Introduction

Aurora, 15 years old, lives with her father and mother in an apartment in a big city. Aurora has an older brother living at home and an older sister living in another city. The parents have only recently understood that Aurora has a restrictive eating problem. Both feel guilty for not having seen what was happening earlier. The mother tells us that she suffered from an eating disorder herself some years ago, and that her experience with the health care system was rather poor. This experience has made it particularly difficult for her to trust the therapist’s credibility in helping Aurora. Her own knowledge and experience with healing from an eating disorder play an important role in the therapeutic process. Aurora shows limited self-awareness of being sick. Her BMI (Body Mass Index) is, by the time she was referred, 15,8.

The gap between science and clinical practice has somehow got lost in the debate about evidence-based practice and the use of manuals. Clinicians know that, even though we are fairly faithful to the manual’s guidelines, we are still experiencing difficulties in adaption to the needs of individual families. The knowledge covered in a manual is just one of many competencies we are using in our meetings with families and clients (Fruggeri, 2012; Fruggeri et al., 2022). We need a new perspective, a new horizon to handle the dilemmas between established empirical knowledge and the adaptions to the specific needs of the individual family. This chapter introduces a tool that may be useful in this important, but challenging task. We are using the Family-Based Treatment manual (FBT) and the work with eating disorders as an example. The work described is nevertheless applicable to other contexts of trouble and other manuals as well.

The treatment with the highest level of empirical support for adolescents below 18 years with a short duration of illness is Family-Based Treatment (FBT; Couturier et al., 2013). Our first meeting with Aurora and her parents followed the interventions underscored in the FBT manual. We underscored the seriousness of the situation, instructed the parents to take responsibility for Aurora’s meals and meal plans and gave them information about the importance of underweight reduction for recovery. The manual will be described in greater detail later.

But this way of working did not work well with this family. They returned some days later, the parents desperate and angry with each other. Aurora had shut down and would not say much. The parents told us that they found it difficult to do things in a way that made Aurora comply with their instructions. Instead, their meals had ended in tears and anger and had not resulted in an increase in Aurora’s diet. They partly blamed the strict criteria of the manuals’ interventions. Mother even cited the title of an article she had found on the Internet: “This must be somebody else’s roadmap” (Conti et al., 2017)!

This is a common concern amongst therapists working within the frames of a manual. To some families, the instructions seem to worsen what they already experience as difficult and traumatic. Even if the FBT-interventions are efficient (Couturier et al., 2013), still only about 50% of the families involved have success. The authors of the manual conclude like this: “We do know that efficacy data for FBT, especially adolescent AN, are quite robust, even though remission rates remain elusive for more than half of all cases. While preliminary, moderators of FBT for adolescent AN have been identified and could aid us in determining the most (or least) responsive patient groups… What we do not know, yet, is whether specific adaptations to manualized FBT will confer improved remission rates” (Lock & Le Grange, 2018). The modifications we have seen so far are mostly additions given as an extended therapeutic period, e.g. CBT, RO-DBT, etc. Some of these are added because of an uncertainty about whether the FBT takes good enough care of the youth’s needs.

Our intention with this chapter is to create some ideas about a new horizon in working within the framework of a manual. The FBT manual works as an example, but the points we underscore can be useful in any manualized context. We will suggest a possible way to modify the manual without removing the efficient factors that have been the core of the positive FBT results. That means focusing on what we so far know about the success factors, combined with ideas that can be positive modifiers of the stringent manual in order to individualize interventions to each family and arguing for these modifications as possibilities to make family therapy an even more efficient intervention for the families who need our assistance. And we will get back to Aurora and her family later.

Eating Disorders

First: a short introduction to eating disorders. They are dangerous illnesses with potentially high mortality rates, potentially long-term medical consequences and a high risk for chronification even for adolescents. Early and adequate interventions reduce these risks. In recent years, we have seen an intensified effort to find effective interventions to help families who are affected. The illness has a great impact on the whole family, both on parents (Rhind et al., 2016) and siblings (Fjermestad et al., 2020).

As with many problems that affect young persons, eating disorders put parents in a position of helplessness and despair. The overwhelming anxiety parents may experience reduces their ability to take efficient action against the illness. When parents doubt their own strength or skills to counter the eating disorder, the fear of making the situation even worse also follows. This uncertainty gets stronger due to changes in the young person. Parents often describe this as a big change in personality: from an independent, caring, responsible position to a bewildered young person with one goal in life: to reduce the intake of food as much as possible.

