Why Clinicians Are Resistant to Maudsley FBT

Research has shown that the Maudsley Method of Family-Based Treatment (FBT) is more effective than any other treatment for anorexia nervosa (AN) or bulimia nervosa (BN) in patients under age 18. Despite this fact, many clinicians who treat eating disorders are very resistant to using FBT to treat their patients. There are a variety of reasons for this resistance – some legitimate, some personal, some inexcusable, and some bred from ignorance.

Here are some of the most common reasons why clinicians who treat eating disorders are resistant to using FBT, along with my rebuttals to each:

1.) “I work with adults. FBT is not applicable to most adults.”

While FBT has not been adequately studied in adults, the reality is that there are no evidence-based treatments for adults with AN yet. I believe that patients over age 18 need to have loved ones fully informed about their illness and actively involved in their treatment just as much as young patients. The basic principles of FBT (with some age-appropriate modifications) are now being applied to older patients with very promising results.

As Cynthia Bulik’s recent study on Uniting Couples Against Anorexia Nervosa demonstrated, the principles of FBT can be applied very successfully to adults, using spouses or significant others for support rather than parents.

Also, there is some preliminary evidence that a modified version of FBT can be useful for college-aged patients who are temporarily living at home with parents during recovery. There may very well be a time in the not-too-distant future in which a modified form of FBT is an evidence-based treatment for adults.

2.) “Some families can’t do it.”

This statement is absolutely true – some families can’t do it. However, I believe that the true percentage of families who “can’t do it” is actually much smaller than one may think. FBT can be successful in divorced families, step-families, single-parent families, families with many children, families where both parents work full time, and families in which a parent suffers from a mental illness.

The only real contraindications for FBT in patients under18 are cases in which the patient has been physically or sexually abused by a parent, or both parents are so mentally or physically ill that they are unable to care for their children. Both of these contraindications are relatively rare, and even in these cases, one would hope that the patient would be living in a safe environment with other adults (e.g., relatives, foster parents) who could participate in FBT with the patient.

What happens too often is that parents don’t purse FBT because they aren’t aware it exists, or aren’t aware of the evidence behind it. It is also common for parents to be discouraged from doing FBT with their child because the child’s clinician (who is not really familiar with FBT or who doesn’t agree with it) tells the parent that it won’t work for their particular child for some reason.

In sum, I would estimate that maybe 10 % of families really can’t do it (I have no data to support this percentage; it is just an educated guess). The majority of families can do it if they have the proper clinical support and encouragement. The majority of parents love their children immensely and will do anything to help them recover if given the opportunity. It is up to us, the clinicians, to give families that opportunity.

3.) “Some adolescents don’t improve with FBT.”

I have no counterpoint to this one. The reality is that FBT is not effective for everyone. This is not a shortcoming unique to FBT, as there are no treatments that work for 100% of patients. I doubt that there will ever be one treatment that works for everyone in the same diagnostic category, because each individual patient is unique and has their own set of circumstances. Therefore, we must continue to research other forms of treatment and work to improve upon the existing treatments. When a patient does not improve with FBT, we must offer something else – residential treatment, day treatment, cognitive behavioral therapy – whatever is most appropriate for that particular patient and that particular family.

4.) “My training and inclination is as an individual therapist. Making the switch to working with families is intimidating. Learning FBT would be like starting from scratch.”

I don’t see it as starting from scratch. Rather, I see it as adding another (very effective) tool to your existing toolbox. You certainly don’t need to abandon individual therapy just because you’ve added a new treatment to your repertoire.

While some patients will recover fully with FBT and never need individual therapy, most patients do have co-morbid disorders or other issues which need to be addressed with individual therapy. In these cases, individual therapy comes after FBT. Many times I have transitioned to individual therapy with a patient after the patient has successfully recovered with FBT. The great thing about this approach is that the eating disorder has already been fully addressed through FBT, so you and the patient can focus all your time and energy on other things, such as depression, OCD, body image issues, perfectionism, and social difficulties.

5.) “My training is in psychodynamic therapy and relational approaches. FBT is pretty concrete and behavioral. Adopting FBT would seem to remove the very things that made me want to become a therapist in the first place – the focus on depth and the therapeutic relationship.”

