Maudsley family therapy

Maudsley family therapy also known as family-based treatment or Maudsley approach, is a family therapy for the treatment of anorexia nervosa devised by Christopher Dare and colleagues at the Maudsley Hospital in London. A comparison of family to individual therapy was conducted with eighty anorexia patients. The study showed family therapy to be the more effective approach in patients under 18 and within 3 years of the onset of their illness.[1] Subsequent research confirmed the efficacy of family-based treatment for teens with anorexia nervosa.[2][3][4][5] Family-based treatment has been adapted for bulimia nervosa and showed promising results in a randomized controlled trial comparing it to supportive individual therapy.[6]

Maudsley Family Therapy is an evidenced-based approach to the treatment of anorexia nervosa and bulimia nervosa whose efficacy has been supported by empirical research.[7]

Phases of treatment

There are three phases involved in the Maudsley method, the treatment usually lasts one year and involves between 15-20 sessions.[8] Daniel Le Grange, PhD and James Lock, MD, PhD describe the treatment as follows:

"The Maudsley approach can mostly be construed as an intensive outpatient treatment where parents play an active and positive role in order to: Help restore their child’s weight to normal levels expected given their adolescent’s age and height; hand the control over eating back to the adolescent, and; encourage normal adolescent development through an in-depth discussion of these crucial developmental issues as they pertain to their child.

More ‘traditional’ treatment of AN suggests that the clinician’s efforts should be individually based. Strict adherents to the perspective of only individual treatment will insist that the participation of parents, whatever the format, is at best unnecessary, but worse still interference in the recovery process. In fact, many proponents of this approach would consider ‘family problems’ as part of the etiology of the AN. No doubt, this view might contribute to parents feeling themselves to blame for their child’s illness. The Maudsley Approach opposes the notion that families are pathological or should be blamed for the development of AN. On the contrary, the Maudsley Approach considers the parents as a resource and essential in successful treatment for AN.

Phase I: Weight restoration

The Maudsley Approach proceeds through three clearly defined phases, and is usually conducted within 15-20 treatment sessions over a period of about 12 months. In Phase I, also referred to as the weight restoration phase, the therapist focuses on the dangers of severe malnutrition associated with AN, such as hypothermia, growth hormone changes, cardiac dysfunction, and cognitive and emotional changes to name but a few, assessing the family’s typical interaction pattern and eating habits, and assisting parents in re-feeding their daughter or son. The therapist will make every effort to help the parents in their joint attempt to restore their adolescent’s weight. At the same time, the therapist will endeavor to align the patient with her/his siblings. A family meal is typically conducted during this phase, which serves at least two functions: It allows the therapist to observe the family’s typical interaction patterns around eating, and it provides the therapist with an opportunity to assist the parents in their endeavor to encourage their adolescent to eat a little more than she was prepared to.

The way in which the parents go about this difficult but delicate task does not differ much in terms of the key principles and steps that a competent inpatient nursing team would follow. That is, an expression of sympathy and understanding by the parents with their adolescent’s predicament of being ambivalent about this debilitating eating disorder, while at the same time being verbally persistent in their expectation that starvation is not an option. Most of this first phase of treatment is taken up by coaching the parents toward success in the weight restoration of their offspring, expressing support and empathy toward the adolescent given her dire predicament of entanglement with the illness, and realigning her with her siblings and peers. Realignment with one’s siblings or peers means helping the adolescent to form stronger and more age appropriate relationships as opposed to being ‘taken up’ into a parental relationship.

Throughout, the role of the therapist is to model to the parents an uncritical stance toward the adolescent – the Maudsley Approach adheres to the tenet that the adolescent is not to blame for the challenging eating disorder behaviors, but rather that these symptoms are mostly outside of the adolescent’s control (externalizing the illness). At no point should this phase of treatment be interpreted as a ‘green light’ for parents to be critical of their child. Quite the contrary, the therapist will work hard to address any parental criticism or hostility toward the adolescent.

Phase II: Returning control over eating to the adolescent

The patient’s acceptance of parental demand for increased food intake, steady weight gain, as well as a change in the mood of the family (i.e., relief at having taken charge of the eating disorder), all signal the start of Phase II of treatment.

