It seems that there are quite a few ineffective therapists who treat eating disorders (ED’s), and this is particularly dangerous given that EDs have such a high mortality rate and are associated with many medical and psychiatric complications.

I have had the privilege of working with many ED patients and families who have received ineffective or actively harmful treatment in the past. In talking with these patients and families about their prior treatment experiences, I have come to recognize many red flags that are very commonly associated with ineffective or harmful ED treatment.

Red Flags re: Etiology
1.) The professional informs the patient or family that the ED is “not about the food.”
2.) The professional informs the patient or family that the ED “is about control.”
3.) The professional is not knowledgeable about recent science regarding the etiology of EDs.
4.) The professional emphasizes psychosocial “causes” of EDs (e.g., family dynamics, societal pressures, identity issues) while ignoring, discounting, or minimizing the genetic and biological underpinnings.

Red Flags re: Family
1.) The professional blames the parents (either subtly or overtly) for causing or “contributing to the development of” the patient’s ED.
2.) The professional advises the parents: “Don’t be the food police.”
3.) The professional does not keep parents of minor patients (< 18 years) fully informed and actively involved in their child’s treatment.
4.) The professional views parents with suspicion or keeps them at arm’s length, without reasonable cause.

Red Flags re: Treatment
1.) The professional is not knowledgeable about evidence-based treatment for EDs.
2.) The professional cannot, or does not, explain the treatment method she uses and / or the rationale behind it.
3.) The professional recommends or allows individual psychotherapy without ongoing nutritional restoration, weight restoration, and medical monitoring.
4.) The professional is very interested in exploring “underlying issues” in an acutely symptomatic patient.
5.) The professional insists on addressing the patient’s co-morbid conditions without also (either first or simultaneously) addressing the ED symptoms.
6.) The professional has never heard of Maudsley / Family-Based Treatment (FBT), or has heard the term but knows nothing about it.
7.) The professional asserts that Maudsley / FBT “will not work” for this particular patient, without giving a convincing explanation for this assertion.
8.) The professional blames the patient (either subtly or overtly) for having an ED.
9.) The professional advises parents to send their child or adolescent away to a residential treatment center without first trying Maudsley / FBT, unless it is clearly contraindicated.

Red Flags re: Recovery
1.) The professional asserts that the acutely ill patient “has to want to eat” or “has to want to recover.”
2.) The professional emphasizes the adolescent or young adult patient’s need for control and independence as more important than her recovery from ED.
3.) The professional sets or allows a target weight range based on population indices (e.g., BMI of 18.5) or percentiles (e.g., 50th percentile for age/height) without consideration of the individual patient’s build, weight history, or optimal weight.
4.) The professional declares the patient “recovered” based on weight alone, without regard for her behavior or mental state.
5.) The professional asserts that one never recovers from an eating disorder.

This list of red flags may be useful when you are looking for or ruling out a professional or treatment program based on information on their website; it may also be useful in interviewing potential new therapists. If you or your loved one have been in treatment for a while without making progress, you can also use these red flags to help you assess the situation and determine whether to go elsewhere for a second opinion.

My advice? If you see one or two of these red flags in your therapist or treatment program, investigate and proceed with caution. If you see three or more, find a new therapist.

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.

So naturally, I was thrilled to read the recent news article in the Sun Sentinel with a headline describing Maudsley as “a controversial treatment.”

This article gives an overview of the Maudsley Method and describes the experiences of two families – one with a 12-year-old girl and one with an 18-year-old boy – who used this approach to help their children recover from Anorexia Nervosa (AN). In a fair and balanced way, the article also lists some of the criticisms of the Maudsley Method that make it so controversial.

I believe that controversy is healthy part of living in a free society. Without controversy, there cannot be progress in the areas of ethics, morals, politics, or social norms. We must challenge old ideas and new ideas alike. We must approach life with an open mind as well as a healthy degree of skepticism. Some of the best ideas in the history of humanity, such as racial integration, freedom of religion, and equal rights for both genders, were born amidst extreme controversy. Thousands of people devoted their lives to the pursuit of these ideas. People died fighting for these causes. And to my generation, they seem so obvious and self-evident that we take them for granted.

Controversy accelerates progress in the aforementioned areas by shedding new light on old ideas. On the contrary, controversy tends to hinder progress in science. This happens because controversy over scientific ideas generally arises when people criticize or oppose scientific discoveries on the grounds of theology, politics, morality, or philosophy. Many scientific truths were initially met with extreme controversy. Galileo was tried – and convicted – by the Vatican for his scientific explanation of a heliocentric universe. And although Darwin’s theory of evolution has been almost universally supported by the modern scientific community, it was (and still is, in some communities) highly controversial for cultural, theological, and political reasons.

All viewpoints have equal merit in debating different perspectives on morality, philosophy, or politics. The winning idea is the one which is shared by the majority of people, which is then often supported by legislation and reinforced by social norms. This is what happened with racial integration, religious freedom, and gender equality. In debates over science, however, some answers are clearly superior to others. Ideas supported by scientific research are superior to ideas not supported by scientific research. Scientists conduct reliable studies, interpret the data, and present the results to their peers. Eventually, these results are disseminated into the public domain. Personal beliefs and political viewpoints and religious doctrines have no place in scientific inquiry. They obscure the truth.

In this vein, we have the controversy over the Maudsley Approach. Some clinicians say that they “don’t believe in Maudsley” just as some people say they don’t believe in God or Santa Clause or evolution. Maudsley, like evolution, is not a “belief” to be accepted or rejected. Maudsley, like evolution, is supported by a wealth of scientific literature which should be evaluated empirically and used effectively to understand and advance the human condition. To treat Maudsley as a socio-political issue like gay marriage that one sides “for” or “against” muddies the waters, misses the point, and makes one look scientifically illiterate.

