The Maudsley Approach and Other Family Therapies

By: Theresa Fassihi, Ph.D.
Director, Houston Eating Disorders Center

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It is estimated that 10 million Americans suffer from eating disorders, which usually first strike young women between the ages of fourteen and 20.  That means 10 million American families are affected by eating disorders. 1

So many parents describe the desperation of watching helplessly as their child or adolescent starves herself or himself, or engages in other frightening behaviors such as bingeing and purging, or abuse of laxatives and diuretics, or driven exercise.  When families seek help for their child, they have sometimes been told that “it’s not about food” or that their child must learn to manage their eating on their own and they should not take the role of “food police.”  Sometimes they are told that it will be better to separate the child from the family for recovery to occur.  Essentially, they are being told to get out of the way and let others fix the problem.  Parents report that this makes them feel helpless and blamed.2

This also impacts the results of treatment.  When young people do participate in residential or inpatient treatment, far away from their families, often in other states, they often return home in the stage of early recovery to limited support, and the risk of relapse is high.  Families may have had some involvement in treatment, but may still feel unprepared to support their child’s recovery.

“In-patient programs are not cost-effective and there is no evidence for their long-term efficacy,” James Lock explained (personal communication, March, 2009).  Also, he notes that patients are in an artificial environment when they go away for treatment, so translating what they learned to their own homes remains a challenge.

In many cases, residential or inpatient treatment is necessary, and should not be ruled out as an option. Fortunately, many programs are making more of an effort to include families more in the treatment process.  Research findings strongly support involving families extensively in treatment.

The Academy for Eating Disorders (AED) issued a position paper in 2009 that supports family based treatment:  “The AED stands firmly against any etiologic model of eating disorders in which family influences are seen as the primary cause of anorexia nervosa or bulimia nervosa, and condemns generalizing statements that imply families are to blame for their child’s illness. The AED recommends that families be included in the treatment of younger patients, unless doing so is clearly ill advised on clinical grounds.” 3

It is becoming more common to involve the family closely in the treatment of children and adolescents with eating disorders.  One promising model of treatment is The Maudsley Approach, and a version developed in the U.S. known as Family Based Treatment.  These treatments share the view that  the family is the most powerful resource for a young person’s treatment.  The family plays a crucial part in supporting a patient’s recovery.  Instead of getting out of the way, parents take a more natural role in making sure their children are eating in a nutritionally sound way and not engaging in any other dangerous behaviors.  This treatment model was originally developed in England at The Maudsley Hospital in London in the late 1970s by Christopher Dare and Ivan Eisler.4

According to the AED, “a consistent finding in work completed recently is that family involvement appears to be useful in reducing both psychological and medical morbidity, especially for younger patients with a short duration eating disorder, and that this form of treatment is acceptable to parents and patients alike.”

Family Based Treatment (FBT), has been manualized in the U.S. by James Lock and Daniel Le Grange.  Training in the techniques also is offered regularly through their training institute (http://www.train2treat4ed.com).  They have conducted extensive research supporting the efficacy of this treatment. 5

Briefly, FBT occurs in three phases.  In Phase I, the parents are in charge of their son/daughter’s weight restoration.  Siblings take a role of supporting their brother or sister, but do not get involved in their eating.  A therapist supports the whole family, serving as consultant rather than “boss” of the process.   The emphasis is on empowering the parents to take care of their child’s health and well-being.  Parents collaborate closely together and identify their shared goals and strategies.  They stay “on the same page.”  Parents learn to understand what is going on in their child’s mind as a result of the eating disorder, the cognitive distortions and the obsessions caused by the illness.  While they learn to be empathic, they also deliver the firm message that they are not going to let their child continue the eating disorder behaviors.  Ongoing medical monitoring ensures that the process is medically safe.6,7

In Phase II, when the child or adolescent is eating normally and has attained a healthy weight, he or she begins to gradually take back control of his or her eating, perhaps starting with one meal or snack and building up.   Along with this growing independence in meeting nutritional needs, it becomes possible for the individual in recovery to regain more freedom and autonomy in other areas, so that staying well has both intrinsic and extrinsic rewards.  Of course, the eating disorder thoughts will still be present and the child or adolescent will continue to need support to battle the powerful urges that result.   In therapy sessions, the patient is very engaged in describing these challenges and also working to resolve them.  If there are setbacks, more family support of nutrition can be established temporarily as the patient and family develop strategies to move forward again.

