Does the MinnieMaud Method Have Roots in Maudsley Family-Based Treatment?

Yes MinnieMaud Method (MM) does indeed closely mirror the FBT treatment model.

The MinnieMaud Method is the term that was adopted to frame both the science behind an approach for adults seeking remission from a restrictive eating disorder that is described here on this site, as well as to reflect evidence-based treatment that is in place for children and adolescents with the condition (i.e. FBT).

The Minnesota Starvation Experiment (“Minnie”) is just one foundational piece of MM, along with reams of peer-reviewed published data on actual energy requirements of otherwise healthy humans using doubly labeled water trial method confirmation that inform the minimum intake guidelines. MM also reflects the systematic reviews, randomized controlled trials and as much clinical trial data as seems reasonable to include, to support the necessity of sufficient energy replenishment and rest in order to return to an energy-balanced state after a period of creating progressive and cumulative energy deficits in the body.

Restriction of food intake, and/or creating energy deficits within the body through other compensatory behaviors, marks the presence of a restrictive eating disorder. The following discrete mental illness classifications all have restrictive behaviors and all reflect the same, from a neurobiological standpoint, restrictive eating disorder spectrum: anorexia nervosa, avoidant/restrictive food intake disorder, bulimia nervosa, binge eating disorder, rumination disorder and other specified feeding or eating disorder (which will commonly include layperson’s terminology such as orthorexia, diabulimia, anorexia athletica (or exercise bulimia), bigorexia/manorexia etc.).

However, resting and re-feeding alone rarely realize full remission from a restrictive eating disorder. Central to FBT is the construct that reversing the energy deficit within a child or adolescent with an active restrictive eating disorder is Step One. FBT’s first step coincides with the first and second legs of the three-legged stool of MM: weight restoration and repair of physical damage (through rest and re-feeding).

A starved brain is not a working brain. Much of the distress present for the patient will naturally lessen as the brain is provided with enough energy to function. Within FBT the initial responsibility for adequate rest and re-feeding is transferred entirely to the parents. However as the patient progresses through treatment, FBT’s steps two and thee are designed to help the patient regain control over his or her own healthcare decisions and to receive sufficient psycho-educational guidance such that the patient will return to maturational and developmental norms.

Returning children to these norms is the dominant approach in child psychology today. The tenet of this approach is that chronic mental and physical illness may cause a child or teen to veer from age-appropriate developmental markers but that all children and teens have a natural pull towards returning to such norms. Therefore the role of a child psychologist is to support and help the patient find his or her way back to age-appropriate maturity and growth. MM reflects how FBT might be redesigned to suit adult populations with restrictive eating disorders.

For most adults with active restrictive eating behaviors, the condition was initially activated at some point in childhood. The condition is genetic in origin, but its activation and perseveration in each individual involve innumerable environmental inputs that are invariably unique to each person.

For adult patients, they might have deviated from maturational and developmental norms when their condition was first activated in childhood and they might not have ever returned to a normative state in the intervening years to adulthood; or they might have experienced remission and a normative state fleetingly only to regress upon the condition’s reactivation at some point; or they might have managed to navigate a sub-clinical eating disorder allowing for most developmental and maturational markers to have been achieved in an age-appropriate fashion, but they are now struggling to reach ongoing adult developmental markers.

In other words, each adult patient may or may not face the need to undergo some form of catch-up childhood and adolescent maturation. However all adult patients need to address how pervasively integrated their restrictive eating behaviors have become into their coping mechanisms and interactions with others as a whole; and how the pervasiveness of these behaviors has knocked them from their own developmental arc as adults.

Unlike children and teens with a recently activated eating disorder, many adults cannot connect to a time in which they lived without applying restrictive behaviors. Even when they think back to perhaps very young years when they ate “normally”, that recollection is distinct from a memory linked to self-as-adult. That disconnect is why leaders in the field of restrictive eating disorder research, such as Dr. Tim Walsh, are working now towards trying to disentangle how habits form as a way to try to realize better treatment outcomes for adults.

