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Is Maudsley Family Based Therapy the right treatment for you?

16/2/2012

10 Comments

 
By Chris Thornton - Clinical Director of The Redleaf Practice
and Dr. Stuart Murray - Director of Family Therapy at The Redleaf Practice
The learned doctor says to the family of the young girl suffering from anorexia nervosa, "I'm not sure if Maudsley is the right treatment for you. I think individual therapy would be much better for you".  

There may be many reasons that said learned doctor may say this to this patients family. Some of the most common ones will be; “we know that Maudsley doesn't work for everyone (and you are one of those)”; “you/your daughter is too old or to psychologically mature”; “anorexia is a chronic illness and is resistant to treatment so it is not logical that a family could renourish a starving child in the long term ( as hospital has often failed to do)”; “your daughter is not motivated to change”; “your daughter's eating disorder is too severe to be treated with family therapy”; “your daughter needs to be helped to separate for you and learn to make her own decisions”; and the less often expressed but implied - “your daughter has an eating disorder which means you have caused it by over enmeshment with your child; as it was your fault you can not be involved in fixing it.”


I'm sure that the learned doctor is not trying to practice in an uninformed or unethical way. They mean no malintent. It is just by behaving in an uninformed way, they are potentially depriving their patient of the leading treatment available for adolescents with anorexia. This is a potentially lethal mistake. In my humble opinion it is also unethical

“MFBT does not work for everyone”

Numerous reviews of the scientific literature have reported six Randomised Control Trials involving MFBT.  These have indicated the clinical effectiveness of the treatment approach.  The outcome data for this therapy is strong with around 70-80% of patients undertaking MFBT achieving a good recovery after 12 months and 90% recovery after 5 years (Lock et al. 2006).

 Previously, one fair criticism was that MFBT had not been compared to an individual therapy that would be suitable for adolescents. This was rectified in 2010 when Lock et al (2010) published data that indicated that MFBT was superior to Adolescent Focused Therapy in terms of weight gain and change on the Eating Disorders Examination (a measure of eating disorder behaviour and cognitions) at end of treatment.  MFBT was also superior in terms of full remission rates at both 6 and 12 month follow up.

That is between 70 - 90% of patients do well with MFBT, and MFBT seems superior to  when the adolescent was treated in individual therapy. It is correct to say that MFBT won't work for everyone, it will however assist 70-90% of patients gets well. This compares favourably with the natural history of Anorexia Nervosa which shows a recovery rate of less than 50% at 5 years.

MFBT is, without question, the first line treatment of choice for an adolescent or child with anorexia nervosa.  Any practitioner that recommends against it is giving you bad advice.



“MBFT will not work for your child because the Anorexia is too severe”

It is important to work out which families may do well with MFBT. We now have some data, based on one study, done by the originators of MFBT,  that might help use science to answer some of the learned (but paradoxically, uninformed) doctors other criticisms.

The paper I'm looking at today is by Daniel le Grange et al (2112). This paper tries to break down the data and see if we can be guided in looking at which families MFBT may work best for.  Previous studies have indicated that for greater weight change, patients with HIGH levels of eating related obsessionality  did better with a longer, rather than a shorter course of MFBT. This makes sense as it is typically thought that the higher levels of obsessionality the more severe the patients anorexia.  Single parent or non intact families also did better ( in terms of eating disorder psychopathology) with a shorter rather than longer course. This again makes sense as MFBT is difficult enough for "intact families" and single parent families are likely to need support over a longer period.

The most recent study found the following :

Again, patients with the MORE SEVERE ILLNESS DID BETTER WITH MFBT than AOT. Both patients with higher level of obsessionality and higher global EDE scores did better when treated with MFBT than in individual therapy at the end of treatment. In addition the presence of the binge-purge subtype of anorexia seemed also to do better at follow up when treated with FBT over individual therapy. This was not a significant result but is interesting because the presence of binge-purge behaviour is also an indication of the drivenness of the patient to lose weight (ie higher anorexic severity).

It did not matter as to how depressed you were, what your level of self esteem was, your level of self efficacy (of patient or parent), or BMI at beginning of treatment (although patients weights were above 75% of ideal body weight at the beginning of the study). There was no difference between treatment here. 

This means that these variables, including markers of severity such as weight and depression, do not help us determine if MFBT or individual therapy would be better. MFBT should not be denied on these markers of “severity”.

