Family-Based Treatment: New Directions
By Nancy Matsumoto
Two decades ago Christopher Dare and Ivan Eisler laid out the principles of their groundbreaking Maudsley method of family based treatment for adolescent anorexia nervosa at the University of London's Maudsley Hospital. This approach, which disregards the idea that parents are to blame for their child's self-starvation and instead views them as key players in restoring their child's weight and health, has increased in popularity in America following the influential publications of James Lock, M.D., Ph.D. and Daniel le Grange, Ph.D: Treatment Manual for Anorexia Nervosa: A Family-Based Approach (with Agras, W.S. and Dare, C., Guilford, 2002); Help Your Teenager Beat an Eating Disorders (Guilford, 2005), and Treating Bulimia in Adolescents: A Family-Based Approach (Guilford, 2007).
Though Maudsley has won loyal adherents throughout the world, there is still a shortage of professionals trained in this approach. Those who do use Maudsley sometimes encounter resistance from doctors, therapists, and nutritionists who either aren't familiar with the practice, or view it as overly harsh and demanding of both patient and family.
I wanted to get a sense of how Maudsley, also known as Family Based Treatment (FBT) was making the transition from the seminars and writings of Drs. Lock and le Grange to big city eating disorder treatment centers and small town practitioners. What are some of the practical adaptations to this approach being developed in the field to make FBT work in less than optimal settings? Where do practitioners see Maudsley going in the future? I found a number of exciting new directions, many of them tied to NIH-backed studies.
Incorporating FTB with a Multidimensional Approach at UCSD
Walter Kaye, M.D. director of UCSD's Eating Disorder Research and Treatment Program, says, "Most people don't have a Maudsley therapist in their backyard. They often don't have anyone around who is expert in treating anorexia." With this in mind, the goal at UCSD's five-day intensive outpatient family therapy program for adolescent anorexics, says Dr. Kaye, is to "offer evaluation and Maudsley but a lot of other things, too," including tools the family can take home with them and draw from without expert guidance close at hand.
The program consists of family based techniques such as coached family meals and psychoeducational sessions(where families learn about the biology of eating disorders and new brain imaging studies, why they should not blame each other or themselves for the illness, and how to separate their child from the anorexia that is controlling her or him), as well asCBT and cognitive remediation therapy (to improve memory and cognitive flexibility). It also incorporates systemic family therapy, which looks at the family unit as a whole and has traditionally not been part of the FBT approach.
Contracts allow parents to tie rewards (cell phone use or a lip gloss purchase, for example) to specific weight goals, and the cognitive work is designed to help anorexics shift their attention away from food and restrictive eating, something that their particular brain function makes difficult to do. While Maudsley traditionally does not give the family nutritional or meal planning advice, UCSD's program takes a more liberal approach in its use of dietitians who provide these services.
Dr. Kaye and his staff teach parents that a child has to have a certain "constellation of traits," including anxiety, perfectionism, and obsessionality in order to develop anorexia. "These are very anxious people, and not eating is the one thing that makes the anxiety go away," he says. "If you can explain these facts to families and kids, and that this method is what works best for them, the resistance fades away."
In addition to its intensive outpatient program, Dr. Kaye and his team are participating in a six-center NIH-funded grant study comparing FBT to more traditional family therapy. "I think it's a very good therapy, I'm not trying to say it isn't," he says of Maudsley, "but there are other things we can add on to make it more effective."
Advanced doctoral candidate Roxanne Rockwell oversees the three family meals of UCSD's five-day session and has assisted in one notable modification to the traditional Maudsley approach in this area. Rockwell has begun to videotape the meals, and afterward conducts a parent coaching session without the child, using the videotaped session as a learning tool. "We identify things that are working and things that are not working with the child, and try to separate the illness from the patient," Rockwell explains. She points out telltale facial expressions in the video, or how the illness seems to be "attacking" one parent and not the other, suggesting ways that the unaffected parent can step in and help out. While families might be self-conscious about the camera at first, says Rockwell, "when it really gets down to the child having to eat, they forget about it."
More practitioners' experiences with Maudsley
The outpatient Mt. Sinai Eating and Weight Disorders Program in New York City hews more closely to the traditional Maudsley approach. Alicia Hirsch, Psy.D., director of clinical services for the program, says parents often become frustrated by the lack of food and nutritional advice. She recommends they check the website www.maudsleyparents.org for meal planning advice. If parents still find the process difficult, or are hampered by their own struggle with an eating disorder, staff members will provide some nutrition education. Sometimes, says Hirsch, parents will decide to go to a nutritionist for help, but she makes it clear that "under no circumstances can the child be going to the nutritionist or be part of the session. Parents must make all decisions around food."
While Mt. Sinai's program typically won't begin CBT until weight restoration is complete, Hirsch notes that if a family wants to work privately with a therapist before this point they may do so as long as the therapist supports parents being in charge of all food issues.
