The two Maudsleys - mutually exclusive or complementary?

It may be that me and my friend Marcella are the only ones hung up on the distinction between the two "Maudsleys" but I continue to believe it matters.

I notice that many, many people still don't know that the "New Maudsley" is distinct from the "Maudsley" that I and most of the media are talking about. They have nothing in common except:

They originate from the same physical location in London (the Maudsley hospital)
They do not conflict with one another

I am seeing a growing number of people who mistake the two approaches and I'm starting to realize there is a good reason: they are complementary. I have been talking to clinicians who employ both sets of tools at the same time without finding a conflict. I know LOTS of parents who are endlessly grateful to both approaches in their own work to support their kids.

So while I continue to stew over the naming issue, I'm very glad to see all these very good ideas being used.

"Old Maudsley," as Marcella cheekily refers to it, is a method for aligning parents and siblings and the patient and clinical team productively toward the eating disorder behaviors.

"New Maudsley" is a very useful set of ways of personalizing our responses as parents/carers to the behaviors.

I think of New Maudsley as a way to optimize the work of Old Maudsley, myself. Old Maudsley assumes that parents are ready to be Dolphins and St. Bernards, when we often need help getting there. New Maudsley assumes the patient is being monitored and fed and that there is a safety net in place.

For myself, I'd like to see families supplied with a great number of tools at the outset - personalized to what they need. Mr. and Mrs. Dolphin St. Bernard may be able to skip certain "New" lessons. Magic Plate Parents may need extra Rhino-reducing sessions. Dollops of DBT and injections of IPT could be prescribed 'as needed.' Respite by the hour or day, at home or in hospital, 'on demand.'

Old and new, borrowed, too: families need far more than they're getting now - and it probably isn't all going to come out of one toolbox.


  1. Agree 100%. Not sure that Old Maudsley would ever have worked for me as a child and teen, because of my specific difficulties, not because I refute the efficacy of Old Maudsley for the majority. However, it would have helped if my Mum, at least, had been aware of New Maudsley. Not sure that my Dad or brother would have 'got' it but Mum would have, and it would have helped me.

    Glad you haven't mentioned body image therapy, which, IMO is futile; even for people with body dissatisfaction or BDD.

  2. Body image therapy: feh!

    A feel-good thing for healthy people with mistaken ideas.

    A tragically under-powered response to a brain-based condition of BDD.

  3. Should we offer alien image therapy to people who see little green men in the bathtub?

  4. You mean the aliens are not real? Sob. Bathtime will not be so much fun....

    In all seriousness, we have utilised a bit of both therapies, depending on the stages of recovery. I think that learning to be a St Bernard, whilst doing Lock and Le Grange, was an immense help (but REALLY hard work!). Each sufferer is different and has different needs. The length of illness also plays a big part.
    However, what worked for us SO well was learning to seperate the ed from our child and, in doing that, helping her to learn which behaviour was which. This is where the dolphin moment came in handy. Without HYTBAED, we could never have got started.

    Perhaps it is worth mentioning that, although many signs and symptoms of eating disorders are similar, the uniqueness of the family and clinical team who are treating a sufferer make it almost impossible to manualise an effective treatment for ALL sufferers. You have to make do and mend a bit.

  5. I agree Laura. I don't dispute that many people with AN fear weight gain or have BDD, but I don't think that these are what drives the AN. Like you, I believe that AN id more like a form of OCD. Even if initially the individual felt 'too fat' and wished to lose weight (and not everyone develops AN through this route), there comes a 'point of no return' when they feel compelled to continue the behaviours irrespective of their size and weight.

    I think that in terms of therapy for those individuals who do have fat-phobic AN or BDD, body image should be forgotten and the focus should be on promoting health and wellness - i.e. encouraging the individual to focus on life's 'bigger picture', or other activities; NOT on critiquing their body in front of a mirror and discussing associated feelings. That IMO, will only increase obsessive body checking.

  6. Having just finished reading Skills Based Learning, The New Maudsley Method, I'll confess I would not have found the book helpful when my daughter was suffering from anorexia nervosa several years ago.