From the young person’s perspective, the reduction in food intake often goes together with what they believe is a solution to something they perceive as a problem. Lack of self-confidence, wanting more friends, being more attractive or more able to “deliver” on various social media platforms or in activities related to sports amongst a lot of other possible perspectives—perspectives that are important to a young person who is striving to feel good enough to live a satisfying life. Citing Sarah: “it doesn’t help if my mother tells me that I am good enough! Of course she would say that – she is my mother, that’s what mothers do!!!” It is the judgement of her peers that she wants to influence. And it is a perspective that most young persons will recognize as an important goal. The problem arises when this goal overshadows everything else in life, including the big health hazards. And that is when we would say that the young person is overtaken by the eating disorder, not able to recognize any other perspective on his or her life. Even when life itself is reduced to avoid eating, and every other aspect of life is ignored, including school performance, friends and family, or being able to participate in activities that up to this point have been a source of enjoyment, the eating disorder is not recognized as an enemy.

The Manual

FBT is an outpatient treatment which utilizes the adolescent’s family as a resource in re-feeding and recovery (Lock & Le Grange, 2013). The earliest studies of family therapy for anorexia nervosa were conducted at the Maudsley Hospital in London. This approach was subsequently adjusted somewhat, given a more behavioural focus, and called FBT at Stanford University and The University of Chicago in the United States (Rienecke & LeGrange, 2022).

Therapy is conducted in phases. The first phase focuses on achieving weight gain through giving parents responsibility for the young person’s eating and meal-related behaviour. In the second phase, responsibility is gradually returned to the young person (Lock & Le Grange, 2013). Phase three focuses on developmental themes such as independence, social behaviour or sexuality (Lock & Le Grange, 2013). The actual developmental issues addressed depend upon the needs of each family (Medway et al., 2019).

The FBT manual has elements from several family therapy approaches and is based on 5 fundamental assumptions:

  1. 1.

    the therapist holds an agnostic view of the cause of the illness;

  2. 2.

    the therapist takes a non-authoritarian stance in treatment;

  3. 3.

    parents are empowered to bring about the recovery of their child;

  4. 4.

    the eating disorder is separated from the patient and externalized; and.

  5. 5.

    FBT utilizes a pragmatic approach to treatment, with the focus on the here and now (Rienecke & Le Grange, 2022).

Several of these assumptions have been shown to be related to the success of FBT, e.g. agnosticism (Lock et al., 2020), externalization (Lock et al., 2020) and parental competence (Robinson et al., 2012).

The five fundamental assumptions show how FBT represents a combination of elements from several family therapy traditions. First, the basis is structural family therapy, where the hierarchy in the family is underscored, and the parental system has a different kind of responsibility than the children. The strategies designed to give parents increased agency related to the eating disorder are linked to this tradition. Parental confidence regarding how to handle meals and food intake is an important success factor. Aurora’s parents were instructed to take responsibility for her meals to secure a sufficient nutritional intake. Included in these instructions is the therapist’s conviction that they have the necessary strength and willpower to do this. The agnostic and pragmatic approach to the problem and the therapeutic process reminds us of solution-focused therapy, insisting on the futility of understanding the causes of the eating disorder, and that therapy must be concentrated on what are useful steps to reduce the influence of the eating disordered on the young person and the family. The therapist’s non-authoritarian and consultative stance reminds us of the systemic and the dialogic-collaborative approach to the therapeutic process which views the family’s own resources and responses as the key factors securing therapeutic success.

One of the changes that was introduced in the manual developed in the United States, was a stronger focus on behavioural change. This is particularly evident in Phase 1, with, as we have seen, the concentration on giving the parents confidence in their ability to take control of the young persons’ meals and food intake and securing a weight gain in the young person. The reason for this is of course that early weight gain is an important predictor of outcome (Doyle et al., 2009; Le Grange et al., 2014). At the same time, many of the families who have not experienced FBT as useful emphasize that a one-sided focus on weight gain has not given them the therapeutic platform they needed in their efforts to combat the eating disorder (Conti et al., 2017). So, is it possible to expand the focus in the start-up phase so that both therapist and family can navigate within a new horizon, a larger room for action than the manual recommends?

The Active Elements in FBT

Some of the active elements in the FBT manual are, as we have underscored, the importance of parents being the driving force in the reduction of the eating disorders influence, the active focus on reduction of underweight, and the change of behavioural patterns related to the reduction of eating. This did not work for Aurora’s family and still is insufficient for a large number of families.

