Maudsley family therapy

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Maudsley family therapy
Other namesMaudsley approach

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]

Contents

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

Phases of treatment

The Maudsley Approach proceeds through three clearly defined phases. The process is divided into 15–20 treatment sessions and takes about 12 months to complete. [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

In Phase I (the "weight restoration phase"), therapy focuses on the consequences of anorexia-associated malnutrition, e.g., changes in growth hormone levels, cardiac dysfunction, and behavioral disturbances. The therapist assesses the family's typical interaction pattern and eating habits and assists the family in re-feeding their child. This may involve reestablishing the patient's relationships with their siblings and peers. Typically, the therapist will attend a family meal during this phase. Conducting a family meal serves at least two functions: (1) it allows the therapist to observe the family's typical interaction patterns around eating, and (2) it provides the therapist with an opportunity to assist the family in encouraging their adolescent to eat a restorative amount of food.

The therapist will spend phase I coaching the parents, supporting the adolescent, and realigning the adolescent with their siblings and peers. Parents are coached to adopt an attitude similar to that of an inpatient nursing team (sometimes termed "home hospital"). That is, parents are to express sympathy and understanding of their adolescent's ambivalence towards the eating disorder, while remaining steadfast in their expectation that the adolescent will work to restore a healthy weight. Realigning the adolescent with their siblings and peers involves helping the adolescent to form stronger and more age-appropriate relationships. This is essential in adolescence, as sibling and peer relationships are more central to the patient than parent–child relationships. Such realigned relationships lessen the possibility of the patient–parent relationship regressing to one defined by age-inappropriate dependency.

Throughout this phase, the therapist must anticipate and prevent parental criticism of the adolescent. In part, this is accomplished by modeling to the parents an uncritical stance toward the adolescent. This is a tenet of the Maudsley Approach: the adolescent is not to blame for their eating disorder behaviors, as these behaviors are symptoms largely outside the adolescent's control.

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 their friends to have dinner and a movie. However, while the parents are still unsure whether their child would eat entirely on their own accord, they might be required to have dinner with their 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 their own and self-starvation has abated.

Treatment focus starts to shift to the impact the eating disorder 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 four 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 five 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 (six months) and a long course (one 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]

Related Research Articles

An eating disorder is a mental disorder defined by abnormal eating behaviors that adversely affect a person's physical or mental health. Types of eating disorders include binge eating disorder, where the patient eats a large amount in a short period of time; anorexia nervosa, where the person has an intense fear of gaining weight and restricts food or overexercises to manage this fear; bulimia nervosa, where individuals eat a large quantity (binging) then try to rid themselves of the food (purging); pica, where the patient eats non-food items; rumination syndrome, where the patient regurgitates undigested or minimally digested food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons; and a group of other specified feeding or eating disorders. Anxiety disorders, depression and substance abuse are common among people with eating disorders. These disorders do not include obesity. People often experience comorbidity between an eating disorder and OCD. It is estimated 20–60% of patients with an ED have a history of OCD.

<span class="mw-page-title-main">Bulimia nervosa</span> Type of eating disorder

Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. This activity aims to expel the body of calories eaten from the binging phase of the process. Binge eating refers to eating a large amount of food in a short amount of time. Purging refers to the attempts to get rid of the food consumed. This may be done by vomiting or taking laxatives.

Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFED, or the binge-purge subtype of anorexia nervosa.

Binge eating is a pattern of disordered eating which consists of episodes of uncontrollable eating. It is a common symptom of eating disorders such as binge eating disorder and bulimia nervosa. During such binges, a person rapidly consumes an excessive quantity of food. A diagnosis of binge eating is associated with feelings of loss of control. Binge eating disorder is also linked with being overweight and obesity.

Cognitive analytic therapy (CAT) is a form of psychological therapy initially developed in the United Kingdom by Anthony Ryle. This time-limited therapy was developed in the context of the UK's National Health Service with the aim of providing effective and affordable psychological treatment which could be realistically provided in a resource constrained public health system. It is distinctive due to its intensive use of reformulation, its integration of cognitive and analytic practice and its collaborative nature, involving the patient very actively in their treatment.

Gerald Francis Morris Russell was a British psychiatrist. In 1979 he published one of the first descriptions of bulimia nervosa, and Russell's sign has been named after him.

The Eating Attitudes Test, created by David Garner, is a widely used 26-item, standardized self-reported questionnaire of symptoms and concerns characteristic of eating disorders. The EAT is useful in assessing "eating disorder risk" in high school, college and other special risk samples such as athletes. EAT has been extremely effective in screening for anorexia nervosa in many populations.

Avoidant/restrictive food intake disorder (ARFID) is a feeding or eating disorder in which people avoid eating certain foods, or restrict their diets to the point it ultimately results in nutritional deficiencies. This can be due to the sensory characteristics of food, such as its appearance, smell, texture, or taste; due to fear of negative consequences such as choking or vomiting; having little interest in eating or food, or a combination of these factors. People with ARFID may also be afraid of trying new foods, a fear known as food neophobia.

