Eating disorders (EDs) such as anorexia nervosa (AN) and bulimia nervosa (BN) are complex biopsychosocial conditions with high morbidity and mortality (1). Early approaches emphasized intrapsychic conflict or biological predisposition, often focusing treatment on the individual. From the 1970s onward, systemic and family theorists reframed EDs as disorders of relational interaction, leading to a fundamental paradigm shift (2, 3).

The family-oriented movement in eating-disorder care arose simultaneously in Europe and North America, blending general systems theory, structural family therapy, and psychodynamic perspectives. It sought to understand how family patterns sustain or alleviate disordered eating and to harness family strengths for recovery. This review traces that evolution from early systemic formulations to current evidence-based models, highlighting research, practice, and future hypothetical directions.

It is however important to remark that in contemporary clinical practice, family-oriented therapy is best understood as one component within a multimodal treatment framework for eating disorders. Evidence-based care typically integrates nutritional rehabilitation, medical monitoring, and psychological interventions, including cognitive-behavioral approaches (e.g., CBT or CBT-E), with pharmacological support and inpatient or day-treatment programs when clinically indicated. Family-based and systemic interventions do not replace these modalities but rather complement them by mobilizing the family environment to support behavioral change, medical stabilization, and developmental recovery, particularly in children and adolescents. The present review focuses specifically on family-oriented approaches while acknowledging their role as part of an integrated continuum of care.

This article is conceived as a narrative, state-of-the-art review of family-oriented therapeutic approaches in the treatment of eating disorders. Rather than aiming for exhaustive systematic coverage, the review synthesizes historically influential models, landmark empirical studies, and contemporary developments that have shaped clinical practice and research over the past five decades.

The literature was identified through the author's longstanding engagement with the field and through targeted searches of major bibliographic databases commonly used in psychiatric and psychological research, including PubMed/MEDLINE, PsycINFO, and Web of Science. Searches focused on key terms such as eating disorders, family therapy, family-based treatment, multifamily therapy, anorexia nervosa, and bulimia nervosa, in various combinations.

The temporal scope spans from the early systemic formulations of the 1970s to recent empirical and implementation studies published up to 2025. Inclusion was guided by conceptual relevance, clinical influence, and empirical significance, with particular attention to foundational theoretical contributions, randomized controlled trials, meta-analyses, and major guideline-defining publications. The review prioritizes work that has had demonstrable impact on clinical models, treatment dissemination, or outcome research in child and adolescent populations.

In the late 1970s and early 1980s, clinicians at the Maudsley Hospital in London, including Christopher Dare, Ivan Eisler, Gerald Russell, and colleagues, translated systemic and structural concepts into a phased, manualized treatment designed specifically for adolescent anorexia nervosa (AN). This approach, first described by Russell and collegues (9), became known as Family-Based Treatment (FBT) or the Maudsley method. Although the Maudsley method is often presented as a discrete and well-defined treatment model, it is more accurately understood as a foundational framework that has continued to evolve in response to clinical experience, empirical findings, and broader developments in family therapy. Subsequent family-based interventions have extended the Maudsley approach both theoretically and technically, while retaining its core emphasis on parental empowerment and behavioral change.

FBT conceptualizes anorexia as a “biopsychosocial disorder” in which parents are the primary resource for facilitating recovery. The model is explicitly agnostic about etiology, assuming that family members did not cause the disorder but are best positioned to support the adolescent's restoration of healthy eating (15). FBT comprises three sequential phases:

Phase I: Weight restoration. Parents take full responsibility for supervising meals and interrupting weight-loss behaviors.

The evolution of family-based interventions following the Maudsley method can be broadly characterized along three intersecting dimensions. Theoretically, later models have incorporated insights from attachment theory, emotion regulation, and developmental psychopathology, thereby expanding the original agnostic stance toward a more nuanced understanding of relational and affective processes. Technically, adaptations have refined the use of parental coaching, meal support, and externalization strategies, and have introduced greater flexibility in session structure, therapist stance, and pacing of responsibility transfer. At the level of service delivery, family-based treatment has been extended into multifamily formats (see paragraph 5), parent-focused variants, and stepped-care and telehealth models, reflecting efforts to enhance engagement, acceptability, and scalability within diverse health-care system savior (11).

The following section adopts a theoretical and hypothesis-generating perspective to explore potential links between family support, refeeding processes, and neural circuitry in eating disorders. While emerging findings from neuroscience and psychophysiology provide suggestive correlates, these formulations should be understood as conceptual integrations rather than empirically established mechanisms.

