What is the “Maudsley Method?”
Family-Based Treatment (FBT): The Gold Standard for Adolescents with Anorexia Nervosa
According to the Diagnostic and Statistical Manual for Mental Illness (DSM-5-TR), anorexia nervosa (AN) is defined as (American Psychiatric Association, 2022):
“Restriction of energy intake relative to requirements, leading to a significant low body weight”
“Intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain”
“Disturbed by one’s body weight or shape, self-worth influenced by body weight or shape, or persistent lack of recognition of seriousness of low bodyweight.”
When a parent learns their child has been diagnosed with anorexia nervosa, understanding what to do next can be overwhelming. The current gold standard treatment for adolescents with anorexia nervosa is Family-Based Treatment, also known as ‘FBT’ or the Maudsley Method.
What is FBT?
FBT is an intensive, manualized outpatient treatment that focuses on restoring a teenager to health with the close support of their parents or guardians.This is a three phase treatment that requires parents to essentially be on-call to support their child during the duration of the illness and treatment.
Phase 1: Weight restoration
In this phase, the therapist will review growth curves and establish the expected body weight range for the adolescent. Anorexia nervosa is considered ego-syntonic, which means the child will struggle to independently make healthy decisions about nourishing their body. During this phase, all control over eating and exercise are temporarily given to parents. Parents will make decisions about when their teenager eats, how much they eat, and what they are eating. They will also place limits on exercise in collaboration with the treatment team. This is often called a ‘home-based hospitalization,’ as the limits are similar to what is seen on an inpatient unit; however, the goal is to allow the teenager to recover at home with their support system. Treatment is weekly at this phase.
Phase 2: Restoring control of eating to the young person
Once a teen is steadily regaining weight, at a minimum of 90% of their expected body weight, and demonstrating increased flexibility with allowing parental control, the second phase of FBT begins. This phase involves slowly returning control and responsibility back to the adolescent, based on what is normative within the family and developmentally appropriate. Independence is returned gradually to prevent backtracking on progress. Treatment moves to bi-weekly at this phase.
Phase 3: Returning to normal adolescent development
The final phase of FBT occurs once the teen is weight restored and control over eating and exercise have been returned to the teenager without relapse into anorexia. The family and therapist discuss typical adolescent development to see if the eating disorder has interrupted any aspects of normal living for the teen. The focus of this phase also involves healthy parent-child interactions, increasing personal autonomy for the teen, and appropriate family boundaries post-recovery. Sessions are spaced every 4-6 weeks at this phase.
The Key Principles of FBT
Agnostic View of the Illness: The FBT therapist assumes that anorexia nervosa is a complex illness. The treatment does not focus on what causes the illness, but on helping the teen quickly recover. Neither the parents nor the teen are blamed for the illness.
Externalizing the Illness: FBT emphasizes that the eating disorder and the teenager are not the same. The view is that teens are “driving under the influence of anorexia,” and therefore cannot choose to stop the behavior without parental support.
Empowering Parents: Parents are viewed as the best resources to help their child and the primary drivers of change in the treatment.
Non-authoritarian Therapeutic Stance: The therapist takes an active role in supporting parents, but does not tell the family exactly how to help their child recover. There is not a one-size-fits all way to weight restore and recover from anorexia. The therapist is an expert consultant, but the parents are the experts on their family.
Unwavering Initial Focus on Symptom Reduction: FBT emphasizes quickly restoring the teenager to physical health to reduce the long-term damage that can be caused by sustained malnutrition. Other problems associated with the eating disorder (anxiety, depression, social issues, etc.) are not addressed directly in phase one of treatment.
Evidence for FBT
Research on FBT consistently supports the message that “weight gain was faster, hospitalization rates were lower, and maintenance of recovery rates was greater in FBT,” compared to individual therapies (Lock & LeGrange, 2013).
In one study of adolescents with anorexia nervosa who had been ill for less than three years, 90% of patients receiving family therapy demonstrated significant improvement, compared to 18% of patients receiving individual therapy. These results were maintained at a 5 year follow up (Russell et al., 1987; Eisler et al., 1997).
In a study comparing FBT to individual AFT (adolescent focused therapy), initial full remission rates were similar, but significantly more patients who had completed FBT maintained that remission at a 6- and 12-month follow up (Lock et al., 2010).
In a comparison of FBT to systemic family therapy (SFT), families participating in FBT had significantly faster rates of weight restoration, significantly lower rates of hospitalization, and overall lower treatment cost (Agras et al., 2014)
Looking for further consultation for eating disorders? Get started with Dr. Hosford.
References
Agras, W. S., Lock, J., Brandt, H., Bryson, S. W., Dodge, E., Halmi, K. A., Jo, B., Johnson, C., Kaye, W., Wilfley, D., & Woodside, B. (2014). Comparison of 2 family therapies for adolescent anorexia nervosa: A randomized parallel trial. JAMA Psychiatry, 71(11), 1279–1286. https://doi.org/10.1001/jamapsychiatry.2014.1025
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Eisler, I., Dare, C., Russell, G. F., Szmukler, G. I., Le Grange, D., & Dodge, E. (1997). Family and individual therapy in anorexia nervosa: A five-year follow-up. Archives of General Psychiatry, 54(11), 1025–1030. https://doi.org/10.1001/archpsyc.1997.01830230063008
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), 1025–1032. https://doi.org/10.1001/archgenpsychiatry.2010.128
Lock, J., & Le Grange, D. (2013). Treatment manual for anorexia nervosa: A family-based approach (2nd ed.). The Guilford Press.
Russell, G. F., Szmukler, G. I., Dare, C., & Eisler, I. (1987). An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44(11), 1047–1056. https://doi.org/10.1001/archpsyc.1987.01800240021004
