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New family therapy for anorexia

Tribune Media Services

MIAMI - When her parents told her that she had to eat her dinner, Holly Zimmerman burst into hysterical tears and screams. Then, after several hours, the once docile third-grader leaped from her seat and tried to stab them with a fork.

"This is a little 9-year-old, and the devil was coming out of her because we were making her eat," Orlando, Fla., mom Lauren Zimmerman says, recalling the time her home became a battlefield because of a new, no-compromise policy of three meals and three snacks a day.

At age 7, Holly started to show symptoms of anorexia nervosa, which, in addition to self-starvation, can also involve purging and over-exercise. She hid snacks, squirreled away food in her mouth, and sniffed grains of rice, putting them down uneaten. But four weeks after her parents implemented the new rules, Holly stopped complaining and started eating.

Holly's family was using an obscure, family-based treatment known as the Maudsley approach. Developed in the 1980s at Maudsley Hospital in South London, the method has demonstrated empirical success combating a condition that affects approximately 10 million females and 1 million males in the United States. The American Psychological Association reports that the mortality rate for anorexic patients is 10 percent - one of the highest of all psychiatric disorders.


"The cornerstone of the Maudsley approach is what we call an agnostic view of the illness, which means we don't know what causes anorexia and frankly we don't care," says psychologist Dr. Sarah Ravin, one of South Florida's few Maudsley practitioners. "This is very different from traditional treatment, which focuses first and foremost on what caused this illness."

Maudsley treatment consists of three clearly defined stages.

Phase one - lasting from weeks to a year - hinges entirely upon weight restoration. Whereas traditional anorexia therapy often excludes parents from treatment, Maudsley parents' active involvement is seen as essential to their child's recovery.

"If a 15-year-old had a bottle of vodka before school every morning would you say, 'Well, that adolescent is asserting her need for control, so parents back off?"" Ravin said. "No, because drinking alcohol before school is not OK."

Leaving the child out of the decision-making process, parents serve three meals and three snacks a day, and then wait however long it takes for their child to clean the plate.

Once weight is restored and food is consumed without resistance, control over meals is gradually returned to the patient in phase two. Phase three - traditional therapy's first step - addresses the psychological, environmental or family issues that contributed to the disorder.

Ravin sees futility in trying to treat a child's psychological issues until they've reached a normal weight.

"Once kids start eating more normally and become better nourished, their brain starts to work better and they start to become more rational and ... are able participate in their own recovery," Ravin says.

Traditional treatments often involve what Leslie Long, parent of a recovering anorexic daughter, describes as a "parent-ectomy." The child is often placed in a residential treatment center, where "there is a nod and a wink that something has gone wrong in your family and that the parents are not to be trusted," Long says.

Parents who elect inpatient treatment for their child often worry about what will happen next.

"They do well in inpatient care but what do we do when they come home?"" said Elena Kruglyak, whose daughter Rebecca, 16, improved in the hospital but relapsed when she returned home in Delray Beach, Fla.

Because Maudsley is not widely available, many families must seek treatment far from home. The University of San Diego and Rush University Medical Center in Chicago have prominent programs.

Zimmerman, Long and Kruglyak found Maudsley through desperate online searches for alternative treatments for their struggling daughters. All three met with resistance from their children's physicians: When Zimmerman turned to Maudsley, Holly's pediatrician sent a letter withdrawing as Holly's physician.

Long brought her daughter to Miami from Connecticut for treatment with Ravin in December. Long describes her daughter, now 25, as healthy for the first time since she was 12.

Some Maudsley parents find empowerment through their hands-on role in their child's treatment. Implementing Maudsley, however, requires substantial time commitment and patience. Families must be able to handle the stressful physical and emotional backlash from the child that inevitably occurs in phase one. Parents often take off work during stage one as the family meal is reintroduced. School nurses are sometimes enlisted to supervise school lunches.

"I was a little apprehensive because the feeling was we would have to be there every time for each meal and each snack," Kruglyak says. "We were scared because we both worked and weren't in a position to stop working."


Maudsley practitioners say that the treatment is most effective for adolescents between 12 and 18 who have been anorexic for three years or less.

According to the APA, there is "strong research support" for the efficacy of Maudsley-style family-based treatment. Studies indicate that approximately two-thirds of adolescent anorexia nervosa patients are recovered at the end of family-based treatment, while 75 to 90 percent are fully weight-recovered at five-year follow-ups.

Some clinicians raise concerns that Maudsley is not for everyone.

"There are situations where the child, paradoxically, is the healthiest member of the family and the eating disorder is perhaps a coping mechanism for them to handle this family environment," Miami psychologist Dr. Amy Boyers says.

Refeeding a malnourished person can be dangerous and usually must involve physicians and nutritionists. But for those who have used the treatment and recovered from anorexia, Maudsley is a life-saving process.

"I have strong feelings for Maudsley," says Rebecca Zelmanovich, 16, who described her first phase of treatment two years ago as the worst experience of her life.

"I don't think anyone with an eating disorder will be gracious for it at all. It's not something you want, especially for me _ I am very independent.

"But being here today, I know I wouldn't have been able to recover without it. No matter how badly I wanted to recover earlier on my own, I just couldn't do it."



There are numerous websites and online forums that provide comprehensive information about the Maudsley approach. Here are a few: is a support forum for parents and caregivers of anorexia, bulemia and other eating disorder patients

F.E.A.S.T., which stands for Families Empowered and Supporting Treatment of Eating Disorders, has eating disorder information at is a volunteer organization of parents who used the family-based treatment to combat their children's eating disorder.

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