Clinical or methodological significance of this article: The study provides important insights into adolescents’ experiences of FBT, suggesting that they appreciate the rationale of treatment and perceive parents taking over responsibility for renourishment as a key factor in their liberation from AN. Importantly, according to the adolescents in the current study, parent‒child relationships at the end of treatment were not negatively affected. In contrast, adolescents reported becoming closer to their parents through shared challenges and parents’ efforts to understand them. The findings also highlight the necessity of active involvement from both parents, as relational repair with the less-engaged parent was less consistently achieved. Trust emerged as a central and often challenging issue, encompassing both adolescents’ ability to be trusted and their ability to trust parents and clinicians. This underscores the importance of providing a safe space, including dedicated one-to-one time, for emotional processing and reflection. Finally, the findings suggest a need for adaptations of FBT to better support transitional-age youth, who may be less receptive to standard approaches.

Introduction

Anorexia nervosa (AN) is a severe psychiatric disorder that typically emerges in early adolescence. It carries significant physical and psychological consequences, including an elevated mortality rate, impaired psychosocial functioning, and a substantial burden on families (Arcelus et al., 2011; Giles et al., 2022).

Family-Based Treatment (FBT) is internationally recommended as the first-line treatment for children and adolescents with AN (Hay et al., 2014; Jones et al., 2021). When family therapy for adolescent AN was first introduced, it was grounded in systemic theory and Minuchin's concept of “the psychosomatic family” (Minuchin et al., 1978), where AN were seen as a systemic response to family enmeshment, rigidity and conflict avoidance. Later research has discarded this view of AN and demonstrated complex interactions of genetics, biology, temperament and social factors. Moreover, therapeutic theory has shifted its focus away from aetiology to an understanding of how families become organized around a potentially life-threatening problem (Eisler, 2005). Still, despite change in theory of AN, evidence supports the effectiveness of family therapy, and FBT integrates interventions from behavioural, systemic-narrative and structural family therapy.

FBT is a structured, manualised treatment model in which parents are supported in taking primary responsibility for restoring their child's weight and normalizing eating behaviour (Lock et al., 2001). By temporarily shifting responsibility for food- and weight-related decisions from the adolescent to the parents, FBT aims to bypass the ambivalence and limited illness insight characteristic of adolescents with AN. The model seeks to mobilize the parent–child relationship as a therapeutic resource, drawing on parental authority, emotional attunement, and care as mechanisms of change (Lock et al., 2001). One of the core therapeutic strategies in FBT is externalization, whereby AN is framed as an external force that exerts control over the adolescent’s behaviour rather than an intrinsic part of the adolescent. The aim of externalization is to reduce blame and guilt within families (e.g., “AN is making it hard to eat” rather than “you are being stubborn”), to mobilize parents to fight for their child by countering that which is not the true personality of their child, and to support a collaboration between parent and adolescents to side against AN. It aligns with the core assumption of FBT that neither parents nor adolescent are to blame for AN, and the adolescent is not choosing the illness. Externalization further provides a strong rationale for parents to intervene, while remaining non-critical and securing emotional support in the process (Rienecke & Le Grange, 2022)

The sessions begin with a weigh-in, followed by a family session. The weigh-in is the only time the adolescent is seen alone by clinicians. FBT follows a three-phase structure (Lock et al., 2001). In Phase 1, parents assume full responsibility for ensuring renourishment and weight restoration, often requiring one parent to take leave from work while the adolescent is on medical leave from school. Phase 2 begins as the adolescent approaches a healthy weight and their resistance to eating diminishes. The main task in this phase is the gradual transfer of responsibility for eating back to the adolescent, while parents continue to provide support and supervision as needed. Phase 3 focuses on relapse prevention and reintegration into everyday life (Lock et al., 2001).

Despite its clinical endorsement and growing empirical support, FBT has also attracted criticism for being emotionally demanding, for increasing family conflicts, and for potentially straining the parent–child bond, as parents are required to insist that their child does what they fear the most: eat regularly and sufficiently and gain weight (Conti et al., 2017; Thibault et al., 2023; Waage et al., 2025). While a recent review revealed no overall differences in the development of family functioning or family well-being between families undergoing FBT and those receiving alternative treatments (Pedersen et al., 2024), such aggregate findings may obscure important variations in how families experience relational changes during FBT, including the influence of cultural context. For instance, Scandinavian parenting norms, which tend to emphasize children's autonomy over parental authority (Doepke & Zilibotti, 2019), may conflict with FBT’s emphasis on parental empowerment.

