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 [3]. 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.
Communication Techniques
Motivational Interviewing
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. There are four interlocking elements: partnership, the fundamental belief that the way forward is a collaborative journey, acceptance that opinions may differ without you having to agree with them. The third element is compassion, working alongside the person with the ED whilst trying to understand their experience, focusing on their best interests and lastly, empowerment, helping evoke the person’s realization of his/her own strengths and abilities by actively encouraging their autonomy in the record process.
In MI, there are four main phases: engaging, focusing, evoking and planning [4]
Engaging: Can we work together on this? Engaging involves establishing mutual rapport, trust and respect, agreement on goals and collaboration on mutually agreed steps to reach those goals.
Focusing: Where are we going? Although not directive, MI is directional and purposeful moving towards intended outcomes.
Evoking: Why would you go there? Evoking is about promoting change talk as opposed to sustain talk by asking certain questions rather than others and using appropriate reflections and affirmations, i.e. reflecting on the parts of the dialogue that strengthen their own reasons as to why change might be possible.
Planning: How will you get there? Planning occurs when there is sufficient motivation for change and talk usually shifts into how change will happen.
Emotion Focused Therapy
Emotional coaching is based on the work developed by L. Greenberg [5] from the field of emotion focused therapy. This approach has been applied to families of people with eating disorders by Joanne Dolhanty and Adele LaFrance Robinson [6].
According to Greenberg, an important first step in regulating emotions is awareness of them. People need to be guided to become aware of their emotions so they can allow and accept them, be informed by them and then work with them to solve problems. Ultimately, people need to evaluate whether the emotion they are experiencing is adaptive and can be used as a guide or whether it is maladaptive and not to be followed. The development of skill in emotional regulation is thus an important part of emotional intelligence. When experiencing periods of excessive anxiety, for example, we need to be able to reflect on those feelings and ultimately be able to soothe them.
Validating others’ feelings is a basic technique in emotional coaching. The best way to validate people’s emotional experience is to communicate that their emotional responses are understandable. Emotional regulation skills involve identifying and labelling emotions, increasing positive emotions, self-soothing, breathing and distraction [7]. Of particular importance is developing a person’s abilities to self-soothe.
When applying emotion focused therapy to eating disorders, the premise is that emotional regulation can be acquired within a safe, compassionate relationship. People with eating disorders generally have difficulty both identifying and displaying their emotional states. An acronym for practicing emotional coaching is ALVS (attend, label, validate, soothe):
Attend to feelings in the here and now (including physical sensations, thoughts, actions).
Label by taking a guess and put the emotional state into words
Validation by making sense of the experience. The stem ‘because’ can be helpful in showing validation, e.g., it is not surprising you feel anxious/frightened/confused because….
Soothe – Address the need signalled by the emotion (e.g., sadness/solace, perhaps with a hug). Even if the emotion is not acknowledged, suggest that strong feelings of any sort can feel overwhelming and difficult to manage.
References:
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.
4. Miller, W,M. and S. Rollnick, Motivational Interviewing, Helping People Change and Grow (Fourth Edition), 2023, New York, London: The Guildford Press.
5. Greenberg, L., The therapeutic relationship in emotion-focused therapy. Psychotherapy, 2014. 51(3): p. 350-57.
6. LaFrance, Robinson, A., Dolhanty, J., Stillar, A. et al., Emotion-focused family therapy for eating disorders across the lifespan: a pilot study of a 2-day transdiagnostic intervention for parents. Clinical Psychology & Psychotherapy, 2016. 23(1): P. 14-23.
7. Greenberg, L., Emotion-focused therapy: Coaching clients to work through their feelings. 2001, New York: American Psychological Association.