FBT is more concrete and behavioral than other types of therapy, and I believe that is part of why it is so effective in treating these malignant illnesses which demand immediate behavioral management in order to save the patient’s health. That being said, the therapeutic relationship is just as essential in FBT as it is in other types of treatment. The parents and the therapist must develop trust in one another, and mutual respect is key, because the parents and therapist are allies working together against the illness on behalf of the child. It is extremely rewarding to be able to offer this kind of assistance and support to terrified, confused, guilt-stricken parents, who blossom with confidence as you educate them about the illness and empower them to do what needs to be done to help their child recover.

And the kids! It is nothing short of amazing to watch the therapeutic relationship evolve and unfold so quickly as recovery progresses. In the first few sessions, the kid typically presents as catatonically depressed, curled up in a fetal position under a blanket, sobbing quietly; or the kid reacts with extreme anger and resistance, yelling and hurling insults and dropping f-bombs before running out of the room. Entire tissue boxes are gone through in one session; stuffed animals need to be placed back on the shelves after being thrown. And within a few months, the kid is smiling, laughing, so happy to see you, chattering on about their trip to Disney World or their new boyfriend or how much they love ‘90’s music exclaiming “Wow, Dr. Ravin, it must have been so cool to be a teenager back in the ‘90’s!” The transformation is astounding.

Furthermore, there is lots of room for a tremendous amount of depth when continuing to work with the patient individually after FBT has been successfully completed. In fact, is even more feasible to go into greater depth in these cases, because the eating disorder is in remission and health-threatening behaviors have long-since been eliminated, so treatment can focus exclusively on other (often more interesting!) issues.

6.) “FBT is agnostic on etiology, and I think etiology is very important.”

Yes, FBT is agnostic with regards to etiology. In other words, the clinician states clearly at the outset of treatment that we don’t know exactly what causes eating disorders, and that it is not relevant for the purposes of this treatment. I believe this agnostic stance is one of the strengths of FBT: it does not waste time on “why” but instead focuses on “how” to help the patient recover.

I agree that etiology is very important because our ideas about etiology (for better or for worse) have a huge impact on how we treat patients. Therefore, clinicians and researchers must continue to have professional discussions about etiology amongst themselves.

My concern is not the discussion of etiology amongst professionals in the field. Rather, my concerns are 1.) When clinicians have a particular presumption about etiology which is not consistent with recent scientific evidence, 2.) When that particular presumption guides the use of treatments that are less effective, and 3.) When those presumptions about etiology cause harm to patients and their families by subtly or overtly blaming the patient or the family.

In my opinion, when clinicians discuss etiology with patients and their families, these discussions should be limited to the following points:

A.) Clarifying that neither the patient nor the family is to blame for the illness.

B.) Dispelling common myths about etiology (e.g., media, control issues, overprotective parents)

C.) Discussing the “Four P’s:” predisposing factors (e.g., genetic predisposition), precipitating factors (e.g., weight loss through dieting or illness), perpetuating factors (e.g., malnutrition has a calming and mood-elevating effect on those who are vulnerable to eating disorders), and prognostic factors (e.g., importance of early and aggressive intervention, maintenance of optimal body weight).

This is all the information patients and families need to know about etiology, because let’s be frank: this is all we really know about etiology. Anything else is just a distraction.

5 Replies to “Why Clinicians Are Resistant to Maudsley FBT”

  1. Thanks, Dr. Ravin, for a heckuva post! I’m sure I’ll be linking it often so that as many people as possible can learn from it.

  2. Another fantastic blog, Dr Ravin. Thank you. I can think of a few people to share this with!

  3. Dr Ravin, I am such a fan of your blogs. You express these important insights with such clarity. I wish there was one of you in every town. Thanks.

  4. There are three issues I have with this post.

    1.) “I work with adults. FBT is not applicable to most adults.”

    I have actually not seen any evidence of this (outside of the age range of 18-20 which is practically no different from 17-18 anyway).

    A case study I HAVE read from the University of Chicago (I believe by Dr. Chen) was a ridiculous piece of literature supporting FBT in young adults.