Those who criticize Maudsley are doing so on philosophical, rather than scientific, grounds. They have not devised reliable, valid studies yielding data to the contrary. Rather, they cite antiquated and unproven ideas about eating disorders, they make criticisms that show a clear ignorance of the scientific process, or they ask irrelevant questions.

Some day soon, the Maudsley Approach will join the ranks of Darwin’s evolution and Galileo’s heliocentric solar system as a scientifically accepted truth. Some day soon, all therapists will approach psychology as a science – like biology and astronomy – which is guided by empirical data and impervious to personal beliefs.

On the other hand, there are therapists who over-pathologize and overanalyze. These therapists are married to unscientific, unsupported psychodynamic theories about the etiology of psychological problems which tend to attribute symptoms to supposed family dysfunction and internal conflicts. These therapists fail to take into account the powerful role of genetics and neurobiology in contributing to the patient’s symptoms. They ignore or discount the recent scientific advances in our field, and they do not employ empirically-supported treatments which have been demonstrated to be effective. They rely instead on their opinions and “clinical judgment.”

Neither side of this dichotomy serves its patients well, as both sides fail to appreciate the true complexity of the human experience. One side places all eggs in one very small proverbial basket (a pill), effectively abnegating the patient of any responsibility for behavioral, psychological, or environmental change. The other side places an unfair amount of blame on the patient and / or her family, searching for root causes that may not exist, traumas that may never have occurred, or dysfunction in normal thoughts and behaviors. Consequently, it is implied, if not blatantly asserted, that biologically-driven thoughts and behaviors are freely chosen and can be un-chosen just as freely with enough insight into said root causes, traumas, and dysfunction.

I am often disappointed by those mental health professionals who have so little scientific understanding of the interaction between genes and environment, between biology and psychology, between experience and neurodevelopment. They seem to forget that the mind is an abstraction of the brain, and the brain is part of the body. Their thinking is so dichotomous – disorder X was caused by either genes OR environment; treatment must be medication OR psychotherapy; it’s a neurobiological illness OR it is caused by environmental factors. They don’t seem to understand that, with mental illness, it’s rarely a question of “nature or nurture.” Rather, it is nature AND nurture, both of which come in many forms. Biology, psychology, and environment are constantly interacting, with each of these components profoundly impacting the other two.

I would like to see all mental health professionals develop a full understanding of and appreciation for biopsychosocial models of mental illness and evidence-based treatments. It is my hope that psychologists, psychiatrists, and mental health professionals from all disciplines will begin taking a more well-rounded approach to treating psychiatric disorders and helping people achieve mental health.

There is one recently published randomized controlled trial of outpatient vs. residential treatment. Results of this study demonstrated that adolescents who were randomly assigned to outpatient treatment fared just as well as those who were randomly assigned to residential treatment. Given that outpatient treatment is less expensive and less disruptive to the adolescent’s life, the authors conclude that outpatient treatment is preferable.

I am a firm believer in evidence-based outpatient treatments which keep family members fully informed and actively involved whenever possible. Patients who receive treatment which prioritizes nutritional rehabilitation, weight restoration, and cessation of restricting/bingeing/purging behaviors as the essential first step, are more likely to achieve full recovery in less time. In an ideal situation, a skilled therapist can utilize the strengths and resources of the family and coach them in understanding eating disorders, refeeding their loved one, and interrupting her eating disorder behaviors. Families can also be coached in how to maintain a home environment which is conducive to recovery while their loved one participates in therapy to acquire healthy coping skills, learn how to prevent relapse, and manage any comorbid conditions. This is how the Maudsley Method of Family-Based Treatment works. At this time, the Maudsley method is the only empirically-supported treatment for adolescent anorexia nervosa, and has also been shown to be equally effective in treating adolescent bulimia nervosa. Empirical studies on the use of a modified Maudsley approach in treating young adults with eating disorders have not yet been published. However, anecdotal evidence suggests that many young adults respond favorably to a modified Maudsley approach – even those who have been ill for many years and have had numerous stays in inpatient or residential treatment. And, let’s face it: we don’t really have a good alternative treatment for young adults with anorexia nervosa.

The majority of patients who are treated with Maudsley do achieve and maintain full recovery. Simply put, Maudsley works, and there aren’t any great alternatives. Thus, Maudsley should typically be the first-line treatment, especially for adolescents with anorexia nervosa, and should commence immediately following diagnosis. That being said, Maudsley may not be appropriate in a minority of cases. For example, families who are unable to find evidence-based treatment providers near their home, families in which neither parent has the necessary time or energy due to very demanding careers or caring for other small children, families in which parents cannot agree to Maudsley and refuse to compromise or work together, families in which there is abuse or addiction, or families in which one or both parents suffers from a physical or mental illness which impairs their ability to parent their child effectively.

Despite the promise of the Maudsley Method, it is not necessarily effective or appropriate for all patients (this statement, while often cited by critics of Maudsley, is annoying and virtually meaningless because NO form of treatment for any psychological or medical illness is ever appropriate and effective for 100% of patients. This is not a weakness of a particular treatment method; this is just reality). For the aforementioned reasons, there is, and probably always will be, a need for residential treatment for eating disorders.

