book cover "Brave Girl Eating: A Family's Struggle With Anorexia'
Harriet Brown once made a near science of packing the most calories possible into everything her daughter ate. A Häagen-Dazs coffee ice-cream milkshake made the way Kitty had always loved it crammed 690 calories into one small glass. That it took two hours of coaxing, pleading, and cajoling to make Kitty swallow it didn't matter. Long after the shake warmed to room temperature, Brown sat with Kitty, her voice soothing and straw in hand, until sip by sip, tear by tear, the milkshake was gone. Her anorexic daughter's life depended on it. She had all but stopped eating and had dropped to 71 pounds, more than 25 pounds below her healthy weight.
Brown, author of Brave Girl Eating: A Family's Struggle With Anorexia, and her husband nursed their 14-year-old daughter back to physical and emotional health, relying on an unconventional method that has been gaining traction. Named for the London hospital where it was devised in the 1980s specifically to treat children with eating disorders, "the Maudsley approach"—also called family-based therapy—emphasizes recovery over cause and care provided by parents, not by doctors. The first priority in the Maudsley program is to feed the child. Examining the issues behind the child's disorder can wait.
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According to a report released today in the Archives of General Psychiatry, a family-based treatment approach was found to be effective at the 12-month mark for 42 percent of adolescent participants, meaning their weight was at least 95 percent of normal and they achieved at least an average score on an assessment of eating disorder symptoms. Standard therapy—inpatient care that addresses healthy eating and the psychological underpinnings of the disorder, followed by continued counseling after the child is discharged—was only 23 percent effective. Parents are mere bystanders, says Brown, instructed not to pressure their child to eat or, for that matter, not to talk about food at all to avoid becoming the "food police." And they are viewed as likely to be part of the problem. "They're told to butt out," Brown writes. Conventional therapy holds that eating disorders are not about eating anyway, but about control.
That is why getting at the psychology of the problem is the primary goal of conventional therapy, says Daniel Le Grange, director of the Eating Disorders Program at the University of Chicago Medical Center. But he maintains that it accomplishes little. "There's no evidence that understanding what causes an eating disorder helps the adolescent recover," he says. "But we know that if you give the child medicine—in this case it's food—she has a much better chance of recovery." The reference to "she" may be inadvertent, but it is a fact that some 90 percent of children with eating disorders are girls.
The Maudsley regimen moves through three phases of 6 to 12 months each, depending on the severity of the disorder. Children are hospitalized only if they need medical care. After that, says Le Grange, repeat visits often can be prevented if parents take action immediately and fully embrace the Maudsley approach. In phase one, parents commit to feeding their child three meals and three snacks every day, even if that entails sitting at the table hour after hour to put on pounds. Phase two gradually transfers control to the child after a reasonably healthy weight is attained and she eats without rebelling. Phase three finally introduces counseling, to address the psychological issues that contributed to the disorder.
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The program appealed to Brown. "Sending Kitty away to residential treatment just didn't seem right," she says. "I did the research and found the recovery rate for a lot of these hospitals wasn't very good. It seems like they're a bit of a revolving door--people go, they get better, they come back out and they get worse." Kitty would benefit most from a program that kept her at home, Brown thought. "When you send someone away--whether it be for alcoholism or anorexia—they have to come back. You could be very successful in a residential place, but you're always going to have to make the adjustment upon return."
But the enormity of the commitment Maudsley demands of parents, draining their hearts, minds, and energy, shocked Brown. Mealtimes became battles waged across the dinner table. Confronted with a piece of chocolate cake or a plate of macaroni and cheese, Kitty morphed into an demonic stranger. It was the demon, says Brown, not Kitty, who swore she would starve herself, who screamed, "I'm so fat," who told her parents countless times that she hated them. Says Brown:"The thought crossed my mind many times—'I wonder if we're going to have a relationship after this?'" Her and her husband faced scheduling nightmares, with one parent or the other having to dash home from work to sit with Kitty and feed her. "There was always the next meal, the next snack, the next doctor's appointment," says Brown. "There really was no break possible, we were in crisis mode."
The heated struggles inherent to this approach eat away at the trust between parent and child, according to critics of Maudsley. Le Grange's research rebuts that. He was lead author of a 2007 study in the Archives of General Psychiatry that examined Maudsley's effect on the parent-child relationship in 80 bulimic adolescents over five years. The study found no evidence that the children stopped trusting their parents. "Quite the contrary," says Le Grange. "If a child is out of control to the point of starvation and a parent steps in to save her life, it only reinforces that trust."
Brown agrees. She believes her relationship with her daughter is stronger than before. "When you go through this kind of extreme experience with your child, it creates a whole different level of bonding," she says. "She knows we're there for her no matter what, and that's only been an asset to our relationship."
Mental health specialists say the success of the family-centered approach also is helping to put hoary and toxic stigmas to rest. "There was this old-fashioned notion that children have this problem because of overinvolved and hypercritical parents," says Le Grange. "None of that has ever been proven. The truth is that parents have been shown again and again to be the best agents for treatment."
Blaming yourself for your child's anorexia is not only a waste of time, it's a roadblock to recovery. "Every moment I spent blaming myself, Kitty was getting sicker," says Brown. "What she really needed was someone to stand up to the eating disorder," she says. "She needed me to stand with her and be bigger and stronger than that voice in her head."
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Updated on 10/04/10: This article, originally published on September 16, 2010, has been updated to include the most recent research on family-based therapy for eating disorders.
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