The Maudsley approach to Family-Based Treatment (MFBT) is an evidence-based treatment for treating children and adolescents with anorexia nervosa (AN).1 MFBT is a three-phase, comprehensive family therapy treatment, which typically spans 20-24 sessions over the course of about a year.2 MFBT views the family as a central support system for AN recovery.2
MFBT is typically conducted in an outpatient setting but can also be done in conjunction with inpatient or day-treatment programs.
What Is the Maudsley Approach to Family-Based Treatment?
The Maudsley approach is a family-based treatment that supports the family in refeeding the adolescent with anorexia and helping the patient and family recover. MFBT posits that because the patient is unable to function normally, it is the duty of family members to develop solutions on how they will work together to manage anorexia.1
MFBT empowers caregivers to take on the task of “saving” their loved one from AN by refeeding and stabilizing their weight, and then working to return the responsibility of eating to the adolescent and returning the family to appropriate boundaries, addressing age-appropriate issues with the adolescent.
Core Concepts of the Maudsley Method
The Maudsley Method is a three-phase, protocol-based treatment that usually spans 20-24 sessions over the course of a year.2 MFBT establishes the importance of family in both maintaining and resolving the eating disorder.2 MFBT aids parents in the task of finding solutions for refeeding their child and helping the child recover and restore their weight. The therapist helps guide the parents through this process and provides support and suggestions for any issues that may arise during the process.
MFBT posits that the youth with anorexia is no longer functioning at a developmentally appropriate level due to their anorexia nervosa, and that the parents must take charge to refeed and restore weight for their starving child.1
Who Is the Maudsley Method Right For?
MFBT is suitable for children and adolescents with anorexia nervoxia who are medically stable enough to receive outpatient treatment supervised by a medical professional. MFBT is also suitable for children and adolescents that have just been discharged from inpatient treatment or are part of a partial or inpatient treatment program that includes the family in the process so that the family is able to maintain gains made once the child returns home and no longer has these intensive forms of treatment.
3 Phases of the Maudsley Approach2
MFBT consists of three phases of treatment that span 6 to 12 months.3 MFBT helps to empower parents to help their child recover by tasking the parents with refeeding their starving child in the first phase, then in phase two returning the responsibility of feeding back to the child or adolescent. In the third phase, therapy focuses on the patient’s development of a healthy identity, the patient’s age-appropriate autonomy, and the reestablishing of family boundaries, as well as encouraging parents to refocus on their relationship, which may have suffered during the course of their child’s treatment and recovery.
Phase 1: Weight Restoration
The goal of phase one is to complete the initial evaluation, set up treatment, help the parents identify and develop ways to effectively refeed and weight restore their child. From the point of initial contact (the phone call to set up the appointment), the therapist acknowledges the seriousness of the illness and the need for everyone in the family to attend the initial therapy sessions.
During this phase, the therapist provides support, encouragement, feedback and expert advice and consultation tailored to the unique needs of the family and the decisions the parents have made regarding how they will manage refeeding their child. While the parents are charged with the task of refeeding, siblings are asked to provide the patient with support and encouragement.
In phase one, sessions typically start with the weighing of the patient, discussing challenges and successes with refeeding, providing support and help to parents in their efforts to refeed, encouraging the siblings to provide support to the patient, and helping the family cope with frustrations with the patient by externalizing the eating disorder (i.e., separating the AN from the patient). Once the parents are in control of the eating disorder and the patient is gaining weight and approaching their ideal body weight, then it is time to consider moving to phase 2.
Phase 2: Returning Control of Eating to the Adolescent
Phase two consists of slowly returning the age-appropriate responsibility of eating and seeing whether the patient is able to maintain appropriate weight. The return of the control of eating is typically done in a gradual manner, increasing independence as mastery of each step occurs. For example, if the parents decide to allow their child to feed themselves one meal a day and their weight is maintained, then the family could add on more meals and age-appropriate opportunities for independence (i.e., additional meals with friends or a sleepover).
Toward the end of phase 2 the family may address other issues that have been postponed due to the need to focus on saving the patient’s life.
Phase 3: Establishing a Healthy identity
Once the patient has established regular independent eating and has maintained a stable weight independent of parental monitoring, then phase three can begin. Phase three is brief and typically consists of reintegrating the adolescent into their normal adolescent life with more autonomy and re-engaging in activities that may have been disrupted due to the anorexia.
