The Maudsley Model of Anorexia Nervosa Treatment For Adults (MANTRA) : Development, Key Features, and Preliminary Evidence

Journal of Cognitive Psychotherapy: An International Quarterly
Volume 28, Number 1 • 2014
The Maudsley Model of Anorexia Nervosa

Treatment for Adults (MANTRA):
Development, Key Features, and
Preliminary Evidence
Ulrike Schmidt, MD, PhD, FRCPsych
Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London
Tracey D. Wade, PhD

School of Psychology, Flinders University, Australia
Janet Treasure, MD, PhD, FRCP, FRCPsych

Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London
Anorexia nervosa (AN) is a severe mental disorder that affects mainly young females. In adults with a
well-established form of the illness, it is hard to treat. In 2006, we proposed a maintenance model of
AN, combining intra- and interpersonal factors and we have recently refined this model. The model
encompasses four main maintaining factors (a thinking style c haracterized by rigidity, detail focus,
and a fear of making mistakes; an avoidant emotion processing and relational style; positive beliefs
about the use of anorexia for the person [pro-anorexia beliefs]; and a response of close others to the
illness characterized by high expressed emotion and enabling of and accommodation to the illness).
In this article, we describe how the model has been translated into a novel treatment for AN and the
preliminary evidence supporting this. Implications for clinical practice and research are discussed.
Keywords: eating disorders; anorexia nervosa; psychological therapy; MANTRA
A
norexia nervosa (AN) is a perplexing disorder for the clinician. Patients often present
as blank-faced, reserved, and stoical with little emotional expression. Alternatively, they
appear inexplicably cheerful, telling the clinician that everything is fine, that they do not
have any problems, and that everyone around them worries unnecessarily. History taking takes
little time and reveals little of note. This enigmatic and bland psychological presentation sharply
contrasts with the emaciated, perhaps even skeletal, physical appearance of the person. It also
contrasts with the intense distress and frustration of families and close others who are terrified
that their loved one will come to serious harm or may die.
Key symptoms of AN include a relentless pursuit of thinness and overvaluation of e maciation
in combination with and driven by an extreme dread of food, eating, and normal body weight
(Koskina, Campbell, & Schmidt, 2013). Often, the only time a person with AN will show distress
or anger is if asked to eat.
48 © 2014 Springer Publishing Company

http://dx.doi.org/10.1891/0889-8391.28.1.48
Maudsley Model of Anorexia Nervosa Treatment for Adults 49
Indeed, AN is a life-threatening illness, with a mortality rate twice that of other psychiatric
disorders, a suicide rate 200 times that of the general population, and high levels of disability and
psychological and physical comorbidity (Guillaume et al., 2011; Treasure, Claudino, & Zucker,
2010). The costs to the individual, their families, and society are high (Kyriacou, Treasure, &
Schmidt, 2008b; Simon, Schmidt, & Pilling, 2005). AN affects mainly young females and the typ-
ical age of onset is in mid-adolescence (Currin, Schmidt, Treasure, & Jick, 2005). This is the time
when brain development undergoes significant changes, in particular the brain’s social infor-
mation processing network (e.g., Blakemore, 2008; Mills, Lalonde, Clasen, Giedd, & Blakemore,
2012). The poor provision of nutrients and/or raised levels of stress hormones associated with
prolonged starvation have a deleterious effect on the developing brain and have the potential to
alter brain structure and function in a lasting way (Currin & Schmidt, 2005), changes that can be
passed on to offspring through epigenetic mechanisms (Campbell, Mill, Uher, & Schmidt, 2011).
Although there is a brief window for early intervention (within about 3 years of onset), once the
illness is well-established (i.e., usually in adulthood), the treatment response is poor and dropout
from treatment is high (Dejong, Broadbent, & Schmidt, 2012; Treasure & Russell, 2011). The
evidence base for psychological treatment of adults with AN is extremely limited and the urgent
need to develop more effective treatments for adults with AN has been highlighted (e.g., National
Collaborating Centre for Mental Health, 2004; Watson & Bulik, 2012).
The aim of this article is to describe development and key features of a novel treatment
of AN, tailored to the perplexing symptoms of this disorder, namely the Maudsley Model of
Anorexia Nervosa Treatment for Adults (MANTRA) and the preliminary evidence supporting it.
Development of the MANTRA Model and Treatment

