“Dinner’s Ready”:
Creative ways to navigate meals
with young people and their families
during treatment
Dr Annaleise Robertson
Dr Lisa Dawson
Ms Joanne Titterton
Dr Kate Godfrey
Dr Julian Baudinet
History of the meal as treatment
• 1970s
• Minuchin
• 1980s
• Use of lunch session
popular among structural
family therapists
• Maudsley Model (Dare & Eisler)
• 2000s
• Family-based treatment
(Lock & LeGrange)
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What are the intentions
behind meals in your
service?
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Our service…
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Inpatient
Outpatient
Day program
Multi-family group
2 week family intensive admissions
➡️ Got us thinking about meals…
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Are meals important?
• Research questions the usefulness of
meals (Eisler et al., 2000; Herscovici et al., 2015; LeGrange et al.,
2016)
• FBT works for approximately 50% of
young people (Lock et al., 2010)
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Are meals important?
• Research questions the usefulness of meals
(Eisler et al., 2000; Herscovici et al., 2015; LeGrange et al., 2016)
• FBT works for approximately 50% of young
people (Lock et al., 2010)
• Meals can be very stressful for both clinicians
and families. Is it really worth it?
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Why are we running this
workshop?
• We see meals are an essential part of treatment
• Practical and relational opportunities
• Few opportunities to practice
• Few ways in which to practically connect with
families around meals
• Meals can be clinically useful but we may need to
get creative
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Workshop Objectives
• Looking beyond traditional therapeutic meals
• How can meals be used across different
settings
• How can meals be used to target your clinical
intervention
• How can meals be used to address targets
beyond weight gain
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Outline
• Insights and techniques from our
experience
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Inpatient
Day Program
Multi-Family
Outpatient
• Designing Meal Activities
• Application to your setting
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Inpatient
Priority is medical stabilisation and refeeding
• Clear expectations
• Non-negotiables
• Prescriptive (meal plans)
• Dietitian education and support to parents
• Dietitian resource
• Parents order meals for their child
• Leave and discharge are heavily focused on
managing meals and weight
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Inpatient
Steps towards discharge
• Supervised by nurses
• Meals off ward with parents
• Meals outside of the hospital
When meals with families don’t go to plan
• Coached meals for families
• Managing distress
• Managing refusal (how to push through)
• Challenging foods (increasing variety)
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Characteristics for meal
supervision
• Be clear and consistent
• Clear expectations of eating behaviour
• Clear expectations of completing meals
• Staff understand and are supportive of program
• Be prepared
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Meals confirmed
Meal times on time and set length
Table set with all necessary utensils
Staff informed of previous interactions
Have planned topics/distraction techniques ready
• Be calm
• Be empathic
• Have a positive therapeutic relationship with the patient
• Be aware
• Own eating concerns and expectations
• Impact of your day on your interactions
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Quotes
It’s like going to the dentist, I feel sick but
you know you have to do it. And when you
get there the dentist says you need a filling.
Its like I have had no pain, the tooth feels
fine (I look fine no really I look fat) but he
does the filling anyway. When he is done I
can fill my mouth it is fat and swollen and
sore from the needle
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Helpful ideas around meals
• Be clear about expectations
• Remember we already feel self conscious about
eating in front of other people
• No sarcasm around the method of eating
• Firm but friendly (can use joking style to reinforce
rules)
• Empathy
• Consistency between staff
• No choice/clear consequences
• Don’t compare patients
• Time limits
• No well dones
quotes from patients in the day program and inpatient setting
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Day Program
• Day program meals
• Similar principles to inpatient meals but also
lean heavily on the relationship and
emphasise normal eating
• Using the relationship to get the meal done
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Engagement
Humour
Music, games
Maintaining boundaries and firmness
Staff modelling healthy eating
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Day Program
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We sit together and eat with staff, there are friendly prompts to eat on time.
There is a time limit and penalties for refusal. There are more professional
resources and expertise in helping you to eat normally. Eating the right
amount, without eating disorder behaviours
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The staff are trained accordingly to spot and manage manipulations
around food.
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Usually the conversation at meals is pretty light hearted and off the topic
of food.
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It’s a nice environment to be honest; the staff are nice and not staring. It
feels relaxed.
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It feels as comfortable as it can possibly be.
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The talking and everyone being upbeat and happy is a good distraction.
