Don't be shocked: Family-Based Maudsley therapy data published

Long-awaited data on the Maudsley approach has just been published and the news wires are humming. From what I'm seeing, the coverage is pretty darned good. (The data is, too)

National Public Radio
Chicago Tribune
Bloomberg Business week
The Wall Street Journal
Science Codex
Los Angeles Times
US News and World Report

News stories about the Maudsley approach have always had a certain breathless "this is completely new and shocking" quality, then sink to obscurity and business as usual. Until recently this coverage hasn't translated to a real change in the availability and acceptance - or deep understanding - of the ideas. My hope for this wave of coverage - and it is HUGE this time - is that we will stop calling Family-Based therapy "controversial" and start calling it shocking and controversial that the availability of this approach, which you'll hear in the interviews "should be the first line of treatment," is still so thin on the ground.

What should be controversial is that children and adolescents with anorexia are still being treated first with approaches that are KNOWN to be less successful and their parents are never even told about the option.


  1. I have forwarded this to the lady, Cassandra Jardine, who wrote the article in the Daily Telegraph last week. I shall be interested to see if she responds.

  2. yes yes yes!!!!!! All your hard work and the hard work of FBT researchers and clinicians is paying off, Laura!

  3. I would like to thank the researchers and the families who participated in this study. In the case of anorexia nervosa, it is very easy to become paralyzed with fear and uncertainty. These families and kids who were in this research project have shown us all great courage. Your identities will never be know to the general public, but your legacy will live on.

  4. I'll be the devil's advocate here (don't flame me!)

    I haven't looked at any of the news articles because I wanted to read the whole study first. . . (I can send the study to you if you want!)

    I think this study shows 100% that FBT is effective for children/adolescents.

    However, according to the study, this seemed to be conditional on some factors.

    Both groups in the sample had short illness duration (something like 8-9 months) and this could have contributed to their excellent FBT outcome. I know if I had been treated with FBT upon diagnosis as opposed to 3 years later, I may have been less "entrenched" in AN.

    It was also commented on by the authors that the AFT group (individual therapy group) had a significantly greater EDE score than the FBT group -- In my mind this is a slight bias because it may have meant that this group had more AN psychopathology/disordered thinking and therefore would have had more trouble regardless of the treatment method. I don't know why they didn't try to sort this difference out before randomization. . .

    It was also commented on that the group as a whole met AN criteria, but were not severely emaciated -- so this study indicates that for adolescents with little weight to gain (10-15lbs, etc.) FBT may have a better outcome than for individuals with 30+lbs to gain. This is also similar to what a "big shot" psychiatrist told my family who was working with Lock/Legrange on a multi-site Maudsley pilot study.

    Also, particpants were excluded if they had had individual or FBT therapy previously and only 50% of the participants had reached a level of illness where hospitalization was necessary.

    I guess what I am saying is that this study is promsing, but the results aren't necessarily surprising:
    * FBT has been show to be effective
    * Adolescents/children with less weight loss, shorter duration of illness and less hospitalizations do better
    * Therefore, FBT in recently diagnosed adolescents is effective. . .

    It isn't difficult to conclude that the study would be successful.

    I would LOVE to see this study redone with cohorts based illness severity in addition to different treatment types --> compare the outcome rates for FBT with individuals of greater AN severity to those who individuals who have just been diagnosed. It would also be interesting to vary treatments with severity and determine whether one treatment is effective regardless of severity, or different treatments depending on different characteristics.


  5. Points taken A:) but, given the reluctance of many to stop calling FBT "new", "radical" and "alternative" perhaps they are lost on the wider community who haven't been debating this and known the names of Lock and LeGrange for almost a decade.

    What this study shows is that FBT is the frontline treatment of choice for early onset AN in adolescents. The penicillin of the ED world. No, it's not effective in 100% of cases and some people will come up in a nasty rash, and yes, more work needs to be done to identify those people early and offer evidence based alternatives but, unlike anything else, for the majority, it works. Let's see see it available to all, as and when required, and then sort out what we're going to do with those (my own loved ones included) who it doesn't suit.

  6. A:) It turns out that the mean duration of illness in the study was 8.6 months. Consequently, since that represents the average, there would have been many individuals who had been ill longer than that.
    The mean at the beginning of the experiment was 82% of IBW. So, these indviduals actually did have a lot of weight to gain before they reached the definiation of recovery, which was 95%.
    It's true that patients who had previously received FBT or AFT were excluded, but that was because the researchers didn't want the results influenced by previous therapy. However, that doesn't mean the patients were not very ill when the study began. 45% had had a history of hospitalizations for AN or related medical problems before they were recruited into the study.
    While it's also true, as you note, that at the start of the study the AFT group had greater scores on the EDE, that was not planned. The two groups were randomized and it turned out to be a fluke that the EDE scores in the AFT group were higher. However, that slight difference wouldn't account for the dramatic difference in outcomes.
    Also, in any event, it's not clear that the EDE is a good way to measure anorexic thoughts or behaviors. For example, one of the questions on the EDE is "Have you been deliberately trying to limit the amount of food that you eat to influence your shape or weight?" In my experience, many (if not most) people suffering from anorexia end up restricting not to influence shape or weight but because, for reasons unknown to everyone, that's what the illness makes them do. Conversely, there are many people who "deliberately" restrict to "influence" shape or weight who don't have an eating disorder, including people who are told by their doctors to lose weight. The point is that the EDE arguably measures the wrong things.
    Finally, while it would certainly be possible to do another experiment segregating cohorts by eating disorder severity, its not clear how one would measure severity or why a less intensive treatment model (AFT) would do better than a more intensive one (FBT) with more severely ill patients.

  7. It continues to confound me why saying that X treatment is a good thing is responded to with "but not always" or "but here's all the reasons not to do it."

    Why do that?

    Why not say "Cool. A useful tool. To add to the list, to continue to refine, to give us new insights."

    The automatic "but" stuff just doesn't make sense.

    If this was a new drug treatment for cancer would anyone be sitting around cautioning "it won't work for everyone?" No, because we already assume that about cancer treatment. But try to add THIS treatment to the choices - JUST ADD IT - and the skepticism abounds.

    Let's congratulate these WONDERFUL researchers who have discovered a useful and more often effective tool for saving these patients. Let's assume they won't stop there and will go on to do even MORE great things. Let's assume that if it isn't working that other alternatives will be tried.

  8. A (not A:) -- maybe I should pick a new letter)1:58 PM, October 06, 2010

    That's a good point, Laura, but I'm not convinced that's always true about new treatments for other illnesses. When there's a new medication for, there are usually a lot of "but what kind of side effects?" comments and similar questions, and I think there should be. Embracing a new treatment can be dangerous if you don't understand who it works for and who it doesn't.

    There's also a difference in coming out with, say, a new medication as opposed to a new form of treatment, which I think Maudsley falls under. For example, there have been a lot of people pushing homeopathic cures even for illnesses like cancer, and that has been met with enormous skepticism (I certainly am skeptical, to put it lightly).

    Anyway, Maudsley is different, and I think it's pretty normal for people to be skeptical and to jump to finding cases it wouldn't work for. I think this will decrease as people get more exposed to the idea. I'm really pleased it's getting all this coverage. It's really exciting to see how quickly mental health care in general, or at least ideas about mental health, is changing.

  9. I don't know about the "quickly" (since I've been working on this topic for nine years now...) but I'm with you on the exciting and the positive!

  10. "Anyway, Maudsley is different, and I think it's pretty normal for people to be skeptical and to jump to finding cases it wouldn't work for."

    To be honest A, it depends how desperate you are.

    The ineffectual treatments we were given for the first 4 months meant that jumping into Maudsley with eyes closed was the only option that would enable ME to help my daughter recover. And I was the only thing standing between my daughter and hopeless despair.


  11. I definitely know what you mean, Charlotte. I have a friend who has a daughter about to get brain surgery for OCD. It seems extreme to most, but it's their last option left. They are desperate. I think it's awesome that those options exist.

    Not that Maudsley is like brain surgery, except that it's a relatively new treatment for a mental illness.

    Nine years actually doesn't seem long to me on a large scale, but for you, an individual, it must feel like a lifetime. I really admire all the work you've done.

    I'm referring to mental illness in general, though. I've read that psychiatry is one of the fastest changing medical fields. People are getting rid of those old ideas of mental illness and realizing that mental and physical illnesses aren't so different. I'm not sure how long this has been the case, but psychiatry residents have to have training in neurology, too. Unfortunately, people seem to be hanging on to those old ideas with some illnesses, like EDs, more than others.


Post a Comment

Popular Posts