So how can this situation be improved? Is it possible to see a new horizon where a greater percentage of the families troubled by eating disorders can be helped? The following is a summary of a large Norwegian study of families that have been through several treatment processes at different levels of service:

…former inpatients prefer tailored treatment and a collaborative approach. Eight subthemes constituting two main themes emerged: 1) There are no ready-made solutions. Staff should facilitate collaboration by tailoring treatment toward the young person’s perspectives, and 2) Emphasizing skills that matter. Staff should display a non-judgmental stance, educate patients, stimulate motivation, enable activities and prevent iatrogenic effects during the stay. (Nilsen et al., 2019)

The young persons also underscore a real dilemma that is clinically easily recognizable. They want and need the support and determination of their parents/family, but they also “place a distinctive emphasis on self-responsibility and determination” (Nilsen et al., 2020). This has been a point of interest for years although little has been done to secure the young person’s active contributions with their perspective as part of the process in the early phases (Krauter & Lock, 2004).

The Challenges of Using a Manual

Based on group data, a manual gives the therapist a structure and an overview that has been documented as useful for many families. But group data are often not a sufficient basis for interventions in the individual family, even if they have been useful for a large percentage of the families that have been involved in the actual studies. To clinicians, who want to be useful to as many families as possible, there often has to be room to adjust and to take into consideration the specific needs and wishes of the individual family. To achieve this, it must be possible to take into account the specific therapeutic context that the therapist team and family develop together and to the special needs that the individual family presents (Robertson & Thornton, 2021).

The relationship between following the manual from step to step and the outcome of therapy is complex. There is a multitude of factors that can influence the relationship. Included in these factors are the kind of therapy that is offered, the concrete problems that each family brings with them to therapy, the alliance between the family and the therapists, and the young person’s motivation to help create change. If the young person is negative to any kind of change, being true to the manual can be counterproductive, or, at best be an ineffective strategy. The young person with an eating disorder is often identified with the eating disorder and sees the eating disorder as their own project associated with some aspects of their lives that they want to improve. Even if the parents most of the time are very motivated to create changes in a very troubling and scary situation, the young person’s engagement in the healing process is important for long-term changes to occur (Nilsen et al., 2020). In Aurora’s family, a number of these points could be the reasons for them not having the intended effect of the manual’s directions.

In the therapeutic context, we would like to turn the attention from following the manual letter by letter to a process that is more flexible and tailored, but which nevertheless takes into account the active ingredients in the manual that are documented by the empirical research. How can we connect and create a dialogue with Aurora and her family in a way that helps us to be useful to them? In addition, we think that this approach to a greater degree underscores the importance of the therapeutic alliance (Robertson & Thornton, 2021). The increased attention to the young person’s perspective also makes it possible to focus to a greater extent on their motivation for change (Nilsen et al., 2019).

Another argument for being flexible and individualizing treatment is presented by Medway et al. (2019). The aim of their study was to let parents and young persons describe the different ways that AN impacts adolescent development, and how FBT helps families out of the eating disorder. The informants describe three distinct ways, relating to different meaning context in the young persons and the families’ lives (called developmental difficulties by the authors). “For some young people, FBT plays a key role in easing their return to activities that promote healthy development, or in adjusting their relationship with their family of origin to be more developmentally appropriate. For others, the role of FBT is largely limited to weight gain; however, this can allow young people to find their own path back to healthy development post-treatment” (Medway et al., 2019). In this way, the meaning context associated with the eating disorder onset can give valuable (and necessary) clues as to what changes the family needs to work on to get rid of the ED.

Suggestions About How to Customize the Manual to Meet Individual Families Needs

So how can we base our treatment on the strong involvement of the parents, together with a collaborative stance where the young person also is invited to participate, and help them take a stance against the destructive forces of the eating disorder together? From our perspective, working with a systemic formulation at the start of treatment could be a way to open possibilities to expand and go beyond the manual without neglecting the active and efficient ingredients of the manual. It gives us the possibility to work with the will (and wish) to cooperate in the family, which is a success factor in any family therapy process (Friedlander et al., 2011). In addition, it includes the young person’s voice in an early part of the process to a much greater degree.

