Advice on understanding and finding family-based treatment:printable view
Navigating the Search for True Maudsley Treatment By Angela Celio Doyle, PhD and Renee Rienecke Hoste, PhD
The process of seeking treatment for a child’s eating disorder can be overwhelming and emotionally draining. Unfortunately, this process can be even more difficult due to confusion over terms and names for treatment approaches. If you are interested in finding a provider who uses the Maudsley approach, it is important to have a clear understanding of how to ask for it and how to determine which providers actually offer this treatment in its true form.
The History of the Maudsley Approach
In the late 1970s and early 1980s, a new kind of family therapy which supported and empowered families in eliminating anorexia nervosa in their children was first developed and tested at the Institute of Psychiatry at the Maudsley Hospital in London, England. This therapy has more recently come to be known as "the Maudsley approach" or "Maudsley method". Drs. Christopher Dare, Ivan Eisler, Gerald Russell, and George Szmukler were the original creators of this family-based approach and their research team subsequently published several early and important articles documenting the treatment’s success. In 1986, Dr. Daniel le Grange, PhD, a clinical psychologist, joined this team and began his training at the Maudsley Hospital. While there, he developed a keen passion for this family treatment, especially in its application to adolescents with anorexia nervosa.
Dr. Daniel le Grange introduced the Maudsley approach to his colleagues in the United States in 1994, when he trained at Stanford University. It was through the relationships he established at Stanford University that Dr. le Grange teamed up with Dr. James Lock, MD, a psychiatrist, to collaborate on studying the Maudsley approach in clinical research trials targeting adolescents with anorexia nervosa and bulimia nervosa. Much of their work, both collaboratively and independently, has been funded through highly competitive awards of federal grant money through the National Institutes of Health (NIH). Dr. le Grange’s and Dr. Lock’s research, along with a growing number of other talented researchers in the field, has been crucial to understanding the potential for this treatment to help young people with eating disorders and their families.
Family-Based Treatment versus Family Therapy
The Maudsley approach is more commonly known within the scientific community as Family-Based Treatment (FBT). This is to be distinguished from traditional family therapy. In fact, we believe that many people beginning their search for Maudsley treatment will mistakenly look for providers who offer "family therapy". However, "family therapy" is quite a different treatment and one that does not have scientifically-sound evidence to support its effectiveness for eating disorders. A good definition of family therapy is as follows:
"Family therapy is both a theory and a treatment method. It offers a way to view clinical problems within the context of a family’s transactional patterns. Family therapy also represents a form of intervention in which members of a family are assisted to identify and change problematic, maladaptive, self-defeating, repetitive relationship patterns. Unlike individually-focused therapies, the identified patient (the family member considered to be the problem in the family) is viewed as a symptom bearer, expressing the family’s disequilibrium or current dysfunction. The family system itself is the primary unit of treatment and not the identified patient. Helping families change leads to improved functioning of individuals as well as families." (p. 375; Goldenberg & Goldenberg, 2000).
Family Therapy is not the same as Family Based Treatment (FBT)
"FBT" is interchangeable with "Maudsley approach", and is the term used by many researchers and some outside the research field. In the Maudsley approach, the eating disorder is not seen as an expression of family dysfunction. On the contrary, the eating disorder is seen as an illness and the family is seen as the solution to the problem. The Maudsley approach only deals with problematic family patterns inasmuch as these patterns interfere with the elimination of the eating disordered symptoms and the reestablishment of normal adolescent development. Another difference between the Maudsley approach and family therapy, in general, is that the Maudsley approach necessarily involves a pediatrician working as a consultant to the therapist (whether the therapist is a psychologist, psychiatrist, LCSW, etc.). This is particularly true in the case of individuals with anorexia nervosa. Eating disorders are life-threatening, so a pediatrician can help to monitor your child’s health, provide nutritional information if needed, decide when it is appropriate to return to normal activities (e.g., gym class, sports teams), and help to determine a healthy body weight.
Another term worth mentioning in relation to the Maudsley approach is "family". In the context of this treatment approach, as in many other settings, "family" is not merely dictated by biology or law. The family engaging in Maudsley treatment can be composed of parents, step-parents, long-term significant others, siblings, grandparents, aunts, uncles, etc. Each week, the therapist will want to meet with everyone who lives with the individual with the eating disorder. Also, the therapist might want to meet with people who are involved in caring for/feeding the individual, but who do not live with the individual with the eating disorder. For instance, if grandparents care for the child/adolescent after school, or if there are no siblings and support is needed from close friends, it could be important for these other individuals to join a few sessions to learn more about the Maudsley approach. All caregivers are enlisted to be on "the same page" with one another in the way that the disorder is viewed and treated, and siblings play an important role as well as supportive peers.