We recently conducted a qualitative study (Pedersen et al., 2025), which highlighted how parents, in a Danish context, experienced FBT as emotionally demanding and markedly different from their usual parenting style. Despite these challenges, parents described becoming closer to their child through the process of overcoming a significant challenge together. Importantly, the parents’ experiences of FBT were shaped by whether they found the model meaningful and could align with its rationale. These findings warrant the exploration of adolescents’ perspectives to gain a more complete understanding of how FBT is experienced and how it works.

To date, only three qualitative studies have examined adolescents’ perspectives on FBT and its impact on family relationships (Conti et al., 2021; Gao et al., 2025; Wallis et al., 2017). These studies report improvements in parent–child closeness (Gao et al., 2025; Wallis et al., 2017), with FBT described as providing relational containment that enables adolescents to trust their parents, feel more secure, and gradually engage in treatment (Wallis et al., 2017). At the same time, FBT was found to sideline family conflict and overlook adolescents’ emotional distress (Conti et al., 2021; Gao et al., 2025). Beyond these emerging insights, little is known about how adolescents experience FBT and how they perceive its impact on family relationships at the end of treatment, particularly within cultural contexts that prioritize youth autonomy and egalitarian family dynamics, such as those in Denmark and other Scandinavian countries.

Therefore, the primary aim of this study was to explore adolescents’ experiences of participating in FBT, with particular attention to how they perceived changes in family relationships at the end of treatment, as well as their views on both its helpful and challenging aspects.

Methods

This study employed an exploratory design aimed at gaining an in-depth understanding of adolescents’ perspectives and experiences of Family-Based Treatment (FBT) for anorexia nervosa (AN).

The inclusion criteria were adolescents aged 13–18 years who had received FBT for AN (ICD-10 codes F50.0 and F50.1) (World Health Organization, 1992) at a specialist eating disorder unit within a Danish Child and Adolescent Mental Health Centre (CAMHS). To ensure information richness and a broad range of perspectives, a strategic, maximum variation sampling approach was initially planned. The aim was to include adolescents reflecting diverse experiences with FBT, ranging from positive to less favourable outcomes, as well as variation in age and the presence of comorbidities. Adolescents who had completed all phases of FBT were included alongside those who discontinued treatment early or were redirected to treatment for comorbid conditions. This approach was chosen to reflect the diversity of treatment trajectories typically seen in routine CAMHS practice. Adolescents may discontinue FBT for various reasons, including limited perceived fit, illness severity, family circumstances, or emerging comorbidities requiring alternative interventions, and their perspectives were therefore considered relevant to the study aim of capturing how FBT is experienced in everyday clinical settings. Recruitment was carried out by a research assistant within the participating CAMHS unit and occurred at the end of treatment, regardless of whether the adolescent had completed all phases of FBT, discontinued early, or been redirected to treatment for comorbid conditions elsewhere within CAMHS. During recruitment, the research team monitored participant characteristics to ensure sufficient diversity across the predefined dimensions. In practice, however, sufficient variation emerged naturally through open invitations to all eligible adolescents, and no active steering of selection was required. The interviews were conducted between March 2023 and January 2025. The FBT approach remained consistent over the two-year recruitment period, with no adaptations to the treatment model. Adolescents received a gift card worth 400 Danish kroner (approximately 55 USD) as compensation for their time and contribution.

Data saturation was approached not as a discrete event, but as an analytic principle to be pursued throughout the research process (Thorne, 2020). Accordingly, sample adequacy was guided by the concept of information power, whereby the sample size was considered sufficient in relation to the focused study aim, the specificity of the sample, and the relevance and richness of the data (Malterud et al., 2016). High information power was further pursued by maintaining a relatively narrow study aim, ensuring dense data specificity, and facilitating strong dialogue during data collection (Malterud et al., 2016). In addition, saturation was addressed analytically through an ongoing assessment of whether further data collection would contribute meaningfully to theme refinement, analytic depth, or explanatory power — that is, inductive thematic saturation (Saunders et al., 2018).