A systemic formulation is, from this stance, a therapeutic tool that can help the therapist bridge the gap between the manuals’ more generic guidelines and the here and now unique meeting with the family (Baudinet et al., 2021). We have chosen to work with a systemic formulation to underline both the theoretic baseline, the context in which it is made and the way it is carried out. We need something more to help us navigate in the uniqueness and complexity that each young person and family represents. We need something that can translate the general guidelines into appropriate idiosyncratic judgements about what to do.

Manuals are designed to ensure that families and clients are given evidence-based help for their presented problems. Despite this, the tool the manual is given through is inevitably the therapist (Blow et al., 2007). This influences the way the manual and the therapy are provided in the real world. As therapists, we use clinical judgements based on more than the manual at hand. We are, amongst other things, driven by well-rehearsed habits, personal preferences and other blind spots. A systemic formulation ensures that the therapists’ ideas are openly shared. The family are given the opportunity to contribute to the dialogue with additional and relevant information and to be active participants in the process. The systemic formulation ensures that we involve the family as active participants and collaborators.

So, what exactly is a systemic formulation? A systemic formulation can, in a broad sense, be described as the process in which the therapist, together with the family, tries to make sense of the situation (Baudinet et al., 2021). We, as well as the family and the young person are, by virtue of being human, always searching for meaning. A systemic formulation is a way to formalize this natural search for how things are connected. Through this collaborative exploration, the aim is to end up with a current plan helping the young person get well. This plan is based on general knowledge about eating disorders, the FBT manuals active ingredients, and the information from the family and the young person that has evolved through the formulation process. The process was initially inspired by Baudinet et al. (2021) and is further developed from other written sources on formulations (Johnstone & Dallos, 2014; Kennerley et al., 2016) and adapted to our local clinical culture and practice.

The formulation work we have adopted has naturally evolved into two separate phases. The first phase is an exploring conversation structured around some core features. The first step in this phase is to create a genogram. The genogram is made to get an overview of the young person’s family and network. In the following steps, the genogram will function as a stepping stone into the different categories of interest. Circular questions facilitate an exploring conversation.

The conversation covers some core elements that are integrated in the systemic formulation, but does not necessarily follow a strict, sequential order. The aim is to create a common understanding between the therapist and the family. The best way to manage this is to follow the family in their preferred directions. At the same time, the therapist takes responsibility for covering the structure inherent in the systemic formulation. The conversation is predominantly fueled by circular questions to bring forth the family’s reflections, experiences and assumptions. For example, how does it make sense that the young person has developed this particular eating disorder, what and who affects the current problem, what made the eating disorder develop in the first place and what makes it so hard to escape from it? It is important to emphasize that the purpose here is to ask for the family’s understandings. Not to find “the real causes” for the disease. This is an essential part of all systemic practice and in agreement with the agnostic attitude of FBT.

When the genogram is drawn, the next step is to explore the family’s experience of the current difficulty (Baudinet et al., 2021; Kennerley et al., 2016). This will, in our context, normally present itself as different stories of troublesome eating behaviours or distorted thoughts connected to food and body image. We have found it useful to adapt the four steps in Michael Whites externalizing map in this part of the formulation (White, 2007). That is, first, collaboratively find a proper name for the problem; second, explore the effects it has on the young person and the important relationships in his or her life. Third, ask the young person to evaluate the effects and, finally, ask for a justification of this evaluation to bring forth the young person’s values, dreams and preferred ways of living. This part of the systemic formulation supports the FBT manual’s emphasis on using an externalizing language and lays the foundation to maintain an externalizing language throughout the whole therapy process. It also helps the therapist and the parents to discover any possible motivation the young person may have for getting well. During the exploring conversation (the first part of the systemic formulation) the following themes should also be covered to get as rich a picture as possible; triggers, modifiers, precipitants, vulnerability factors, protective factors and perpetuating patterns (see Fig. 6.1).

Fig. 6.1
Nine text boxes for genogram, current difficulties, triggers, modifiers, precipitants, vulnerability factors, protective factors, perpetuating patterns, and plan.

A template formulation 1

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Based on the length and focus of this chapter, we choose to limit ourselves to describe how the systemic formulation can influence how we work with the effects of the perpetuating patterns and can have relevance for facilitating and adapting a unique treatment process.