While our biological maturation is complete at around age 25, humans are social primates whereby their brains develop and are structurally modified in response to environmental inputs throughout their entire lives. The most common impact that any serious chronic illness will have on an adult is that it invariably narrows the variety and intensity of environmental inputs that allow for normative levels of brain modification and development. While it is true that the rate of maturation and development in adulthood is not nearly as steep as what we see up to the age of 25, the presence of a restrictive eating disorder inexorably pushes an adult from her developmental arc.

When we first coined the term MinnieMaud on the Your Eatopia forums back in 2012, it was done to create a shorthand way to refer to the treatment approach I developed through synthesizing the research. MM has developed lockstep with my continual review and synthesis of the scientific material on restrictive eating disorders since that time. MM is no more a static treatment protocol than is FBT, as many of you know from reading the blog series UCSD Eating Disorders Conference 2014 on recent modifications of FBT treatment. But at no point in time has MM not included an equivalent to FBT’s steps one, two and three. Psycho-educational guidance to help nudge a patient back to adult developmental norms is foundational to MM. A three-legged stool won’t wobble and that third leg makes the stool sturdy. The third leg of MM is psycho-educational support and guidance— counseling and therapy.

As we know, much of the kerfuffle associated with MM is that it actually spells out minimum intake guidelines matched to age, sex and height healthy control intake levels that have been confirmed with doubly labeled water trial method results. To review the scientific material for yourself, check out MinnieMaud Method and Temperament-Based Treatment where all the references can be found at the end of the article. So much intellectual energy is sunk into disbelief surrounding the necessity of resting and re-feeding to those intake levels when it comes to lay person third parties who review MM, that the third leg of the three-legged stool that supports MM is completely ignored.  

When a person develops influenza, there are some basic treatments that are universal to all of us that offer our immune system its best chance at overcoming the virus. Equivalently, the basics of re-feeding and resting for treating a restrictive eating disorder are universal.

If you came across a treatment protocol for the flu that suggested you drastically restrict fluid intake, be placed in a full body cast and submerged in a vat of cold water for six hours, then the best that could be hoped for is that the treatment will have an irrelevant impact on your ability to recover from the flu. However the most likely outcome would be severe medical complications and perhaps death.

Another reason that everyone overlooks the third leg of MM is probably because adult treatment options for restrictive eating disorders (none of which is evidence-based by the way) tend to only offer psycho-educational guidance, strangely overlooking the fact that evidence-based treatment for children and adolescents requires rest and re-feeding with subsequent psycho-educational guidance.

Using flu as the analogy, imagine if we suggested children and teens with the flu should rest, drink plenty of fluids and seek medical intervention if fever and dehydration get out of hand, but that adults should “visualize their well state” and that will ensure their return to health.

Adult humans are not silicon-based life forms from another planet. They actually have extremely close and overlapping needs for supporting life that can be seen in their immature progeny. So yes, resting and re-feeding are universal for children and adults with restrictive eating disorders if they are looking to have a chance at remission.

The psycho-educational guidance necessary to return to a normative developmental arc needs to be tailored for the individual. Psycho-educational guidance does not replace the need to rest and re-feed, nor does resting and re-feeding replace the necessity of psycho-educational guidance. Remember the three “R’s” of remission: re-feed, rest and re-train.

The 3 R’s are framed within the FBT model as: 1) handover the responsibility of re-feeding and resting to the parents, 2) incrementally transfer that responsibility back to the child as treatment progresses to reflect a return to developmental norms, and throughout the process 3) provide the entire family (and patient in particular) with sufficient and tailored psycho-educational guidance that remission can be achieved and sustained.

And this FBT model is reflected in the MM model as follows: 1) and 2) rest and re-feed in a structured way that would mimic how a parent would help a child return to an energy-balanced state and in such a way that the energy deficit can be rectified and the physical damage throughout the body repaired, and 3) seek sufficient psycho-educational guidance to uncover the ingrained nature of restriction in both coping and human interaction strategies that have resulted in reducing or halting a natural adult developmental arc; then learn and practice the techniques specific to your needs that increase resilience in coping strategies and broaden natural and needed human interactions to return you to your optimal adult developmental arc. 

And it’s also a good idea to remember that remission only gets the right patina and will feel truly comfortable if it is used regularly. Remission is practiced and is not a “one-time and done” destination.

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