Outcome in both treatment was worse if you had required an inpatient admission. Notably it did not mean that MFBT was less helpful if you had this marker of severity and is hence not a reason to note use MBFT as your first line treatment. Again in BOTH conditions older adolescents had a poorer level of remission of illness irrespective of the type of treatment. The same can be said for duration of illness. What these point to is the need for early and active treatment of the illness with the most effective treatment. 

A common ‘learned Doctor” reason to not use MFBT is that the older adolescent, with their assumed greater maturity and insight may be more suitable to an individual approach (actually the studies authors of the current study predicted this). This data says that this is not the case. Age is not a factor in not choosing MFBT. 

“You shouldn’t use MFBT because you can’t trust the research”

I have heard this said often as an argument to not use Evidence Based Treatments.   It is tantamount to saying the data supporting MBFT is scientific fraud.  Clinicians will often claim that the patients selected in the research studies are “not like my patients”.  They usually sound very convincing, but I’m not sure how they know. What may not be openly discussed, is that in such cases the learned doctor may be (unintentionally) overlooking many years of international scientific and rigorous research, on the basis of an opinion with no scientific support. This advice may jeopardize your child’s well being. 

The only way to work this out is to look at the exclusion criteria used in studies.  In the study discussed above the exclusion criteria were: currently psychotic, dependent on drugs or alcohol, had diabetes or were pregnant, or had previously had MFBT or AFT.  Patients were not excluded for common comorbid diagnosis such as anxiety, OCD, or depression.  In my practice I would not engage in an active treatment for an eating disorder patients with psychosis or active substance issue. I would treat patients with diabetes and who are pregnant.  Patients also had to be seen to be medically fit for outpatient treatment, which is entirely reasonable. 

The patients in these studies are the same as the patients who present to an eating disorders clinic.  There is no reason not to apply the scientific findings to your child.

“Individual therapy would be better for your child (... because it is your 
fault she has it)”  

If anyone can show me any data about an etiological role for families in anorexia I would be very happy to see it.  Until then, I am going to keep putting it out there that families are not the cause of anorexia.  To continue to hold this view restrains the treatment of anorexia.  To the contrary, families are the single most effective resource in getting children well from anorexia.

To say that families cause or maintain anorexia is wholly uninformed. The presence of any life threatening illness naturally causes changes within family functioning, and anorexia is no different. Simply put, everybody in the family is effected by the presence of AN, and not just the patient. It can make some family members to feel guilty, others to feel angry, and it can often coerce us away from our normal instincts and relationships through fear of not wanting to elicit an anorexic backlash or exacerbate symptom severity. In a sense, the presence of anorexia, and the fear it sometimes elicits, can result in some families almost becoming used to the anorexic regime. To my mind, this a symptom of the anorexia which impacts the whole family, and does not mean that the family caused or is maintaining their child’s anorexia.

What strikes me is that it is impossible to address such family wide effects of anorexia in individual therapy.  In my opinion, one of the reasons why MFBT is so effective is precisely that it relies on parental expertise. Nobody knows children better than their parents, nobody loves them more, and nobody will fight harder to save their life. Also, the changes brought about in MFBT (which include addressing the family wide symptoms) lead to lasting change because children live and exist in the context of their families 24/7. This is most certainly support by scientific research which shows that even after 5 years, 90% of children who undergo MFBT are still symptom free.

MFBT is most certainly a difficult form of treatment, and in many instances is one of the tougher challenges a family will face. However, this alone is not sufficient to dissuade people from commencing a treatment which although difficult, is highly effective in saving their child’s life. In my experience, every single family I have worked with has said during the course of treatment that the sacrifices and challenges involved in getting their child well pale into insignificance when considering the potential thought of their child not getting well.


“MFBT is only about weight gain and will not take into account the underlying psychological factors that have caused the anorexia”

Even if this was true, and MFBT was a only a vehicle for weight gain, this may not be a bad thing as weight gain and full nutrition is needed in recovery from anorexia.  However, weight gain is necessary but not sufficient for recovery.  Otherwise, hospitalisng patients and refeeding to normal weights would be curative.  We know that it is not.  

