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By Dr. Cris Haltom
The reasons for a new treatment
In 2001 four researchers, James Lock, Daniel LeGrange, W. Stewart Agras, and Christopher Dare, published a manual for a family-based treatment of anorexia nervosa in adolescents, (Treatment Manual for Anorexia Nervosa, 2001). Continued research has demonstrated their evidence-based model of treatment, known as the Maudsley Approach, is applicable to adolescents with bulimia as well. Parents and guardians may have read about this approach in the media, e.g., New York Times, June 11, 2002.
There were several reasons the Maudsley Approach was developed. First, there has been little family therapy research using controlled trials of family treatment for anorexia. Lock et al pointed out controlled research trials evaluating the effectiveness of therapy have been important not just for evaluating what approaches work, but also for determining the best duration and frequency for interventions.
The Maudsley Approach addresses the common observation that anorexia can become a chronic illness involving multiple hospitalizations and prolonged treatment. The Maudsley Approach is applied to adolescents 18 and under who are living with their families. It is designed to intervene aggressively in the first stages of illness and is a short-term model, as short as twenty sessions or six months in duration. It is conventional wisdom that recovery is best achieved when eating disorders are treated in the earliest stages, in order to prevent long term, chronic illness. Long term consequences of lingering illness include migration of anorexic symptoms to chronic bulimia.
The Maudsley Approach builds on evidence that family therapy approaches are superior to individual therapy approaches with younger patients (Russell et al, 1987; Eisler et al, 1997). The Maudsley Approach involves the family from the outset of treatment and relies heavily on parent involvement in the re-feeding of the child with an eating disorder.
A unique aspect of this approach is that families are not thought to be pathological in the etiology of the eating disorder. Parents are exonerated from blame. Their creative resources and strengths are drawn on to move their child toward health. Dr. Le Grange recently pointed out (6/18/04, seminar at the University of Rochester School of Medicine) that a relative or close friend involved in a child's therapy and trained by the treating clinician in the application of the Maudsley Approach at home could supplement a single parent attempting to use the model in treating their child if a second parent was not available. The model can also be used with a single parent, if necessary. This flexibility broadens the range of family constellations the Maudsley Approach can be used by.
The Maudsley Approach is a response to the rising costs of inpatient care and the restrictions by insurance companies on coverage of inpatient care. Outpatient alternatives to inpatient care are increasingly being examined and implemented. Lock et al have examined both short and long term effectiveness of the Maudsley Approach. Short- term treatment for young patients with anorexia has been shown to be promising. The benefits of this treatment, according to research, have been sustained for five years after treatment.
In the Maudsley approach parents are empowered to use their resources and creativity to figure out ways to feed their child the type and amounts of food needed to restore health. However, once health is reasonably restored (determined by medical indicators such as achieving 95% of ideal weight) the model returns responsibility for re-feeding back to the adolescent. At that point, the adolescent in treatment is presumed to be ready to undertake the age-appropriate adolescent task of self-feeding. In later stages of treatment (there are three phases) attention is turned to central issues of normal adolescent development. Such tasks as supporting the autonomy of the adolescent, establishing appropriate parent-child boundaries, and assisting parents in pursuing their own individual and marital needs are addressed.
In the first stage of treatment, the therapist plays an active and key role in helping parents separate their child from the child's illness. The therapist explains that discovering why the eating disorder occurred (other than medical etiology) is neither assumed or important to the beginning stage of this approach. Parents are given the task of re-feeding and removing the illness from the child. With the family present, they are mobilized by the therapist on a weekly basis to keep the focus on the illness.
With the Maudsley Approach, The therapist encourages parents to minimize criticism of their ill child when her or his expected resistance to eating arises. This is based on research reviewed by Lock et al that parental criticism can hinder treatment.
Dr. Le Grange stressed that the Maudsley Approach is not a "green light" for parents to be critical, aggressive, controlling or hostile toward their children with eating disorders. The skilled hand of "qualified therapists who have experience in the assessment and treatment of eating disorders in adolescents (Lock et al, p. 23)" is needed to guide the process. The skills of a consulting nutritionist and physician, and a consulting child psychiatrist, if needed, are essential to the treatment team as well. Lock et al are also clear their treatment manual is not to be used as a self-help intervention.
This treatment model, like all treatment models, isn't for everyone. For example, Dr. Le Grange noted that the responsibility for re-feeding a child, while empowering for parents, is also labor-intensive and time-consuming. Parents, like the nursing staff in an impatient setting, are "on duty" all day for feedings, including snacks. While parents may tag-team each other for meals and snacks, at least one parent or guardian needs to be present for all planned snacks and meals. Applications for bulimic behavior may include purge-prevention supervision, as well, as worked out with the therapist. Parent and/or guardian at-home "teams" need to be able to work in unity and to cooperate with each other.
The Maudsley Approach offers parents an empowered way to play a pivotal, positive role in restoring an adolescent with anorexia or bulimia to health. Because eating disorders remain complex and stubbornly resistant to cure and short-term solutions the Maudsley Approach offers a promising, important, new, clinically-tested method for treatment of eating disorders appropriate for some young people and their families.
Eisler, I., Dare, C., Russell, G., Szmukler, G., Le Grange, D., Dodge, E. (1997) A five-year follow-up of a controlled trial of family therapy in severe eating disorders. Archives of General Psychiatry, 54, 1025- 1030.
Lock, J., Le Grange, D., Agras, W.S., Dare, C. (2001) Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: The Guilford Press.
Russell, G.F.M., Szmukler, G.I., Dare, C., and Eisler, I. (1987) Archives of General Psychiatry, 44, 1047-1056.
Cris Haltom has a Ph.D. from Cornell University. She is a licensed psychologist in private practice in Ithaca, N. Y. Cris is an Approved Supervisor (#110) for the International Association of Eating Disorder Professionals. She is available for training, presentations, and workshops. She has published articles, co-edited a text book, appeared on cable television, taught workshops, and taught academic courses as adjunct faculty at Cornell University and other colleges.
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