In Phase III, the therapy focuses on adolescent developmental issues.  At this point, the adolescent is controlling his or her eating and maintaining a stable weight.  The eating disorder symptoms are no longer the idiom of communication between parents and the child, so discussion of other adolescent issues such as independence, leaving home and sexuality may now be discussed.  As the adolescent is now functioning age appropriately, the parents are more about their own relationship and other interests.  Everyone knows the eating disorder could resurface and need to be addressed again, but there is hope for full recovery.

Of course there is no one-size-fits-all treatment that works for everybody.  There are advantages and disadvantages to Family Based Treatment.  Notable advantages include:

  1. Cost effectiveness – Many more people can recover without going into inpatient or residential treatment with strong family support of nutritional rehabilitation.  Or, lengths of stay can be much shorter.  For example, University of California at San Diego has a model of family treatment in which the family and patient are trained in the Maudsley Approach in one week of inpatient care.  Most are then able to complete weight restoration with outpatient support.
  2. Reduces risk of relapse – With ongoing family support available, individuals in early recovery who begin to engage in eating disorder behaviors can quickly get back on track by increasing family involvement in supporting healthy nutritional behavior.  The amount of support can be quickly adjusted to meet the individual’s needs.  Research has indicated that relapse rates are much lower for patients treated with Family-based therapy than with individually focused treatments.
  3. Healing relationships – Working on recovery together as a family can be an excellent way to strengthen family connections and clarify healthy roles, which may have been disrupted by the eating disorder.

There are certain families that may not find this to be a suitable treatment.  Some factors that could interfere with the effectiveness of this approach include:

  1. Practical barriers – it may not be possible for family members to make themselves available to support nutritional rehabilitation on the ongoing basis that is necessary in initial stages of recovery.
  2. Lack of clinical support – therapists trained in the Maudsley model of treatment are not available in all cities.  Although the approach has been around for a while, the training has only recently become widely available. Fortunately, it is now possible to participate in intensive training and supervision and become a credentialed FBT therapist.
  3. Patient refusal – some adolescents are unwilling to work with their families on nutritional rehabilitation.  Although some resistance is to be expected, if it seems insurmountable, it may be better to look at other options.

Although Maudsley, or Family Based Treatment, may not be right for all families, the model has strengthened awareness in our field of the importance of making families a part of the recovery process to the greatest extent possible.  Given the strong research support for family-based treatment for adolescents with eating disorders, researchers are also looking at ways to include families more closely in adult treatment.  For example, research is being conducted into treatments for eating disorders that involve spouses. 

References

  1. Brown, Harriet. Brave girl eating: A Family’s Struggle with Anorexia. New York: Harper Collins, 2010.
  2. Lock, James, le Grange, D.  Help Your Teenager Beat an Eating Disorder. New York: Guilford Press, 2005.
  3. LeGrange, Daniel,  Lock, J.,  Loeb, K., and  Nicholls, D.  “Academy for Eating Disorders  Position Paper: ” The Role of the Family in Eating Disorders.”  International Journal of Eating Disorders 43 no. 1, (2010): 1-5.
  4. Robin, A. L., Siegel, P. T. and  Moye, A. (1995), Family versus individual therapy for anorexia: Impact on family conflict. International Journal of Eating Disorders, 17: 313–322.
  5. Lock, James; Le Grange, D;  Agras, WSD; Moye, A; Bryson, S;  Jo, B.  “Randomized Clinical Trial Comparing Family-Based Treatment With Adolescent-Focused Individual Therapy for Adolescents With Anorexia Nervosa.”  Archives of General Psychiatry 67 no. 10, (2010).  Downloaded from ww.archgenpsychiatry.com on February 20, 2012.
  6. Lock, James, le Grange, D.  Treatment Manual for Anorexia: A Family-Based Approach. New York: Guilford Press, 2001.
  7. Lock, James, le Grange, D.  Treating Bulimia in Adolescents: A Family-Based Approach. New York: Guilford Press, 2007.

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