12/30/10

What the Maudsley Treatment Might Mean for Adults

The Maudsley Therapy is a relatively new treatment for adolescents with Anorexia Nervosa. In a nutshell, the parents are responsible for feeding the child and finding any acceptable way to be sure she eats. The treatment team aids the parents and empowers them to leave no wiggle room for the child to continue to restrict. The parents are full members of the treatment process and an integral part of recovery.

There is nothing novel about the concept behind the Maudsley treatment. Behavioral problems in children more often than not stem from ongoing issues in family dynamics. Accordingly, treating adolescents almost always includes family therapy, and that therapy also must support the parents' authority. Although teenagers are continually working on--and pushing acceptable limits of--their independence, parents ultimately have the responsibility and ability to set rules and enforce them.
What does make the Maudsley method unique is that, unlike so much of the treatment for Anorexia Nervosa, it seems to work. This approach focuses on children early in the course of the illness, and, as I have written many times, the chance for a relatively fast and full recovery is greatest before the eating disorder has fully taken hold. Using Maudsley either after inpatient treatment or right after initial diagnosis can enable a child and family to overcome the eating disorder and its psychological and emotional causes in the initial stages of the illness. The treatment tackles the triggers in daily life and helps heal the family dynamics that may be at the core of the disorder. With the eating disorder so exposed, the child can no longer hide her feelings or her symptoms and is instantly brought back into her life and into the relationships around her. The process does not allow the eating disorder to transform from starvation into a way of life.
Any ray of hope within the professional community quickly makes its way into clinical practice. Effectively, this means that therapists will try to incorporate new, promising treatment alternatives into the process of recovery. The Maudsley method is no exception.
But there are several obstacles to adapting the treatment to adults with a chronic eating disorder. First, the patient is an adult. As I wrote in the last post, it is critical that this adult have the autonomy to make decisions about her treatment. Imposing any steadfast rules--and the fear and uncertainty that is sure to follow--only strengthens the hold of the eating disorder: the patient has no other tools to cope with high levels of stress. Second, what does relinquishing some control over food look like for an adult? Third, who is the person (or are the people) in charge of supervising the eating? And exactly what role does this person have in treatment?
The first step is one simple fundamental adaptation to the Maudsley concept. A child often has little awareness of the scope of the eating disorder, how much the illness consumes her and the long term risk to her life. Most adults with a chronic eating disorder--those without the delusional component I discussed in an early post--are much more aware of these realities. Because of this difference, a patient will often be willing to accept that, despite her resolve and motivation to get better, she cannot do so on her own. The eating disorder thoughts remain too powerful. And that means she will need help throughout the day to eat. If more structured programs have had limited long term benefit, using the relationships in her life to help her eat can not only be effective but can be appealing to the patient herself. It can offer a new alternative rather than returning to the limited and largely ineffective options she has tried in the past.
The other difference is that the patient cannot be forced to eat the way a child can. Instead, she needs first to establish the proposed changes to the meal plan on a regular basis--preferably daily to weekly--with her nutritionist. She then needs to share these changes with the designated person or people in her life who are going to help her face the eating disorder thoughts. And third, she needs to empower her helpers and herself to make these changes happen. The patient needs to acknowledge that the changes in her eating will only take place when people in her personal life are allowed to support her against the eating disorder. This person is usually a parent or friend, significant other or spouse. Under certain circumstances, the therapist can also offer this kind of support and be effective. The difference between this situation and a parent helping an adolescent is that this helper does not have the same kind of authority a parent does. Accordingly, the power to make changes comes only from the collaboration between this person and the patient herself. So the crucial component to success is the patient's ability to let people into her life. That is how the Maudsley approach is most similar for adults: it insists the patient no longer is so alone.  
After the last two posts indirectly referred to the possible role families play both in the inception of an eating disorder and in the healing process, I think the next post should focus more specifically on the family as a whole and how disordered eating and an eating disorder disrupts its function.

5 comments:

  1. Here is an important resource for parents going through this with their children - Give Food A Chance by Dr. Julie O'Toole. Dr. O'Toole founded the Kartini Clinic in Portland OR, a treatment facility that specializes in treating teens and children with ED
    http://www.perfscipress.com/give-food-a-chance-julie-otoole-eating-disorder-bulimia-kartini-clinic/

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  2. Maudsley is only effective for those rare families that are actually stable enough to put so much united effort into feeding their eating disordered child. And, practically speaking, acting as a nutritionist/psychologist/parent/"caring-nurturer" is a full-time job; how many parents are fortunate enough to get enough time off from work to do this? See “Brave Girl Eating”-- the author/mom brought up the issue of having to juggle her work schedule in order to be home to eat with her daughter. Many folks just do not have flexible enough schedules.

    Can Maudesly be used on adults? Sure, if someone is willing to play parent. It’s unfair to put a spouse in this role, and it causes some really screwed up dynamics in the marriage. But a therapist can step in and play parent; of course, this would be very expensive, having a therapist on hand for every meal (even by phone). But maybe the logistics can be worked out- intensive food journals, phone sessions, e-mails, etc. As for whether the therapist can effectively play the role of the parent in the Maudsley situation, why the heckers not? Lotsa patients have a warped, trasnferency Daddy (or Mommy) image of their therapists.

    “I think the next post should focus more specifically on the family as a whole and how disordered eating and an eating disorder disrupts its function.” ---- Maybe I am a negative nelly, but I think in more cases than not the FAMILY is disordered from the beginning, and the ED is just a symptom of that overall familial dysfunction.

    I look forward to your next blog post! Your writing is so insightful.