Some years ago, based on a focused review of the literature, we developed a specific cognitive-
interpersonal maintenance model and treatment of AN (Schmidt & Treasure, 2006). We have
since refined the model based on further research evidence (Treasure & Schmidt, 2013). The
model proposes that AN typically arises in people who have sensitive/anxious and perfectionist/
obsessional traits.1 It further suggests that AN is maintained by four broad factors. These include
the following: first, a rigid, detail-focused, and perfectionist information processing style; second,
impairments in the socioemotional domain (such as avoidance of the experience and expres-
sion of emotions in the context of close relationships); third, consonant with these impairments,
these individuals typically develop beliefs about the use of AN in their lives; fourth, close others
may inadvertently maintain AN by high levels of expressed emotion or by accommodation and
enabling behaviors. Starvation intensifies all of these problems, thereby forming a recursive loop
between the consequences of starvation and these maintenance factors.
Our model is a radical departure from classical cognitive behavioral therapy (CBT) models for AN
which focus on weight and shape concerns as the central psychopathology of the disorder (e.g., Murphy,
Straebler, Cooper, & Fairburn, 2010; Pike, Walsh, Vitousek, Wilson, & Bauer, 2003). Treatments based
on these models aim to identify and challenge weight/shape-related cognitions and use self-monitoring
of food intake and cognitions related to eating, weight, and shape as a key therapeutic tool throughout
treatment. However, we have previously shown that although on the surface, patients with AN mainly
worry about aspects of their eating disorder (ED), these worries are simply a symptom of more pro-
found and troubling issues. Underlying worries only rarely concern ED-related themes (1%), whereas
the most common underlying worries were interpersonal difficulties, including rejection and abandon-
ment (42%); negative perception of self (22%); and experience of negative emotions (20%; Sternheim,
Startup, Saedi, et al., 2012), highlighting the importance of relationships and emotions in AN.
As detailed in the following text, our model suggests that a different style, focus, and structure
of treatment may be fruitful.
50 Schmidt et al.
Key Features of MANTRA

The MANTRA model and treatment was developed using the U.K. Medical Research Council’s
(2008) framework for the development of complex interventions and involved an iterative
translational process between basic research and model/treatment development. It has combined
a top-down (theory-led, data-driven, quantitative) and bottom-up (patient and clinician
experience led; qualitative) approach.
MANTRA is a cognitive-interpersonal treatment of AN, which is novel in several respects:
(a) it is biologically informed and empirically based, drawing on and incorporating recent
neuroimaging, neuropsychological, social cognitive, and personality trait research in AN; (b) it
includes both intra- and interpersonal maintaining factors and strategies to address these; and
(c) it is modularized with a clear hierarchy of procedures, tailored to the need of the individual.
It is also formulation-based and manualized.
Structure and Dose of MANTRA

MANTRA was designed as an outpatient treatment for adults with AN. It consists of 20–40 in-
dividual weekly sessions depending on illness severity,2 together with 4 or 5 follow-up meetings
which are more spread out (monthly). Usually, there is flexible involvement of family members
as appropriate to the severity of the illness, developmental stage, and practical considerations.
MANTRA consists of different treatment phases, which are depicted in Figure 1. MANTRA
treatment is centered around a user-friendly workbook-style patient manual, which is used f lexibly
with patient and therapist deciding collaboratively which parts might be relevant (see Table 1).
Thus, the treatment has elements of guided self-care.
Therapeutic Style of MANTRA

Patients are very used to others being worried about their health and warning, lecturing, or even
threatening them regarding the health risks associated with their illness, which makes patients
“defend” their anorexia. Thus, the therapist needs to position themselves differently. In MANTRA,
the therapy style is that of motivational interviewing (Miller & Rollnick, 2002), that is, highly
warm and empathic, reflective, responsive, and collaborative. It is also highly strategic; that is, the
therapist constantly has to maintain the momentum for moving the patient in the direction of
change, that is, in the direction of healthy eating and weight gain. Details of the adaptations of a
motivational approach to EDs and empirical findings supporting this can be found in Treasure and
Ongoing Risk Monitoring
Working on Joint Relapse

Assessment Case Working for
Nutritional Treatment Prevention
Engagement Formulation Change
Health Plan & Ending
(Module 1) (Module 4) (Modules 6-8)
(Module 3) (Module 5) (Module 9)
Involve
Close Others for Support (Module 2)
Figure 1. Treatment phases of MANTRA.