FBT has been the standard treatment for AN in the unit since 2010. The clinical team received initial training from James Lock, coauthor of the FBT manual (Lock et al., 2001), and has since participated in additional training and supervision by the Maudsley NHS Foundation Trust in addition to continued internal training and supervision. Within this unit, the original FBT manual was adapted in several ways, most notably by removing the specification of a fixed number of sessions. These modifications are discussed in greater detail elsewhere (Bentz et al., 2021).

The assessment, diagnosis, and introduction of parents to the FBT approach were all completed in a single day. Following this, families were seen on a weekly basis, with each session lasting one hour. Over time, the session frequency was reduced. Siblings were welcome to participate in the sessions but were generally not present. During the first month of treatment, all parents were invited to attend a six-hour workshop focused on psychoeducation and peer exchange.

To explore each adolescent’s individual experience of undergoing FBT and its perceived impact on family dynamics in depth, we opted for individual semi-structured interviews, as this method allowed us to follow up on and explore issues that appeared particularly significant to the individual adolescent while ensuring that all key topics were addressed. The interview guide was developed on the basis of clinical experience and existing research on FBT. It covered topics including experiences of the initial assessment and receiving the diagnosis; reactions to the expectation that parents assume responsibility for renourishment; aspects of treatment perceived as helpful or unhelpful; perceptions of whether parents were able to understand their emotional experiences; experiences across the different phases of treatment; and the perceived impact of FBT on family relationships and everyday life. Various visual aids were used during the interviews, including a scale to assess the development of the relationship between adolescents and parents and quotes about FBT based on experiences from former patients (see supplementary material for interviewer guides and visual aids). We are aware that the use of quotes may carry a risk of influencing adolescent’s responses towards perspectives on FBT they might not otherwise have articulated. At the same time, we experienced that using quotes as a supportive tool contributed to richer, more in-depth descriptions, as participants were asked to explain any recognition in the quotes with reference to their own lives and examples.

To allow adolescents to speak freely, interviews were conducted outside the clinical setting, either online or at the premises of the Danish National Association for Eating Disorders and Self-Harm (a patient organization). All interviews were carried out by SB, an experienced interviewer independent of the treatment unit. Each interview lasted approximately 40 min and was audio-recorded and transcribed verbatim. The transcripts were then reviewed by participants, who were invited to correct any errors or clarify points.

Data were analysed inductively using Braun and Clarke’s reflexive thematic analysis (Braun & Clarke, 2006), following their six-phase approach. Initially, SHP and SB familiarized themselves with the material through repeated readings of the interview transcripts, noting initial ideas and impressions. Preliminary coding was conducted using NVivo 15 (QSR International), with each transcript imported as a case, open coding applied to identify initial concepts, and codes organized into nodes representing overarching themes linked to supporting quotes. To enhance reflexivity, four transcripts were independently coded by both SHP and SB. The codes were then discussed and compared before SHP proceeded to code the remaining interviews. In the subsequent phases, codes were examined for patterns and grouped into potential themes. These themes were then reviewed in relation to the coded data and the entire dataset to ensure internal coherence and analytic depth. Finally, the themes were defined and named to capture their essence, and an analytic narrative was developed, supported by representative data extracts. At this stage, the themes demonstrated sufficient coherence, depth, and variation across participants to address the research aim, and as the dataset did not indicate substantive gaps requiring further data, 15 interviews were considered sufficient in line with the concept of information power (Malterud et al., 2016). The process was iterative and reflexive, involving continuous movement between the phases to ensure thematic saturation and a nuanced and grounded interpretation. To ensure the credibility of the analysis further, participant validation was conducted with experts by experience to assess the relevance of the identified themes. The themes were presented to youth mentors working within the CAMHS service where the treatment had been provided, who confirmed that the themes aligned with their own experiences of FBT and with accounts from other patients. Quotations from adolescents were anonymised and identified by participant number (A1-A15). Finally, the manuscript was uploaded to Curie’s free language editing AI service for proofreading and language correction, as the authors are not native English speakers.