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Day Program
• Meal objectives:
• Re-feeding
• Provides an example of a meal that can feel
safe or safer
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Contained
Structure
Warm
Fun
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Social eating
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Practice eating ‘normal teenage’ foods
Young people eat together with whole team
Can be onsite or go together to a restaurant
Foods include
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Thai takeaway (Pad thai with chicken and juice)
Subway (6 inch sub with cookie)
Pizza
Kebabs
• Expectation that parents repeat at home
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Social eating
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Social eating
• Meal objectives
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Increase food variety
Practice flexibility
Exposure
Normalising eating
Re-engaging in normal adolescence
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Multi-family therapy meals
• Up to 8 families working together for 4
consecutive days and six follow up days
over six months
• Includes morning tea, lunch, and afternoon
tea
• Families bring their own meals (some food
also provided)
• Families eat with other families
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Multi-family therapy meals
• Day 1
• Morning tea: opportunity for assessment
• Quantity, variety, tone, distress, eating habits etc.
• Parent discussion on meals
• “What are you thinking about for lunch today?”
• Support parents in thinking about what needs to be
different for their child to move forward in recovery
• Use experiences of those in the group for alternative
solutions and highlight possibility for change
• Lunch: Staff more interventive
• Check in with families
• Asking questions and gently challenging fixed ideas
• End of day: Homework
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Multi-family therapy meals
• Meal objectives:
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Assessment
Change of context
Mutual support
Role modelling
Meal coaching
Learning or practicing new ways of managing meals
Multiple opportunities to experiment/make changes
Multiple sources of information
Emphasise the importance of tone
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Re-constituted families
• Re-constituted families
• All family members change
• Allocations are strategic and decided upon
by therapists in advance
• Provides a different experience of meal
times
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Re-constituted families
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Re-constituted families
• Meal objectives:
• Different experience of meal times
• Change in tone
• Less conflict
• Less food-focussed conversation
• Parents
• Experience of connecting with a young person, increase in self-efficacy,
reinforces the message of importance of tone, shows parents that
young people can do it
• Young person
• experience of having parent engage and connect, less conflict, able to
eat meal when tone/context is changed
• When the tone is different, the meal is more manageable
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Sunday Lunch
• Parents work together using paper plates,
scissors, glue, and food magazines to create
a meal that they think their child needs
• Young people: Create the meal you think
your parents want to feed you
• Siblings: Create a meal you are missing
eating at the moment
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Sunday Lunch
• Parents and young people compare plates
• Therapist questions:
- How did you reach your decision?
- Are these decisions interrupted day to day by
arguments/Anorexia
- How long has it been since you’ve had this meal?
- What was it like when you used to have this
together?
- What message would you be sending to Anorexia
if this was back on the menu?
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Sunday Lunch
• Meal objectives:
• Patient’s nutritional needs can be highlighted
• Explore the way in which Anorexia has most
likely interfered with parent’s decision making
and confidence
• Help increase confidence and knowledge
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Role play
• Parent: Plays the role of a young person
with Anorexia
• Young person: Role of parent trying to refeed their child
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Themes from the role play
• Parents:
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Seeing AN in the room was very powerful
As soon as the ‘parent’ lacked confidence I knew I wouldn’t have to eat
It was much more difficult to resist once there was second ‘parent’
When they said how much they cared it really connected with me
As soon as the ‘parent’ got angry I knew I wouldn't’t have to eat
• Young People:
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It was really difficult
I realised how frustrating it is
When I had a second ‘parent’ came in I felt so much better
When we were saying the same thing we were way more effective
When AN was in the room it felt way harder to push
It holds a magnifying glass to the way the parents are managing the
meals – both helfpul and unhelpful
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Themes from the role play
• Parents:
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Seeing AN in the room was very powerful
As soon as the ‘parent’ lacked confidence I knew I wouldn’t have to eat
It was much more difficult to resist once there was second ‘parent’
When they said how much they cared it really connected with me
As soon as the ‘parent’ got angry I knew I wouldn't’t have to eat
• Young People:
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It was really difficult
I realised how frustrating it is
When I had a second ‘parent’ came in I felt so much better
When we were saying the same thing we were way more effective
When AN was in the room it felt way harder to push
It holds a magnifying glass to the way the parents are managing the
meals and the experience of the young person with Anorexia
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Role play
• Meal objectives:
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Increase insight
Increase in empathy
Externalisation
Learning strategies for meal times
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Importance of parents’ tone
Disadvantages of getting angry
Importance of parents being on the same page
Veering away from negotiation or non-task related
conversation (not being distracted by AN)
• How to use consequences
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Visual meal planning
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Visual meal planning
MEAL CHECK-LIST
Please rate your level of agreement with the following statements where 1= do not agree at all and
10= agree completely
Breakfast
Is this meal enough for my child to gain weight? (Quantity)
1
2
3
4
5
6
7
8
9
10
7
8
9
10
7
8
9
10
8
9
10
Does this meal include enough variety? (Variety)
1
2
3
4
5
6
Does this meal challenge anorexia? (Challenge)
1
2
3
4
5
6
Will I have to persist and stay calm during this meal?