TABLE 1. Treatment Modules of the MANTRA Patient Manual

Module Number and Title Content
Module 1: Getting started Exploration of motivation to change through readiness rulers,
imagining a future with or without AN, casting one’s mind
backward to life before AN, identification of pro-AN beliefs and
the function of AN in the person’s life, use of externalization, and
exploration of personal values and how AN has changed these
Module 2: Working with Identifying potential support persons, taking the perspective of
support others, identifying helpful and unhelpful interactions with
others, planning for involving others
Module 3: Nutrition Assessment of medical risk, others’ assessment of risk and
ability to change, daily calorie needs for maintaining weight
and for gaining weight, education about the consequences of
starvation, what to eat/healthy eating, bingeing/overeating,
a day in the life of my stomach, supports and blocks to
safeguarding nutritional health, nutritional change plan
Module 4: My anorexia: This module allows patients to build a case conceptualization of
why, what, and how? how their AN developed and is maintained.
Module 5: Goals and Identifying areas of concern or difficulty and aspirations, how to
experiments set SMART goals for yourself (specific, measurable, achievable,
realistic, tangible), using behavioral experiments to achieve goals
Module 6: Exploring Thinking about thinking: Am I overly focused on detail at the
thinking styles expense of the bigger picture? Am I finding it hard to be
flexible and switch between different thoughts, rules, tasks,
and perspectives? What is the impact of this thinking style on
my life? The balance between speed and accuracy
The impact of anxiety about making mistakes
What does your thinking style mean for you?
How to make most of your thinking style; strengthening
bigger picture thinking, strengthening cognitive flexibility,
strengthening being good enough; problem solving
Module 7: The emotional What are emotions and why do we have them? Emotions in
and social mind the context of relationships/relationship patterns, becoming
an expert on your emotions: listening to your emotions,
identifying your beliefs about emotions, and learning to express
emotions and needs appropriately; learning to manage extreme
and overwhelming emotions; the emotional lives of others:
learning to see the world from other people’s perspective to
get a more balanced bigger picture view of interpersonal/
emotionally distressing situations; developing self-compassion
Module 8: Identity Anorexia and my identity; my best possible self, qualities,
values, struggles, and coping skills of others, who I admire,
developing a new identity beyond AN, who will allow me to
develop? Practicing living a new identity
Module 9: Moving Reflection on how to maintain gains, what else needs doing,
forward what could get in the way; tool kit for keeping well,
managing difficult thoughts, feelings, and behaviors during
the recovery process; developing mottos for a bigger life
52 Schmidt et al.
Schmidt (2007). Feedback about medical risk and “thinking style” based on neuropsychological
findings is used to increase motivation to change (Lopez, Roberts, Tchanturia, & Treasure, 2008;
Musiat, Hoffmann, & Schmidt, 2012) and to provide the patient with arguments for change. The
principles of behavioral change are used to guide people toward recovery (Abraham & Mitchie,
2008; National Institute for Health and Clinical Excellence, 2007).
Facets of the MANTRA Treatment Program