Trustworthiness was addressed in accordance with Lincoln and Guba’s criteria, as operationalized by Shenton (Shenton, 2004). Credibility, dependability, and confirmability were supported through prolonged engagement with the data, an iterative and reflexive analytic process, systematic documentation of analytic decisions, and ongoing discussions within a multidisciplinary research team. Transferability was addressed through rich descriptions of the clinical context, participants, and analytic procedures. Written informed consent was obtained from all the adolescents and their legal guardians in accordance with the Danish Health Authority. The study was approved by the regional Data Protection Agency (P-2021-422). Transcripts were anonymised to remove identifying information. The participants were informed that their responses would remain confidential and would not be shared with clinicians. In the event that the interview raised emotional discomfort, participants were offered support from a trained counsellor affiliated with the patient organization. Neither SHP nor MB, who are clinicians at the recruitment site, served as primary therapists for the adolescents interviewed in this study except for one participant.

Findings

A total of 15 interviews were conducted within a few weeks after the termination of treatment with adolescents who had undergone Family-Based Treatment (FBT) for anorexia nervosa (AN). In one interview, an adolescent was accompanied by their mother for support. Of the 15 adolescents, 11 completed the full course of FBT. Two were referred to other CAMHS departments for the treatment of comorbidities during Phase 2 of FBT, one was transferred to adult services for continued treatment of AN during Phase 2, and one discontinued FBT during Phase 1. Although adolescents had followed different treatment trajectories, their accounts were analysed together, as all had received substantial elements of FBT within CAMHS and were therefore able to reflect on their experiences of the approach. The aim of the study was to explore how FBT is encountered in routine clinical practice, and grouping the responses allowed for the identification of shared themes across varied pathways as well as nuances linked to individual trajectories. Eight adolescents (53.3%) presented with at least one psychiatric comorbidity, the most common of which were anxiety disorders, followed by depression and autism spectrum disorder. The demographic characteristics of the participants are presented in Table I. Although the interview guide included questions about siblings, the adolescents provided very limited reflections on this topic. Consequently, sibling relationships are not discussed in the findings.

The analysis identified three main themes: Losing Control — Gaining Freedom, The Difficult Trust, and From Conflict to Closeness.

Losing Control — Gaining Freedom

When reflecting on their experience of the FBT process, the adolescents emphasized the substantial quantities of food they were required to consume, including both the magnitude of the intake and the accompanying physical challenges such as stomach aches and nausea. Based on the adolescents’ accounts, it appears that, beneath these explicit remarks regarding food, there was a concern about having to relinquish control, which, at least initially, seemed to overshadow all other concerns. This underlying theme was articulated succinctly by one participant, when asked what the most challenging aspect of the treatment had been: “It was the loss of control. That it wasn’t me who was allowed to decide.” (A14).

This fear of loss of control began even before the formal treatment process started. The adolescents described feelings of apprehension before their first appointment at CAMHS, particularly regarding what might happen and the potential impact of treatment on their dietary intake and weight. Following this, participants recounted that the introduction to FBT during the initial assessment and the information that their parents should temporarily assume responsibility for their renourishment elicited considerable distress, and even anxiety, alongside speculation about how they could deceive their parents and clinicians: “Yes. I remember sitting there thinking, ‘Okay, I need to find a way to fool them’.” (A4).

The experienced loss of influence appeared to leave adolescents with little agency, generating frustration and reinforcing a pervasive sense of entrapment. Closely tied to this loss of control was a persistent feeling of being “stuck,” often resulting from prolonged absence from school, friends, and extracurricular activities, which left adolescents isolated and disconnected from everyday teenage life: “And yes, my classmates went on a study trip, and I wasn’t allowed to come along, so that was strange too. I had to stay at home, and I was very much at home. Constantly surrounded by thoughts.” (A11). The sense of being stuck extended beyond physical confinement to an emotional entrapment within the disorder itself. Adolescents described a continuous inner struggle, caught between ambivalence and resistance towards recovery, where even the possibility of change triggered hesitation rather than relief:

I can remember feeling a bit like now there was finally someone reaching out who wanted to help me, but I hesitated terribly and stuff, and I remember having lots of thoughts because should I now accept the help, or should I just keep doing what I usually did? (A14).

Paradoxically, the experience of losing control was perceived in retrospect to be associated with a sense of relief, as it represented liberation from the dominance of AN.

It has both been nice and very annoying that my dad had to control how much I had in the beginning. It was just really a lot of food to eat, and I couldn’t control it myself. But at the same time, it has been good, because I couldn’t have taken responsibility for eating myself, because then I probably wouldn’t have eaten anything (A3).

So, at the beginning, it was very, very unpleasant because you were forced to gain weight and all that. But it was kind of what saved me and such. You kind of became free again. Yeah, and now, of course, I’m really glad we went through that process. Yeah, because otherwise I wouldn’t be feeling so well today at all. (A5).

