Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA)

Theory of change

The person changes when they understand and weaken the loops that make anorexia functional and self-perpetuating, recover their nutritional health and build more flexible ways of thinking, feeling, relating and defining themselves.

Core ideas

1. Anorexia is maintained because it serves functions, not only because beliefs about weight and shape exist

   MANTRA foregrounds the valued nature of anorexia: restriction may provide control, identity, safety, emotional regulation, structure or a way of managing interpersonal threat. These functions make it understandable that a person continues to defend dangerous behaviours even when they know their medical consequences. Treatment seeks to understand what solution anorexia is providing and to create alternatives capable of serving those functions without demanding the same cost. (Schmidt & Treasure, 2006, Anorexia nervosa: Valued and visible; Schmidt, Wade & Treasure, 2014).

2. The maintenance of anorexia is cognitive, emotional, biological and interpersonal all at once

   The model integrates multiple mutually reinforcing loops: rigidity and detail favour restrictive rules; emotional avoidance makes starvation's capacity to dampen affect attractive; the positive functions strengthen commitment to the disorder; the reactions of close others may feed conflict or accommodation; and starvation itself worsens flexibility and socio-emotional processing. This architecture explains why intervening in a single domain may prove insufficient in adults with established illness. (Treasure & Schmidt, 2013; Schmidt, Wade & Treasure, 2014).

3. The traits that increase vulnerability can also become resources for recovery

   MANTRA pays attention to sensitivity, persistence, perfectionism, scrupulosity and obsessional styles because they may facilitate the consolidation of anorexic habits, but it avoids reducing them to deficits. The formulation explicitly identifies strengths and resources and seeks to redirect capacities such as perseverance, attention, responsibility or commitment towards recovery goals. The intervention aims to loosen the extreme expression of a trait rather than to erase valuable personality characteristics. (Schmidt, Wade & Treasure, 2014; Schmidt, Startup & Treasure, 2019).

4. Starvation modifies the very psychological systems needed for recovery

   Sustained restriction functions not only as a symptom but as a mechanism that narrows cognition still further, intensifies rules and preoccupations, alters bodily signals and impedes emotional and social processing. MANTRA therefore integrates nutritional improvement within the psychological theory of change: restoring nutrition helps to restore the neurocognitive and physiological conditions needed to loosen thinking, connect emotionally and benefit from treatment. (Schmidt & Treasure, 2006; Treasure & Schmidt, 2013; Schmidt et al., 2017).

5. Motivation is built within treatment and is not demanded as a precondition

   Ambivalence is considered to be expectable when anorexia serves important functions. The therapist uses motivational interviewing, discrepancy, personalised information, values, possible futures and experiments to increase readiness for change progressively. This stance remains oriented towards nutritional recovery and does not amount to accepting the status quo indefinitely: the therapist maintains clinical direction while avoiding power struggles that would force the patient to defend anorexia more intensely. (Schmidt, Wade & Treasure, 2014; Schmidt, Startup & Treasure, 2019).

6. Formulation is an active intervention and not merely an explanation of the case

   The vicious flower and the formulation letter allow patient and therapist to see how anorexia is embedded in a particular history, set of traits, strengths and cycles. The therapeutic value depends as much on the way it is communicated as on the content: MANTRA's written formulations use collaboration, respect, tentative language, affirmation, empathy and compassion. Studies from the programme itself found associations between certain characteristics of these letters and greater acceptability or symptomatic improvement. (Allen et al., 2016, Written case formulations in the treatment of anorexia nervosa).

7. Technical flexibility rests on a defined clinical architecture

   MANTRA allows the order, duration and emphasis of its modules to be changed, but personalisation is guided by a cognitive-interpersonal formulation, a hierarchy of priorities and a specific therapeutic style. The manual functions as a backbone and a shared resource, not as a list to be completed mechanically. This combination makes it possible to adapt the therapy to each person's profile without turning flexibility into a non-specific 'anything goes' approach. (Schmidt, Wade & Treasure, 2014; Waterman-Collins et al., 2014).

8. Emotions and relationships are part of the mechanism that maintains anorexia

   MANTRA understands that some people with anorexia experience the emotional world as confusing, unpredictable or threatening and may have difficulties expressing needs, interpreting others or seeking support. Restriction may temporarily reduce emotional intensity, but in the long term it fosters isolation and socio-emotional impoverishment. Learning to listen to emotions, communicate needs, adopt alternative perspectives and relate to oneself and others more compassionately reduces the functional need for anorexia. (Schmidt & Treasure, 2006; Treasure & Schmidt, 2013; Schmidt, Startup & Treasure, 2019).

9. Recovery requires an identity and a life capable of competing with anorexia

   When the disorder has structured routines, self-esteem, belonging and a sense of who one is for years, losing anorexia can feel like a loss of identity. MANTRA works explicitly on qualities, values, admired models, possible selves and behavioural experiences that make it possible to live an alternative identity. The ultimate goal is formulated as a 'bigger life': a life in which relationships, interests, health, spontaneity and projects provide the sources of meaning that anorexia previously monopolised. (Schmidt, Startup & Treasure, 2019, Identity chapter).

