As a carer, you may have come across the RAVES model of eating disorder recovery. This model, developed by dietician Shane Jeffrey, explains in practical terms what we are trying to aim toward to ensure our loved one recovers from their eating disorder.
For those doing FBT (family led refeeding), the “end goals” are very similar. So in this newsletter we talk about the connection between the two.
RAVES stands for :
The model is worked through in order and aligns perfectly with the principles of FBT (Family Based Treatment or Family Led Refeeding).
Phase I of FBT: REGULAR
Why is regularity important?
Regularity is necessary to reverse the restrictive eating that will have developed as part of the eating problem. It often surprises parents/carers to know that regularity is just as important in an Anorexia Nervosa (AN) diagnosis as with Binge Eating Disorder (BED). Binge eating is mostly brought about by restriction throughout the day which in turn creates strong feelings of hunger, and the propensity to binge due to the hunger. This can then create feelings of shame and guilt such that in order to compensate for the binge, the cycle of restriction starts again.
Regularity also ‘starts the engine’ and gets the gut moving again. It sets the foundation for the next step – increasing the amount of food necessary for weight gain.
ADEQUACY: Isn’t “something better than nothing?”
This might be true at first whilst regularity is established but now it is important to ensure that the young person gets the adequate amount of energy needed. This is difficult to do in only 3 meals a day, especially if they are ordinary or smaller sizes. This is why during Family Led Refeeding we coach the family to increase the caloric content required for weight gain by implementing the 3 + 3 + 3 approach. 3 meals, 3 snacks, no more than 3 hours in between. The right amount of food will ensure the body temperature is regulated and that internal organs impacted by restriction start to work properly again.
In essence, the R and the A of the RAVES approach are what we do throughout Stage 1 of FBT. This is the most intensive part of weight restoration treatment as our loved ones are afraid of gaining weight and often display a lot of distress. As carers, we have to draw on our existing skills and perhaps learn new ones to be able to support our young person through this stage. Tolerating the distress of our young person is essential to the success of this stage. This provides the solid building blocks to help our young person through the next stages of recovery.
Phase II of FBT – (the V,E & S of RAVES)
The goal throughout Phase II is to very, very slowly hand back choice and control to our loved one. We want them to be able to connect back to family, friends and their social life and to live free of any habits still holding them back to their eating problem.
Why is VARIETY necessary to move forward with recovery?
Variety is important for well-balanced nutrition and to challenge rigid rules. It is very difficult to fully recover from an eating disorder if variety is not challenged.
Our goal through FBT practices is to have no remaining fear around food so that life is, well, easier! Sometimes the ED has created rigid rules around food and we need to break these down so that our loved ones are not held hostage by these rules. This is important, not only in relation to food but to challenge rigid thinking generally.
For example, if they will only feel “safe” with certain foods, we begin to introduce foods that are not on the safe list that we know they used to enjoy before the eating problem. This is done through exposure. Some parents/carers “rip the Band-Aid off” and introduce fear foods early with zero negotiation (and lots of compassionate support). Other parents/carers find it easier to let their loved one know what is to come when they are changing things up and to allow them some choice when introducing variety.
This part of refeeding is important for engagement back in life. We want our loved ones to happily be able to attend a family function, a BBQ, go to a café with friends, enjoy pizza with their netball team etc. without the ED holding them back from such events. Very often the ED has made our young people withdraw socially as they suffer from feelings of being unworthy or feel they are being judged or have nothing to offer their friendship group.
How can we implement eating socially?
To assist with this, it is important to practice eating socially, usually with family or trusted friends. Some parents/carers find it useful to download the menu first so that the young person can choose before they go to the restaurant hence avoiding the anxiety of choosing under pressure or having their ED trying to calorie count as to which is the ‘best’ option. Some young people have said it is easier if they are positioned in a corner table rather than the centre of the restaurant. First sleepovers or school camps during recovery can be anxiety provoking so think of a back-up plan to ensure that if the young person was not able to eat, then the back up plan can be implemented. Reassure your young person that it is ok if they found it difficult and that you will support them to “practice” until they can do it.
SPONTANEOUS EATING – easing into Stage III of FBT
To fully engage in life, travel, university and other normal age appropriate activities, spontaneous eating is essential.
What signs show us that our loved one is at this stage?
In Carer Coaching, we often refer to this stage as the “cup cake” or “pizza” test. It is an excellent test to gauge the strength of any lingering eating disordered thoughts. We present our young person with a cup cake or pizza with no forewarning and they should be able to freely eat it. If met with high resistance we can see that the eating disorder is still quite strong and whilst generally they are able to eat planned meals and snacks they are still in the clutches of the eating disorder. Don’t be alarmed. This is great information that tells you that continued scaffolding is needed for your young one. We can take this as feedback and try the test again in a month.
In spontaneous eating, we are looking for flexibility such that last minute changes to planned meals are met with no anxiety or resistance. If travelling, they are able to stop at a roadside service station and pick out a sandwich from the display, eat in an airport café, if Mum brings home takeaway after a busy day at work it is not an issue, if a friend calls and says everyone is going out for pizza and a drink. We want to see our young people embracing these situations and not making excuses through fear of not knowing what the meal might be.
How long will each stage last?!
This is the most common question we are asked as Carer Coaches! But what we really need to ask is, “What do we need to do as Carers so that we can endure however long each stage takes”.
All families travel this road at a different pace and some take a wrong turn and have to find their way back. That is ok. Just keep moving toward the destination which is full recovery.
When R-A-V-E-S has been completed and this is where FBT stage 3 consolidates the work.
Once normal eating is re-established and no compensatory behaviours remain it is time to work on other things that came in with or perhaps preceded the eating disorder such as perfectionist thinking, OCD, low self worth and anxiety. This is important so that when life’s inevitable challenges arise the young person has strategies to be able to work through the challenge without returning to the ED as a coping mechanism. This is the time when psychology, recovery coaching or other mental health assistance is most beneficial.