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Examining the effectiveness of the Maudsley method to treatment for anorexia

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The Maudsley family-based treatment approach was developed by psychiatrists and psychologists at the Maudsley Hospital in London as a treatment cure for anorexia nervosa (AN). This type of therapy has several goals, including: (1,2) 

  • To prevent hospitalization of adolescents who struggle with anorexia nervosa by recruiting the help of parents
  • To help individuals recover from anorexia and return to life without symptoms of anorexia
  • Help the adolescent manage eating habits without engaging in disordered eating patterns
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The Maudsley approach was first developed in 1987 for patients who had been admitted to the hospital for treatment of severe anorexia and bulimia nervosa. After those with AN were restored to a weight appropriate for their body type, they were discharged and randomly placed into family therapy or a control treatment group (individual supportive therapy). (3) 

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

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Phases of treatment

The Maudsley approach consists of several phases of treatment with 15-20 treatment sessions over one year.

Phase 1: weight restoration 

Phase 1 is called weight restoration. During this time, the therapist educates the adolescent on the long-term dangers of malnutrition, such as hormone imbalances, heart risks, and cognitive/emotional changes. 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 a few 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 that starvation is not an option. (1) 

Phase 2: returning control

Phase 2 involves returning control over eating to the adolescent. This happens when they fully accept their parent’s demand to eat more, have shown consistent behavior change, and can keep a steady weight, and the family can be confident the child has taken charge. If any anorexia symptoms resurface, the child is placed back into Phase 1. Any other family relationship issues or day-to-day concerns can slowly be introduced into family discussions again. (1,2) 

The child is given more freedom as parents feel comfortable. For example, the adolescent may want to have dinner with friends before going to see a concert. The parents can choose to have dinner together with their child and friends to ensure they eat, then let them go to the show after. If the adolescent 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 3: establishing a healthy identity

Phase 3 is establishing healthy adolescent identity. This occurs when the adolescent can maintain a weight above 95% of ideal weight on their own, without any prodding or episodes of starving. Therapy shifts from focusing exclusively on food to the impact that anorexia 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.

Key aspects of treatment: (1,2) 

  • Families should persistently encourage and participate in therapy until a stable weight has been achieved.
  • General adolescent and family issues are deferred until the eating disorder behaviors are under control.
  • Parents are encouraged to remain sympathetic, patient, and understanding, without showing signs of anger, criticism, frustration, or hostility.

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Who does it best help? 

Research found those who benefited most from the Maudsley approach had the following criteria: (4) 

  • Developed anorexia nervosa before the age of 18
  • Struggled with symptoms for less than three years
  • Started with around 10 weeks of inpatient care
  • Strong nuclear families and friendships who also participated in treatment
  • Committed to at least 12 months of treatment

What are the limitations?

To be most effective, the Maudsley approach hinges on several key assumptions. Most importantly, the adolescent must have a safe, supportive, nuclear family with siblings and friends that are willing to help. Many families now are raised by single parents who often work more than one job. The amount of time spent at home around the dinner table together can be slim to none. Children living in abusive home situations, inconsistent foster care, or with parents who do not have the time or energy to commit to therapy will not be able to participate in treatment using the Maudsley approach. (5)

The amount of patience, energy, and compassion required takes an enormous toll on families, as every meal becomes centered around anorexia. Important family discussions, vacations, and events get placed on hold. Often, parents end up enrolling in therapy for themselves, as this can put considerable strain on a marriage. It’s 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 like “force-feeding” their child. 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. 

A helpful tool for parents is to view food as medicine. When the conversation feels hard, compare the situation to someone with cancer refusing chemotherapy. The resistance to eating stems from the disease (AN), not the person. 

Some parents fear the Maudsley approach will damage their relationship. Children say and act out in harmful ways when they resist eating. But parents must keep in mind this is the illness talking, not the child. When the child recovers, and as they age, they will realize their parents acted out of love, and not out of punishment. Studies show that the child-parent relationship is not generally harmed, but, instead, draws families together. 

If you suspect your teen or an adolescent you know may have anorexia nervosa, Within Health is here to help. Treatment is available, and recovery is possible. Learn more about our virtual care program for eating disorders by calling our helpline now.

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Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Grange, D., Lock, J. (2005) Family-based Treatment of Adolescent Anorexia Nervosa: The Maudsley Approach. Maudsleyparents.org.
  2. LE Grange D. (2005). The Maudsley family-based treatment for adolescent anorexia nervosa. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 4(3), 142–146.
  3. Russell, G., Szmukler, G., Dare, C. (1987). An Evaluation of Family Therapy in Anorexia Nervosa and Bulimia Nervosa. Arch Gen Psychiatry, 44(12):1047-1056. doi:10.1001/archpsyc.1987.01800240021004.
  4. Eisler I, Dare C, Russell GF, et al. (1997). Family and individual therapy in anorexia nervosa. A 5-year follow-up. Arch Gen Psychiatry, 54(11):1025-30.
  5. Doyle, A. Maudsley Misconceptions. Maudlseyparents.org. http://maudsleyparents.org/maudsleymisconceptions.html

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