The Patient Manual. The content of the workbook-style patient manual is described in
Table 1. Manual development was based on the principles outlined by Carroll and Nuro (2002).
Throughout, a user-friendly easy-to-read style with text broken up by images, stories, diagrams,
or checklists is used.
Patients and therapists like the manual and find its content highly pertinent (Lose et al., 2014;
Waterman-Collins et al., 2014). Doing therapy with a manual to guide the approach requires
considerable skill from therapists and it is certainly not “painting by numbers.” Therapists
have to be highly familiar with the content so they can decide which sections are most help-
ful to a p articular patient at certain times. They also have to be mindful on how they introduce
the manual to patients. Many patients like the fact that there is a manual that they can follow,
especially because high anxiety levels or being physically compromised with poor attention and
concentration can make it hard to hold on to what is discussed in therapy. However, some may
feel overwhelmed by the amount of material that is available and also by having to do homework.
Perfectionist patients may also worry about getting the exercises “right.” With others, there is the
danger that doing therapeutic exercises from the manual becomes a “mindless activity,” serving the
purpose of keeping the person busy without taking time to stop and reflect. Thus, it is important
that the therapist helps patients to pace themselves appropriately in the use of the manual.
A key advantage of a manual-based approach is that patients can refer back to the manual
and the work they have done within it after treatment. Moreover, they can also share parts or all
of the manual content with close others to increase their understanding and support.
A Formulation-Based Approach. MANTRA uses two different ways of formulating the case
which complement each other. First, we use letter-based formulations derived from cognitive
analytical therapy (Ryle, 1995). These highly individualized formulations focus on emotional
meaning and help make sense of the individual’s narrative in a new way. Such letters convey
the metacommunication that the therapist really has thought about the patient and patients see
these letters as very precious and feel validated by them (Lose et al., 2014). The limitation of a
formulation in letter form is that it cannot be altered as needed over the course of therapy.
We therefore also use a diagrammatic formulation that combines a developmental c omponent
(“what the person brings to the AN”) and a maintenance component (“what keeps AN going”)
with several maintenance loops, that is, “the petals of a vicious flower.” This can be put on the table
during sessions as a work in progress to guide therapy. Similar formulation diagrams have previ-
ously been used in the anxiety disorders and depression (e.g., Moorey, 2010). The vicious circles/
maintenance loops making up the “petals” of the flower map onto the putative maintaining fac-
tors described in the MANTRA model. For each maintaining factor, there are two petals. In addi-
tion, we include one “wild card” or “other” maintaining factor in the formulation to be able to
deal with idiosyncratic factors that the patient himself or herself identifies as key in maintaining
his or her disorder. As Moorey (2010) suggests, the idea is not that all cycles will be relevant for
every person. Importantly, each of these factors maintains AN, but they also may have an effect
on each other. Figure 2 shows the formulation template.
All in all, this formulation helps to frame the patient’s current illness with its maintaining
factors in the context of their temperamental makeup and to understand AN as arising from the
What you bring to AN
Traits/Personality: Strengths:
Event/challenges/difficulties that have Support:

shaped your view of the world:
Mismatch between challenges and resources
Thinking
Valued nature style
Inflexible
of AN AN as identity thinking
Excessive
Pro-anorexia detail focus
beliefs
What keeps AN going
AN
Difficulties
with emotions
Other
Social and
Difficulties with emotional
relationships mind
Enabling
High expressed
emotion
How others
keep AN going
Figure 2. MANTRA patient-friendly case formulation. AN 5 anorexia nervosa.

54 Schmidt et al.
interaction between their traits and earlier life events and challenges. It also allows people to see
that some of their traits have both positive and problematic aspects.3 We use the metaphor of
the “orchids and dandelions” to help patients understand that their “different” temperament has
both pros and cons. Most people are like dandelions, that is, robust, resilient, and able to thrive
even under poor growing conditions. In contrast, people with AN are more like orchids, they
are delicate and wilt easily and need the right growing conditions to thrive, but if they get these
conditions, they blossom in a spectacular fashion (Cain, 2012). Finally, by including “strengths”
and “supports,” the formulation helps patients to identify internal and external resources that can
help them to get out of the vicious cycles of AN.
Prioritizing Interventions. MANTRA has a clear hierarchy of treatment procedures
depending on the person’s clinical profile and balancing treatment motivation, level of medical
risk, and personal resources and supports available. The decision-making process is depicted in
Figure 3. As is essential in the treatment of AN, medical risk is monitored throughout treatment,
including patients being regularly weighed in the sessions and relevant clinical and laboratory
examinations being carried out at intervals. Medical risk assessments are used to give feedback to
patients (for details, see section on nutrition).
Motivation, readiness, and/or confidence high
Decide jointly with patient Work closely with patient

most appropriate and and carers to ensure patient
profitable area to work on safety. Keep motivation in
mind because this may
reduce as weight increases.
Go through nutrition module
and set small goals
Low risk High risk
Focus on motivation Work closely with carers

to ensure patient safety.
Work on patient’s motivation.
Present nutrition module
“for info only”
Motivation, readiness, and confidence low
Figure 3. Early treatment decisions: Motivation and physical risk.