This phase of treatment focuses on encouraging the parents to help their child to take more control over eating once again. The therapist advises the parents to accept that the main task here is the return of their child to physical health, and that this now happens mostly in a way that is in keeping with their child’s age and their parenting style. Although symptoms remain central in the discussions between the therapist and the family, weight gain with minimum tension is encouraged. In addition, all other general family relationship issues or difficulties in terms of day-to-day adolescent or parenting concerns that the family has had to postpone can now be brought forward for review. This, however, occurs only in relationship to the effect these issues have on the parents in their task of assuring steady weight gain. For example, the patient may want to go out with her friends to have dinner and a movie. However, while the parents are still unsure whether their child would eat entirely on her own accord, she might be required to have dinner with her parents and then be allowed to join friends for a movie.

Phase III: Establishing healthy adolescent identity

Phase III is initiated when the adolescent is able to maintain weight above 95% of ideal weight on her/his own and self-starvation has abated.

Treatment focus starts to shift to the impact AN has had on the individual establishing a healthy adolescent identity. This entails a review of central issues of adolescence and includes supporting increased personal autonomy for the adolescent, the development of appropriate parental boundaries, as well as the need for the parents to reorganize their life together after their children’s prospective departure."[9]

Evidence-based strategy

To date there have been 4 randomized controlled trials of Maudsley Family Therapy. The first (Russell et al., 1987) compared the Maudsley Model to individual therapy and found that family-based treatment was more effective for patients under 19 years of age with less than three years duration of illness. Ninety percent of these patients achieved a normal weight or the return of menses at the end of treatment including at 5 year follow-up (Eisler, et al., 1997).Two further randomised trials compared standard Maudsley treatment with a modified version where the patients and parents were seen separately (Le Grange et al. 1992, Eisler et al., 2000). In these trials approximately 70% of patients returned to a normal body weight (>90% IBW) or experienced the return of menses at the end of treatment, regardless of which version of the model was employed. Results from a more recent randomised controlled trial suggest that results are maintained with the manualisation of the Maudsley approach (Lock & Le Grange, 2001). There is also evidence that a short (6 months) and a long course (1 year) of treatment results in a similar positive outcome (Lock et al., 2005). Finally, the outcome using family-based treatment appears just as positive for children (9–12 years old) as it does for adolescents (Lock et al., 2006).[10]

References

  1. ↑ Russell, GF; Szmukler, GI; Dare, C; Eisler, I (1987). "An evaluation of family therapy in anorexia nervosa and bulimia nervosa". Archives of General Psychiatry 44 (12): 1047–56. doi:10.1001/archpsyc.1987.01800240021004. PMID 3318754.
  2. ↑ Robin, AL; Siegel, PT; Koepke, T; Moye, AW; Tice, S (1994). "Family therapy versus individual therapy for adolescent females with anorexia nervosa". Journal of Developmental and Behavioral Pediatrics 15 (2): 111–6. doi:10.1097/00004703-199404000-00008. PMID 8034762.
  3. ↑ Eisler, I; Dare, C; Hodes, M; Russell, G; Dodge, E; Le Grange, D (2000). "Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions". Journal of Child Psychology and Psychiatry, and Allied Disciplines 41 (6): 727–36. doi:10.1111/1469-7610.00660. PMID 11039685.
  4. ↑ Lock, J; Couturier, J; Agras, WS (2006). "Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy". Journal of the American Academy of Child and Adolescent Psychiatry 45 (6): 666–72. doi:10.1097/01.chi.0000215152.61400.ca. PMID 16721316.
  5. ↑ Lock, J.; Le Grange, D.; Agras, W. S.; Moye, A.; Bryson, S. W.; Jo, B. (2010). "Randomized Clinical Trial Comparing Family-Based Treatment with Adolescent-Focused Individual Therapy for Adolescents with Anorexia Nervosa". Archives of General Psychiatry 67 (10): 1025–32. doi:10.1001/archgenpsychiatry.2010.128. PMC 3038846. PMID 20921118.
  6. ↑ Le Grange, D; Crosby, RD; Rathouz, PJ; Leventhal, BL (2007). "A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa". Archives of General Psychiatry 64 (9): 1049–56. doi:10.1001/archpsyc.64.9.1049. PMID 17768270.
  7. ↑ Lock, J (2011). "Evaluation of family treatment models for eating disorders". Current Opinion in Psychiatry 24 (4): 274–9. doi:10.1097/YCO.0b013e328346f71e. PMID 21519263.
  8. ↑ Lock and Le Grange, Treatment Manual for Anorexia Nervosa: A Family-based Approach, 2001, p. 18-19, ISBN 978-1-57230-836-7
  9. ↑ Le Grange and Lock, "'Family-based Treatment of Adolescent Anorexia Nervosa: The Maudsley Approach, 2010
  10. ↑ Wallis A. "The Maudsley Model of Family Based Treatment." 2013

Bibliography

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