"We only have one treatment"

Look, there are no magic bullets for eating disorders, but what has always troubled me about critiques of the Maudsley approach is the assumption that there are some better alternatives out there for which there is research. There aren't.

It's hard, it's not perfect, and we need to keep searching for improvements but:

'To be really honest with families, we should say: 'We only have one treatment. There is a fair amount of evidence, and it's what you should start with,'' Le Grange said. 'If clinicians are not willing to do that, then we have to agree we're just improvising.

Maudsley Approach a little-known but evidence-based treatment for anorexia

It's time to stop calling FBT/Maudsley 'controversial' and start working on improvements, but parents need to know that if they are not being offered Maudsley first then something is wrong.


  1. I must admit that I am getting more 'switched on' by the Maudsley method - even through a comparable treatment in the 1970s didn't work for me. The main reason why it didn't work for me was because I was an atypical anorexic and have a mild ASD/Asperger's. AN was a 'special interest' for me - and by that I don't mean it was a hobby.

    The 'special interest' for people with ASD serves several purposes, an important role being to make the world feel more predictable/less chaotic and so relieving anxiety. It is also enforced isolation, and isolation is often seen as desirable by people with ASD, especially when they are stressed.

    The article you link to states:

    "Critics of the approach say forcing adolescents to relinquish their power over food can exacerbate underlying control issues. They question whether Maudsley teaches children how to eat intuitively."

    My answer to these points are:

    First, that the underlying control issues in AN are not about trying to control parents, or trying to be autonomous. It is true that AN is often about control, but for me that control was about trying to make my life feel more predictable (via eating and exercise routines/rituals). It had nothing to do with rebelling against my parents, or trying to control them, even if that was how it seemed.

    Second, when you are anorexic you lack the capacity to eat intuitively. You either have no appetite and undereat (as I did, as a restricting anorexic), or you feel a constant urge to binge (as do many people with b/p AN). Prro interoceptive awareness is a symptom of AN. Therefore, it is vital that someone with an ED eats to a meal plan and learns what is a normal and adequate food intake.

  2. "It's time to stop calling FBT/Maudsley 'controversial' and start working on improvements" - absolutely and I'm proud and not a little relieved that that's exactly what's happening locally to me.

    It isn't happening like that 30 miles down the road in the next county, let alone world wide, so I can't see how anyone could say that there was now no need to trumpet FBT - rather there is a need to continue its development.

  3. I have a few kind of scattered thoughts.

    + There are families that will not force their daughter to eat. My family was unwilling to help with that aspect in anyway. I have friends who are much more supportive, but even they would never force me to that extent.
    + When I've been in treatment, it's never been FBT, but they have their defaults and if the defaults don't work, they just push them harder. I have often wished that when something is clearly not working, that they would accept that and help me try something else. It does not seem productive to me to push the same thing that isn't working harder. Evidence-based or not, we still don't have any single treatment that works for all patients. (Although, I'm not actually certain that you are excluding the possibility of trying something else, or just saying that FBT is the only good starting point we have because it has the best track record in studies. FBT as just the default starting point is something I am totally on board with, but we need to be willing to change tactics and able to recognize when it is time to do so.)
    + I know there are people here who probably disagree with me on this, but I don't think that for everyone with a diagnosable eating disorder it is the eating disorder that is the primary problem. In my case, I think of the ED as my attempted solution to depression, depression being my primary problem. (And I'm not just in denial, my treatment team has come to agree with this.) Such exclusive focus on the ED can be like putting a bandaid on a broken arm, sometimes fostering other maladaptive coping skills, like self-injury or drugs (yes, again, this comes out of experience).

  4. For my part, I would be satisfied if it was a choice for every family: an option.

    But there also needs to be a Plan B, and C, and sufficient support to all plans when under way.

  5. It worries me only from my experience. . .

    I have said this before that my parents have their own issues/comorbidities in terms of mental illness. The therapist gave almost no direction with regard to refeeding except to "do what works."

    This wasn't working for my parents and as the therapist put more pressure on their responsibility/failure to achieve weight gain, there was often verbal and physical abuse. They justified this because it was against the ED and not me. I couldn't tell the therapist this because I was afraid of repercussions on the part of child services, etc.

    Although it is a wonderful thought that parents can stay strong and calm and compassionately provide meal support, for some parents this is not possible -- or rather the training is not given.

    My worry is when it degenerates into being hit over the head, punched, food thrown, screamed at, sworn at, dragged out of bed, etc. . . This is when Maudsley becomes something else and the capacity for Maudsley to degenerate into this always scares me -- Especially when I read of parents on the ATDT forum who appear very stressed and anxious.

    There needs to be a safeguard for children and right now there is not.


  6. A,

    I am so deeply sad that your family became abusive during your treatment. You deserved a safe and nurturing environment to recover.

    Maudsley treatment isn't, or at least should not be, done without safeguards in place: a skilled therapist, medical monitoring, and a back-up plan in case of lack of progress. I believe skilled therapists could discern whether parents are overwhelmed or abusive and intervene.

    Abuse is, although rare, a game-changer.

  7. Not to belittle the serious and thought-provoking comments that have come before, but I must interject that there is a Magic Bullet for eating disorders. Load it up with some high-calorie smoothie ingredients, and I hear that it can work almost better than a blender. :)

  8. Not to belittle the serious and thought-provoking comments that have come before, but I must interject that there is a Magic Bullet for eating disorders. Load it up with some high-calorie smoothie ingredients, and I hear that it can work almost better than a blender. :)


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