Maudsley Misconceptions: printable view An Interview with Dr. Angela Celio Doyle, University of Chicago's Eating Disorders Program
Dr. Celio Doyle, thank you so much for taking the time to give us your input. Increasingly parents are aware that the Maudsley approach is a treatment option but there are still many questions and misunderstandings about it. We hope you can address some specific concerns people have about Maudsley.
I am thrilled to have a chance to talk about the Maudsley approach for the treatment of adolescent eating disorders. I work closely with Dr. Le Grange and have treated many adolescents and their families using this approach here at the University of Chicago. I feel very enthusiastic about the ways in which it can help adolescents and their families struggling with an eating disorder.
I've been surprised by some of the things I've heard about how the Maudsley approach is implemented. The inaccurate idea that Maudsley advocates "force feeding" seems widespread.
Describing what we do in the Maudsley approach as "force feeding" is very misleading and I hope that we are able to continue to get the word out that this is a misconception. If anyone tells you that the Maudsley approach consists of "holding down your daughter and forcing food into her mouth," they are wrong. Hearing something like this, I can imagine why people might be concerned about this treatment!
The true nature of the Maudsley approach is empowering parents to help their adolescent recover from this life-threatening illness, rather than having them watch passively from the sidelines. The treatment involves compassionate, yet persistent and firm expectations that your adolescent eat an amount of food that can reverse the state of starvation his or her body is in and help them gain weight. Due to the nature of anorexia nervosa, which causes an adolescent to truly fear the effects of food and weight gain, anorexic adolescents will resist eating - especially the amounts and kinds of foods that are necessary for weight gain. In these situations, professional treatment assists parents in determining how to make the three meals and three snacks per day happen in a compassionate and successful way. Some families encounter a moderate amount of resistance from their adolescent during meals and some encounter a lot - hearing stories from other families about their experiences can be helpful in depicting the variations in how this "looks" for any particular family. Working with a professional trained in the Maudsley approach will help to determine the best way to address the resistance to eating.
Another common misunderstanding is that food is pushed at the expense of emotional support. For example, a parent once asked me "Maudsley is very punitive, isn't it?"
This is another very inaccurate belief. Maudsley is not punitive in any way and involves quite a bit of emotional support. Some parents may fear that they are being insensitive to their adolescent if they "push" their child to eat a plate of fettuccini alfredo when the adolescent is refusing, crying, or otherwise resisting. However, if you consider a child or adolescent with a chronic illness, such as cancer, who pleads with their parent to avoid another bout of chemotherapy because it makes them feel sick, a parent would compassionately, yet firmly, determine that the chemotherapy is needed, despite how it makes them feel. In this way, some parents of adolescents with anorexia find it helpful to view food as "medicine" for their child's illness that is required to, quite literally, save their life. It is also important to remember that the resistance to eating stems from the anorexia, not the healthy, wonderful child who was overtaken by this illness. Understanding that the anorexia is separate from your adolescent may help in remembering that you are helping your child while eliminating the anorexia nervosa through increasing calorie consumption.
Some parents also become concerned that if they ask their adolescent to eat more than they want that this will harm their relationship with their child. For instance, one father I worked with did not want to insist upon whole milk with every meal because his daughter would cry and sob, saying that it was "disgusting." She would tell him how much she hated him for making her eat calorie-laden meals and snacks, which was initially quite upsetting for the father. While this was a challenging situation to deal with, when his daughter's weight was fully restored and we had progressed through the other phases of therapy (i.e., handing food control back to the adolescent and facilitating healthy adolescent development), their relationship was quite positive and strong. The daughter, when finally healthy, could see that her father had done these things because of his love for her and his devotion to keeping her alive. This situation is the norm for the families we see in the Maudsley treatment, such that the parent-child relationship is not harmed – it generally returns to pre-anorexia status.
My clinical experiences working with these situations are supported by research demonstrating the same thing: in a study by Robin, Siegel, and Moye (1995), parent-adolescent relationships were actually improved at post-treatment and one-year follow-up compared with pre-treatment. In this study, there were reductions in conflict over food as well as mother-reported decreases in general conflict following treatment. The take-home message from this finding and our clinical experiences is that although you may face difficult conflicts during treatment due to the anorexia, as the anorexia retreats, conflicts will ultimately decrease.