1
2
3
4
5
6
7
→ What can I do to help my child feel supported?
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Visual meal planning
• Objectives:
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Increase parent knowledge
Increase confidence
Pair the importance of tone with challenge
Practice thinking about meals in a different
way
• Parents understanding their own blindspots
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Progress Review
1. Food variety
a) Not concerned at all
b) Completely on top of this
c) Requires no focus
Very concerned
Not managed at all
Requires extreme vigilance
2. Flexibility around food
a) Not concerned at all
b) Completely on top of this
c) Requires no focus
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Very concerned
Not managed at all
Requires extreme vigilance
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Progress Review
• Objectives:
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Self-check
Parents to understand their blindspots
Parental unity
Increase knowledge re: all the areas of meals
that anorexia nervosa impacts
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Modifications to Traditional FBT Meal
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Greater challenge presented to AN
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Therapists observe rather than intervene directly
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Families video meal without therapist and then review
together
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Have parent meal planning session prior to meal to plan
potential areas of difficulty
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Opportunity to set food
challenge and review later
the same day
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Celebratory Meal
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Planned Medical “Top-Up”
Feeds
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Video: Observed Meal
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Video: Meal at Home
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Parent review of video meal
• What are you looking for in the video?
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Eating disorder behaviours
Parental tone (firm/kind mix)
Parental unity
Sibling support
Volume/type of food
• How do you address this?
• Praise and encouragement
• Being curious
• Creating opportunities for change
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Considerations for the therapist
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Confidence
Purpose of meal
Modelling firmness and warmth
Further assessment
Fostering engagement
Coaching
• When doing practical meals there are three key concepts to making
them most effective
• Therapist confidence
• Food prompts
• Tone
• Our experience tells is that this applies to all meal related activities
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Clinician Map - Handout
Pre-Session
Step 1
Hypothesize
Step 2
Identify meal objectives &
meal task to match
In Session
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Step 3
Set the scene
Step 4
The task
Step 5
Summary
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Emma is a 15 year old who has had anorexia nervosa for about
1 year. She lives with her mother, father, and older sister. She
has been attending outpatient FBT but is still 3kg off her target
weight range and is struggling to progress to Phase 2 of
treatment. During the family’s initial meal in session 2 Anorexia
did not emerge in the room and Emma ate what her parent’s
brought without noticeable difficulty. Accordingly, the parents did
not have a chance to practice managing Anorexia at meal times.
They report that meals at home are very difficult with Emma
being largely non-communicative. Mum appears confused about
the right amount of food for Emma and is happy when Emma
eats anything, even if it is ‘safe’ food that keeps Anorexia happy.
Even though Emma’s intake is quite restrictive, Mum sees it as
much more varied than it used to be when Anorexia was at its
worst and therefore does not see the need to work on increasing
variety. Dad is frustrated and can’t understand why Emma can’t
just ‘eat normally’. Her older sister has not been attending all the
family sessions and is missing the way the family used to get to
get together at meal times. She also describes being angry at
Emma
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• What are the barriers to progressing in
treatment?
• In your service, how could a meal be used
to target one of the identified challenges?
• What would the goals of the therapist be?
What would you need to focus on?
• How would you judge the outcome of the
meal?
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Meal Options
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Inpatient Meals
Day Program
Social Eating
MFT Meals
Re-Constituted/Foster Family Meals
Role Play
Sunday Lunch
Visual Meal Planning
Progress Review
Observed Meal
Video Meal at Home
Celebratory Meal
Second meal with increased challenge
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Summary
• Meal activities opportunity offer incredible
and unique opportunities to
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Provide additional support to families
Understand families better
Provide practical assistance
Increase empathy and validation
They’re really hard, but they’re really
important Don’t forget about them
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