Skip to main content

The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors

  • Janet Treasure (a1) and Gerald Russell (a2)

Here we revisit and reinterpret the original study in which the so-called ‘Maudsley (London) model’ of family therapy was compared with individual therapy for anorexia nervosa. Family therapy was more effective in adolescents with a short duration of illness. However, this is only part of the story. A later study describing the 5-year outcome contains important information. Those adolescents randomised to family therapy achieved a better outcome 5 years later. Moreover, the group with an onset in adolescence but who had been ill for over 3 years had a poor response to both family and individual therapy, suggesting that unless effective treatment is given within the first 3 years of illness onset, the outcome is poor. We examine other evidence supporting this conclusion and consider the developmental and neurobiological factors that can account for this.

    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors
      Available formats
Corresponding author
Janet Treasure, Box PO59, Section of Eating Disorders, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK. Email:
Hide All

Declaration of interest


Hide All
1 Hjern, A, Lindberg, L, Lindblad, F. Outcome and prognostic factors for adolescent female in-patients with anorexia nervosa: 9- to 14-year follow-up. Br J Psychiatry 2006; 189: 428–32.
2 Wentz, E, Gillberg, IC, Anckarsäter, H, Gillberg, C, Råstam, M. Adolescent-onset anorexia nervosa: 18-year outcome. Br J Psychiatry 2009; 194: 168–74.
3 Von Holle, A, Pinheiro, AP, Thornton, LM, Klump, KL, Berrettini, WH, Brandt, H, et al. Temporal patterns of recovery across eating disorder subtypes. Aust N Z J Psychiatry 2008; 42: 108–17.
4 Russell, GF, Szmukler, GI, Dare, C, Eisler, I. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry 1987; 44: 1047–56.
5 Eisler, I, Dara, C, Russell, GF, Szmukler, GI, Le Grange, D, Dodge, E. Family and individual therapy in anorexia nervosa: 5-year follow-up. Arch Gen Psychiatry 1997; 54: 1025–30.
6 National Collaborating Centre for Mental Health. Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa, and Related Eating Disorders. The British Psychological Society & Gaskell, 2004.
7 Fisher, CA, Hetrick, SE, Rushford, N. Family therapy for anorexia nervosa. Cochrane Database Syst Rev 2010; 4: CD004780.
8 Lock, J, Couturier, J, Agras, WS. Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy. J Am Acad Child Adolesc Psychiatry 2006; 45: 666–72.
9 Lock, J, Le Grange, D, Agras, WS, Moye, A, Bryson, SW, Jo, B. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry 2010; 67: 1025–32.
10 Nelson, EE, Leibenluft, E, McClure, EB, Pine, DS. The social re-orientation of adolescence: a neuroscience perspective on the process and its relation to psychopathology. Psychol Med 2005; 35: 163–74.
11 Lutter, M, Nestler, EJ. Homeostatic and hedonic signals interact in the regulation of food intake. J Nutr 2009; 139: 629–32.
12 Treasure, J, Claudino, AM, Zucker, N. Eating disorders. Lancet 2010; 375: 583–93.
13 Wolfson, P, Holloway, F, Killaspy, H, (eds). Enabling Recovery for People with Complex Mental Health Needs. A Template for Rehabilitation Services (Faculty Report FR/RS/1). Faculty of Rehabilitation and Social Psychiatry, Royal College of Psychiatrists, 2009.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 55 *
Loading metrics...

Abstract views

Total abstract views: 113 *
Loading metrics...

* Views captured on Cambridge Core between 3rd January 2018 - 19th March 2018. This data will be updated every 24 hours.

The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors

  • Janet Treasure (a1) and Gerald Russell (a2)
Submit a response


Janet Treasure, Professor of Psychiatry
31 August 2011

We thank Professor Morgan for responding to our Editorial and raisingtwo important points. First, he is correct in saying that there was already some evidence favouring the outcome in anorexia nervosa if patients were enrolled in treatment as soon as possible after the onset ofthe illness. This came from his follow-up study of patients treated in Bristol where the emphasis was on local, easily accessible, treatments. The outcome in the Bristol patients was significantly better than in thosetreated in two London hospitals providing “national services” (The Maudsley and St. George’s). This difference favouring Bristol was acknowledged by other experts in the field (1). But in his 1982 article Professor Morgan had already acknowledged the difficulty of assessing different therapeutic approaches in view of the selection of patients. Itis inescapable that an evaluation of the treatment requires randomised controlled trials, as in the studies of family therapy reviewed in our editorial.

Professor Morgan’s second point was to stress that family processesare crucial in contributing to the success of early intervention in anorexia nervosa. He is right in recognising the risks of alienation in the patients’ relatives which undermines their contributions to a successful treatment. Again we welcome his observations enabling us to expand our too brief description of the essential principles of successfulfamily therapy:1.Exonerating parents from causing the illness.2.Getting them to take joint control of their child’s eating so that he/she is enabled to maintain a normal body weight.