Additionally, the parents must re-establish a healthy relationship with the patient that does not involve the illness as the basis for their interactions. Also, parents are encouraged to focus on their relationship as a couple and discuss the reintegration of their professional and leisure activities that may have been modified when supporting their child through the illness.
In this phase, the therapist will aid the family in utilizing problem solving skills and addressing any familial issues that were not addressed previously in treatment. The therapist will also provide the parents with support about how to proceed in the future should eating problems arise again following termination of treatment.
How to Find a Therapist Who Practices the Maudsley Approach
Providers of the Maudsley Method should have undergone training through courses, supervision, and field experience at a clinic or hospital that provides MFBT to AN patients and their families. Another way to be trained in utilizing MFBT is receiving an online training and certification for MFBT through an accredited website.
One directory for finding clinicians that implement MFBT is through the Maudsley Parents website.
Additionally, major hospitals that implement evidence-based treatment for eating disorders will also conduct MFBT. Another way to find an MFBT therapist is through a pediatrician or adolescent medical doctor who specializes in the treatment of eating disorders, as they typically have clinicians they refer their patients to.
How Much Does MFBT Cost?
MFBT ranges in cost, but is often considered a more cost-effective alternative to partial or inpatient programs, which are often used for patients with anorexia nervosa.
What to Expect at Your First Maudsley Family Therapy Appointment
The whole family is expected to attend the first session as it is important for the therapist to understand how the family functions and the impact AN has had on the whole family. Each family member will be asked to talk about themselves and the impact the AN has had on them. Additionally, the family will be charged with the task of refeeding and weight restoring the patient. The patient’s weight will be taken and charted, which will occur at every session to track progress. The family will also be prepped for the next session where they will have a family meal during the therapy session.
Is the Maudsley Method Effective?
MFBT is an evidence-based treatment for anorexia nervosa in children and adolescents. Studies have shown that about two thirds of youth undergoing MFBT recover by the end of the treatment.2 Longitudinal studies show that 75%-90% of patients who undergo MFBT continue to be weight restored at the five-year follow up,7 whereas patients who have received inpatient treatment are likely to be readmitted to treatment again (at least once) for a longer stay than they had previously. These findings indicate that the relapse/recurrence rate is higher for inpatient treatment than MFBT.2
Additionally, another longitudinal study showed that 89% of patients maintain appropriate body weight, 74% score within normal range on the Eating Disorder Examination Questionnaire, and 91% of participants not on birth control had their menses return following MFBT treatment.8
Criticisms of MFBT
MFBT has been criticized for being behaviorally focused and not providing enough space to explore the impact of the AN on the patient’s life and identity as well as their families’ life, especially in the initial phase of treatment.5 MFBT may also not be effective with patients who are more mature or patients with a longer duration of AN.9
Maudsley therapy has been criticized for failing to address body-image issues and perfectionistic tendencies associated with AN, and oftentimes the patient needs to seek further treatment once weight has been restored to work through these other problem areas.
An Example of the Maudsley Approach
Let’s consider a sample case involving “Sally” and her family. Sally Smith is a 17-year-old girl who lives with her mother, father and younger sister who is 12 years old. Sally started narrowing her diet (i.e., cutting out carbs, sugar, dairy and most meat from her diet), becoming more focused on her body, and has steadily been losing weight for the last 6 months and recently lost her period (amenorrhea).
Sally’s mom took Sally to the pediatrician where she was diagnosed with anorexia nervosa by her pediatrician. Sally is 5’5” and at her last annual physical, Sally weighed 125 lbs (20.8 Body Mass Index; BMI). But recently, when Sally came to see her pediatrician, she was underweight, weighing only 100lbs (16.64 BMI). Sally’s pediatrician evaluated Sally and concluded that she has AN. The pediatrician advised that the family seek treatment for Sally while she continued to be monitored medically for any complications related to AN by the pediatrician.
Sally’s parents reached out to Dr. M, an MFBT therapist to set up an appointment. During the initial call, Dr. M sounded very concerned and conveyed to the parents the seriousness of the AN—that this was a life-threatening crisis that the parents needed to manage. Dr. M also emphasized the need for the entire family (everyone in the household) to be present for the therapy, and confirmed that Sally would have medical monitoring from her pediatrician.
Phase 1 (sessions 1-10)
The first session is very important, as it sets the tone for the treatment. In the first session, Dr. M began by weighing Sally, then met the Smith family and expressed to the family the grave crisis they are in. He tasked the family with saving Sally’s life by encouraging the parents to take a drastic stand against the illness and refeed their daughter.
Dr. M engaged each family member in the session while learning Sally’s history with the disorder (i.e., understanding the disorder, when it started, how it has evolved and the impact it’s had on the family and each family member) and gathering information about how the family system functions. Dr. M also demonstrated externalization, thus separating the illness from Sally, by talking about what the illness has taken away from Sally, how it is out of Sally’s control and how it causes her to behave and think in ways she normally wouldn’t.
Dr. M explained that Sally’s parents must refeed her and are the best resource for restoring Sally’s health. Her parents are the best resource because they know Sally best, they are vested in her recovery, and they have helped Sally through other challenges so they can use those skills in this situation.
Dr. M told Mr. and Mrs. Smith to provide their starving child with the foods they think she needed and not conceding to the demands of Sally’s AN. Dr. M provided support and suggestions as necessary to the family. For example, Dr. M suggested that Mr. and Mrs. Smith continue to send Sally to school, but to give her two breakfasts in the morning before school and then go to the school to monitor Sally’s lunch. Dr. M also encouraged the family to set a schedule for who will be monitoring meals.
Dr. M then prepared the family for the next session, which was the family meal. The Smith parents were asked to bring and have a picnic meal in the office with enough food for the whole family. Each session closes with a review of progress.
Session two was another information gathering session for Dr. M. He assessed the way the family interacts at meals and how they manage meals, the challenges that arise with Sally during mealtime and the choices the parents are making surrounding meals.
Like in all sessions, Sally was first weighed by Dr. M. Knowing the weight prior to starting the session helps set the tone for each session and assess progress. Dr. M then observed the meal, asked questions about the meal (i.e., who typically makes meals, who serves the meal, etc.) and asked the children how the parents have supported them through challenges and fears. He also asked Sally and her sister about ways to make meals more fun and what Sally might want to name her AN (this is optional for the patient but can be helpful in externalizing the disorder).
Once Sally said she was done eating, Dr. M aided the parents in asking Sally to have at least one more spoonful of food. This helped the parents to feel empowered and gave the parents a sense of control surrounding refeeding their child, and enforced change by disrupting previous dynamics between the patient, parents, and food.
Having Sally’s parents feed Sally one more bite helped the parents experience a success with refeeding Sally. Dr. M also helped to align Sally with her sister so that Sally can utilize her sister for support and to vent to her about her parents and the challenges she is facing.
The subsequent sessions of phase one revolved around assessing progress by weigh-ins, discussing food, meals, and eating behaviors, and troubleshooting any challenges the family was facing with the illness. The sessions were also spent encouraging and supporting Sally’s parents to utilize things that have worked in the past. For example, Sally was refusing to complete her dinners and supportive tactics weren’t working. Sally’s parents decided to set up a consequence that would occur if Sally did not eat, which was no screen time for the rest of the night; Sally’s parents had used this as a consequence in the past and it was very effective, and it was successful in this scenario as well.
Sally’s sister expressed feeling frustrated with Sally and Dr. M empathized with the frustration she was experiencing. He reminded Sally’s sister that the AN is in control of her sister and these behaviors aren’t Sally—they are the AN. Dr. M reiterated the importance of her being a source of support for Sally. Each session concluded with a review of progress made. Dr. M constantly encouraged the family and pointed out strengths that can be built upon in an effort to defeat the AN.
After eight weeks, Mr. and Mrs. Smith made great strides; they were working as a team to defeat the AN, and Sally steadily gained weight, creating more separation between Sally and the AN. Eight weeks in, Sally weighed 115lbs, which is 92% of her ideal body weight of 125lbs. Typically, a patient has gained at least 87% of target weight and eats meals without major struggles or arguing with parents before proceeding to phase 2.2 The Smith family was now ready to begin phase 2.
Phase 2 (sessions 11-16)
Sally has now complied with her parents demands to increase caloric intake and has been gaining weight steadily, and the parents feel more in control and relieved about their ability to support their child in overcoming the AN. In phase 2, the parents began to slowly turn over the responsibility of eating meals to Sally, and toward the end of phase 2, normal adolescent issues were being addressed (e.g., peer relationships, puberty).
Dr. M also reduced sessions to every other week in phase 2, continuing to weigh Sally at the start of each session and monitor progress as Sally still had not achieved her optimal weight. Dr. M aided the Smith family in negotiating the return of age-appropriate control of eating to Sally. Mr. and Mrs. Smith decided to start by allowing Sally to eat her lunch on her own with her peers. Sally continued to gain weight, so she was then able to both select a meal for her school lunch and eat it on her own with her peers. As Sally continued to progress and show she could feed herself, more freedom and responsibility around meals was provided to her by her parents.
At week 14, Sally had lost a half pound and had admitted to not completing parts of unsupervised meals due to her AN’s increased distress surrounding weight gain. Mr. and Mrs. Smith pulled back on the number of unsupervised meals Sally had and set up a check-in call after all unsupervised meals for Sally to discuss any challenges that arose and confirm she completed the meal.
Sally continued to progress and met her goal weight. Therapy began to focus more on typical adolescent issues that have been arising, such as not wanting to do her homework and wanting more time with friends. Additionally, Dr. M began to explore Sally’s own ideas, needs, and interests, and how they differ from the AN. Sally was now weight restored, engaging in age-appropriate eating and self-feeding, and experiencing increased independence. Dr. M then transitioned the Smith family into phase 3.
Phase 3 (Sessions 17-20)
Phase 3 begins once the patient has reached 90%-100% of the ideal weight and has gained control over his or her food intake.4 The focus shifts away from the refeeding process and individuation begins to be explored in detail.4
Dr. M told the Smith family that she has noticed that the main focus of therapy is no longer the AN but other adolescent issues, which indicated to her that the family is ready to begin the termination phase of treatment.
The central goal of phase 3 was to establish a healthy parent-child relationship between Sally and her parents, where the basis of their interactions did not involve AN and refeeding, to address future problems that may arise and to review and terminate treatment. Dr. M aided the parents in establishing appropriate boundaries between the parents and children, understanding and learning to problem-solve adolescent issues. For example, Sally had withdrawn from her friends and activities of interest (theater and art) due to her illness, and once she was recovered, she needed to re-engage and re-establish these bonds with peers.
Other adolescent issues Dr. M brought up surrounded Sally’s identity development, sexuality, bodily changes, and career identity development. Dr. M helped Sally explore how these issues have been impacted by the AN and whether any of these stressors were part of what triggered the AN.
Sally’s parents were encouraged to aid Sally in becoming more independent and connecting more with her peers, despite the anxiety they might face with giving her more freedom. To aid in this goal, Dr. M focused on Mr. and Ms. Smith’s relationship as a couple and a return to their leisure interests and work, as this was neglected during the course of Sally’s treatment. Additionally, having Mr. and Ms. Smith re-engage in their previous activities helped in reducing their focus on Sally. Mr. and Ms. Smith returned to having a weekly date night out, seeing friends for meals and going to nonessential work events that they had previously stopped attending.
Dr. M also explored possible future issues. She checked in with the family about the state of Sally’s schoolwork to ensure Sally won’t be held back next year, and encouraged the family to look out for previous warning signs for the AN. This led to a discussion of how Mr. and Ms. Smith would manage warning signs in the future. For instance, if Sally begins restricting her diet or avoiding certain foods again or has an increase in focus or concern on her body, these are indicators Sally may be at risk for recurrence of an eating disorder and should seek professional services, like individual therapy.
During the penultimate session, Dr. M asked the family about their plans for the next 2 months. Dr. M reviewed all the progress the family and patient had made throughout treatment and all the resources they have for addressing any future problems as this provided hope and encouragement for the family during this extended time without meeting with the therapist and the subsequent termination of treatment.
Final Thoughts on the Maudsley Approach
MFBT is the leading evidence-based treatment for children and adolescents with AN. MFBT can be an alternative to partial or inpatient treatment programs, which are costly and have a high rate of recurrence and rehospitalization.2 Additionally, MFBT can be utilized after inpatient hospitalization weight restoration and has been shown to have better outcomes for recovery and weight maintenance when compared with individual therapy.6
If you or a loved one are struggling with anorexia or another eating disorder, it is crucial to get help as soon as possible. If you have a child with AN, the Maudsley approach may be the best path forward to restoring your child’s health and moving forward together as a family.