Residential treatment for eating disorders, as it exists today, has several benefits and several drawbacks. The benefits include:
• Supported nutrition to promote appropriate weight restoration
• Round-the-clock monitoring to prevent patients from engaging in bingeing, purging, restricting, and substance use
• Protection from self-harm and suicide
• Providing the patient with a respite from the stresses of school, work, sports, and everyday life
• Providing the family with a respite from the daily strain of caring for their loved one

The drawbacks to residential treatment, as it exists today, include:
• Prolonged separation from the family and home environment
• Prolonged absence from school, friends, extracurricular activities, and normal routines
• Exposure to other eating disorder patients, which can result in acquisition of new symptoms, solidification of identity as an “eating disorder patient,” and competitiveness with other patients about who is sicker or thinner
• Artificial environment – a “bubble” – which does not translate to real-world living
• Exposure to outdated and unproven theories about the etiology and treatment of eating disorders (e.g., blaming “family dysfunction,” search for “root causes,” exploration of supposed “underlying issues”)
• Failure to plan adequately for a smooth transition home
• Insufficient family involvement (weekly phone sessions and “family weekend” pay lip service to family involvement, but they often play the blame game, focus on presumed family dysfunction, advise parents to “back off” and not be the “food police,” and fail to educate families as to how to help their loved one recover. In essence, many family sessions send all the wrong messages and fail to send the helpful ones).
• Over-diagnosis of and over-medication for supposed comorbid disorders which are largely, if not entirely, the result of malnourishment and / or refeeding
• Attempts to use psychotherapy of any kind on patients who are not able to benefit cognitively or emotionally.

These last two points are particularly striking to me (granted, these problems occur with less-informed outpatient treatment as well). I have had many patients who were diagnosed with and medicated for severe mental illnesses such as major depression, bipolar disorder, or even borderline personality disorder, while they were underweight or re-feeding in residential treatment. In many patients, these symptoms decrease substantially or disappear altogether once the patient has reached and maintained a healthy body weight for a number of months. I have several patients who arrived at my office after years of ineffective treatment, with multiple psychiatric diagnoses, taking multiple medications. After weight restoration and maintenance along with evidence-based psychological interventions, these patients no longer required medication for any psychiatric symptoms and no longer met criteria for ANY mental disorder. Sometimes, less is more.

What many psychiatrists and other mental health professionals fail to understand is that all people who are malnourished or re-feeding, even those without eating disorders, exhibit symptoms that mimic certain mental disorders (see Minnesota Starvation Study). Diagnoses made while a patient is underweight or re-feeding are often inaccurate. Medicating a patient for a presumed mental illness which is actually the direct result of a malnourished and / or refeeding brain is at best ineffective and at worst quite harmful. Obviously, many patients with eating disorders do have genuine comorbid psychiatric issues, and clearly these need to be identified and treated. But even those patients with legitimate comorbidities may find that their other symptoms are more manageable, or require less medication, when their eating disorder is under control.

Nearly all patients in residential treatment for eating disorders are there because they are significantly malnourished or actively engaging in frequent binge/purge behaviors. These are patients with significant (though temporary) brain damage which renders them unable to process emotions, think rationally, perceive other people’s intentions, or think logically about food, weight, or body image. We know that this brain damage is reversible only after months of full nutrition, weight restoration, and abstinence from eating disorder symptoms. I understand the rationale that, since patients are in residential treatment, they should be given every possible type of treatment available from equine therapy to process groups to CBT to psychoanalysis to making pretty necklaces. I understand that the directors of residential treatment centers want to provide patients with every possible tool for recovery. But what if the patients are not yet equipped to use these tools? And what if some of these tools can be harmful? Again, this may be a case of less is more.

In my ideal world, residential treatment would retain the benefits it currently has while eliminating the drawbacks. Here’s how it would work:
• The immediate focus would be on full nutrition, full time so that patients can restore their weight as quickly as is medically safe and can break the binge/purge cycle (if applicable). This would include three meals and three snacks per day, carefully monitored. “Magic plate” would be employed, and patients would be required to eat 100% of their meals and snacks. There would be no “rewards” for eating well or “punishments” for eating too little. Eating disorder patients are punished enough by their illness, so the last thing they need is a punitive external measure. Rather, there would be no alternative other than to consume full nutrition, preferably through food, but otherwise through a supplement or nasogastric tube.
• Patients would be carefully monitored and prevented from hiding food, bingeing, or purging.
• Patients would be monitored for urges to self-injure or commit suicide and kept safe from any possible means of self-harm.
• No new diagnoses would be made and no new medications prescribed.
• No individual therapy, family therapy, or group therapy of any kind would be provided. However, a psychologist specializing in eating disorders would be available daily to provide supportive counseling for patients who request it.
• Patients would spend their days participating in relaxing, rejuvenating activities such as reading, watching movies, playing board games, getting massages, taking nature walks and practicing gentle yoga (when medically appropriate).
• Patients would be educated about the genetic and neurobiological basis of eating disorders as well as the role of under-nutrition and compulsive exercise in the development and maintenance of these illnesses. They would be provided with scientifically valid information on effective treatments for eating disorders and relapse prevention.
• Through phone conferences and/or in-person sessions, family members would be educated about the genetic and neurobiological basis of eating disorders as well as the role of under-nutrition and compulsive exercise in the development and maintenance of these illnesses. They would be provided with scientifically valid information on effective treatments for eating disorders and skills to help their loved one continue on the path to recovery at home.
• Family members would be provided with daily updates on their loved one’s progress, regardless of the patient’s age. Family members would also be encouraged to contact the treatment center at any time with questions or concerns.
• Family members and friends of the patient would be strongly encouraged to call and visit the patient whenever possible.
• A physician would set an accurate target weight range for each patient, taking into account her pediatric growth charts, weight/build history, and genetics. The target range would represent the patients’ ideal, healthiest weight, not some arbitrary minimum BMI. Research shows that the vast majority of adult patients require a BMI of at least 20 in order to achieve complete physical and mental recovery, so that would be a good starting point.

Patients would be discharged from my ideal treatment facility only after the following criteria were met:
• The patient has achieved 100% of her ideal body weight.
• The patient eats 100% of her meals and snacks with little resistance.
• The patient reports a significant decrease in urges to restrict, binge, or purge.
• The patient is not experiencing suicidal ideation or urges to self-harm.
• The patient expresses readiness for discharge and willingness to work towards recovery.
• The family has been well-educated about eating disorders and feels confident to manage their loved one’s symptoms at home.
• The patient and her family members have collaboratively developed a specific, written outpatient treatment plan. This plan includes referrals for evidence-based psychological treatment for the individual patient and her family as well as regular medical monitoring. In addition, the plan contains specific strategies for dealing with the patient’s eating disorder behaviors and for creating a pro-recovery home environment.

