and we only have half an hour and we’re talking only about crisis flash issues that we really need to communicate about so it becomes a lot more like, “well 2 weeks ago, the dad came in and said…and then now we’re…” And it’s like, I just want to know what happened yesterday in that clinical appointment because we’re trying to figure out if she needs to go to [a partial hospitalization program], you know? So, it feels like we’re translating a lot to the supervising staff.”

Physician, specialty eating disorders clinic