"The New Maudsley Method"
Dr. Janet Treasure, a prominent psychiatrist at Guy’s Hospital at King’s College, London, has recently published a book entitled, "Skills-based Learning for Caring for a Loved One with an Eating Disorder: The New Maudsley Method." This is not a new version of the original Maudsley approach. Rather, Dr. Treasure’s new book provides specific and practical information and strategies for caregivers to use in the context of Maudsley treatment. In addition, Dr. Treasure’s book includes information for caregivers of adults with eating disorders, whereas the original Maudsley approach has focused on treatment of adolescents with eating disorders.
Given the several names by which this method is called - Maudsley approach, Family-based Treatment, and others - it is not surprising that many families have difficulty knowing whether a particular practitioner is trained in and provides the true Maudsley approach. In 2009, a formal credentialing system was established by Drs. le Grange and Lock. Their Training Institute for Child and Adolescent Eating Disorders provides a current listing of certified Maudsley therapists. Each of these individuals have obtained extensive training and experience in the treatment. If, for some reason, you are unable to find a certified therapist in your area, you may still be able to find a practitioner who has received some degree of training in the Maudsley approach. Here are a few ways that you can make sure you are receiving Maudsley treatment:
First, make sure that the practitioner is a licensed mental health professional. This would include clinical psychologists (PhD, PsyD), psychiatrists (MD), licensed social workers (LCSW), marriage and family therapists (MFT), etc. Do not be afraid to ask about a professional’s credentials.
Inquire about their training. If they have received training from either Dr. Daniel le Grange or Dr. James Lock in the form of a workshop or have trained with them at their respective universities, this is promising. Other practitioners will have taught themselves the treatment through reading the treatment manuals (Lock, Le Grange, Agras, & Dare, 2002; Le Grange & Lock, 2007), which can also be a helpful source of training for talented therapists, but is far from ideal. Again, do not be afraid to ask about a professional’s training experiences in the Maudsley approach.
Inquire about their view of treatment. Professionals who have been trained in the Maudsley approach will ask that all family members who live with the child/adolescent are present for sessions and will focus on the importance of parents taking charge of their child’s eating. Treatment follows three phases with the first phase dedicated to weight restoration (in anorexia nervosa) and the elimination of binge eating and purging, if present. The therapist will initially focus almost exclusively on eating disorder symptom reduction, rather than discussing why the eating disorder started. Additionally, parents are not assigned any blame for the development or maintenance of the eating disorder. The therapist will put parents fully in charge of food choices and weight restoration at first, rather than leaving these decisions to the child/adolescent. Therapists well-trained in the Maudsley approach will weigh the child/adolescent at each appointment to determine progress and will share this information openly. The therapist will work with a physician to monitor the individual’s physical health. Finally, therapists offering true Maudsley treatment will ask that other therapies for the child/adolescent (for instance, an individual therapist or a nutritional counselor) be discontinued until the Maudsley treatment has concluded.
Think carefully if an inpatient/residential program advertises that they provide the Maudsley approach or Family-Based Treatment. One of the fundamental principles of the Maudsley approach is that families can restore their child to health in their own home, providing that their child is medically stable. Naturally, to learn and use this approach in a setting that is not the home is extremely challenging, if not incompatible with the very basic philosophy of the Maudsley approach. However, you will find that a number of inpatient/residential programs do share a similar philosophy to the Maudsley approach, where parents are taught to help re-feed their child in a blame-free environment. Following discharge from aninpatient/residential program, it is highly recommended that families find a skilled, outpatient therapist to guide them in the Maudsley approach.
Goldenberg, I. & Goldenberg, H. 2000. Family Therapy. In R.J. Corsini, D. Wedding (Eds.) Current Psychotherapies, 6th Edition. F.E. Peacock Publishers: Itasca Illinios, pp 375-406. Le Grange, D., & Lock, J. (2007). Treating Bulimia in Adolescents: A Family-Based Approach. The Guilford Press: New York. Lock, J., Le Grange, D., Agras, W.S., Dare, C. (2002). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. The Guilford Press: New York.