Although it exists only in my imagination, I would predict that a residential treatment center such as the one I described would be more effective than most currently existing treatment centers. It would also be much cheaper, since far fewer staff would be required. Granted, patients may have a longer duration of residential treatment than they do now, since the goal is 100% weight restoration, but patients would be less likely to relapse. Since this treatment center would be cheaper anyway, and patients would be less likely to require repeated admissions, the overall cost to the patient’s family and to society would be much lower.

The following data were collected from parents of some of my patients (past and present) as well as from parents on FEAST’s caregiver forum, Around the Dinner Table. A total of 22 parents submitted responses. The patients (20 female, 2 male) ranged in age from 10 – 24 years when their family started Maudsley (mean age = 15.3 years).

The patients in my sample varied dramatically with regard to the length of their illness. Some parents reported that they began Maudsley within a month after their child’s first eating disorder symptoms appeared. Other parents had watched their child continue to suffer from the devastating effects of ED through many years of ineffective treatment and numerous hospitalizations before finally turning to Maudsley as a last resort.
Granted, this is not good science, but it is a start.

Length of time from onset of symptoms to beginning of refeeding
Mean = 18.8 months
Median = 6.25 months
Range = 1 – 132 months

Length of time from start of refeeding to weight restoration
Mean = 6.7 months
Median = 4.5 months
Range = 2 – 24 months

Length of time from weight restoration to acknowledgement of having ED
Mean = 1.1 months
Median = 0 (acknowledged having ED when he/she became weight restored)
Range = 0 – 16 months
(90 % of the sample acknowledged having ED at or before weight-restoration)

Length of time from weight restoration to developing motivation to recover
Mean = 4.6 months
Median = 0 months (motivation developed at the time of weight restoration)
Range = 0 – 24 months

Length of time from weight restoration to eating independently while maintaining weight
Mean = 7.8 months
Median = 6.5 months
Range = 0 – 36 months

Length of time from weight restoration to mood normalization
Mean = 3.3 months
Median = 2 months
Range = 0 – 12 months

Length of time from weight restoration to normalization in anxiety (return to pre-ED level)
Mean = 6.5 months
Median = 3 months
Range = 0 – 36 months

Length of time from weight-restoration to absence of body dysmorphia
Mean = 6.9 months
Median = 4 months
Range = 0 – 24 months

Clearly, more rigorous research is necessary in order to draw definitive conclusions. However, I’ve drawn some preliminary conclusions based on my data:

1.) The Maudsley Method can be effective for children, adolescents, and adults. It can be effective for both males and females.
2.) The Maudsley Method can be effective even for young adults who have been ill for 10 years or more.
3.) Most patients who are beginning Maudsley treatment have anosognosia – they do not recognize that they are ill and do not have motivation to recover. The patient does not have to “want to get better” in order for treatment to begin.
4.) The majority of patients develop insight and motivation to recover around the time that they reach a healthy body weight. For some patients, insight and motivation develop gradually after a number of months at ideal body weight.
5.) Patients generally require continued meal support for an average of 6 months after weight restoration.
6.) The manualized Maudsley approach (Lock, LeGrange, Agras, & Dare, 2001) recommends beginning to hand control of eating back to the patient when she reaches 90% of ideal body weight. This is probably too soon for most patients.
7.) The majority of patients must sustain a healthy body weight for 3-6 months before depression, anxiety, and body dysmorphia abate.

This is interesting food for thought (pun intended). I am interested in conducting a much larger survey on families that have used Maudsley. I’d like to gather enough participants and enough data points to be able to do some actual complex statistical analyses – maybe some ANOVA’s or multiple regressions. Through this study, I’d like to examine which variables contribute to recovery time. For example, what features differentiate patients who are able to eat independently at weight restoration vs. those who need continued meal support? What differentiates the patients whose psychological symptoms melt away with weight restoration vs. those who continue to struggle? Most importantly, I would like to use data from this future study to find ways in which the Maudsley method could be improved.

What questions would you like to see answered? I welcome any and all suggestions!

And then it hit me. I opened my private practice in March 2009. A number of patients have come and gone since then – mostly those with mild or moderate issues who did very well with just a few months of CBT and were ready to end their treatment. Then there are those with more severe mental illnesses whom I’ve been seeing since last spring – those with anorexia, bulimia, severe depression, and personality disorders. Those longer-term patients are doing exceptionally well now because a full year has passed since they began treatment.

So many ingredients go into a successful recovery from mental illness. My recipe typically includes some combination of the following: psycho-education for patient and family, weekly therapy using evidence-based practice, full and consistent nutrition, restoration of physical health and weight, family support, a stable and low-stress environment, acquisition of healthy coping skills, plenty of sleep and exercise, psychotropic medication, clarification of core values, creating a full and meaningful life, and time.

That last ingredient – time – is often forgotten but absolutely essential for recovery. It takes time for parents to learn how to manage their child’s mental illness. It takes time for a patient and her family to grasp fully what it means to have major depression or borderline personality disorder or anorexia nervosa. It takes time for a patient’s brain to heal, for her neural pathways to re-wire. It takes time for the therapeutic relationship to flourish. It takes time to learn and master new skills and implement them in daily life. It takes time to heal broken relationships and build a life worth living. It takes time for the dedication, persistence, and heroic efforts of the patient and family to translate into psychological health and stability.

We live in a fast-paced world of high-speed internet and instant coffee, of fast food and quicktrim and rapid refills. Patience is a virtue so few of us possess. As burgeoning technology has made so many things quicker and easier, we have become far less tolerant of things that require us to wait and persevere. It can be humbling and frustrating to realize that some things still require considerable time and effort.

