making a success of Maudsley
I'm asked with some regularity by therapists for ideas or advice on cases where parents struggle to succeed in Family-Based Maudsley Treatment. They describe trying their hardest to empower parents who don't get it, relieve the guilt of parents who won't let it go, giving parents information they won't use. I can't imagine how difficult that must be on a clinician.
Here was one of my recent answers, slightly edited:
What you describe is not uncommon. I've watched so many families start and stop and falter. I've heard from many clinicians with similar struggles.
It could be that the families you speak of truly are not going to be successful. FBT has great rates of success but still only 80%, right? But we have to always consider that there isn't a good second option so giving up on FBT isn't usually turning to something better. If they don't make a success at FBT what's the alternative? Has every avenue of supporting FBT been tried? Quitting job, bringing in more adults, a leave from school, partial hospitalization, a family training week, anti-anxiety meds: there are usually options that haven't been tried.
Context matters, too. If a family has 50 minutes with you a week and the rest of their life is surrounded by people and influences that counteract what YOU are saying to them it's like being told to take deep yoga breaths in a smoke-filled room: right advice, wrong life to do it. And to absolutely TORTURE my analogy here, living with an anxious possibly fatally ill young person is more like trying to breathe in a burning house. You don't have control over all that. No matter how good YOU are, the family may not have the environment it needs to help them hear you.
We are a society that believes deeply in personal agency, in parents as friends, in food and the body as metaphors, and in the urgency of individuation. You can't erase that in a therapeutic method. Parenting style doesn't change overnight or through a simple intellectual discussion. Some families start out closer to the ideal FBT stance, others tragically distant.
What written and video materials are you giving them? That can really matter in giving context to what you are telling them.
How firm are you in the dangers, the necessary commitment, and the difficulty?
You won't like this one… There are specific clinical skills to empowering parents in this way. It really pulls against the usual clinical stance. Not all clinicians have drunk the Kool-Aid of complete confidence in parental ability, and not all clinicians are equally good at conveying both the confidence in the family AND the confidence in their OWN ability to guide them through it. People get down on FBT for being too out of the book but I really think this approach requires some of the best clinical connection and ability – but for the parents and not the patient, which is what everyone is trained in. I'm just throwing that out there, because the approach has to be a good match with the clinician, not just the family. That said, anyone treating child and adolescent Eds needs to get good at FBT in their toolbox, I believe. Have you had the train2treat4ed training and are you in close touch with others who are working through this change in practice?
Marital splitting is the single most undermining factor in FBT, from what I observe. The natural differences between men and women, the personal intimate history between a couple, the legacy of coping in crisis… it's rife with hazards. Many couples depend on that interplay to maintain their connection, even, or grudges nursed for years become icebergs of danger to the process of that "same page, same line, same letter." Ugh, the stories I hear. I get very frustrated with people.
I also see a lot of families who struggle intellectually with the concepts here. They grasp only one issue at a time and when relieved of that worry forget there are other layers. For example, "may die" becomes the only consideration and once the patient is, as you mention, a little better appearing the alarms are off and instead of tackling the next phase they go off to their regularly scheduled life. As tedious as it is, the world has to keep reminding the family that an eating disorder is not just a risk of death now – it's a complex and chronic predisposition.
Each family has its own learning style. Some respond to authoritative words by the therapist, others like to be entrusted to read very scientific info, others feel condescended to with too much jargon, still others need to talk to others in their situation and some just distrust clinicians. Honestly, I wonder how I might have responded to FBT had it been offered to me instead of me seeking it out!
That said, I have seen ALL KINDS of families end up successful at this. Angry, meek, stupid, mentally ill, unpleasant, manipulative, anxious, self-involved, and even deeply disordered. I'm sure there are more suited and less but I've been amazed at the variety of ways it works out. So hard to know what the family CAN be if given a chance, good care, and time.
Last, I want to say how much I admire clinicians who do this work, like you. It's really hard. I know a lot of you and have seen the struggles and the flak you get from colleagues. I also know that it is harder in many ways than traditional therapy. But I do also see more and more clinicians who find their way and feel a great deal more effective and satisfied in their work when they are fluent and experienced in it, adding it to all the other qualities and therapeutic techniques that make a psychotherapist good at what they do. The fact is, you're asking parents to do very difficult stuff and even when you are right they are not always going to see that. Parents can be "a stiff-necked people."