Katharine Loeb, Ph.D., director of research at the Mt. Sinai eating disorders program, is heading another Maudsley related study, looking at the effectiveness of FBT on sub-threshold anorexics, those who have some but not all of the symptoms of the disease. Given the high level of research surrounding Maudsley style treatment, Dr. Hirsch says she can foresee the day when it will be used with adults as well as adolescents, perhaps with spouses taking on the support role of parents.
Maudsley trained nutritionist Marcia Herrin, M.P.H., R.D., Ed.D., who practices privately in a small New Hampshire town and with whom I have collaborated on a book on childhood and adolescent eating disorders, has added Maudsley features such as the coached family meal into her toolkit of treatment options and created a Maudsley influenced meal plan she calls Parent-Assisted Meals and Snacks (PAMS). "Incorporating the Maudsley principle that families can successfully refeed an anorexic child at home has significantly enhanced my nutrition counseling," says Dr. Herrin. "Both patients and parents tell me that the family meal they eat in my office is a turning point in the recovery process." Dr. Herrin conducts workshops across the country for nutritionists on how to incorporate a coached family meal into their practice.
Joy Jacobs, J.D., Ph.D., a psychologist who helped develop the UCSD intensive family program, is now in private practice in San Diego. She has established an international niche counseling families as far away as Hong Kong and Israel who are attempting FBT but cannot find a Maudsley trained professional locally. "I ask them to schedule a phone session, map out a list of questions, a history of the family and illness," explains Dr. Jacobs. "Depending on the severity, it might just be a one-time phone consult. I help tailor their approach."
Common issues are lack of parental cooperation needed to best help their child fight the eating disorder, or a feeling of isolation that comes with attempting this challenging treatment method on their own. Dr. Jacobs has even conducted a few coached meals via webcam, but says that she makes sure that all parties agree that they can't have 100 percent confidentiality and security via the Internet.
The Kartini Clinic in Portland, OR specializes in treating adolescents up to age 21. Medical director Julie O'Toole, M.D., M.P.H., who founded the clinic in 1988, says her "bio-psycho-social" approach has always been family based, although it predated her awareness of Maudsley. Treatment is based on Dr. O'Toole's belief that "parents don't cause eating disorders and children don't choose to have them" and looks to recent research in neurobiology and genetics showing that eating disorders are inherited conditions driven by poorly understood brain chemistry and environmental risk factors.
Much of Kartini's approach is similar to Maudsley; one area of difference is its use of a meal plan, which the family is expected to use for at least a year after diagnosis. Educating families on how to use the meal plan begins at the start of treatment, with a portion of weekly family therapy meetings focused on compliance with the plan. While the clinic does not conduct family meals, Kartini began holding cooking classes for parents after it became clear that many parents did not know how or what to cook. Classes emphasize how to shop and cook according to meal plan guidelines.
At Duke University Nancy Zucker, Ph.D., director of the Duke Eating Disorder Program, developed a parent skills program called Off the C.U.F.F. (Calm, Unwavering, Firm and Funny) at about the same time that Maudsley first came into use, around 2000. As FBT gained in popularity, Dr. Zucker realized her program was the perfect complement to Maudsley: it provides "the tools parents need to be able to do what's being asked of them with Maudsley," she explains.
The program, influenced by Dialectical Behavioral Therapy, teaches parents skills to help their child manage disordered eating and weight concerns. By tuning into a child's emotional state, a parent can help distract or soothe her before negative emotions take over. By taking care of themselves and each other, staying calm, firm, and retaining their sense of humor, parents model healthy behaviors and counter the lack of joy that the seriously anorexic child experiences.
Off the C.U.F.F.'s parent group sessions can be done concurrently with Maudsley, and provide isolated and exhausted parents a safe haven where they can let off steam, compare notes, set goals, and learn healthy coping strategies. The program's success has led to its adoption by hospitals and eating disorder programs around the world. A current NIH study is comparing FBT with separate Off the C.U.F.F.-style parent and adolescent group therapy to see which is more effective, and a manualized version of Off the C.U.F.F. is also available.
While the majority of American doctors, therapists and nutritionist treating eating disorders may not be familiar with or trained in the Maudsley approach, it is heartening to see the many ways that FBT's basic components—lack of blame toward parents and families, making parents key players in recovery, instilling the confidence parents need to turn around the disease, giving parents the tools they need to successfully refeed their child—are being implemented in centers and by practitioners around the country, in some cases in protocols that pre-date Maudsley. Parents, as Dr. Kaye says, might not have a Maudsley-trained professional in their backyard, but if they are willing to look for them, a number of Maudsley informed or like-minded alternatives are out there.
Two sites that offer Maudsley information, tips on how to search for a qualified Maudsley practitioner, and a list of family-based practitioners around the world are F.E.A.S.T. (www.feast-ed.org) and Maudsley Parents (www.maudsleyparents.org). For information on how to become trained in the Maudsley approach visit The Training Institute for Child and Adolescent Eating Disorders (www.train2treat4ed.com) site. The institute was founded by Drs. Lock and le Grange and offers six different training courses in FBT for clinicians.