How Does HDRM Differ from Family Based Treatment?

There are a couple of EDI papers on how FBT was the jump off point for HDRM and how heavily HDRM depends upon the science that is also applied within the FBT protocol. But there are several ways in which HDRM differs from FBT and this entry will outline those differences.

Step One: Handing Over Feeding Responsibility

FBT is designed for children and adolescents who live with their guardians. There are three basic steps to FBT: handover feeding responsibility to the parents, then slowly transfer feeding responsibility back to the child, then apply psychotherapeutic treatment to help the child return to a normal developmental arc.

Although some work has been done to expand upon FBT into young adult populations, fundamentally Step One is difficult to enact for the vast majority of adults with eating disorders who either live alone, or do not wish their adult relationships to lose a sense of equality by having one partner or close friend assume the role of substitute parent to help the patient refeed.

HDRM is designed for the adult population. It can be readily used by guardians with their children as well and might be preferable for some adolescents.

FBT does not define refeeding minimum calorie intake amounts. Itemizing intake minimums exists exclusively within HDRM. The reason for delineating minimum intake amounts is that the vast majority applying HDRM are in community and not in inpatient settings where intake amounts are directed by the program and not the individual in recovery. Many eating disorder practitioners flag the minimum intake guidelines as too low for early recovery efforts, and they are right. If any patient applying HDRM treats them as a maximum amount, they will not recover and get to remission. A patient should expect to eat several thousand calories more per day than the minimum guidelines for their age, sex, weight during refeeding.

So why does HDRM list minimum calorie refeeding guidelines when they are too low for those recovering from an eating disorder?

The minimum guidelines are a line drawn in the sand to correct the cultural misunderstandings of what constitutes the actual intake of energy-balanced individuals who do not have eating disorders. But in recovery, most patients should expect to have a protracted phase of extreme hunger where an easy 6,000 to 8,000+ calories will be consumed each day. Details on how that works can be found in the Extreme Hunger. The other reason that minimum guidelines are in place is to staunch the huge number of patients who cycle through periods of weight restoration and relapse. Once a patient has restored their energy balance in the body, they will be encouraged to return to calorie guidelines that have been proven to be too low to maintain energy balance (e.g. 2000 kcal/day for adult women over age 25) and this precipitates a fast and hard relapse.

Patients recovering in community need a target intake to begin recovery in a way that those in inpatient settings, or undergoing FBT as a child, do not. While many will treat the minimum intake as a maximum, the experience I have had watching those applying HDRRM is once a patient gets to those actual intake levels, extreme hunger will take over.

Step Two: Returning Feeding Responsibility Back to the Patient

From the outset, refeeding is the responsibility of the patient in HDRM but both FBT and HDRM recognize that energy needs to be getting into the system first and foremost.

As the child or adolescent begins to restore weight and enough energy is getting in them to allow for better brain function, FBT progressively helps the family to shift responsibility for feeding from the guardians back to the child.

With HDRM, as the patient is responsible for refeeding from the outset, the second facet for HDRM is resting and it happens at the same time as refeeding right from the get go.

FBT is loose around applying exercise. Exercise often becomes a negotiating point for the child and when target weights are reached then exercise is often reintroduced or allowed. There is too much evidence in the literature to confirm that shifting restrictive behaviours undermines the ability to reach remission. We know that after eight years of an active eating disorder, behaviours such as purging, compulsive exercise, abuse of laxatives, orthorexic rigidity over food choice all creep in when frank avoidance of food is either difficult to maintain, or, as in the case of FBT, other restrictive behaviours are not frowned upon and allow the child to now adopt so-called “healthy behaviours” all while reinforcing the underlying misidentification of food as a threat. These facts are discussed elsewhere on this site with all the accompanying references.

Step Three: Psychotherapy to Return to Normal Development

The brain has to be sufficiently nourished to get the benefit of various psychotherapeutic modalities and on that both FBT and HDRM are in agreement. And both are aligned that as soon as the patient is functioning enough, these therapies should be included in the treatment process.

Within HDRM this psychoeducational piece is entirely mix and match and unique to the patient’s goals and history. All the other science-based treatment modalities listed under the Treatment Options section of this site are predominantly psychotherapeutic and psychoeducational options that can be used alongside HDRM depending on patient preference.

Returning a child to their normal developmental arc is a very dominant framework in child psychology today and unsurprisingly is identified as the ultimate goal for a successful FBT application. Within the HDRM framework, the pscyhoeducational effort is critical for protecting a remission and maintaining its presence for life. However, the goal is not necessarily to “return to normal” or “to be normal,” but rather to develop advanced metacognitive skills to allow for a high tolerance of discomfort when fight/flight responses to food rear up.