Maudsley Parents

My 16-year-old daughter began skipping meals and restricting her food intake more than two years ago. Since then we have struggled to find help. Despite consulting a few therapists and a brief admission to an eating disorder clinic she remained unwell. Each time she gained weight it was suggested we back off and she began to lose weight immediately. Excessive exercise has been a big problem too.

Working on our own we have managed to get her near a healthy weight. We recently found a new therapist familiar with the Maudsley approach and asked her to help us reach goal weight and then transition into phase 2. At the first session control was handed back to our daughter and she quickly lost 8 pounds. We have managed to help her regain that weight, but we are stuck. The therapist has suggested that we allow her to choose snacks and resume running but when we’ve tried she quickly loses weight. How do we move forward?

Lauren Muhlheim, PsyD responds

First of all, congratulations on getting your daughter to near a healthy weight. The transition to Phase 2 is often a difficult one to navigate and more ambiguous than Phase 1.  The criteria for beginning Phase 2 are:  1) the client is nearly weight restored (the Lock and LeGrange manual specifies 87% of ideal body weight), 2) meals are going smoothly, and 3) parents are empowered to step back in if need be. This final criterion is especially important; the reason for this is that the transition to Phase 2 is rarely smooth. 

As in all aspects of treatment, not all patients may be prepared to regain control at the same point, and some patients may not be ready for more control until they have maintained 100% of ideal body weight for a few months. Introducing a vigorous exercise like running can burn a lot of calories and is therefore more risky than handing back other types of control. One strategy might be to talk to the FBT therapist about handing back control more gradually:  for example, to let your daughter choose and prepare one snack per day under parental supervision.  You can then wait a week or so before handing back control of another snack or meal, still under parental supervision so that you have the ability to correct her if she doesn’t choose enough food. You might want to hold off on reintroducing running until she has maintained 100% of ideal body weight for a few months. When you feel she is ready to resume running, you could start small (30 minutes once per week) and tie it to an extra snack or make it contingent upon maintaining a minimum weight. 

Regular weighing during Phase 2 is crucial as it allows you to spot problems early and step back in before significant weight is lost.  If your daughter has trouble in any transition, recognize this as feedback, not failure. Take back control and try again in a month when she may be more ready.