    For one thing, the book does not give proper emphasis, in my opinion, to the essential role of weight gain and nutritional rehabilitation in the recovery from the disease. Although the book is more than 200 pages long, only a handful of paragraphs offer advice on how to refeed a patient who is suffering from the disorder and instead the book says, erroneously, on page 21, that "talking treatments" have been found to be most effective. Many of the emotional and psychological problems experienced by sufferers that are discussed in the book, however, are often, for many patients, the product of semi-starvation and are best addressed by helping with direct intervention to restore full weight, not "talking" about the illness. Little is said in The New Maudsley Method, however, about how to do this, in contrast with the original Maudsley aproach which not only takes direct aim at nutritional rehabilitation as the first priority but offers specific advice on how to help bring it about. The original Maudsley model, which has been shown by scientific study to be the most effective approach available, is based on changing the sufferer's behavior not by talking about it, but by directly helping the sufferer to eat more food. For the New Maudsley Method to suggest that talk therapy has been shown to be most effective is, therefore, in my opinion, a misrepresentation of the research literature as well as misleading to the public.

    In addition, I found important parts of the book to be internally inconsistent. For example, while the authors seem to recommend that generally parents should take a dolphin-like approach to their loved ones who are suffering from an eating disorder, I found most of the specific advice actually more jellyfish-like than dolphin-like in nature, with too much emphasis on negotiating with the eating disoder and not enough on taking decisive action.

    Finally, I am not aware of a single study offering objective evidence that the advice in the New Maudsley book is effective. In other words, where's the evidence? It is not provided anywhere in the book. Unless and until scientifically reliable evidence is offered to support the New Maudsley Method, I'll put this book on the shelf along with all the others that are based more on speculation than on evidence.

  7. Anonymous

    For you

    ■Randomized Clinical Trial Comparing Family-Based Treatment With Adolescent-Focused Individual Therapy for Adolescents With Anorexia Nervosa


    ■Eating Disorders in Children and Adolescents, James Lock, MD

  8. I think Anonymous makes a good point. For my part, I find the Treasure animal analogies silly/childish and the whole thing unhelpful. (Charlotte, the studies you cite are on the Lock and Le Grange FBT, not Treasure's "new Maudsley" carers work. There have been user surveys of the the program, but no randomized controlled trial.)

    I think FBT is misrepresented in the original post. It doesn't assume all parents are St Bernards and dolphins. Issues of parent criticism, etc are addressed if they are present in the family (though it is not assumed that they are.) There's a little more to it than just stopping ED behaviors.

    I think the Treasure animal scheme is LESS personalized than FBT. The representations of parent styles are very cookie-cutter. Whereas families working directly with a therapist in FBT can work on their individual concerns.

  9. Well at least we're not alone Laura - it DOES matter to more than just us two that all that is described as "Maudsley" is not the same.

    Anonymous and Anon are right - there isn't the empirical evidence for Skills Based Learning that there is for Manualised Family Based Therapy. On paper it is also true that whereas the FBT therapist encourages the individual strengths of the family, Skills Based... provides general models of care.

    On the other hand, my personal experience is of very challenging and difficult FBT leaving me as a parent with a lot of shame and my daughter still struggling with an eating disorder, and very empowering encounters with SBL. This leads me to wonder exactly what elements of each are really effecting change, and is it different in each case. In our case FBT was delivered (at least initially) by an inexperienced clinician in an environment not chosen by either the parent or the child. SBL was delivered by the top trainer in her field and I chose and made effort to go. So is the alliance between therapist and client (in the case of these treatments the parent) the most important factor? FBT involved just our nuclear family SBL was delivered in a group setting. Is the feedback from others an effective component of treatment - Ivan Eisler (surely one of the only people REALLY qualified to use the "M" word) may think so. Others would probably differ and would wish to see concentration on the individual family. Are my experiences just the random product of luck? We tried FBT when the illness was particularly strong, SBL when an intensive inpatient stay had broken some of its hold.

