When it comes to eating disorder treatment, few (if any) approaches are as divisive as Family-Based Treatment, also known as the Maudsley Method (I’ll use the terms interchangeably) . When I first heard about Maudsley, sometime during my mid-teens, I thought it was scaaary. But, as I’ve learned more about it, I began to realize it is not as scary as I originally thought.
As a side-note: I know many people reading this post know more about Maudsley than I ever will, so your feedback will be very much appreciated, especially if I get something wrong. I should also mention that I never did FBT or any kind-of family treatment/therapy as part of my ED recovery. (I have done family therapy, but it was unrelated to my ED; it was a component of a family member’s treatment for an unrelated mental health issue.)
In this post, I want to briefly explain what the Maudsley Method entails and put it into context. I also want to discuss some of the key research studies testing the efficacy of FBT and some limitations of the treatment.
THE MAUDSLEY METHOD/FBT
Briefly, Maudsley is an intensive outpatient treatment approach that puts parents in the center of their child’s treatment. It has three main goals: (1) weight restoration, (b) restoring control of eating to patient, and (3) returning to normal adolescent development. This is achieved in three stages in 15-20 treatment sessions over a 12-month period. (More info here.)
The main difference between Maudsley and traditional treatments is that parents are put in charge of their child’s weight restoration and refeeding. In the first stage of the treatment, all meals are prepared and supervised by a parent and physical activity is minimized. As the patient gains weight, he or she is given more and more control over their food intake. The final stage focuses on adolescent development and typical coming-of-age issues.
PUTTING MAUDSLEY INTO CONTEXT
Nowadays, most clinicians (I hope) understand that eating disorders are caused by a complex interplay between genetic and environmental factors. But not so long ago, the blame (much like schizophrenia and autism) was put squarely on the family, namely: the mother.
In the 1800s both Gull’s (in 1874) and Lasegue’s (in 1873) clinical accounts included a list of common physical and behavioral symptoms as well as the notion that families were responsible for the cause of AN and its persistence (Yates, 1989). […] More modern views on etiology emerged in 1960 when Bliss and Branch’s review implicated media messages and social pressures inherent in western societies in the onset of AN (Rehavia- Hanauer, 2003). In the 1970s, psychological and family systems explanations peaked (e.g., Minuchin, Rosman, & Baker, 1978) and in 1973, Bruch described etiology in terms of individuation from one’s mother and the development of personal ineffectiveness (Rehavia-Hanauer, 2003). Accordingly, the notion of enmeshed families and over-controlling parent as causal is nearly archetypal in AN treatment history and still held by many today.
Naturally, when you blame the family for the child’s eating disorder, the most logical solution is to remove the child from the family (perform a “parentectomy”) in order to treat the illness. Naturally, this left a lot of parents out in the cold. They were in the dark about the nature of illness and perhaps more importantly, didn’t know what to do once the child returned home (hello relapse!) Imagine a family member is diagnosed with a mental illness, cancer, or cardiovascular disease, and suddenly you find yourself blamed for causing it, and what’s more, you are completely in the dark about how to manage it. Scary, right?
FBT changed that. It not only lifted the blame from the parents, it sought to empower and utilize them as key figure in eating disorder treatment.
This is why context–context that I wasn’t aware of when I first heard of Maudsley many years ago–matters.
THE EVIDENCE: RANDOMIZED CONTROLLED TRIALS
Onto the evidence. Randomized controlled trials (RCTs) are the ‘gold standard’ of clinical trials and are at the heart of evidence-based medicine. In part because the prevalence of AN is low and treatment dropout rates are high, only a few RCTs have been done examining the effects of family therapy in treating adolescents with anorexia nervosa.
I’ve adapted a table from Smith & Cook-Cottone (2011) summarizing RCTs using the Maudsley Method or variations thereof below:
I don’t want to discuss these studies in too much depth, but needless to say, they all have their strengths and weaknesses. For example, the Robin et al (1999) study which showed that a type of family therapy was more effective than individual therapy for weight gain and resumption of menses is confounded by the fact that 58% (versus 28%) of patients in the BFST group received inpatient treatment during the course of the study. So, is it BFST or inpatient treatment that’s responsible for the superior weight gain?
By far the largest and most robust RCT was published by Lock and colleagues in 2010 (freely available online). The study compared standard FBT with individual therapy called AFT (analogous to EIOT). At the end of treatment, full remission was achieved by 42% and 23% of patients in the FBT and AFT groups, respectively. This, however, was not a statistically significant difference (but at p= 0.055, it was almost there). FBT proved to be significantly superior at the 6 and 12-months follow-up periods (49% and 23% at 12-month for FBT and AFT, respectively).