According to the participants, this continued until the parents acknowledged that the approach was not suited to their family and began advocating to CAMHS for their adolescent to regain more autonomy. In contrast, one adolescent successfully described persuading both their parents and the clinicians that they should retain responsibility for their eating. In retrospect, however, they reflected that this might not have been the best approach, questioning whether their two-year treatment course might have been shorter if their parents had assumed responsibility. “Because I was just kind of allowed to live the way my eating-disordered brain wanted. Because I couldn’t — I mean, I just couldn’t go against it. I was at a low weight for a long time.” (A8).

The Difficult Trust

A central theme across the adolescents’ narratives was the need for, and struggle to be trusted. The fulfilment of this basic need was complicated by the difficulty parents and clinicians faced in discerning when the adolescents were speaking authentically and when AN was “playing tricks.” According to the adolescents, parents and clinicians, particularly early in treatment, tended to interpret much of what they said as being the voice of AN, thereby externalizing even thoughts and wishes that the adolescent experienced as genuine. “But sometimes, I have felt that they didn’t really believe me. Because they were like, well, it’s probably the eating disorder speaking there, and you used to like ice cream or something like that.” (A5). In this way, the clinical technique of externalization, originally introduced in FBT to maintain focus on the adolescent beyond the illness and foster unconditional acceptance, appeared to inadvertently lead the adolescents to feel that parts of their voices were dismissed as invalid:

… where I also say that it was me, and sort of argue why I thought it was me, and that it was me who felt it, and all those kinds of things that you actually don’t really have evidence for. (A10).

But it is difficult for them to judge whether it was me or it who said it, and I do understand that now. But when you are in it, it is really annoying not to be able to argue for yourself in that way. (A10).

The clinicians were generally described as kind, competent, and easy to talk to. “I have had a really nice psychologist who is really nice to talk to. I just think that they have been very helpful up there.” (A5). The relationship with the primary clinician was clearly significant, with adolescents recounting that the match felt good, and they felt understood. “And I have been with some people with whom I felt safe. And with whom I felt that I clicked.” (A14).

However, the adolescents recounted that sharing thoughts and feelings in FBT sessions with parents present felt vulnerable, not only because of the fear of upsetting the parents but also because of concerns that disclosing thoughts about food, body, or exercise might lead to increased parental monitoring and control at home. “Because if I told some of all those strange things […] then my mother would breathe down my neck even more.” (A12). Similarly, despite generally positive perceptions of the clinicians, the adolescents described difficulties in being fully open and honest even when alone with them during the weigh-in, as they felt that what was said was often relayed to parents in the following session and could have consequences for their meals.

Because I think, at least after a while or during certain periods, I could feel that it wasn’t really a psychologist who was supposed to help me, but more someone who was there to listen to what I said, so it could be passed on to my parents. (A8).

However, in contrast, some emphasized a consistently positive experience of trust throughout treatment:

… that I have had a whole lot of support. I could have my parents with me. That has also been really nice. There has been a whole lot of backing around it. And a lot of adults who have believed in me. (A14).

From Conflict to Closeness

The adolescents generally described having good relationships with their parents prior to the onset of AN. However, they explained that once their parents discovered the eating disorder, the relationship became strained by parental worry, desperate attempts to fight the illness, and confusion about why the adolescent had not involved them earlier or disclosed that they were struggling. According to the adolescents, these tensions further intensified when families began FBT, as parents were given responsibility for the adolescent’s renourishment and were advised to insist that their adolescent ate sufficiently.

From the perspective of the adolescents in the current study, the parents’ new, more directive and authoritative role was an unfamiliar experience that caused confusion and contributed to conflicts in the home, initially leading the adolescents to distance themselves from their parents.

But during the process, when they were the ones deciding everything and stuff like that […]. Because I got really angry at them quickly, and I didn’t like it. Because, I mean, now I know that they had to do it, but I just felt like they were doing it just to be annoying and ‘oh, relax, nothing’s going to happen. I mean, I’m fine.’ (A6).

The adolescents described how, either during the course of FBT or by the end of it, their relationship with their parents had improved compared to before because they had been forced to overcome something very difficult together. “Because we all tackled a problem together. I think my dad has said it a lot that he feels we’ve become much closer as a family.” (A11).