    FBT studies in adolescents have mainly been done for AN. This case series had 4 adults — 3 of which did NOT meet criteria for any clinical eating disorder upon beginning the study — both psychological criteria (EDI scores) and behavioural/physical criteria (not underweight, no b/p, etc.). The ONE individual who was considered anorexic had not achieved remission by the time the study had terminated. If I remember correctly, for the others, their EDI scores remained sub-clinical (as would be expected) and some subthreshold behaviours remained.

    Yet the study somehow concluded a 50% recovery rate (from a sample size of 4!!) and made the assumption that FBT could be applicable in adult populations.

    My understanding of Cynthia Bulik’s UCAN research was that there were significant modifications from Maudsley FBT to allow for differences between parent/child and spousal relationships — I don’t know if it is 100% fair to call it Maudsley.

    I realize there is anecdotal evidence from FEAST, etc. that FBT does work in adults — but I think this highly depends on the adult — the financial dependency upon family, emotional immaturity, etc.

    2.) “Some families can’t do it.”

    As you said — true. But I take issue with this statement,

    “The only real contraindications for FBT in patients under18 are cases in which the patient has been physically or sexually abused by a parent, or both parents are so mentally or physically ill that they are unable to care for their children.”

    I’m sorry, but FBT is incredibly stressful for both family and child — especially on the parents who believe that they are solely responsible for their child’s recovery. FBT can quickly exacerbate a mental or physical illness and create turmoil within the family. I speak from my own experience.

    My parents are alcoholics — but highly functioning alcoholics. They only drink at night, they hold prestiguous jobs, have won awards, have hobbies — and yet they fall asleep drunk on the couch each night. My mom has an anxiety disorder that in her youth caused a nervous breakdown and my dad lost both his parents to cancer in his early twenties. My sister has cerebral palsy and is physically disabled. My AN strained the balance of our already fragile family.

    Our FBT knew nothing of this and I was not about to enlighten him. My parents were NEVER physically abusive or verbally abusive, are WONDERFUL people and only wanted to support me. BUT under FBT things increasingly escalated out of control.

    My father didn’t want to lose me as he had lost his parents (even though I was in no physical danger at a BMI of 18 with no medical issues), but weekly sessions with the FBT made him feel like he should be able to help. My resistance and his fear quickly escalated to physical violence (I was punched, dragged out of my bed, food was thrown BY my parents, etc. ) This was a man who had NEVER before been abusive in ANY way.

    My mom become antagonist, angry and irrational when she is intoxicated. This did not bode well for rational mealtime behaviour or support — in fact, she often became verbally abusive and blamed me for the stress and my dad’s reaction.

    My sister became reclusive, terrified and attempted to stop my parents from this. She could see the insanity and spoke strongly against it.

    I wanted to tell my story because this is a family unit that although had problems was functioning, never abusive and had very strong bonds of love/affection. I take issue with the fact that you believe the ONLY time FBT is not appropriate is when things have escalated to such severity (before beginning FBT!) that the child should be in foster care. That is absolutely ridiculous.

    As a therapist, I think you fail to appreciate the strain that FBT puts on families with already existing problems. I think the child DESERVES to be treated by parents who are emotionally stable, rational and healthy — I wonder at the quality of the decisions that are made day by day when a mentally ill parent is driven by fear and desperation.

    It is not enough to say that the therapist should be able to “sense” these issues. It is not enough to expect a terrified child to explain this to a therapist they barely know. More dangerously, once FBT sessions start up, such concerns are in danger of being dismissed as ED stories and do you REALLY believe the parents are going to admit the truth?

    That’s all — besides these points, it was a well written blog post. But I’d encourage you to be careful as to what you say before you post. You are greatly respected by many parents and your words carry great weight.

  5. A:),

    Thank you for your feedback. I appreciate your thoughts on this issue.

    I am so sorry to hear that you and your family had such an awful time with FBT.

    Out of curiosity, what would you have liked your therapist to do differently that would have made treatment more helpful to you? How do you think FBT should be modified or improved in cases like yours? What kind of treatment would have been most effective for you, given your personal and family circumstances?

    I am always looking for ways to improve my practice, and researchers are (or at least should be) trying to improve upon existing treatments. You seem to be in a good position to offer insights on this, having been through the process yourself.

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