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.

The Residential Treatment Option

The decision to go into residential treatment for an eating disorder is a challenging one. First and foremost, the purpose is to restore health to someone who has become too ill to function in the world. In a controlled setting, the eating disorder thoughts cannot reign unabated. The program enables restorative nutrition so that the person's body and mind can heal.

The most pressing concern is how to be sure an inpatient stay fits into the recovery plan. Eating solely to improve short-term health is of little consequence to real recovery. Although the decision to seek a residential program can be harrowing for a patient and her family, it is often followed by a sense of relief on all parts. Just the act of doing something concrete gives the illusion that full recovery is near.

Certainly for many patients, this respite can act as a springboard for more effective treatment after discharge, but a significant minority relapse and return to their pre-inpatient physical state before long. For these patients, restoration of health is not sufficient to overcome the relentless thoughts and compulsions of the eating disorder. And there are times that this sequence of events is more demoralizing than just staying the course.

For the patient with her first, second or even third episode, the professional consensus is that residential treatment is a necessary step. As I have discussed prior, resuming eating and normalizing body function can be enough to stem the onslaught of an eating disorder--especially early in the course of the illness--and to lead to full recovery. However, the patient and family need to understand the purpose and limitations of an inpatient stay, most importantly that the end result is not that the eating disorder just disappears.

Inpatient recovery exists in a bubble without any of the pressures and stresses of daily life that lead someone back to the eating disorder symptoms. On the most basic level, the patient needs to learn new ways to cope with the world and her feelings once she has returned back to her life. A clear, directed treatment plan needs to be in place long before discharge. Everyone must be aware that the inpatient program is a stepping stone towards recovery and not a magical cure.

For patients considering hospitalization after a protracted illness, the decision process looks very different. The severity of the physical symptoms takes precedence. The person's medical status needs to be the top priority because a lengthy but effective treatment does no good if the patient's health completely deteriorates during the process. Inpatient treatment becomes necessary when the person is at high risk to maintain her health and well-being, no matter the other gains in recovery.

However, people who have been struggling with an eating disorder for many years have become accustomed to feeling very ill most of the time. Because of their unusually high pain tolerance combined with the shame of being ill so long, patients find it very hard to admit to their fragile physical state. Even families begin to get used to the patient being sick. The therapist and doctor need to regularly assess the patient's medical condition and reinforce how dire her suffering is and the necessity of trying to be open about her physical state.

At the same time, after a series of hospitalizations, patients and families are aware of the limitations of an inpatient program. The history of disappointment added to growing hopelessness makes it hard to commit to such a disruptive and costly decision in recovery. Medical stability and breaking the eating disorder cycle become the only clear gains of hospitalization. But even when treatment is moving forward, a residential program can be a critical step because it may very well afford the patient more time in a stable medical state to get well. Another round of inpatient treatment often appears to the patient and family to be a futile merry-go-round rather than a part of a larger recovery, but a frank discussion about the purpose of this step often is extremely helpful. The result is to ensure that the patient's physical well-being remain a crucial part of the larger picture of recovery.

The other roadblock to making a clear and useful decision is the patient's role in the process. Someone with a chronic illness needs to reclaim some autonomy when inpatient treatment seems likely or at least a serious consideration. She can't feel like she is being shipped off to the hospital again like a child. These patients are full-fledged adults and, accordingly, can make their own decision about treatment. I have encountered too many patients well into adulthood still submitting to the will of families or paternalistic therapists who imply that having an eating disorder renders a person incompetent. There is no doubt that the eating disorder thoughts, at their most powerful, can affect someone's judgment, but almost all patients can weigh the options with a therapist and make a reasonable decision. The result is a patient who feels empowered by her own role in treatment decisions and feels much more willing to try to take an active part in making this commitment worthwhile.

The second way a patient with chronic illness takes hold of her treatment is a bit paradoxical. As I have stated before, an eating disorder effectively isolates someone from the world around them. There is no room for people and especially intimate relationships when the thoughts and behaviors of an eating disorder consume all of the time and energy a person has. One relatively new treatment program called the Maudsley method is aimed at treating adolescents with anorexia. The protocol entails the patient relinquishing all decisions about food to her parents who supervise every meal and snack and are an integral part of the treatment process at each step and each appointment.