Neuroimaging studies have demonstrated alterations in reward and anxiety circuits among individuals with anorexia nervosa and related conditions, notably within dopaminergic and limbic pathways that influence motivation and emotional regulation (33, 34). However, little is known about how social support—especially from family members—modulates these neural systems in real time. Theoretical frameworks from interpersonal neurobiology and attachment theory propose that relational attunement and co-regulation foster neurophysiological states of safety, potentially influencing the functioning of reward-related and stress-responsive circuits (35–37). Empirical evidence also underscores the importance of family functioning and perceived relational quality in treatment outcomes for eating disorders (38). Therefore, a promising avenue for future research is to investigate whether supportive, emotionally attuned family interactions during refeeding (42) are associated with measurable changes in neural activity within reward-related regions such as the ventral striatum and orbitofrontal cortex, and anxiety-related regions such as the amygdala and insula. Such studies could bridge the gap between psychosocial and neurobiological models of eating disorders, offering novel insight into how interpersonal processes contribute to recovery and resilience at the neural level. Future research may for instance discover that successful family therapy entails embodied as well as cognitive change, families may “learn” new physiological patterns of connection that reinforce recovery. At present, these proposed links between family processes and neural regulation remain largely untested at a mechanistic level and should be regarded as directions for future interdisciplinary research, rather than as explanatory models supported by direct causal evidence.

Family-oriented therapy has transformed ED treatment by redefining parents as therapeutic partners rather than sources of pathology. Its strengths include clear behavioral focus, replicability, and congruence with developmental theory. Moreover, FBT and MFT achieve durable outcomes across varied health systems and cost-effective scalability through manualization (17, 27, 43).

Nonetheless, challenges persist. Conclusions regarding treatment “superiority” in this literature should be understood as referring primarily to clinical outcomes rather than to comparative acceptability or family experience, which remain less consistently evaluated across most studies. Accordingly, FBT's efficacy is strongest in adolescents with anorexia nervosa and with relatively short illness duration and intact family structures (26). Effectiveness for adults, chronic cases, or culturally diverse families is less established (39, 40). Some clinicians question whether FBT underemphasizes emotion processing or autonomy development, proposing integration with Emotion-Focused Family Therapy (41) or Cognitive-Behavioral Therapy–Enhanced (CBT-E) modules (44). Ongoing refinement aims to balance behavioral rigor with emotional depth and cultural sensitivity.

Cultural adaptation is a critical frontier. Trials in East Asia and Latin America emphasize collectivist values and multigenerational involvement, requiring adjustment of Western assumptions about parental authority and individuation (39). Translation and localization of manuals, supervision standards, and digital content remain priorities for global dissemination.

Emerging work seeks to personalize family-based interventions through precision-medicine approaches. Predictive modeling may soon tailor treatment intensity to baseline risk profiles, parental psychopathology, and family dynamics (20). Integrative frameworks combining systemic, attachment, and neurobiological perspectives can illuminate how family interactions regulate stress physiology and reinforce recovery behaviors.

The next generation of research should emphasize longitudinal follow-up, mechanism testing, and health-economic outcomes. Training programs must include not only protocol adherence but also systemic conceptualization skills and sensitivity to cultural and developmental factors. Hybrid telehealth models promise to extend reach while maintaining therapeutic alliance (32). Digital innovation now shapes delivery. Tele-FBT and blended online formats preserve treatment fidelity while enhancing accessibility. Early data show non-inferiority to in-person FBT when structured supervision and monitoring are maintained. Such approaches are vital for reaching families distant from specialty centers. Ultimately, future family-oriented therapy will likely blend relational, technological, and biological knowledge into a unified, flexible system of care (38).

From the systemic formulations of Mara Selvini Palazzoli and Salvador Minuchin to contemporary evidence-based interventions such as FBT and MFT, family- oriented therapy has revolutionized the treatment of eating disorders, especially in the case of the treatment of adolescent anorexia nervosa. Extensions to other diagnoses such as BN, ARFID, adults with eating disorders and chronic eating disorders remain emerging and efficacy of family oriented treatment in these diagnostic groups needs more being researched in the nearby future. This means that transdiagnostic applications are promising but unevenly supported by evidence-based data.

Another important limitation of the present synthesis concerns the contextual concentration of the evidence base. The majority of randomized trials, implementation studies, and guideline-defining publications on family-based treatment originate from Western, high-income health systems and are embedded within cultural assumptions emphasizing nuclear-family structures, parental authority, and access to specialized outpatient services. As a result, the feasibility, acceptability, and effectiveness of these models may be moderated by cultural norms, family organization, and health-system infrastructure in non-Western or resource-limited settings. While emerging adaptations in diverse contexts are promising (39, 40), generalizability beyond the service environments in which these models were developed should be interpreted with appropriate caution

While family-oriented therapy is firmly supported by clinical and outcome research, ongoing advances in neuroscience and related fields may offer future opportunities to refine theoretical models of change. At present, such neurobiological perspectives remain complementary and exploratory, rather than constitutive of the evidence base supporting family-based interventions. Collaboration among researchers, clinicians, and families themselves will ensure that the field continues to evolve toward more inclusive, personalized, and effective models of recovery.