Examining the effectiveness of the Maudsley method to treatment for anorexia

What is the Maudsley model of anorexia nervosa treatment? 

The general idea of Maudsley anorexia nervosa treatment is to have parents or caretakers step in to take a majority of control over a patient's food-based decisions.

Together, patients and their caretakers will undergo 15-20 sessions over the course of a year, learning more about recovery and creating a conducive environment for recovery at home. As patients progress in treatment, parents are advised on how to give them more control over their eating behaviors and choices.

Key aspects of treatment include the following:^1,2 

• Family members (especially parents or caretakers) consistently participate in therapy until a stable weight has been achieved.
• Deferring general adolescent and family issues until the eating disorder behaviors are under control.
• Encouraging parents to remain sympathetic, patient, and understanding without showing signs of anger, criticism, frustration, or hostility.

Maudsley family-based treatment involves parents or caretakers, which is why the approach is generally used with adolescents or younger patients. However, Maudsley anorexia nervosa treatment for adults also exists. In either case, the treatment is not typically considered a stand-alone form of care but instead used alongside other types of treatment for more individual emotional processing, such as cognitive behavioral therapy and nutritional education.

Phases of Maudsley anorexia nervosa treatment

Aside from being a form of family-based treatment, what best defines the Maudsley approach are the distinctive phases of the treatment program.

Phase one: Weight restoration 

Phase one of the Maudsley method focuses on weight restoration. During this time, the therapist educates the patient on the long-term dangers of malnutrition, such as hormone imbalances, heart health risks, and cognitive/emotional changes and challenges.

The therapist teaches parents compassionate methods and language to use while re-feeding their child. Recruiting siblings and friends for heavy emotional support is also critical during this stage.

The therapist may join the family during some of their meals to observe behavioral patterns and family interactions surrounding food. During this time, the therapist will coach parents on how to encourage their child to eat. Sympathy and understanding are key to this process while being firm and persistent in stating that starvation is not an option.¹ 

Phase two: Returning control

Phase two of the Maudsley approach involves returning control over eating-based decisions to the patient. This generally happens over time​​ as the patient gains and maintains a healthy weight and shows a positive and consistent change in behavior.

Once the family feels confident the child is making progress, they work with the therapist to transfer control over these behaviors. At this point, other family dynamic issues or day-to-day concerns can slowly be introduced into group discussions.^1,2 

The child is given more freedom on a schedule that feels comfortable to parents. For example, adolescents may want to have dinner with friends before going to a concert. Parents can choose to have dinner with their child and friends to ensure they eat, then let them go to the show afterward. If the child can demonstrate they’re able to eat an adequate amount in front of their friends without requiring any prodding from parents, then they may be allowed to have dinner with friends alone.^1,2

Phase three: Establishing a healthy identity

Phase three of Maudsley family therapy centers around establishing a healthy adolescent identity. Many patients, especially those who struggle with the condition early on, come to associate anorexia nervosa or disordered eating behaviors connected to it with their personality or identity. It's important for them to create an understanding of themselves outside of this extremely rigid thinking style.

This phase occurs when the adolescent can maintain a weight above 95% of ideal weight on their own, without any prodding or backsliding into AN symptoms. Therapy shifts from focusing exclusively on food to the impact that anorexia nervosa has had on other parts of their life, including friendships, school, sports, emotional intelligence, resilience, and their sense of autonomy. The therapist widens the discussion to re-establish parental boundaries according to normal adolescent development milestones.^1,2 

Living with anorexia nervosa impacts every area of life. Once the habits and symptoms are controlled, the teen can focus on repairing parts of their life that were put on pause.

Effectiveness of Maudsley anorexia nervosa treatment

The Maudsley approach was first developed in 1987 by psychiatrists and psychologists at the Maudsley Hospital in London. It was targeted at patients who had been admitted to the hospital for treatment of severe anorexia and bulimia nervosa.

Once patients with AN were restored to an appropriate weight for their body type, they were discharged and randomly placed into either Maudsley family-based treatment or individual supportive therapy.³ The progress of the two groups was then compared.

This study found adolescents and children who participated in family-centered therapy one year later had the most successful results in resolving symptoms and maintaining a consistent weight.³  90% of those assigned to family-based therapy reported positive outcomes five years after discharge.⁴ Follow-up studies at the University of Chicago and Stanford University illustrated comparable results.²

This effectiveness has made the Maudsley model of anorexia nervosa treatment one of the more popular treatment modalities for AN, especially for younger patients.

Limitations of the Maudsley approach

The Maudsley approach hinges on several key assumptions to be most effective. Most importantly, the adolescent must have a safe, supportive family with siblings and friends willing to help. It may not be as beneficial for those who have either no support network or an unsafe or unstable home environment.

Children living in abusive home situations, inconsistent foster care, or with parents who do not have the time or energy to commit to therapy may not be the best candidates for the Maudsley approach. The treatment may also be particularly difficult for single-parent households.

The amount of patience, energy, and compassion required can take a toll on families, as every meal throughout treatment involves thoughts or discussions around AN. Family vacations, events, or other individual interests may get placed on hold. Often, parents end up enrolling in therapy themselves to help deal with these additional pressures.

It’s also difficult to encourage a child to eat when they’re used to refusing, crying, and resisting. It may feel like torture or punishment. The key is to stay consistent. Some may think the Maudsley approach is akin to “force-feeding” their child, but this couldn’t be farther from the truth.³ Instead, therapists coach parents on how to empower their children, not letting them continue disordered eating behaviors. 

How to make the most out of Maudsley family therapy

Aside from seeking out individual therapy, parents who are interested or already participating in the Maudsley approach can adopt some positive beliefs to help with aspects of the treatment that may be difficult.

One approach is to view food as medicine, which can be especially helpful for those who may see "force feeding" in the Maudsley method. When the conversation feels hard, they may want to compare the situation to someone with cancer refusing chemotherapy or remind themselves that the resistance to eating stems from the disease (AN), not their child. 

Some parents fear the Maudsley approach will damage their relationship with their child. Children say and act out in harmful ways when they resist eating. But parents must keep in mind that this is the illness talking, not the child. When the child recovers and as they age, they will likely realize their parents acted out of love, not out of punishment.