    For me there are still a lot of questions about both of the "Maudsleys" one of which is "are they compatible" which, from the sample we have here I'd say can be answered "they can be but aren't always". The only concrete answer I have for the moment is that they are NOT the same thing.

  10. I suppose that I wonder what the 'magic' ingredient of 'Old Maudsley' is for those families who find it efficacious. A lot of emphasis is placed on food being the drug and repairing the brain, but how do we know that that actually IS the mechanism?

    To recover from AN it is essential that a person achieves 'full nutrition' - which is actually rather hard to define. Some people apparently achieve this state at a BMI of 19; others at a BMI of 25. I guess I wonder whether the mechanism involves desensitisation - as is used in the treatment of phobias and many forms of OCD. The successful recovering anorexic patient is able to contain anxiety associated with eating adequately. Is it simply that with time their levels of anxiety fall in response to eating so that the process of weight gain becomes easier?

  11. Cathy,

    A recent article by Hildebrant et al addresses some of your questions. Anxiety in Anorexia Nervosa and its Management Using Family-Based Treatment. Eur. Eat. Disorders Rev. (2010) They put forward the idea that anxiety is treated through FBT in a number of ways (exposures to uncertainty about calorie counts, fear foods, weight numbers, etc) when parents don't re-inforce or accommodate avoidance. They draw parallels with other therapies (especially CBT) for anxiety and OCD. I'd recommend it if you're interested in understanding more about FBT.

    I think there are also some misconceptions about FBT (what you call "old Maudsley"). It's not just parents feeding their kids up to a healthy weight.

    Re "full nutrition": FBT does not rely on target weights or BMI. "Moreover, FBT does not set a specific target weight; rather, psychological(e.g. reduction in depression and shape and weight concerns) and physiological (e.g. resumption or onset of menses) health markers, as well as reaching a weight range ‘that the patient can sustain without undue dieting (Lock et al., 2001, p. 124)’, guide the course of treatment. This, too, functions as another exposure exercise, in that most patients have difficulty tolerating this uncertainty about a ceiling weight, an unknown which is inherent in adolescent body development even when the AN remits." (Hildebrant et al)

    It's not just about getting to a healthy weight or "brain repair" (and this is not a phrase I've ever come across in writings by FBT researchers/clinicians.)

  12. For those interested in comparing the two approaches, there was a question and answer discussion in Australia on 26th November between Gill Todd (New Maudsley) and Andrew Wallis (MFBT of Westmead). It was filmed and will be available shortly at this site I'm very much looking forward to seeing it.

  13. Anon, "brain repair" is my wording, and I completely agree (and say repeatedly but don't seem to get heard) that weight restoration is only part of FBT, but manualized FBT does set weight goals.

    Phase II begins when:
    Patient at minimum of 87% of "ideal body weight"
    Able to eat without undue cajoling and struggle
    Parents feel empowered and relieved about their ability to manage the illness

  14. "The emphasis on gaining weight should be placed in the overall context of achieving a weight that the patient’s healthy body ‘knows is,’ that is, through a return of healthy skin and hair, return of menses, and an increase in bone density. In other words, the therapist should see weight gain less in terms of ‘norms’ or numbers on a scale and more in terms of a particular patient’s health. The therapist should refrain from setting specific target weight. Instead, the goal of a healthy body should be used to guide the patient toward a healthy weight. This weight is essentially a range that the patient can sustain without undue dieting and, if female, one at which menses is comfortably maintained."

    -Treatment Manual for Anorexia Nervosa: A Family-based Approach, page 124.

    Of course, patients need to get to a healthy weight, but the idea is to look at functional measures, both physical and psychological, rather than specific targets.

  15. The Maudsley Approach. For adolescent and other younger patients in the EARLY STAGES of anorexia nervosa, the Maudsley approach to refeeding may be effective. The Maudsley approach is a type of family therapy that enlists the family as a central player in the patients nutritional recovery. Parents take charge of planning and supervising all of the patients meals and snacks. As recovery progresses, the patient gradually takes on more personal responsibility for determining when and how much to eat. Weekly family meetings and family-based counseling are also part of this therapeutic approach.


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