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  3. My mother performed the Maudsley treatment on me for my eating disorder when I was 20 years old. I was diagnosed with anorexia at the age of 13 and was admitted to hospital as an inpatient until I was stable enough to take part in an inpatient eating disorder treatment program for child and adolescents. The treatment program used the Maudsley Method and once I was weight recovered through the program, I maintained that weight and was happy and able to function and feel like a normal adolescent girl again for a number of years. At 20 years old I relapsed. The only difference between the two bouts with anorexia, was that at 20 I was much more reluctant to get help and much more in denial that I had an eating disorder (again). My mom forced me to move back in with her and my dad. She called my employer, she called my landlord and informed them both about what was happening, without my consent. (yes, I was enraged and threw many a huge fit, but my mother stood her ground beautifully). She cooked/fed me all my meals. Made sure I ate. 3 meals, 3 snack every day every time. If I refused, I was denied privileges. All focus was on eating the food, getting enough calories and gaining weight, the mental work would come later. It worked wonders. However, as I reached nearer and nearer my goal weight, the anxieties and the eating disorder rose to an ultimate high again and I demanded professional treatment. We cut the maudsley treatment with my mom short and I admitted myself into an adult day program for eating disorders. The adult program did not use the Maudsley Approach. They were much more lenient around meal times, only offered lunch and a snack and really, left us with total responsibility when it came to gaining weight and recovery. Throughout this "professional" program, I lost 5 pounds and discharged myself early, lying to my mother about my weight. It was that simple. My eating disorder was happy. Needless to say, a few months later, I had clearly lapsed again and this time I willingly admitted it to my mother. She gave me an alternative. She told me either I must go to hospital, come home and COMPLETE the maudsley treatment from beginning to end, all 3 stages, or her and my dad would cut themselves off from me completely and I wouldn't be allowed to come home again. Naturally, I chose maudsley as the professionals failed me and the idea of the comfort of my own home was far more appealing. So, maudlsey with my mother it was. I was 21. My mother made me eat. I am now 23 and have not lost a pound since that day. And only once I had restored some weight was I able to even think clearly about recovery and my eating disorder. Adults cannot be left or rendered helpless to their eating disorders simply because they are of age. Their mind is not well. Their mind is completely controlled by the disorder, and is not capable of making rational decisions. The maudsley method is what worked for me as a child and as an adult. If the family is not functioning well enough, or is too selfish to take time off work to save their son or daughter's life, professionals can play the role of the parents. But I believe the focus on eating and gaining weight prior to mental therapy is key. Food is the medicine, no matter how old the patient is. Food first, all of it, every day, no excuses. And the mental recovery will come as the brain is fed. As an anorexia survivor, I advocate maudsley for all ages.

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  4. I just recently heard about the Maudsley Method and I believe it can be used with adults; as such, I respectfully disagree with a previous commenter.

    My spouse makes sure I eat dinner daily and I'm praised when I eat during the day. The rest of the time I'm on my own. I do feel nurtured by my husband, but in a loving relationship you should be nurtured so you can grow.

    As for this role being somehow unfair to my spouse, that's almost laughable. When you marry you take the good with the bad, it's somewhere in those vows you take, oh I don't know, maybe the ones about sickness and health?

    In a marriage relationship each person has strengths and weaknesses and it's how you support (or don't support) them that matters - it might be that the lack of support or overwhelming support that causes a screwed up dynamic, but not the actual presence of support.

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  5. I tried to get help for my ED in 1981, going to one therapist after another. They were consistent in ignoring my ED, mainly because they didn't know what to do. It's hard for me to believe now that it went on 30 years before they "noticed" my ED, on my insistence.

    Force is not care. I responded to the forced weigh-in and forced meal plan by losing more. I didn't like being bossed around by my therapist. Not with a therapist 20 years younger than me. On my insistence, the forced weigh-ins ended. I started to get better!

    Then my therapist got laid off. The next one was bossy, using threats and accusations, restarting the use of force. Of course I got much worse! I almost died. My psychiatrist also became very bossy with me, and that, too, made me worse.

    The Maudsley method looks okay to me but clearly can only work with certain types of families, those with...ahem, money, and if you're an adult a lot of it doesn't make much sense to me.

    The one thing that really helped me was to take control. My therapists were acting like babysitters. I didn't like that. I should have been taking adult responsibility for myself, and they were not allowing this.

    I realized that much of what ailed me was expectation. In my community I was expected to act crazy, a mad person, incapable, stupid. I sure wasn't! I realized expectation of madness breeds more madness. It's like a trap.

    So I used the relocation method. It worked! You have to get away from everyone that knows your history and relocate to a place where no one knows. I never saw doctors unless I had to, and when I did, I lied about my history, knowing they'd send me back to psychiatry all over again.

    Also, if they know your history they'll see you as less credible. Almost like your word isn't good enough. The average person who knows your history will automatically discredit everything you say as lying or delusional. But without the knowledge of your past, you get treated just the same as anyone else.

    I was amazed. I really did get better after all those years simply by not being seen in my community as a nutcase. I didn't expect these amazing results. I am nearly 60 and I now live a full life, never think ED-type thoughts and do not do ED-type behaviors.

    I can see Maudsley working for an adolescent, but for me, I needed to take control, take my body back from psychiatric and institutional ownership, and live.

    I was always capable, always rather intelligent. I loved questioning things and in therapy I was never allowed that, I had to follow their rules and act like a child. I was told over and over how limited I was, and how much I "needed" their guidance, which was only a power play on their part. Looking back, it was truly handicapping to go to therapy. I didn't realize that all those years being in the psych system was perpetuating my ED. Thankfully, I am out now. My parents, if they were still living, would be awfully proud of me.

    Julie

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