10. Close others can stop being part of the maintaining cycle and become resources for recovery

    The model recognises that fear, criticism, hostility, accommodation, enabling and overprotection usually arise as understandable reactions to a dangerous illness, but may generate loops that increase rigidity, dependence or conflict. The intervention with family members and other significant figures seeks to understand those cycles and to reorganise support so that the person receives help without others taking over their agency entirely or reinforcing disorder behaviours. (Schmidt & Treasure, 2006; Treasure & Schmidt, 2013; Schmidt, Startup & Treasure, 2019).

Influences

• Cognitive-behavioural therapy
• Motivational Interviewing
• Cognitive Analytic Therapy
• Paul Gilbert's evolutionary psychology
• Neuropsychology of eating disorders
• Social cognition
• Research on expressed emotion and family accommodation
• Principles of behavioural change

Key references

• Schmidt, U., & Treasure, J. (2006). Anorexia nervosa: Valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice. British Journal of Clinical Psychology, 45, 343–366. https://doi.org/10.1348/014466505X53902.
• Treasure, J., & Schmidt, U. (2013). The cognitive-interpersonal maintenance model of anorexia nervosa revisited: A summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. Journal of Eating Disorders, 1, 13. https://doi.org/10.1186/2050-2974-1-13.
• Schmidt, U., Wade, T. D., & Treasure, J. (2014). The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA): Development, key features, and preliminary evidence. Journal of Cognitive Psychotherapy, 28(1), 48–71. https://doi.org/10.1891/0889-8391.28.1.48.
• Schmidt, U., Startup, H., & Treasure, J. (2019). A Cognitive Interpersonal Therapy Workbook for Treating Anorexia Nervosa: The Maudsley Model. Routledge.
• Schmidt, U., Oldershaw, A., Jichi, F., Sternheim, L., Startup, H., McIntosh, V., Jordan, J., Tchanturia, K., Wolff, G., Rooney, M., Landau, S., & Treasure, J. (2012). Out-patient psychological therapies for adults with anorexia nervosa: Randomised controlled trial. British Journal of Psychiatry, 201, 392–399. https://doi.org/10.1192/bjp.bp.112.112078.
• Schmidt, U., Renwick, B., Lose, A., Kenyon, M., DeJong, H., Broadbent, H., Loomes, R., Watson, C., Ghelani, S., Serpell, L., Richards, L., Johnson-Sabine, E., Boughton, N., Whitehead, L., Beecham, J., Treasure, J., & Landau, S. (2013). The MOSAIC study: Comparison of the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) with Specialist Supportive Clinical Management (SSCM): Study protocol for a randomized controlled trial. Trials, 14, 160. https://doi.org/10.1186/1745-6215-14-160.
• Schmidt, U., Magill, N., Renwick, B., Keyes, A., Kenyon, M., DeJong, H., Lose, A., Broadbent, H., Loomes, R., Yasin, H., Watson, C., Ghelani, S., Bonin, E. M., Serpell, L., Richards, L., Johnson-Sabine, E., Boughton, N., Whitehead, L., Beecham, J., Treasure, J., & Landau, S. (2015). The Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC): A randomized controlled trial. Journal of Consulting and Clinical Psychology, 83(4), 796–807. https://doi.org/10.1037/ccp0000019.
• Schmidt, U., Sharpe, H., Bartholdy, S., Bonin, E.-M., Davies, H., Easter, A., et al. (2017). Treatment of anorexia nervosa: A multimethod investigation translating experimental neuroscience into clinical practice. Programme Grants for Applied Research, 5(16). https://doi.org/10.3310/pgfar05160.
• Allen, K. L., O'Hara, C. B., Bartholdy, S., Renwick, B., Keyes, A., Lose, A., Kenyon, M., DeJong, H., Broadbent, H., Loomes, R., McClelland, J., Serpell, L., Richards, L., Johnson-Sabine, E., Boughton, N., Whitehead, L., Treasure, J., Wade, T., & Schmidt, U. (2016). Written case formulations in the treatment of anorexia nervosa: Evidence for therapeutic benefits. International Journal of Eating Disorders, 49, 874–882. https://doi.org/10.1002/eat.22561.
• Zainal, K. A., Renwick, B., Keyes, A., Lose, A., Kenyon, M., DeJong, H., Broadbent, H., Serpell, L., Richards, L., Johnson-Sabine, E., Boughton, N., Whitehead, L., Treasure, J., & Schmidt, U. (2016). Process evaluation of the MOSAIC trial: Treatment experience of two psychological therapies for out-patient treatment of Anorexia Nervosa. Journal of Eating Disorders, 4, 2. https://doi.org/10.1186/s40337-016-0091-5.
• Waterman-Collins, D., Renwick, B., Lose, A., Kenyon, M., Serpell, L., Richards, L., Boughton, N., Treasure, J., & Schmidt, U. (2014). Process Evaluation of the MOSAIC trial, Part I: Therapist experiences of delivering two psychological therapies for treatment of anorexia nervosa. European Eating Disorders Review, 22, 122–130. https://doi.org/10.1002/erv.2278.
• Allen, K., Treasure, J., & Schmidt, U. (2022). MANTRA Therapy Session Rating Scheme.
• Allen, K. L., O'Hara, C. B., Bartholdy, S., et al. (2016). MANTRA Case Formulation Rating Scheme.
• MANTRA. MANTRA Letter Writing Guidelines. Therapist resource.
• MANTRA. MANTRA Formulation Editable Template. Therapist resource.
• MANTRA. MANTRA Readiness Checklist for Individual Practitioners and Teams. Therapist resource.