The idea that MFBT does not address adolescent issues that may be involved in maintaining the anorexia simply indicates that the maker of the statement does not have a rudimentary understanding of, and certainly no training in, MBFT.  Phase 1 - agreed, it is focused on weight gain.  Simply put, the magnitude of the potential medical crisis means that treatment is justifiably focused on weight gain, to reverse the features of starvation which trap many adolescents in long term anorexia. However, to achieve this weight gain there are usually some important changes that occur in the structure of families (such as everyone being present at meal times; health becoming a priority; sibling relationships are strengthened and parent relationships are empowered).  Then in Phase 2 - eating is handed back to the adolescent and in Phase 3- adolescent issues are addressed.  Repeat in phase 3 (and in practice it probably begins in phase 2) adolescent issues are addressed.  It is just that these issues are addressed in an individual without a starved brain rather than prior to refeeding.  I have done enough individual therapy with patients with a starved brain to recommend against it whenever possible.

Conclusion.

When we look at the data, there are very few reasons to suggest an individual approach over MFBT approach in the treatment of adolescent anorexia.  MFBT needs to be the first line treatment as over 70% of families will have a good outcome with MFBT.  Any advice to the contrary is, at best misguided, and is not based on the latest evidence.  We do need some more information about extremely low weight patients, but overall, patients with high levels of severity do as well or better with MFBT.  There does not seem to be any reason to not offer MBFT based on measures of “family dysfunction”.  The initial goals of MFBT are weight gain, as they should be in the treatment of anorexia.  The notion that MFBT is only about refeeding is misguided and shows a lack of training in MFBT.  Lack of initial and ongoing training in Evidence Based Therapy in the eating disorders is a major problem which needs to be addressed as a priority.

with thanks to www.maudsleyparents.org




10 Comments
Rod McClymont
16/2/2012 04:27:20 pm

Bravo! Bravo! Bravo! Well said Chris and Stuart

Reply
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23/9/2012 06:44:59 pm

I was searching for the matter you shared through blog. It is quite interesting and obviously very informative for me. Thanks you very much!

Reply
view site link
24/6/2013 06:40:35 pm

Right health and treatment for the illness and disease is the only way to maintain and lead a good life. I think such treatment method should be taken with great concern and necessary evidence should be kept in case something goes wrong .thanks for the share.

Reply
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24/7/2013 07:19:03 pm

I was completely unaware of the treatment which you have suggested for anorexia. You have indeed shared a vital post.

Reply
Marcella
29/7/2014 08:23:54 pm

any chance of a follow up article for those parents who ARE offered FBT with little or no alternative, but who, ably assisted by the likes of your "good doctor", lack confidence that they will be able to do it?

Reply
Apee
6/11/2014 07:56:43 pm

I agree. I would like to know how parents feel in general - at the beginning at least, as for us, we are in the first week of getting to know about this method, trying to apply it, and we have NO idea of what we are doing. It seems in fact that we are making things worse.

Reply
Lisa
6/11/2014 07:30:10 pm

We did maudesley. My daughter fought her parents and therapists with everything she (or anorexia) had. Nothing could have prepared us for the violence, stress and fear we lived through. We did everything the therapist told us to, and her weight gain was swift. But half way through phase 2 the therapist said our daughter was fighting her and therapy was going nowhere so she said no point continuing. We were left with a child full of hatred, exhausted parents and anxious siblings. 6 mths later and she is relapsing.

Reply
Dr Stuart Murray
10/11/2014 05:12:51 am

Dear Marcella, Apee and Lisa

These are great questions, and ones which come up frequently at the start of treatment. I'd say that the overwhelming first reaction of the majority of parents embarking on FBT is one of fear, anxiety, and trepidation. There are few more disempowering and terrifying illnesses to confront than anorexia nervosa.

In essence, a very typical and normative response for families in responding to meeting anorexia within their family centres around parents being invited away from their parental instincts. The intense magnitude of fear in those with AN, when faced with the necessity of gaining weight, translates behaviourally into high levels of adolescent distress and motivated avoidance of food. As a result, many families I have worked with over the years have reported the notion of attempting to minimise their child's anxiety by giving less challenging food, and less appropriate portion sizes, often times against their better judgement. As one family put it, "if I can avoid World War III by switching out the pizza which the rest of us are eating for a salad, I'll take that option. At least that way she'll actually be eating something." However, as a result of this inadvertent shift in family dynamics, the family may become partially mobilised around avoiding the distress created by the anorexia, rather than overcoming it.

Whilst this may be effective in minimising anxiety and conflict in the short-term, this may (i) support the avoidance of normative eating practices, (ii) inadvertently support the notion that particular foods ought to be avoided in avoiding distress, which supports the idea of some foods being dangerous, (iii) and preclude the learning of any new associations to feared foods.

