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            On Sunday, May 19 Katharine Loeb, Ph.D. presented “Family-Based Treatment of Eating Disorders for Adolescents,” a.k.a, “The Maudsley Method,” to NJ-ACT members. Several randomized controlled studies have demonstrated that FBT is effective for adolescents with anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders with mixed symptomatology (EDNOS).

            FBT puts parents in control of their child’s nourishment until the child is competent to take control. FBT does not blame parents for their children’s disorder.

FBT externalizes the eating disorder by calling it a disease. Food is medicine for the disease, and the parents are responsible for making sure their child takes her medicine.

            FBT assumes that parents are experts on their child and empowers them to decide how to get their child to eat appropriately. In FBT, the therapist’s role is to be the expert who communicates the gravity of having an eating disorder and consults with all members of the household about how to restore the patient to health.

            Every FBT session begins with the therapist meeting with the patient to measure and record the patient’s weight. Later, during the family session, all family members discuss the weight and progress.

            Anorexics must be restored to their full pre-disorder weight because being even five pounds underweight leads to relapse. Eating disordered thinking improves when full weight is restored. BN and EDNOS patients are not allowed to diet or restrict their food choices, and may need to gain some weight.

            During the weigh-ins, the therapist develops a personal relationship with the patient. The therapist asks about personal concerns and about issues the patient wants to bring up in the family meeting. The therapist also learns about patients’ attempts to falsely inflate their weight.

            Ideally, all members of the family attend every FBT session. However, Dr. Loeb stated that as a practical matter, everyone’s presence is imperative for the first two sessions, but thereafter the therapist may work with whoever attends.

Treatment - Phase I

            Session 1: The family lists all of the patient’s disordered eating behaviors. The therapist reviews the patient’s weight trajectory, builds motivation by informing the family of the consequences of the eating disorder, and emphasizes the importance of the entire family participating in treatment.

            The therapist asks how the eating disorder has affected each member of the family. The therapist asks the patient “What did your eating disorder take away from you?” and “What did you gain from your eating disorder?” The patient is resistant at this point.

            Session 2: The family brings a picnic meal to the session. This is an opportunity to evaluate and intervene. Did the parents bring enough food for the patient? If not, allocate an appropriate amount of food to the patient. Planning for an additional feeding at home is not optimal at this point. An anorexic may require 6000 calories a day to regain weight. Does the meal include forbidden foods? Treatment of BN focuses on eating them. Is there enough food for the entire family? Why not? If not, reschedule the mean or have the parents leave and obtain additional food.  

            Ask the parents to feed their AN child. If they don’t know how, suggest sitting closer to the child or spoon feeding her. Eating appropriately is medicine and is a requirement, not a choice. When the patient resists, teach the parents to obtain “one more bite.” Take as long as the patient needs to finish the meal so parents experience success. At the end of Session 2, plan for difficulties that may occur at home.

            Remaining Sessions of Phase I: The family should eat regular, healthful meals together in their home. No one in the family should diet or restrict their food intake in any way. When purging is a problem, parents must prevent it, usually by sitting with the patient until the desire to purge subsides, which may be as long as 2 hours. If the patient is attending school, parents must supervise lunch or arrange for competent supervision.   

            Throughout Phase I, FBT focuses on weight, food, and eating behavior. When parents cannot address a symptom, say: “Every family is different. You must find what works best for your family. However, other families have found it helpful to . . . “

            Check that parents are working as a team. In Phase I, parents are in complete control of the patient’s eating, but instruct them to allow appropriate independence in other domains. Tell the parents to “do whatever you must” to prevent bingeing, purging, excessive exercise, dieting, restricting, and body and weight checking. Parents must have zero tolerance for all eating disordered behaviors, but they should not be punitive.

            Solicit siblings’ views at every session. Siblings have their own perspective and can provide important feedback. Siblings should also offer support to the patient. Work to diminish criticism and appearance-related remarks in the family.

            Phase I sessions occur weekly.

Treatment - Phase II

            Phase II begins when three conditions have been met:

            1. Anorexic patients are above the AN weight threshold and menstruation has returned; or when BN and EDNOS patients have returned to normal eating patterns.           

            2. The parents feel confident in their ability to accomplish weight gain and to control the patient’s eating.

            3. When the patient’s resistance has diminished.

            These benchmarks are usually achieved in 8 sessions. 

            During Phase II, sessions occur every other week and parents gradually cede control over eating and exercise to the patient. This shift should be gradual. Good ways to begin include: attempting an unsupervised snack or school lunch, allowing the patient to serve herself at mealtime, and accepting the patient’s suggestions for family meals. Parents retain veto power over the patient’s food decisions. Steps toward independence should be reversed if the weight trajectory stalls or reverses. In AN, even small weight losses often signal relapse.

            Sometimes parents yield control too quickly because they are exhausted, have eating issues of their own, lack parenting skills, or are resistant to letting go of the child’s pathology. Address these problems by briefly returning to Phase I strategies -- reminding parents of the eating disorder’s serious consequences and re-instituting close parental management of eating; or by giving parents additional training in problem-solving. If these efforts prove ineffective, consider referring a parent or the couple for additional treatment.

            In Phase II, family meals remain a priority. However, Dr. Loeb recommended being flexible and working with the demands of extra-curricular activities, especially siblings’.

            Phase II also focuses on normal psychological development in adolescence. How much autonomy over eating is appropriate at the patient’s age? What are the patient’s developmentally appropriate desires and what are false desires demanded by the eating disorder? How did the eating disorder affect the patient’s psychological development?

            FBT works to return the patient to her age-appropriate stage of development. If the patient is apprehensive or avoidant of these challenges, focus on their positive consequences. If anxiety and avoidance continue, consider referral for individual therapy.

            Dr. Loeb recommended against the FBT therapist becoming the individual or couple therapist for members of the family. FBT may be needed again in the future.

            As the patient re-enters the world of normal adolescence, she becomes less hostile to treatment. At the same time, parents discover a new child and should turn their attention to their own relationship.  

Treatment - Phase III

            Monthly sessions demonstrate treatment’s success or failure.

            Review the patient’s progress with adolescent issues and ask about current concerns. Assess the family’s ability to problem solve. Check on the parents’ relationship. Plan for future difficulties. Terminate when the family is coping well and the eating disorder has disappeared.

Other Clinical Issues

            An extended assessment where the therapist meets individually with the parents and with the patient precedes family treatment. Dr. Loeb recommends medical clearance and ongoing medical involvement because anorexia has a high mortality rate and electrolyte imbalance – an uncommon result of purging – is lethal if it occurs.    

            FBT has been tested with adolescents up to age 18. For college students living at home, FBT is likely to be helpful.

            Depression is usually the result of the eating disorder and remits with successful treatment of the eating disorder. However, when Major Depression, Borderline Personality Disorder, or another Axis II disorder predate the eating disorder, successful FBT improves the symptoms, but does not cure them.

            High levels of eating-specific obsessions and compulsions in AN require a longer course of treatment. In AN, co-morbidity predicts premature termination and treatment failure. In BN, depression, stronger food concerns, and higher levels of bingeing and purging reduce the likelihood of successful outcome.

            Dr. Loeb referred workshop participants to several references, all published by Guilford, for further details:

            Treatment Manual for Anorexia Nervosa: A Family-Based Approach (Lock & LeGrange)

            Treating Bulimia in Adolescents: A Family-Based Approach (LeGrange & Lock)

            Eating Disorders in Children & Adolescents (edited by LeGrange & Locke)

            Dr. Loeb recommended MaudsleyParents.org as a resource for parents.

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