Most things that are truly worthwhile in life take time and effort. Earning an advanced degree, mastering a foreign language, writing a novel, learning a new sport or musical instrument. Starting a business, building a strong friendship, nurturing a romantic relationship, creating a family. None of these things happen quickly. Those who struggle with mental illness have an added challenge of expending considerable time and effort to do the things most people take for granted – getting out of bed in the morning, eating a meal, leaving the house without having a panic attack, tolerating emotional pain without self-destructive behavior. These people face the additional burden of shame and stigma, expensive and time-consuming treatment which is typically not covered by their insurance, family and friends who don’t understand, and the absence of that proverbial quick fix. Treatment for mental illness is SO HARD and it takes SO LONG, but it is definitely worth it!

My time in private practice – 15 months now – has been the most rewarding experience of my life so far. I have seen victims become survivors; suicidal students develop a thirst for life; skeletal teens blossom into self-confident young women. Those desperate parents of sullen kids who once curled up in a fetal position on my couch became joyful and optimistic as their child’s bubbly personality reemerged. All of these miracles took time.

There are new patients now – those who cry in despair and lash out in anger, those who would rather not exist than endure another day enslaved to their own minds. There are the terrified, exhausted parents who wonder when this hell will ever end. These brave souls keep me humble, keep me challenged, and most importantly, keep me going. I have faith and hope that by next spring, they will be strong and stable and full of life, that I can say goodbye and trust that they will never have to see me again.

If you are battling a mental illness in yourself or in your loved one, remember this: time heals. Be a tortoise, not a hare. As Winston Churchill famously said, “When you are going through hell, keep going.”

1. Educate yourself on depression in adolescents.

Learn the signs and symptoms of depression and know how to differentiate between normal sadness or “teen angst” and clinical depression. All teenagers are moody and irritable at times, and sadness is a natural and healthy response to a loss or disappointment. Depression is a serious but treatable mental illness which affects between 2-5% of adolescents at any point in time.

Depression involves a pervasively sad or irritable mood that lasts at least two weeks, but usually several months or more, and causes a noticeable change in functioning. Depressed adolescents also experience physiological symptoms such as changes in appetite and weight, lack of energy, insomnia or hypersomnia, and physical aches or pains. They tend to have poor self-esteem and irrationally negative thoughts, lose interest in activities and friends, isolate themselves, and feel guilty or worthless for no good reason. Many depressed teens feel hopeless and have recurrent thoughts of death or suicide.

2. Take your child to the pediatrician for a complete physical exam to rule out organic causes of depression.

In some cases, depression is the result of a general medical condition such as hypothyroidism or mononucleosis. Depression can also be a side effect of certain medications. Some teens may exhibit depression as a result of abusing alcohol, drugs, or prescription or over-the-counter medications. Finally, simple things like sleep deprivation, too much stress, and nutritional deficiencies can manifest as depression. It is important that your child receives a complete physical exam in order to rule out any of these potential causes.

3. Let go of guilt and blame.

Depression is no one’s fault. Your child did not choose it and you did not cause it. We know that depression is a heritable brain disorder which is often (though not always) triggered by stressful life events and brain changes during puberty. It is unhelpful, even counterproductive, to blame yourself or your child for her depression. While your child is depressed, her moods and behaviors are to some degree out of her control. She cannot “choose to be happy” or “snap out of it.”

4. Don’t be too quick to medicate.

Psychotropic medication has its place, and under certain circumstances, it may be a very helpful adjunct to psychological treatment for depression. Far too often, however, psychiatrists and other physicians use medication as the first line of defense against depression. This is especially dangerous for children and adolescents, whose brains are still developing and who are more likely to suffer from serious side effects.

In addition to the risk of side effects and the lack of evidence about the long-term effects of antidepressants on a developing brain, there are other dangers to using medicating as the first, or only, line of treatment.

First, there has been very little research on the effects of antidepressants in youth. Second, there is only one antidepressant medication (Prozac) which has been FDA-approved to treat depression in adolescents, but doctors regularly use other medications “off-label” to treat them. Third, psychotherapy is more effective than medication for most adolescents with mild-to-moderate depression. Fourth, a child who receives medication without psychotherapy will not learn the necessary skills or make the necessary life changes needed to sustain lasting improvement and prevent relapse. The effects of medication expire when the medication is stopped, whereas the effects of good psychotherapy are longer-lasting.

In order to protect your child from being prescribed unnecessary or harmful medication, I recommend first taking your child to a psychologist (Ph.D. or Psy.D.) rather than a psychiatrist (M.D.). Psychologists perform psychological assessments and conduct psychotherapy but do not prescribe medication. Most psychiatrists, on the other hand, prescribe medication to the vast majority of patients they see, while conducting little (if any) psychotherapy.

If it becomes evident later on that your child could benefit from medication as an adjunct to psychotherapy, you can always ask your child’s psychologist or pediatrician to refer you to a child psychiatrist with whom he/she has a working relationship.

5. Seek evidence-based psychological treatment.

All therapy is not created equal. Some psychological treatments have been shown to work, while others have not. Research supports the effectiveness of three different types of psychotherapy for depressed adolescents: individual cognitive-behavioral therapy (CBT), group CBT, and interpersonal psychotherapy for adolescents (IPT-A). All three of these treatments are relatively short-term, usually consisting of 12-16 weekly sessions over the course of 3-4 months.

CBT focuses on the relationships among thoughts, feelings, and behaviors. CBT directly targets the adolescent’s present symptoms, without much emphasis on the past. The CBT therapist helps the adolescent identify patterns of thinking and acting which are contributing to her depression and teaches her new ways of thinking and behaving that facilitate positive feelings. CBT be delivered individually, with your child meeting 1-on-1 with a therapist, or in a group consisting of one or two therapists and 6-12 other adolescents who are experiencing depression.