The perpetuating patterns are in line with circular hypothesis and with FBT agnostic stance and pragmatic approach to treatment. They can give the therapist and the family a way to collaborate to explore what keeps the problem going, and to discover what natural interventions these patterns invite us to do, to break the vicious circles. In other words, they are important in making concrete plans. The perpetuating patterns we create together with the family should reflect the information given throughout previous conversations. Some perpetuating patterns recur in most eating disorders. This applies, for example, to the pattern created by being in a biological state of starvation (see Fig. 6.2). These patterns are part of the FBT manual and must be presented by the therapist as important knowledge. Other patterns are unique to the individual young person or family and are more to be discovered. The clinical case described below will show an example of this.

Fig. 6.2
A cycle diagram. The flow is as follows. Restrictive eating, the body in a state of starvation, the brain more rigid, and the eating rules is maintained or reinforced.

An example of a perpetuating pattern

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The second phase of the systemic formulation is to create a visual picture of the information given in the first phase (see Fig. 6.3). This can be done in different ways. Our example is just one way to provide a pictorial synthesis of the information. The purpose of this phase is to collect the most important information available at that time in collaboration with the young person and his or her family to make a tailored plan. This plan is the result of a cocreation of meaning during phase 1 and should make sense to the family and be in line with what they believe in. It is made through a coordination of meaning and knowledge from the family and the therapist.

Fig. 6.3
A flow diagram. Vulnerability factors, beliefs or attitudes, and precipitants lead to E D current difficulty. It loops with maintenance patterns 1, 2, and 3 which jointly lead to a treatment plan.

A template formulation 2 (inspired by Kennerley et al. 2016)

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An Example of a Systemic Formulation Process

But let us return to Aurora and her family, restart the therapeutic process and give both therapists and family a new horizon for their cooperation. In the new first session with the family, we drew a genogram. One important vulnerability factor that emerges during this session is Aurora’s bad experiences with peers during her early school years. She has several experiences of being shut out and exploited by supposedly close friends. The parents show grief for all the pain she has suffered. Despite these experiences, Aurora described herself as quite extrovert. She has just started high school when we meet them. Some of her friends from secondary school have left the city to study in other parts of the country. Aurora is ambivalent regarding this. She misses her friends, despite the difficulties that have been, but is, according to herself, also looking forward to a fresh start with new friends. Her parents express great concern regarding drop out and lack of social belonging if the eating disorder makes it difficult to attend school. In a way, it seems even more important to the parents that she attend school than Aurora. Aurora is explicit about her wish to manage school but is also clear about the costs. The manual instructs the therapist to advise reducing school attendance until the weight reduction is stopped and reversed. The parents think that school attendance is crucial for Aurora. Aurora is ambivalent. Is this challenge part of the reason why therapist and family are not moving forward?

Therapist: So, tell me, Aurora. How did all this start? Do you remember?

Aurora: I don’t really know. But I think it was like a solution for me. I didn’t know how to fit in. I felt different and didn’t know how to connect to the others and eating less and getting thinner was a way to cope, I guess. I tried to get thinner to make them see me...

Therapist: So how did the Solution help you? Did It help you in relation to your peers?

Aurora: No, I guess not, but it made me feel better...

Therapist: In what way?

Aurora: I guess it made me less vulnerable. I coped, and I wasn’t dependent on the others in the same way as before. I felt stronger...

Therapist: What can I call this Solution, Aurora? Is it ok by you that I call it an eating disorder?

Aurora: It is more like an eating challenge

Therapist: Ok. So, this eating challenge, does it help you or does it make it more difficult for you to get to know your new peers?

Aurora: I don’t know. It feels difficult to be me. My head goes blank, and I am afraid they think I am stupid...

Mother: That’s because your energy level is low. It will be better as soon as you gain some weight. You will be fine…

Therapist: So, how does this feeling of going blank affect the eating challenge? Does it make you want to eat more or less? Or none of them?

Father: She has never eaten a lot, actually…

Therapist: (to father) So, does that mean that you think the feeling of blankness is not connected with the eating challenge?

Aurora: You don’t understand (to father). It does makes it more difficult to eat!

Therapist: And how does that effect the interaction with the others?

Aurora: What do you mean?

Therapist: Does it make you feel stronger and safer in the interaction with the others? Like at the onset of the eating challenge. You said that on the onset it made you feel stronger. Is it the same now? Or is it different? Does it, in some way or another, affect the feeling of being disconnected from them?

Aurora: I really want to get to know then, but I don’t feel like me. I feel sort of numb and disconnected and feel stupid. But I don’t want to give up. I really want to belong to the group, just like they do…

Therapist: It sounds like the eating challenge disturbs your wish to connect to your new classmates. Is that so?