It is a new concept to apply this approach to patients with chronic eating disorders. An adult cannot have her independence taken away, but she is also acutely aware that she cannot eat normally on her own: the eating disorder thoughts remain too powerful. The general idea is to formulate an individual plan to include an important person in her life in the daily process of eating. This is another powerful way to let someone in. I will elaborate on this idea in the next post.

Love Thyself?

"Love thyself" has become the mantra of the modern woman. According to the current gospel, i.e. women's magazines, the path to a healthy relationship is blocked until you love yourself first. But it's hard to figure out exactly what that means, although there is no shortage of people who think they've figured it out. The answer, for women who are looking for a simple fix, comes in assortment of self-help checklists meant to impart romantic enlightenment. After sifting through the blather, the only consistent message is a covert one: your personal responsibility in society is to make a relationship work and if it's not working, it's your fault. It has been all too easy for women to feel trapped in this double bind.

What has made this message so powerful and also left it relatively uncontested is the isolation of modern day life. Left alone to find their way, women are ripe for any sage advice. The media happily obliges with many--often uneducated--forays into pop psychology. The common wisdom of the day emphasizes that not just self-acceptance but self-love is essential for happiness. But a thread throughout this entire blog is that there is only one reason in our society that a woman can truly love herself: if she stays thin. So the fundamental message equates thinness with suitability as a mate, and the media's attempts to rescue women's self-image actually leads women, obsessively, back to the scale, desperate to shed the pounds that will magically land them in a happy relationship.

What's so backwards in this philosophy is that our own self-image is grounded in relationships., not in loving oneself. Historically and psychologically, that is the cornerstone of how people, and especially women, see themselves. To arbitrarily separate oneself from one's relationships is akin to tearing away the essence of our humanity.

Fundamentally, we have always had a social nature. The successes and downfalls of the human race rest largely on our sense of community, and much of our intellectual pursuit has focused on the dichotomy between our sense of individuality and our social existence.  We have attempted to understand our innate need to relate to others through philosophy in the distant past, but in the last century the mode of inquiry has been scientific, namely psychological and biological.

Some of the most basic understanding of human relationships has come from studies of the mother-child bond. Our identity originally forms in a symbiotic way with the mother. A trove of psychoanalytic research explores every nuance of a baby's transition from literally being one with its mother in utero to learning to differentiate between itself and other objects, also initially its mother. But it's startling to recognize that when a baby first looks at its mother, the baby identifies her as part of itself! And seeing oneself as an individual comes not days but a few years into life. Our sense of being independent is an outgrowth of living in the world and not at all an innate part of our psychological make-up. If that's the case, then "love thyself" as a mantra to adopt in our little bubble ignores the basic facts of our dependence on others. No wonder such an artificial way of living ends up being translated into something so concrete and meaningless as "stay thin."

Further research into child development places increasing importance on parent and peer relationships as the central mechanism a child uses to learn who he or she is. The child studies these reflections from others to learn how to become a fully independent person, also one of the goals of parenting. But if the most powerful tool to foster independence is the relationship with a child, then perhaps the goal is not complete autonomy at all. In a social society, a fully functioning adult learns to hold up her end of the relationships in her life. So the idea is to exist in a web of people and know one's place in one's own network. Maybe that's how to become a mature adult.

The difference between these two philosophies--love thyself or live in a network of relationships--can help direct a confused, at risk adolescent either towards an eating disorder or a healthy self-image. At this stage of life, a child is struggling to form an identity and, as I discussed in a previous post, is routinely trying on different hats to see if they fit. Outside of appearance and weight--things children this age universally criticize--a teenager will see little else in the mirror, so advocating the impossible edict to "love thyself" will only stoke the flame of the self-hatred.

Adolescents use all of the relationships around them to shape their sense of themselves and are susceptible to be quickly influenced by the people around them. For further proof, anyone can remember poor decisions of that time of life, and these powerfully emotional memories are always tinged with shame and the shock of being so painfully vulnerable. But these events remain defined markers of when we learned about ourselves. The positive and negative consequences of those relationships signify the process of coming to know who we are.

The critical importance of relationships to personal development in adolescence leads to an obvious step for parents. The key is to use the personal relationship with children to reflect who they are and what they mean in the world. It's a mistake to think children will acknowledge the information as an adult would. In fact, a child will look in that mirror again and again to be sure of what they saw and often challenge it for years before accepting this reflection. But if adults help the child learn who she is, then she won't end up relying on food and weight as the only barometer. We can only love ourselves as well as we have been loved. Ironically, we best see ourselves in reflections of others than in the mirror.