The adolescents described that the increased closeness with their parents especially arose from being forced to learn to talk about difficult things with them. Some explained how their parents had become better at understanding them: “.. my mum has kind of become a psychologist, if that makes sense.” (A4). Others said this was not always the case but that the parents’ strong desire to understand was, in itself, healing for the relationship. “I mean, the way my mum describes it too — she doesn’t understand it, but she really wants to listen to me, and she wants to understand it.” (A15).

A distinction was made between the closeness felt with the parent who took on the main responsibility for renourishment (hereafter “the primary parent”) and the other parent. The adolescents described how the other parent did not truly understand or try to understand.

Yeah, I mean, he also said things like I should just pull myself together and just eat and stuff like that. I mean, I don’t really think he had taken on board anything they had said at CAMHS. I mean, he didn’t really bring that with him. He just kept saying, oh come on, pull yourself together, or just do it. And then I think I just got a bit frustrated with him for not supporting me in the same way my mum did. (A14).

Discussion

In this study, which explored the experiences of adolescents following Family-Based Treatment (FBT) for Anorexia Nervosa (AN), the analysis developed a coherent pattern of experiences, with adolescents initially feeling distress and frustration when relinquishing responsibility for renourishment to their parents. Retrospectively, however, this loss of control was reframed as liberating, as parental oversight ultimately countered the AN and restored agency to the adolescent. Adolescents also described feeling that parents and clinicians did not necessarily believe or trust them but that competent clinicians ultimately facilitated a sense of understanding and safety. Finally, adolescents reported that initial conflicts arose from parents’ directive role in meals, yet over time, relationships were experienced as strengthened, particularly with the primary parent.

Overall, the findings illustrate the complex interplay between loss of control, trust, and family dynamics in FBT, suggesting that experiences of initial distress can coexist with long-term gains in autonomy, self-understanding, and familial closeness. Notably, older adolescents (aged 16 years and above) appeared to show a somewhat different pattern, often seeking greater involvement and responsibility in the treatment process, highlighting that standard FBT may be less well suited to this age group.

The findings highlight the transformative potential of parent empowerment. In a paradoxical manner, what may initially feel restricting and disempowering can ultimately become the source of freedom, precisely because the constraints reduce the influence of AN. This reflects the theoretical rationale of FBT, in which parents temporarily assume full responsibility for renourishment to provide a structured framework that disrupts the hold of the disorder and enables adolescents to regain agency over their behaviours and daily lives. The adolescents’ accounts in this study thus illustrate how the core mechanism of change in FBT, the temporary parental takeover of responsibility, operates in practice, supporting the theoretical rationale of the treatment (Lock & Le Grange, 2019).

It is interesting to note, that the adolescents' recognition that relinquishing control ultimately facilitated freedom typically emerged towards the end of treatment or retrospectively in the current study. This underscores the importance of clearly communicating to both adolescents and their parents from the outset that FBT is often a lengthy and demanding process and that perceptions of and involvement in treatment may evolve over time.

The finding that FBT may be less suitable for older adolescents is consistent with our previous study of parents’ perspectives on FBT, in which parents of teenagers aged 16 years and above remained reluctant to assume full responsibility for renourishment (Dimitropoulos et al., 2018). This reflects a widely acknowledged challenge in FBT research: the model is generally most effective for younger adolescents (Lock et al., 2010). Transition-aged youth (TAY) are characterized by increasing autonomy and a natural drive towards separation from parents (Erikson, 1950), which can conflict with FBT’s emphasis on parental leadership (Rienecke & Le Grange, 2022). The FBT-TAY model (Dimitropoulos et al., 2018) has been developed to address these challenges by emphasizing greater collaboration with the adolescent and an earlier transfer of responsibility. Early evidence suggests that these modifications may enhance engagement and treatment outcomes (Dimitropoulos et al., 2018), although further research is needed.

Trust emerged as a central theme in the interviews, reflecting a fundamental human need both to be trusted and to trust others (Erikson, 1950). AN complicates this need by creating a paradox: the adolescents wished to be trusted, yet their expressions often convey aspects of the disorder to the outside world, eliciting mistrust in others. It also fostered a fear of honesty with parents and clinicians. In this way, AN isolated the adolescents, placing them in a position of mistrust and social marginalization, both by prompting others to doubt their intentions and by fostering a reciprocal sense of mistrust towards those around them, which is consistent with findings from previous qualitative research (Conti et al., 2021).

