My daughter is 15. I think she is at a healthy weight. However, she does display disordered eating such as going a whole school day without eating and then eating steadily from after school until bedtime. She is somewhat restrictive in her habits and what foods she is comfortable eating.
We are in therapy and the Maudsley method was suggested. We have had two sessions but are having trouble doing our part at home. I am not sure if this method is required or appropriate, as she does not really need to gain weight, but certainly needs help with her relationship with food and her body image.
As expected, she is balking at having us say when and what to eat.
Can you comment whether the Maudsley approach is best or should we be looking at other types of therapy (for her or us as a family).
Katharine Loeb, PhD responds:
You are asking exactly the right question; since your daughter’s troubling behavior around eating and mindset about her body do not reflect the classic diagnosable eating disorders (anorexia nervosa, bulimia nervosa) for which the Maudsley method has been explicitly tested, is this the right approach for your family? The answer is that aspects of family-based treatment could be very helpful for your adolescent, but the specific strategies need to match her symptoms. Parenthetically, you say that she is not underweight, but if she has lost weight via unhealthy dieting practices (while still remaining within a normal range), she may regain some in response to your efforts. Regardless, her restrictive dietary practices - in terms of types of food she is willing to eat and frequency of eating - can carry some negative health implications in their own right, as well as put her at risk for worsening eating disorder symptoms. In addition, severe dietary restriction typically does not alleviate shape and weight concerns in the long run, but instead can potentiate disturbance in body image. Finally, her restriction appears to be leading to a feast-famine pattern wherein she starves herself during the day and then eats throughout the evening – possibly amounts and patterns that may constitute binge eating. Binge eating in turn can heighten shape and weight concerns and prompt further conviction to diet severely. Your daughter can benefit from your help in stopping this vicious cycle. A first step is to provide the scaffolding for your daughter to return to healthier eating habits by setting clear expectations for regular meals and snacks and the consumption of a wide range of foods. You can help manage her temptation to skip meals by providing supportive supervision as well as support in re-introducing anxiety-provoking foods. This can be accomplished more collaboratively than with a child in the throes of severe anorexia nervosa, where the illness is highly influential and extremely irrational. A point for you and your daughter to keep in mind is that she is probably consuming more calories than she intends to in the evening, and you will help her redistribute these in a manner that will protect her from eating episodes during which she feels out of control (such as what may be occurring at night). These strategies are consistent with cognitive behavioral therapy (CBT) as well, but parents assuming some of the responsibility for implementation of treatment techniques reflects the Maudsley framework. If your daughter’s body image issues persist to a concerning level following stabilization of her eating habits for a reasonable period of time, you could also consider CBT to address any residual shape and weight concerns.
Katharine Loeb, PhD
Dr. Loeb is Associate Professor of Psychology at Fairleigh Dickinson University, Director of Research at the Eating and Weight Disorders Program at Mount Sinai School of Medicine, and serves as Clinical Advisor to Maudsley Parents.