However, reversing these behavioural trends and confronting AN is one of the most challenging experiences a family can go through, and it is very common to feel daunted or disempowered at the start of this journey. It is made doubly challenging when considering that our early treatment goal (i.e., weight gain), which is the unrivalled greatest fear of our patients. Thus, when commencing FBT and confronting the tyrannical regime of AN, and in bringing about weight gain, we understandably see a marked increase in adolescent distress. Whilst this can challenge many parents' resolve, this is most definitely par for the course, and we cannot overcome the intense anxiety inherent to anorexia without also experiencing intense anxiety. In a paradoxical kind of way, this intense anxiety often lets us know that we're actually on the right track with treatment, as it is only when there is no option for anorexic compensatory behaviours that psychological shift may begin to take place.

However, what is perhaps the most important part of treatment, without doubt, is sticking to the game plan throughout this escalation in anxiety. I strongly believe that whatever adolescent behaviours are effective in assisting parents in becoming less firm, are immensely reinforcing for the adolescent, and we will see a lot more of them during treatment. For instance, if an adolescent breaks a plate in a particularly distressing meal, and this results in his/her parents becoming less firm and serving a less challenging meal through concern about the anxiety escalating even further, we can expect at future challenging meals that many plates will be broken. This is negative reinforcement, and it is very powerful when considering the neurobiology and temperament of those with AN, which illustrates that consequence-based learning is more effective than reward-based learning. Thus, the avoidance of perceived consequences are of immense important in FBT.

It is based on this notion, Lisa, that I would urge you to continue treatment. A weight-restored child is not always a recovered child. Also keep in mind that if we reintroduce feared foods and feared portion sizes and our teens gain weight, and then treatment stops, we may have actually strengthened their association that some foods and portion sizes result in exponential weight gain, which may actually prime and deepen their fear of these foods, given that the feared outcome was confirmed and there was no new learning which took place.

There is no doubt that anorexia can be one of the most challenging experiences a family will ever face. I would also urge you to keep in mind that there will also be few times in your teen's life when they will need you this much. Anorexia is immensely challenging, but there is no greater calling than saving your child's life. May I refer you guys to a letter which a young woman I was working with wrote to her family after she discharged anorexia from her family's life? Here is the link:

http://www.theredleafpractice.com/blog/category/mfbt

Warm Best Wishes,

Stu


Reply
Marcella
6/10/2015 01:06:40 am

Dear Dr Murray

Thank you for your detailed and thoughtful reply.

I appreciate what you are saying, but why no mention of food? Surely the aim of treatment isn't weight gain because the patient is scared of that or the therapist and parents will feel better if the patient doesn't look like a skeleton, but because emaciation is the most obvious sign of a lack of life giving nutrition. A meal of salad rather than pizza isn't just a bad idea because of the learning opportunities missed but because pizza has more fat soluble vitamins and energy giving calories in it than salad.

When FBT goes wrong, as it did in our case, it can be because it descends into a battle of wills between parent and child, when what it should be is a means of reversing the damage done to the brain by malnutrition even though the nature of both the disease and adolescence make this very difficult for the patient

Reply
Julie Greene link
21/11/2016 04:43:38 pm

I had anorexia and binge eating over three decades. So when I started not too much was known. The first thing the "therapists" did was to blame my parents! In hindsight, I can tell you that parent-blaming really harmed my entire family. My parents are no longer living. One of my brothers continued to blame our mom for everything that went wrong in his life. I believe this was due to the harm that the parent-blaming therapists did.

None of us are stereotypes. They assumed "enmeshed mom" but no, that was not at all the case. They also stereotyped my family based on the fact that we were Jewish. It is only in hindsight now that I know antisemitism fueled much of the way my family was treated throughout those decades.

I think it was a mistake on my part to go to therapy, as I now know it perpetuated my ED. The mental health system itself is a one-way door and you end up a revolving door syndrome very quickly. After I dumped therapy and psych meds my ED went away on its own. I am nearly 60 years old and very thankful!!!

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    Chris Thornton is a Clinical Psychologist and the Clinical Director of The Redleaf Practice, a specialist outpatient clinic for the treatment of eating disorders.  He is interested in bringing elements of positive psychology, Cognitive Behavioural Therapy and Acceptance and Mindfulness approaches to the treatment of eating disorders.   

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