Diabulimia, also known as ED-DMT1 in the US or T1ED in the UK, is an eating disorder in which people with type 1 diabetes deliberately give themselves less insulin than they need or stop taking it altogether for the purpose of weight loss. Diabulimia is not recognized as a formal psychiatric diagnosis in the DSM-5. Because of this, some in the medical or psychiatric communities use the phrases "disturbed eating behavior" or "disordered eating behavior" and disordered eating (DE) are quite common in medical and psychiatric literature addressing patients who have type 1 diabetes and manipulate insulin doses to control weight along with exhibiting bulimic behavior.

Purging disorder is an eating disorder characterized by the DSM-5 as self-induced vomiting, or misuse of laxatives, diuretics, or enemas to forcefully evacuate matter from the body. Purging disorder differs from bulimia nervosa (BN) because individuals do not consume a large amount of food before they purge. In current diagnostic systems, purging disorder is a form of other specified feeding or eating disorder. Research indicates that purging disorder, while not rare, is not as commonly found as anorexia nervosa or bulimia nervosa. This syndrome is associated with clinically significant levels of distress, and that it appears to be distinct from bulimia nervosa on measures of hunger and ability to control food intake. Some of the signs of purging disorder are frequent trips to the bathroom directly after a meal, frequent use of laxatives, and obsession over one's appearance and weight. Other signs include swollen cheeks, popped blood vessels in the eyes, and clear teeth which are all signs of excessive vomiting.

<span class="mw-page-title-main">Anorexia nervosa</span> Type of eating disorder

Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin.

The differential diagnoses of anorexia nervosa (AN) includes various types of medical and psychological conditions, which may be misdiagnosed as AN. In some cases, these conditions may be comorbid with AN because the misdiagnosis of AN is not uncommon. For example, a case of achalasia was misdiagnosed as AN and the patient spent two months confined to a psychiatric hospital. A reason for the differential diagnoses that surround AN arise mainly because, like other disorders, it is primarily, albeit defensively and adaptive for, the individual concerned. Anorexia Nervosa is a psychological disorder characterized by extremely reduced intake of food. People with anorexia nervosa tend to have a low self-image and an inaccurate perception of their body.

Bulimia nervosa and anorexia nervosa are prevalent in Western countries, such as the United States, but recent studies have shown that they are also on the rise in Asian countries such as China. There are several reasons for this, such as, Chinese culture and westernization. Researchers are looking into these causes, so they can know how to treat and prevent them.

Cognitive behavioral therapy (CBT) is derived from both the cognitive and behavioral schools of psychology and focuses on the alteration of thoughts and actions with the goal of treating various disorders. The cognitive behavioral treatment of eating disorders emphasizes on the minimization of negative thoughts about body image and the act of eating, and attempts to alter negative and harmful behaviors that are involved in and perpetuate eating disorders. It also encourages the ability to tolerate negative thoughts and feelings as well as the ability to think about food and body perception in a multi-dimensional way. The emphasis is not only placed on altering cognition, but also on tangible practices like making goals and being rewarded for meeting those goals. CBT is a "time-limited and focused approach" which means that it is important for the patients of this type of therapy to have particular issues that they want to address when they begin treatment. CBT has also proven to be one of the most effective treatments for eating disorders.

<span class="mw-page-title-main">Janet Treasure</span> British psychiatrist

Janet Treasure, OBE PhD FRCP FRCPsych, is a British psychiatrist, who specialises in research and treatment of eating disorders.

Other specified feeding or eating disorder (OSFED) is a subclinical DSM-5 category that, along with unspecified feeding or eating disorder (UFED), replaces the category formerly called eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR. It captures feeding disorders and eating disorders of clinical severity that do not meet diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), pica, or rumination disorder. OSFED includes five examples:

<span class="mw-page-title-main">Kate Tchanturia</span> English psychologist and eating disorders researcher

Kate Tchanturia is a British psychologist who is a professor of psychology in eating disorders at the Institute of Psychiatry, Psychology and Neuroscience, King's College London. She is also Consultant Psychologist at the South London and Maudsley NHS Foundation Trust for the National Eating Disorder Service, and president of the Eating Disorders Research Society. Her main research interests include cultural differences in illness presentations, cognitive profiles in eating disorders, and experimental work in emotion processing and translational research from experimental findings to real clinical practice. Tchanturia has a particular interest in women's mental health and has pioneered the PEACE pathway for autism and eating disorder comorbidity.

Paul E. Garfinkel is a Canadian psychiatrist, researcher and an academic leader. He is a professor at the University of Toronto and a staff psychiatrist at Centre for Addiction and Mental Health (CAMH).

Body image disturbance (BID) is a common symptom in patients with eating disorders and is characterized by an altered perception of one's own body.

Body checking is a compulsive behaviour related but not exclusive to various forms of body dysmorphic disorders. It involves frequently collecting various information about one’s own body in terms of size, shape, appearance or weight. Frequent expressions of this form of behaviour entails for example mirror checking, trying to feel one’s own bones, pinching the abdomen, frequent body weight measurement and comparing your own body to that of others. Studies have shown that an increased rate of body checking correlates with an overall increased dissatisfaction with the own body.

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. S2CID   45620151.
  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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