This dynamic is further complicated in the context of Scandinavian parenting styles. Sociological research emphasizes that parenting in this region is typically trust-based, with parents valuing the child’s autonomy, participation in decision-making, and egalitarian relationships (Alexander & Sandahl, 2016; Elstad & Stefansen, 2014; Mansoory, 2020). Within this framework, the structured assumption of full responsibility for renourishment by parents inherent in FBT may be experienced as a suspension of these core values, potentially challenging the adolescent’s sense of being trusted by their parents. Indeed, both this study on adolescents and our previous study on parents (Pedersen et al., 2025) indicate that FBT involves a shift to a more authoritative parental role than is typical in Scandinavian contexts, which can be experienced as unfamiliar and challenging. Scandinavian parenting ideals may thus further complicate the tension the adolescents navigate: their need for trust and autonomy intersects with both the barriers created by the disorder and the demands of the intervention, making the establishment of trust — in both directions — a central yet complex aspect of treatment.

FBT has been criticized for potentially straining family relationships (Conti et al., 2021; Wufong et al., 2019). Our qualitative studies support this, identifying increased conflicts and distance between adolescents and parents during the early stages of treatment. Nonetheless, both this study and our previous study on parents’ experiences (Pedersen et al., 2025) indicate that relationships are generally restored and often strengthened by the end of treatment.

Importantly, adolescents recounted that statements they perceived as their own were subsequently externalized and reframed as the “voice” of the eating disorder, a phenomenon also described in previous qualitative studies (Conti et al., 2021; Wufong et al., 2019). This underscores the need for caution in the use of externalization, which should only be applied when it appears meaningful to the adolescent and when it facilitates a stronger focus on healthy aspects of the self, as well as alignment between the adolescent and parents in their joint efforts to disentangle the self from AN. When an adolescent does not “buy into” externalization and instead experiences AN as ego-syntonic – as an integrated part of the self-externalizing language can feel profoundly invalidating, delegitimising certain aspects of the self. At the same time, complicating matters, some adolescents described the opposite movement: statements they had initially insisted were their own were later understood as expressions of the disorder. This raises the concern that clinicians and parents may inadvertently validate utterances stemming from AN, thereby reinforcing it as part of the self and contributing to both strengthening the disorder and to the formation of a false or alien self (Pedersen et al., 2014; Winnicott, 1984).

This illuminates a central dilemma in AN treatment: how to remain validating without reinforcing an eating disorder identity. Moreover, this highlights how externalization may complicate the renegotiation of identity during and after recovery. The underlying difficulty lies in the dualistic logic of externalization, which divides experience into what is “ill and not-me” versus “healthy and me.” While this dichotomy may be helpful in highlighting the healthy parts of the self and in reducing guilt and blame within the family, it risks devolving into irresolvable debates about what constitutes the self. An alternative approach may involve a process of “de-externalisation” later in treatment, whereby aspects initially attributed to the disorder are reconsidered as potentially valid parts of the self. Conceptualizing the relationship between self and disorder as a continuum — where movement occurs between more disordered and more healthy aspects of the self — may offer a more flexible framework for supporting identity recovery (Conti, 2018). Further research is needed to explore how these processes unfold in therapy and how clinicians can best support adolescents in negotiating the boundary between self and disorder.

Methodological Considerations

Beyond the thematic content developed from the adolescents’ narratives, a discernible communicative pattern also became apparent. The interviews were characterized by a notable degree of concreteness; when invited to reflect on what they found most challenging, participants frequently provided brief, literal responses — for example, simply stating “the food.” This succinctness necessitated the interviewer’s active use of probing and prompting techniques to elicit more elaborate or reflective accounts, thereby mitigating any potential negative impact of a limited degree of strong dialogue on the study’s information power. The eventual richness of the dataset can thus be attributed to the interviewer’s persistence, subject-matter familiarity, and effective integration of visual aids.