IPT-A focuses on the adolescent’s social functioning and her current relationships with important people in her life. Through IPT-A, the adolescent develops her social skills, learns more effective ways of communicating, identifies connections between certain relationship patterns and her depressive symptoms, and learns to cope effectively with life transitions.

Be conscientious and selective in your search for an appropriate therapist for your child. Try to find a psychologist who has experience in treating adolescent depression. Speak with the psychologist briefly over the phone before making an appointment. Ask her about her philosophy of treatment, and make sure she practices evidence-based treatment.

6. Insist upon being fully informed and actively involved in your child’s treatment.

There is quite a bit you can do to help your child recover from depression, so don’t let any professional tell you otherwise. Treatment works best when you are fully informed and actively involved. Your child will probably be meeting with the therapist individually during most sessions. However, you should be involved in the initial evaluation and treatment planning. You should expect the therapist to check in with you on a regular basis to provide updates on your child’s progress. The therapist should always return your calls in a timely fashion and should definitely tell you if your child is engaging in dangerous behavior.

At the start of treatment, have a frank conversation with the therapist about confidentiality and boundaries. You, the therapist, and your child should come to a clear agreement about what types of information will and will not be disclosed to you as the parent. It is important that your child forms a comfortable, trusting relationship with her therapist. It is even more important, however, that you are made aware of any harmful behaviors (e.g., drug or alcohol use, unprotected sex, eating disorders, cutting) and involved in the process of helping your child overcome these issues.

7. Be willing to consider antidepressant medication under certain circumstances.

Antidepressants are vastly over-prescribed. They should not typically be used as a first-line treatment and should not be prescribed unless the patient is also in psychotherapy. However, there are certain circumstances under which medication may be beneficial and even life-saving:
• If your child has been in evidence-based psychotherapy for two or three months but has not shown any improvement, consider adding an antidepressant to your child’s treatment plan as an adjunct to psychotherapy.
• Depression has a strong genetic component. If your child has a first-degree relative (mother, father, or sibling) who suffers from a mood disorder, this suggests that your child’s depression is likely to be genetic and biologically-based. In this situation, it is more likely that your child will benefit from antidepressants.
• Research has shown that severe depression responds best to a combination of psychotherapy and antidepressant medication. In contrast, mild- to moderate depression can typically be successfully treated with psychotherapy alone. Most cases of depression are mild or moderate, so check with your child’s psychologist to determine the severity of her illness. Adolescents with severe depression are often too ill to engage in psychotherapy without the added benefit of medication to normalize their brain chemistry.
• Your child’s medication should be prescribed and monitored by a board-certified child and adolescent psychiatrist, not by her pediatrician. While pediatricians are able to prescribe antidepressants, they do not have the expertise necessary to monitor your child’s progress and ensure that she is on the correct dose of the right medication.
• You and your child should meet with the psychiatrist for a thorough evaluation before any medication is prescribed. Be sure to ask the psychiatrist about any potential side effects or drug interactions of which you should be aware.
• Your child should be closely monitored by her psychiatrist while she is on the medication, especially during the first month and after a change in dosage. After that, the psychiatrist should follow up with your child at least monthly to monitor her progress and change her dosage if necessary.

8. Create a home environment conducive to overall physical health and mental wellbeing.

Basic self-care habits such as sleep, nutrition, exercise, and stress release are extremely important for someone suffering from depression. Teenagers are notorious for staying up late, eating lots of junk food, and guzzling soda at all hours of the day. While most teens can “get away with” these habits for a few years, teens recovering from depression cannot afford to take shortcuts with their health. Depressive symptoms can be caused or exacerbated by sleep deprivation, poor nutrition, inactivity, and chronic stress.

Prioritize health and well-being above all else. Establish regular bedtimes to ensure that your child gets a minimum of 8 hours of sleep every night. Many adolescents need 9-10 hours of sleep or even more in order to function optimally. Require your child to eat nutritious, balanced meals with the entire family. Supplement her diet with multivitamins and Omega-3 essential fatty acids, which have been shown to improve mood, memory, and general mental functioning. Encourage her to enjoy some physical activity every day. Minimize the stress and tension in your household. Help your child create a balance of study time, personal time, friend time, and family time.

9. Encourage healthy social relationships and fun activities.

Depression causes adolescents to withdraw from their friends and family and lose interest in activities they once enjoyed. Unfortunately, social isolation and inactivity only exacerbate depressive symptoms. Ensure that your child stays connected to the family by sharing meals with the family every day and involving her in a weekly family outing or game night. Encourage her to go out with her friends or invite them over to the house.

See to it that your child is involved in activities that create a sense of purpose, nurture her talents and burgeoning self-concept, and help her connect with other like-minded kids and adults. If your child is artistic, sign her up for art lessons or encourage her to audition for a play. If she is musical, encourage her to join the marching band or take dance classes. If she is athletic, encourage participation on a sports team. Many adolescents find a sense of meaning in volunteer work or involvement in religious activities.

Depressed adolescents often lose motivation and lack the interest and energy to initiate activities on their own. However, once they become involved and engaged in activities, they usually begin to feel a little bit better. Remind your child of this when she expressed reluctance to do something fun or social.

10. Provide your child with plenty of nurturing, comfort, and physical contact.

No parent wants their child to suffer. It will be very difficult to and heart-wrenching to watch your child struggle with depression. However, it is important that you remain calm, steady, compassionate, and optimistic.

Depressed adolescents often feel worthless and guilty for worrying their parents. Tell your child that you love her infinitely and unconditionally, regardless of whether she is happy or depressed. Ensure your child that she is not to blame for being depressed and that she has done nothing wrong. Let her know that you are concerned about her depression, that you are here to support her, and that you will take all the necessary steps to get her good treatment and help her recover.