I want to switch gears for next time. In an early post, I discussed the pros and cons for residential treatment for eating disorders. I'm going to revisit that topic and speak about some alternate treatment ideas.

Expectations

At the end of the last post, the ideas of specialness, hope, living through the future and secretiveness--all discussed here previously--began to seem as relevant to adolescence as they do to eating disorder recovery. The question that came to mind is that perhaps the narrative of an eating disorder tends to remain stuck in the limited scope of adolescent expectations. That doesn't mean that someone with an eating disorder IS an adolescent at all but that having an eating disorder stops the personal development of how one views life's course. And then understanding the difference between the expectations of an adolescent and those of someone with an eating disorder might be a clue to help protect children from getting sick.

The state of becoming--the central theme of adolescence described in the last post--is a precious moment in life when everything seems possible for an instant.  But this developmental stage has instead become the Holy Grail, so revered that people try to extend it well past its expiration date. The sense of becoming is valuable for society at large because, by definition, it remains a brief moment in life. Teenagers embody the hope of a community for a new and improved future, but there is nothing pretty about someone in middle age working too hard to look or seem ten or twenty years younger. At some point, to have value for oneself and one's community, we all have to become something, namely ourselves.

In the world of an eating disorder, one is always becoming: becoming thinner, becoming sicker or imagining a future life when one has become well. In the end, the therapy for an eating disorder must lead to one significant transformation: from becoming to having become. A patient is so used to focusing on a future of being well and the fantasies of what life will be like that she has generally lost the ability to think and feel today, now. The end result is to completely eliminate any expectations for today and to ignore the real process of how life changes. The goal, dictated by the rules of an eating disorder, is predetermined. Each day is the same. Someone with an eating disorder continues to mature but her sense of how to become doesn't. And so expectations become almost contradictory: the aimless musings of a teenager explained by an intelligent, sophisticated adult.

But these free-floating expectations are the essence of adolescence. Suspended between an unrealistic yet somehow universal sense of promise and a tumultuous, emotional present, teenagers seem incomprehensible to any adult. They resemble wild, irrational beasts with the potential brainpower of a Nobel Laureate, the libido of a dog in heat and the emotional intelligence of an infant. The challenge of having a rational conversation can feel like learning Mandarin in one sitting. And even any linear sense of narrative is constantly being interrupted by fantasy and wild expectations. The precarious mental state and instability of a self that dominates adolescence seem to act like bait for disordered eating. As I have written in several posts, focusing on food and weight can provide order and identity to the utter confusion facing these kids. How then does a well-meaning parent talk to them in a language that will make sense? How does a parent be sure that the process of becoming lands a child squarely in the world of having become?

This is where the difference between eating disorder recovery and adolescent angst is useful. In treatment, the relationship in therapy acts like a mirror, and the patient consistently learns about herself by looking at her reflection each session. The disorder makes that image look like a monster: fat, slothful, disgusting and unlovable. Session after session, it becomes harder to believe the disorder when therapy reveals a very different self-image. The role of the therapist is to remember to state the obvious. Consistent positive feedback is  something a patient has never received and needs to hear over and over again. Patients with eating disorders have pretended to be okay while hiding the constant internal suffering. By letting their guard down and still getting regular praise--something most people take for granted--an entirely new reflection comes into focus. The subsequent confusion, emotions and dependence, previously inundated by eating disorder thoughts, represents the patient's introduction to life without the disorder. Living no longer needs to be synonymous with isolation. Being real no longer needs to mean being a burden on others but getting help and support.

The opportunity of involving all of oneself--thoughts, feelings and apprehensions--in the moment is an enormous relief for a patient unable to allow her expectations of life to mature since first becoming ill. For an adolescent, especially one at risk of perpetually becoming, the role of adults in her life is to act like that mirror. The adult doesn't need to tell or retell the child's story. The kid needs to figure that out on her own. But an adult needs to try to translate the Adolescent language (Mandarin perhaps) into something the world can understand. Although it certainly will take a few tries--and likely be very trying--a caring adult needs to show the child her reflection--with a combination of practical advice and regular positive feedback--and attempt to really understand the confusion of identity, emotion and expectations. Just as in therapy, this can create a stabilizing force. Think of it as harnessing all of this energy so it really can become ... something.

The risk of an adolescent slipping into an eating disorder, according to the above argument, hinges not just on self-esteem but on the reflection adolescents get from adults in their lives. I want to speak more about reflections and relationships in the next post.