These principles need some elaboration. Exonerating the parents requires the therapist to communicate a neutral position regarding the causes of the illness. The medical pioneers in this field of study (eg Gull, Charcot) expressed strongly negative views about relatives’ poor management of the problem, views which should be dispelled. Charcot’s influence was, of course, strongest in France where the “cure d’isolement” has only been abandoned within recent memory.

The second essential requirement is fraught with difficulties. Parents at first resist taking the necessary action. Their experience leads them to believe that they have failed to prevent their child’s poor eating and weight loss. Some parents fear that firmness on their part will lead to a loss of their child’s affection. They may also jumpto the conclusion that an invitation to participate in treatment implies that they are being blamed. This can be combated by expressing the aims of therapy not as “changing the family” but rather as helping them manage a sick family member (2).

Successful management requires an on-going search for emotional and inter-personal factors (eg expressed emotion) which are responsible for maintaining (rather than causing) harmful behaviours. One of us (Treasure) has contributed to a practical manual describing the techniquesfor negotiating successful transactions between carer and adolescent, focussing on rapport, language and problem-solving skills (3 & 4).

(1) Theander, S (1985) Outcome and prognosis in anorexia nervosa and bulimia. Some results of previous investigations, compared with a Swedishlong-term study, Journal of Psychosomatic Research, 19, 493-508.

(2) Russell, G. Anorexia nervosa. New Oxford Textbook of Psychiatry, EDS Gelder, M.G., Andreasen, N.C., Lopez-Ibor, J.J. and Geddes, J.R. Second Edition. Oxford University Press, Oxford, p 788 and pp 790-792.

(3) Treasure, J., Smith G. and Crane, A. (2007). Skills-based learning for caring for a loved one with an eating disorder: The new Maudsley method. Routledge, London and New York.

(4) Goddard, L., Macdonald, P., Neuman, U., Sepulveda, A., Schmidt, U. & Treasure, J. (2011). A cognitive interpersonal maintenance modelof eating disorders: an intervention for carers. British Journal of Psychiatry.

... More

Conflict of interest: None declared

Write a reply

Gethin Morgan, Emeritus Professor of Mental Health
19 August 2011

The Correspondence EditorBritish Journal of Psychiatry

6 July 2011

Dear Correspondence Editor,

It is indeed rewarding to see that Treasure and Russell, in their Editorial on early intervention in anorexia nervosa (1), offer much in support of it. Over many years our therapeutic approach in Bristol placed great emphasis on getting patients into treatment as soon as possible after the onset of the anorexic illness. This was supported by evidence from a study which compared outcome in Bristol with two other treatmentcentres (2). In line with this we emphasised the importance of developing local easily accessible treatment facilities.

Given their welcome support for close involvement of relatives in thetreatment process, Treasure and Russell might well have also included family processes along with the several brain mechanisms which they evaluate as possible reasons why early intervention may be important. If the illness continues for any length of time such factors as loss of heart by relatives, and increasing blaming for failure to respond to help can lead to a progressive alienation of an anorexic relative and impairment of the family's ability to contribute constructively to treatment. Though negative attitudes have long been recognized, they remain a serious obstacle to the development of effective treatments of anorexia nervosa. Surely further research is still required into understanding them more fully as well as into their prevention and management, especially when an anorexic illness is at risk of becoming chronic.

1 Janet Treasure and Gerald Russell The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors B JPsych(2011) 19 5-72 H G Morgan, Joan Purgold and Jill Welbourne. Management and Outcome inAnorexia Nervosa: A Standardised Prognostic Study. B J Psych. (1983) 143 282-287

Yours sincerely


Emeritus Professor of Mental Health, University of Bristol.

... More

Conflict of interest: None declared

Write a reply

Early intervention in Anorexia Nervosa

E. Jane B Morris, Psychiatrist
21 July 2011

As a psychiatrist who has worked across the age range and in inpatient,day patient and outpatient settings with people with anorexia nervosa, I wholeheartedly endorse Treasure and Russell's exhortation to usto strenuously pursue effective treatment as soon as the diagnosis of anorexia nervosa is made. We are all too often guilty of delivering healf-hearted or incomplete treatments in the hope that motivation for change will grow as a result of living with the illness. The brain changes hypothesised in this paper provide a powerful counter blast for us to intervene more assertively and then to persist with evidence-based therapy.

When I consider my own recent caseload, however, I am struck by some remarkable recoveries in older women who have been ill for decades, in contrast with pooer outcomes in some much younger women. The difference seems to be that these older sufferers had not previously received specialist treatment and had kept their disorder as private as possible from other people, so that both the treatment team and lay carers came to therapy innocent of the frustration and fatigue that we so often reach in the course of very long and repeated contact with patients.

Whilst it is likely that life with a starved brain, and one which is not available for healthy psychosocial development may well make be associated with poorer prognosis, may I suggest that we should also locatesome of the responsibility in our own brains and those of lay carers. Theauthors of this paper have led the development of the most effective family interventions in the treatment of anorexia nervosa and may be best placed to develop 'remotivating' interventions to counteract despair in both families and treatment teams.
... More

Conflict of interest: None Declared

Write a reply


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *