The New Maudsley Approach is based on a cognitive interpersonal maintenance model which proposes that interpersonal factors (overprotectiveness, hostility, criticism, accommodation and enabling) can develop within families and maintain the illness [1, 2]. Inadvertently, these may hinder recovery. These are modifiable behaviours, however, and it is thought that carers may benefit from skills training in aspects of eating disorder management and communication techniques, similar to those used by professionals in specialized inpatient services.
Eating disorder symptoms frequently lead carers to react in particular ways. It is understandable that responses can be the source of hostile or critical confrontations occurring in all relationship settings. Unfortunately, such responses may result in Edi feeling increasingly alienated and stigmatized and retreating into the comfort of eating disorder behaviour even more. The New Maudsley Approach offers a series of animal metaphors (jelly fish, ostrich, kangaroo, rhinoceros, terrier) in a light-hearted manner to explain how these automatic reactions can be unhelpful. Some ‘animals’ may be the carer’s default way of coping with stress or part of an individual’s natural temperament. Carers frequently swing from over-protection to logic or become overtly emotional or avoidant.
There is no such things as a wrong animal response. There will be times when a behavior is useful: to protect, to be decisive, to ignore, to be upset. Carers need to learn to judge what works when. If something is working do more of it, if something isn’t working, review, reflect and try something else. When medical risk is high, it is of course entirely appropriate for carers to step in and take on the responsibility of a duty of care that society expects when a member cannot do it themselves. Once carers are satisfied that Edi is medically safe then they can start to experiment with becoming more motivational, gently nudging with warmth and empathy like a dolphin and St. Bernard.
Click here to learn more about the animal analogies.
In terms of accommodation and enabling, families frequently become bullied into what they eat, how they eat, where they eat or when they eat. It is only natural that they frequently respond in a manner that accommodates the symptoms in a bid to keep the peace. Accommodating and enabling behaviours often occur as a result of the family removing or covering up negative consequences of the illness in a bid to keep the peace. They can become subservient to eating disorder food rules, safety behaviours (exercise, vomiting, body checking, fasting or restricting) and obsessive-compulsive behaviours (reassurance seeking, counting, checking and control). This behaviour is tolerated by family members in an effort to restore a calmer environment for all. Note: Accommodating is supporting the person carry out their eating disorder behaviours; enabling them is preventing them (or the rest of the family) from having to deal with the negative consequences. In practice, it doesn’t really matter which it is, the effect is that they may help maintain the ED.
Click here to access the Accommodating and Enabling Scale . This scale is used to help carers reflect on the extent to which they accommodate or enable the ED by submitting to the ED voice.
Motivational interviewing is a communication style designed to elicit a behavioural change in people who do not recognize the need for change, or they feel ambivalent about it. This technique has been successfully used in the mental health arena for many years and is successful because it puts a person in control of their own changes. The supporting adult acts as a facilitator, helping them to explore their feelings and different potential outcomes but never telling the person what to do. The person finds their own path to change and is therefore far more likely to stick to it to their plans. Consequently, skills include the use of motivational interviewing as a means of providing calm and compassionate meal support, engaging intrinsic motivation to change. Carers are also taught the application of behaviour change principles and about the cognitive and emotional styles associated with eating disorder behaviour. Skills and techniques include:
- Strengthening carers beliefs in their abilities to make change possible.
- Giving carers the opportunity to express concerns about the illness.
- Discussing the basic principles of behaviour change.
- Teaching communication skills (ability to express & process emotions).
- Promoting respect, satisfaction and a unified approach within the family.
- Learning the skills of problem solving.
- Maximizing carer skills (warmth with limits and boundaries).
- Highlighting those factors which may be aggravating the problem.
1. Schmidt, U. and J. Treasure, Anorexia nervosa: Valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice. British Journal of Clinical Psychology, 2006. 45: p. 343-366.
2. Treasure, J. and U. Schmidt, The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. Journal of Eating Disorders, 2013. 1(13): p. doi: 10.1186/2050-2974-1-13.
3. Sepulveda, A.R., O. Kyriacou, and J. Treasure, Development and validation of the accommodation and enabling scale for eating disorders (AESED) for caregivers in eating disorders. BMC Health Serv Res, 2009. 9: p. 171. doi: 10.1186/2050-2974-1-13.