This difficulty with abstraction may be understood in several ways. It could reflect developmental factors, the awkwardness of discussing sensitive issues with an unfamiliar adult, or the timing of the interviews, conducted at the end of treatment, nearly a year after the initial assessment and commencement of FBT. Physiological factors, such as the effects of malnourishment on memory and the emotionally demanding nature of the topic, may also have contributed, as adolescents might have consciously or unconsciously avoided recollection. An alternative or complementary explanation may lie in alexithymia, i.e., difficulty in recognizing and articulating emotions. Individuals with eating disorders commonly struggle with emotional awareness, a trait vulnerability that may precede the disorder (Cogodi et al., 2024). Consistent with this, the concreteness of adolescents’ accounts may also reflect compromised mentalisation: a rigid, literal understanding of thoughts and feelings that limits emotion regulation, which is instead enacted through disordered behaviours (Robinson et al., 2019; Skårderud, 2007).

An important strength of this study lies in the composition of the research team, which brought together complementary forms of expertise: two clinicians (psychologists) with extensive experience in FBT, a representative from a patient organization with in-depth knowledge of eating disorders and how families are affected, and a researcher specialized in qualitative methods and mental health. This combination of perspectives fostered reflexivity throughout the process and helped to counteract potential blind spots, thereby enriching the analysis and strengthening the credibility of the findings.

Nonetheless, certain limitations should be acknowledged. All interviews were conducted after treatment had ended, which means that adolescents’ narratives may have been shaped by hindsight and influenced by their treatment outcomes. Future research could benefit from longitudinal designs, following adolescents during treatment, to capture how their experiences and relationships develop over time. Although most adolescents completed all phases of FBT, a few discontinued early or were redirected to other services, meaning that treatment duration varied. Perspectives of YP with differing duration and forms of treatment termination was considered relevant for exploring adolescents’ experiences in routine clinical practice, but the variation may also have influenced how some experienced the treatment overall, as perspectives often change over the course of treatment. Moreover, the adolescents spoke very little about their siblings, and as a result, this study does not include the sibling perspective at all — an aspect that future research could explore more systematically.

Although the sample included one male participant and one transgender participant, it was otherwise predominantly composed of cisgender girls, which is broadly consistent with the demographic profile typically observed in eating disorder populations. Similarly, all participants were of white, Western background, reflecting the composition of the clinical context from which the sample was drawn. This mirrors a broader trend in the field, where most research on eating disorders has been conducted in Western populations, meaning that knowledge about experiences among adolescents from more diverse cultural or ethnic backgrounds remains relatively limited. Future studies could therefore explore how sociocultural context shapes the understanding and treatment of eating disorders across different groups.

Implications for Clinical Practice

While FBT can be challenging and initially provoke conflict, the perspectives of adolescents uncovered in the study indicate that parental insistence in taking over responsibility for renourishment facilitates the adolescent’s recovery from AN, ultimately restoring or even strengthening parent–child relationships. These findings underscore the importance of preparing families for early difficulties, emphasizing that short-term conflict is often followed by long-term gains in autonomy and familial bonds. Moreover, the study highlights that both parents’ active involvement in sessions and home-based renourishment are crucial, as limited engagement by one parent appears to prevent relational repair with that parent.

Trust and confidentiality also emerged as central concerns. Adolescents explicitly requested a safe space and increased one-to-one time with clinicians, where disclosures would not be shared without consent. Although this can be challenging within the context of adolescent eating disorder treatment, the findings indicate that clinicians need to establish and communicate clear boundaries, making it explicit that information shared during weigh-ins will be disclosed only if immediate intervention is warranted (e.g., in cases of suicidal plans or serious self-harm). While one-to-one sessions are not aligned with the core tenets of FBT and should not reduce the emphazis on parental empowerment, they can provide a valuable space for the adolescent to reflect, process emotions, and enhance mentalisation skills, thereby supporting engagement with treatment.

Finally, the study suggests that older adolescents may be less receptive to FBT, indicating a need for adaptations that enhance the adolescents’ motivation, involvement, and sense of shared responsibility throughout treatment.

Conclusion

This study suggests that adolescents experience the process of going through Family-Based Treatment (FBT) for Anorexia Nervosa (AN) with their parents as profoundly challenging. They describe feeling both physically and emotionally trapped, with the disorder itself generating barriers to trust and temporarily straining the parent–child relationship. Nevertheless, by the end of treatment, adolescents perceived the treatment process as meaningful, recognizing that the transfer of responsibility to their parents ultimately enabled them to regain autonomy and recover from AN. Moreover, they consistently emphasize that navigating this demanding process together strengthened their relationship with their parents and fosters a deeper sense of being understood and supported.