Physical contact through affection, hugging, kissing can be very comforting to a distraught adolescent. If your child resists being touched, use a soothing voice and reassuring words to comfort her and let her know that you are always available for a hug whenever she needs one. Express empathy towards your child and be willing to listen to her thoughts and feelings. However, you must keep in mind that depressed adolescents may have many irrational thoughts and negative perceptions about themselves and others. For example, your child may be extremely self-critical, believe that no one likes her, tell you her life is a living hell, or fear that you are angry with her. You can gently explain to your child her depression is causing her to see things through a “negative filter” such that many of her perceptions are colored by the depression and are not necessarily accurate.

11. Be patient and realistic.

Recovery from depression takes time. Your child will not feel better right away, nor should you expect her to. It takes weeks for the effects of psychotherapy and medication to become evident. Your child may begin to feel hopeless and worry that she will be depressed forever. This hopelessness is a symptom of depression, rather than an accurate assessment of her situation. You must remain hopeful and optimistic regardless of your child’s attitude. Reassure your child that recovery takes time; that she will begin to feel better soon; that she must stick with treatment.

It is often helpful to lower your standards while your child is depressed. This is difficult for many parents to accept. However, it is important to recognize that depression is a very real and very disabling condition that will have a major impact on your child’s functioning, personality, and behavior. Depression in teens can manifest in a variety of ways. Some teens may suffer a decline in academic performance due to inability to concentrate. Many depressed teens will become quiet and withdrawn; others will become angry and volatile. Some depressed adolescents will act out, abuse drugs, cut themselves, or get into trouble at school. However your child’s depression manifests, be aware of one thing: your child will NOT seem like herself while she is depressed. Just be aware of this fact and accept it. This is not to say that you must tolerate blatant disrespect, delinquency, or dangerous behavior. Continue to maintain appropriate boundaries and limits to keep everyone safe. However, recognize that your child is suffering from a serious mental illness that impairs her ability to function. If her grades slip, or she doesn’t do her chores, or she mouths off to you more than usual, show compassion and empathy, and try to maintain perspective.

Some adolescents experience one episode of depression and that’s it. However, more than half of adolescents who experience major depression will go on to have more episodes in the future. This does not mean that treatment didn’t work, or that your child failed, or that you failed your child. This is simply the nature of major depressive disorder. The good news is that if your child has been successfully treated the first time, you know exactly what to do if she begins to develop symptoms again. With the knowledge, insight, skills, and professional contacts gained the first time around, relapse should be briefer and easier to manage.

Just a decade ago, only 30% of patients fully recovered, and now nearly 50% will fully recover. The reasons for the improved prognosis include greater awareness about eating disorders, which leads to earlier diagnosis and treatment, and the advent of more effective, evidence-based treatment for adolescent AN, such as Maudsley Family-Based Treatment. But early diagnosis, early intervention, and the Maudsley method primarily benefit adolescents. Consequently, I would presume that the 20% increase in recovery rates over the past decade is primarily due to the recovery of more adolescents, not the recovery of more chronically-ill adults.

Although AN typically begins in early adolescence, those who die from the disease are more often adults who have battled it for many years. The most effective course of action is early diagnosis and aggressive, evidence-based treatment as soon as symptoms appear. Unfortunately, there are countless adults with AN who have struggled for years or even decades. As of this time, there are no evidence-based treatments for adults with AN, nor are there any medications which have been proven to benefit adults with AN. CBT has been shown to be moderately beneficial in preventing relapse in weight-restored AN patients but shows no benefit in underweight anorexics.

A lot of the AN treatment offered today is outdated and ineffective. Fortunately, however, there are more and more clinicians and treatment centers who are adopting modern, evidence-based approaches to treating adolescent AN that have much higher success rates. For example, the Kartini Clinic, the UCSD 5-Day Intensive Family Program, and the Children’s Hospital at the University of Chicago have adopted a highly-practical family-based, evidence-based approach to treating adolescent AN based on the Maudsley Method.

We can learn a lot from the success of these adolescent programs. I believe that we can use the basic principles of Maudsley FBT and the philosophy of these adolescent treatment programs to develop effective treatments for adults. Medicine, psychology, and psychiatry do this all the time in the reverse; that is, they extend effective adult treatments to adolescents. If a particular medication or psychotherapy approach demonstrates effectiveness in adults, clinicians automatically begin using it in adolescents, often without any research data to support its use in this population. Clinical trials are then conducted on adolescents, and research data follows.

Consider the basic principles of Maudsley FBT:
1. Conceptualization of AN as a biologically-based brain disorder of unknown origin
2. Externalizing the illness
3. Viewing family members as vital resources in a patient’s recovery
4. Recognition that most of the symptoms of AN are direct result of malnutrition and thus will abate after weight restoration
5. Focus on nutritional rehabilitation and weight restoration as non-negotiable first priorities in treatment
6. Acknowledgment that patients with AN are unable, in the acute phase of illness, to make healthy decisions regarding food and weight
7. Coaching parents to provide emotional and nutritional support to their child
8. Addressing psychological symptoms and other comorbid disorders after weight restoration

Which of these principles are irrelevant in the treatment of adults?

I see no logical reason why we cannot use Maudsley FBT in the treatment of adults with AN. Based on the patient’s circumstance and living situation, spouses, roommates, friends, or significant others may be enlisted for meal support in lieu of parents. The specific details may need to be tweaked in order to be relevant to an adult patient’s situation, but the general principles would remain the same. After all, the physical and psychological symptoms of AN are the same regardless of whether the patient is an adolescent or an adult. AN stunts growth and development and prevent sufferers from becoming independent, fully-functional beings. Thus, adults with AN are regressed physically, sexually, and socially to the point that they often resemble adolescents anyway.