Aurora: Maybe. But I am not sure it is all about the eating challenge...

One dilemma that occurs during the initial formulating conversation was whether Aurora should attend school at this stage of her illness or not. Given Aurora’s low BMI, and her low food intake, our normal advice would be to limit school attendance. But given the information about her earlier history, her explicit wish to connect with peers and the parents’ conviction about the importance of her going to school, made us hesitate. This was reinforced by the mothers own bad experiences with the health care system, her personal competency regarding eating disorders and her reluctance to give us authority. This was an example of a discrepancy between the manual’s guidelines and the family’s unique history and its implications. The following dialogue shows how the exploration of some of the perpetuating patterns gave us an opening to establishing an agreed upon plan for the following weeks.

Therapist: To me it sounds like we are talking about two different self-perpetuating patterns. One good and one less good. The good pattern captures a wish that you have been explicit about (to parents). Because of Aurora’s painful history from previous school years, it makes it important for you to give her the opportunity to have a good start in this new school. By letting her attend school as normal, you hope to give her the opportunity to establish new friendships, that hopefully promotes a better life for her in general, improves her self- esteem and hopefully makes it easier for her to eat.

Father: Yes, that’s right…

Therapist: (to Aurora). What do you think Aurora? Does it feel important to you, as well?

Aurora: I guess so…

Therapist: So, this is one possible, and wished for development for all of you. On the other hand, you (Aurora) have said something about the struggle you are exposed to attending school these days. And that leads me to the other possible, but more vicious perpetuating pattern. May I say something about that one as well?

Mother: Of course…

Therapist: Even though the hoped-for consequence of attending school is to help Aurora to get well, it might also be that her current energy level is too low to allow this to happen. It might be that, as she says, she struggles too much to be present in a way that helps her. It might be too tiring for her, and it might drive her into a vicious circle where all her energy goes to a project that doesn’t succeed, that makes her feel as a failure amongst her peers and makes it even harder to eat. It might trigger her original solution to eat less to have control in an overwhelming and difficult situation, which sabotages the sufficient weight gain, and might prolong the time she stays sick. How can we make sure to be wise in our next step? The margins aren’t too good, so we have to make sure we don’t try something that doesn’t work for too long. What do you think?

Mother: I think that we must see a weight gain in one or two weeks, that she has a better mood, and that she manages to eat without too much trouble

Therapist: That sounds like a feasible plan? You (parents) let Aurora have the chance to get into the positive effects of attending school, by letting her attend full time for one or two weeks. If Aurora continues to show negative signs on those three parameters, then we must reconsider the plan? Is that so?

Therapist: (to Aurora): How does this plan affect you? Can you do this? And how can mom and dad notice or even help you if the struggle gets too tough before next week?

Aurora: Now that I think they understand that this is not all about the eating challenges, I want to try, and I wish they will let me do it. I think they will notice if the plan doesn’t work, and I think we all want to give it a try!

The parents agreed on giving the plan a try for the two weeks. They came back for a new appointment the next week. Aurora had gained 700 grams, and the parents thought her mood had become better. Aurora hadn’t noticed any difference, but she was still determined to try another week. We met weekly for a long period and followed up the three parameters every session. Aurora gradually gained weight, and the conversations turned in other directions. We made another systemic formulation at this point. Our experience was that we had a good and safe working alliance with both Aurora and her parents. The themes that Aurora brought forth were painful and demanding for all to talk about, but they were an important part of her healing process. Our experience was that the formulations helped us make the context, the dialogue and the collaboration good enough to help Aurora get well in a rather smooth way.

Concluding Comments

Our intentions with this chapter have been to show how a modification of the original FBT manual can help us develop our treatment processes in a way that makes the resources of both the family and the therapist team important ingredients in planning and implementing a constructive dialogue and the feeling of cooperation. That is, to create a new and wider horizon to ensure cooperation and dialogue as the decisive element in establishing a foundation for a working alliance for the family.

The FBT manual underscoring the importance of a consultative stance encourages a cooperative stance from the therapist team. Through our examples, we hope to show that a less instructive stance than the manual prescribes can be beneficial to the process, and still make room for the knowledge and experience in the therapist team. We hope this can be the start of making the FBT manual a useful intervention for a larger group of families that struggles with restrictive eating disorders in a young person. We also hope that it can inspire therapists working with other manuals to expand their work in similar ways.