The strengths of the Lock et al study are: (1) comparatively large sample size; (2) collection of data across multiple sites in different cities; (3) using a manualized treatment protocol (which means that, in theory, everyone in one group gets the same treatment); and (4) training and supervision of all treatment therapists.
A criticism, however, is that AFT is not an evidence-based control. From my understanding (and in my experience), most outpatient, inpatient, and residential treatment is multidisciplinary: it includes individual therapy, group therapy, and nutritional therapy, among other things. In this study, AFT was comprised solely of individual therapy (with “collateral contacts” with parents outside of the individual therapy sessions with the patient.)
Edit: Correction to the above from Anon in the comments: “AFT did not consist solely of individual therapy sessions. Both the FBT and AFT groups were seen also by pediatricians with extensive eating disorder expertise who gave guidance on physical requirements for recovery.”
In the end, though, I think Lock et al.’s conclusions are fair and balanced: “The findings of this study together with the existing smaller-scale studies, suggests that FBT is superior to AFT for adolescent AN, though AFT remains an important alternative treatment for families that would prefer a largely individual treatment.”
One important component for why FBT was superior to AFT at follow-up was that patients in the FBT group experienced considerably lower rates of relapse compared to those in the AFT group. This is not surprising: in FBT, parents are integrated into the treatment process and as a result, become much more aware and more educated about eating disorders and what to watch for.
In my opinion, this is one of the biggest strengths of FBT, and it is also why I’m excited about UCAN (Uniting Couples in the Treatment of Anorexia Nervosa).
LIMITATIONS OF FAMILY-BASED TREATMENT
For an illness that’s soooo difficult to treat, having a treatment approach that works–even for a subset of the patient population–is pretty freaking amazing. And here’s a key point: no treatment for anorexia nervosa will work for the entire population. It is just not going to happen.
From my observation, it seems that some practitioners and/or parents are really into FBT because they’ve seen it work. On the other hand, suffers that had terrible experiences (because when FBT doesn’t work, it can be a disaster) or those who know it would not work for them, get very defensive and interpret the excitement over FBT as an attempt to convince them that FBT should/will work for them and if it didn’t, they must have been doing something wrong.
I see this repeated often and I’m definitely not free of blame. I know I used to (and probably still do) get defensive. This is because when individuals claim that FBT works for 80-90% of adolescent patients, a plethora of different reasons for why that actually can’t be the case in practice flash in my mind. (Please note: I’m not denying results of studies.)
Here’s what I think. We know that FBT works really well for a subpopulation of adolescent AN patients who haven’t been sick for a long time (~12 month on average). And research seems to suggest that for this subpopulation, FBT should probably be the first-line of treatment as it seems superior to other forms of treatment. And given that something works, at least for some patients, it is only logical to see what other ED patient subgroups would benefit from it as well. Adults with AN? Adolescents with BN?
However, I do fear that some proponents of FBT–those that are really into it–sometimes fail to see that it simply cannot be used in many situations. I also feel that some fail to acknowledge the intense self-selection bias to occurs in these studies.
These are NOT the fault of FBT, nor are they criticisms of FBT as a treatment modality. As Laura Collins said on the FEAST FB page recently: FBT is a tool in a toolkit of treatments for eating disorders.
I want to finish by listing just some of the reasons why FBT might not be appropriate. This is not a comprehensive list, and admittedly, it is one that’s formed largely as a result of my own experiences, living in Toronto:
- Language barriers (English as a second language)
- Financial barriers (To pay for it, to take time off)
- Mental health issues of parent(s)
- Mental health or physical health issues of a sibling (or grandparents, for that matter)
- Cultural barriers (to understanding/accepting mental health issues, mental health stigma, etc.)
- Other factors that disrupt family functioning (as an example: unfortunately, homophobic and transphobic parents still exist, and likely in higher numbers among immigrants from more religious or conservative countries)
- Emotional, physical, or sexual abuse
Living in Toronto for the last 15 years, I see families who encounter one or more of these difficulties more often than I see those who don’t.
I think it is irrefutable that FBT works really well for a subset of adolescent AN patients. That’s a great accomplishment for an illness that’s so difficult to treat. But as we continue to search for other treatments for anorexia nervosa, and other eating disorders, let’s be mindful of some of the challenges that some families face (and as I said, in some cities more (a lot more) than others). So, in my view, FBT is mostly hope with a bit of hype (but that probably depends on what circle you are in, too!)
Smith, A., & Cook-Cottone, C. (2011). A Review of Family Therapy as an Effective Intervention for Anorexia Nervosa in Adolescents Journal of Clinical Psychology in Medical Settings, 18 (4), 323-334 DOI: 10.1007/s10880-011-9262-3