The differences that do exist between adolescent and adult forms of AN are not inherent to the disease itself or even to the age of the patient. Rather, they are imposed by society. We, as a society, have arbitrarily determined that teenagers are fully responsible for their own healthcare decisions once they reach their 18th birthday. This is the case regardless of whether the patient has an ego-syntonic, anosognosic condition such as AN which impairs their judgment and insight. By virtue of their illness, adults with AN are unable to make healthy decisions for themselves. And yet, the law prohibits parental involvement, even parental notification of treatment, unless the patient signs a release. The law clearly sides with AN, not with the patient.

Family support and family involvement are powerful predictors of good outcome. Unfortunately, most therapists consider parental involvement in an adult patient’s treatment unnecessary or even detrimental. These therapists believe that the etiology of AN is rooted in controlling parents, separation anxiety, and issues related to independence and autonomy. Thus, they keep patients separated from the very people who love them most and who may be best equipped to help them achieve full recovery. This is counterproductive because a patient’s physical and psychological wellbeing must always take precedence over the developmental issues of emerging adults which, incidentally, have never been proven to be causally related to AN. Adult patients’ lives are threatened as a result of ignorant adherence to an unproven theory.

I firmly believe that Maudsley Family-Based Treatment can be effective in young adults. In fact, I have used this approach with young adults in my practice with great success. I have seen patients who have been sick for a decade, hospitalized multiple times, and endured several courses of ineffective residential treatment finally achieve recovery as outpatients through FBT. I look forward to the day when FBT is widely available to adults, as well as adolescents, with AN.

To put it succinctly, a highly effective therapist is one whose patients get better. Here are the qualities, in my opinion, that highly effective therapists possess.

1. A highly effective therapist conducts a thorough assessment at the start of treatment, including, but not limited to: diagnostic interviews with the patient and her parents (if she is <18), psychosocial / developmental history, family history, medical and psychiatric history, and consultations with the patient’s other treating professionals (e.g., primary care physician, psychiatrist). She synthesizes this information to arrive at an accurate diagnosis. She is cognizant of the multifaceted etiology of mental disorders, and takes into account genetics, biology, temperament, psychosocial issues, environmental factors, lifestyle and behaviors (e.g., stress, sleep, nutrition, exercise) when determining the cause(s) of the patient’s problems.

2. At the end of the initial assessment, a highly effective therapist has an in-depth discussion with the patient, and the parents of minor patients, in which diagnostic impressions are shared. The therapist provides the patient and her family with a scientifically-grounded explanation of her disorder(s) and explains the full range of treatment options available.

3. In collaboration with the patient, and parents of minor patients, the highly effective therapist develops a treatment plan. This treatment plan may consist of services delivered by other professionals (e.g., psychiatrist, pediatrician, dietician) and may consist of one or more modalities of treatment (e.g., individual therapy, family therapy, group therapy). Parental involvement is an integral part of the treatment plan for children and adolescents, except in rare cases when parental involvement may be contraindicated. For adult patients, family members are often included in the treatment plan to participate in family therapy or to play a support role. The highly effective therapist coordinates the patient’s treatment with the other professionals on her treatment team and maintains regular contact with all team members throughout the patient’s course of treatment.

4. A highly effective therapist has training and experience in empirically-supported treatments, such as CBT, DBT, ACT, Maudsley FBT, and IPT. She stays abreast of recent developments in the etiology and treatment of the disorders she treats so that she may better serve her patients. She uses empirically-supported treatments with her patients unless contraindicated.

5. A highly effective therapist is well-prepared and fully present, in body and in mind, with her patients. Therefore, the highly effective therapist is not over-scheduled or over-stressed. She has enough time in her schedule to meet with every patient as often as necessary, including last-minute emergency appointments when needed. She has adequate time to devote to preparing treatment interventions, adequate record keeping, maintaining regular contact with other professionals, and returning patients’ calls and emails in a timely fashion. The highly effective therapist demonstrates respect for her patients’ time by starting and ending appointments promptly and refraining from canceling or rescheduling sessions in the absence of a true emergency. She has sufficient flexibility in her schedule so that, if a patient must cancel a session, she can reschedule the patient within the week. The highly effective therapist devotes her full attention to her patient during sessions by turning off her phone, not responding to emails, and not allowing visitors to knock on the door.

6. A highly effective therapist knows when, and when not, to refer her patients to psychiatrists. She knows which symptoms and disorders usually require medication and which symptoms and disorders can be treated solely with behavioral or psychological interventions. She is conservative in her approach to psychotropic medication and views it as an adjunct to effective psychotherapy. She prefers for her patients to be on medication only when necessary, and on as little medication as necessary for optimal functioning. A psychiatric referral almost always results in medication prescribed. Thus, a highly effective therapist refers patients to psychiatrists only if there is evidence that psychological interventions alone will not be sufficient for recovery. When a psychiatric referral is indicated, a highly effective therapist obtains a signed release of information from the patient to communicate with the psychiatrist. Thereafter, the highly effective therapist maintains communication with the psychiatrist for the duration of the patient’s treatment and is closely involved with decisions to start, stop, and change dosage of the patient’s medications.

7. A highly effective therapist terminates treatment at the appropriate time and in the appropriate manner. Typically, therapy is over when the patient has reached maximum benefit. Sometimes treatment must be terminated because a patient is not progressing. At this point, the therapist assists the patient in formulating a plan for future care. When it is clear that a patient requires a higher level of care than the therapist can provide (e.g., residential or inpatient treatment), she makes the appropriate referrals and supports the patient in following through with these referrals. She does not allow the patient to settle for a lower level of care than she requires. Regardless of the reason treatment ends, the therapist provides the patient with the opportunity to create meaning out of her therapeutic experience. At the end of treatment, the therapist allows at least two sessions for the patient to reflect on her experience in therapy, the progress that she has made, and the therapeutic relationship.