One other point I want to make about the Maudsley approach is that siblings, if there are any, are asked in treatment to provide emotional support to their sister or brother. The siblings are not involved in the decisions about food or in monitoring eating - which is up to the parents. Instead, siblings can be someone to complain to, a shoulder to cry on, or someone to distract them from the difficult task of eating. The exact role will depend on the age and pre-existing relationships, but siblings can be incredible resources for helping an adolescent in their recovery.
And weight restoration is just one part of the Maudsley approach, correct?
Yes, weight restoration is just one part of the Maudsley approach. It is emphasized first during treatment and may take many months, for most families, to address. Most of the symptoms experienced by people with anorexia, from dizziness and feeling cold to irritability and depressed mood, are a result of physical starvation. Likewise, many of the distorted thoughts about food and body weight/shape are reinforced and perpetuated by a low weight. So, it is critical as the first step that parents are resolute about helping their adolescent achieve a healthy weight. Once an adolescent is weight-restored and the parents feel confident in their ability to prevent their adolescent from losing weight, decisions about food and eating are slowly and carefully returned to their adolescent. This is done slowly inorder to ensure that the adolescent is capable of making these decisions without the anorexia making the decisions for them. Finally, the last phase is focused on establishing a healthy parent-adolescent relationship that does not involve the anorexia and addressing the ways in which the anorexia may have prevented the adolescent from going through normal adolescent development. For instance, some adolescents with anorexia may have become very withdrawn from friends, so one focus might be improving the adolescent's peer relationships by encouraging age-appropriate activities. In effect, the goal is to get the adolescent "back on track" with their health, their relationships, and their personal life goals.
Eating disorders often arise during adolescence; just when we expect teens to become more independent. Another stumbling block in understanding is that it seems "wrong" for parents to oversee something as basic as eating at this time of life. Can you address that?
It may feel strange to oversee and be in charge of something as basic and seemingly personal as eating, especially with older teenagers. Developing independence is an important part of healthy adolescent development. When an adolescent has anorexia nervosa, however, food choices are one part of independence that must be temporarily withdrawn. Other aspects of an adolescent's independence, as determined by the parents, are not restricted. For instance, a 17-year old who previously was allowed to drive his/her car to friend's houses, go to school dances, and decide what movies they want to see would still have those important freedoms. Decisions about meals and snacks and when/what to eat, on the other hand, are temporarily in the hands of parents. These decisions are returned as soon as the adolescent is able to keep themselves healthy because the ultimate goal is to help the adolescent return to a normal adolescent life, with increasing independence in all areas of life.
Something important to remember is that anorexianervosa renders even the smartest and most rational adolescent unable to make consistently healthy decisions about eating. In every other way, your adolescent may be functioning at a very high level, and this is to be supported and applauded. But it is important to understand that if food choices are left to a person with anorexia, the almost inevitable consequence is weight loss or maintenance of an unhealthy low weight.
The idea that eating disorders are "about control" is something I hear often. Along those same lines it's sometimes suggested that Maudsley treatment will make the eating disorder worse.
Both from our clinical experience and reflected in the research data, the majority of adolescents respond well to the Maudsley treatment. Of course, no treatment works for everybody, so there are a small number who do not "respond" to this treatment - in other words, they maintain their current status rather than get "worse."
That said, a desire for control is often cited as a reason for the development and persistence of anorexia nervosa and this may, indeed, be the case for many adolescents. However, eating is in fact out of a person's control when one has anorexia, such that they are not able to eat enough to achieve a healthy weight. The healthy adolescent is no longer in control - the anorexia is.
Another important aspect to consider is that control over a life-sustaining function, like eating, should not be negotiable as the way to express control. If you found out your adolescent was using cocaine, would you allow them to continue using the drug, for fear of taking away their "control"? Probably not, because you know that drugs will have a detrimental effect on his/her life. In the same way, allowing your adolescent to starve oneself for fear of taking away "control" will have a detrimental effect. Ultimately, the treatment can address the concerns leading to this need for control once the adolescent is physically healthy (and thus mentally able) to discuss these issues. Parents have a responsibility to help a sick child, whether it is by helping them with their insulin injections for diabetes, or by expecting that they maintain a healthy weight. By helping your adolescent overcome this illness, you will actually enable them and prepare them to have more effective control over their lives.