Treatment Phases
Early Phase (Sessions 1–4). Addressing pro-anorexia beliefs and building motivation for
change: Put simply, this early phase of treatment is a way of playfully exploring where persons are
coming from (i.e., what mattered to them before the onset of their illness), where they are heading
(i.e., their hopes and aspirations for the future), and how AN helps and hinders them in their life.
Specifically, this section explores the patient’s pro-anorexia beliefs which give the illness its own
unique meaning for a particular person. Examples of typical pro-AN beliefs include the follow-
ing: “AN makes me safe, AN numbs my emotions, AN helps me to express my distress” (Serpell,
Neiderman, Haworth, Emmanueli &, Lask, 2003; Serpell, Teasdale, Troop, & Treasure, 2004;
Serpell, Treasure, Teasdale, & Sullivan, 1999). These beliefs are found in both AN subtypes (Gale,
Holliday, Troop, Serpell, & Treasure, 2006). Of note, pro-AN beliefs also find their expression in
pro-Ana websites, which e ndorse AN as a lifestyle choice (Sharpe, Musiat, Knapton, & Schmidt,
2011). Patients often spend a lot of time on pro-Ana sites, thereby reinforcing and strengthening
their pro-AN beliefs and clinicians need to be aware of this. Reduction in pro-AN beliefs signifi-
cantly predicts better ED treatment outcomes, whereas increase in anti-AN beliefs does not predict
outcome (Kenyon et al., n.d.). Thus an important part of this early stage of therapy is to begin to
question the helpfulness of pro-AN beliefs and of building motivation to change. Key exercises are
adapted from the motivational interviewing literature and include motivational readiness rulers;
several therapeutic writing exercises that explore and question the value of AN in the person’s life,
including letters to AN as a friend or enemy; letters imagining a future with or without AN; and
casting one’s mind backward to life before AN. The content of these letters and exercises is designed
to help identify the function of AN in the person’s life. A helpful addition to this is the exploration
of patients’ personal values and how AN has changed these, because research has shown that AN
erodes and alters patients’ values, with being thin acquiring paramount importance and other
aspects of life and indeed life in general coming to be seen as valueless (Tan, Hope, Stewart, &
Fitzpatrick, 2006). Values are principles/aspirations that guide behavior and which help people
have a sense of worth, identity, and meaning. We get patients to think about values that are highly
important now and also get them to look at how their values may have changed since the onset of
AN and how AN may have made it hard for them to live according to certain values or has brought
some values into conflict with each other. We also use exercises that externalize AN to help dislodge
the idea that AN is part of the person’s identity (Espíndola & Blay, 2009; Sternheim, Konstantellou,
Startup, & Schmidt, 2011; Tan, Hope, & Stewart, 2003).
In addition, and again in accordance with the motivational literature, we use personalized
ipsative and normative feedback, for example, about nutritional/physical risk (weight, blood
pressure, pulse, blood tests), neuropsychological tests, and other assessment measures to build
motivation for change (Lopez, Roberts, et al., 2008; Musiat et al., 2012).
Importantly, in patients who are very ill and poorly motivated, this phase may need extending
beyond four sessions.
Doing these motivational exercises often helps in an easy shoulder-to-shoulder way to build
a therapeutic alliance and starts questioning the use of AN in the person’s life in relation to their
life goals and aspirations.
Introducing support and reducing interpersonal maintenance factors: People with AN often
feel extremely isolated and alone, despite the fact that close others usually very much want to
support the person. In part, this is because the illness erodes social relationships and fosters social
withdrawal. In part, close others may inadvertently strengthen AN, for example, through high
expressed emotion or accommodation and enabling of AN behaviors (Sepulveda, Kyriacou, &
Treasure, 2009; Kyriacou, Treasure, & Schmidt, 2008a). We introduce the notion that support
from others is important early on in treatment. Patients complete a support questionnaire that
helps them to think who in their social network might be most helpful to them in beating AN
and who they therefore might want to invite to join some sessions. In preparation of these
56 Schmidt et al.
eetings, the patient’s understanding of close others’ inadvertent maintenance of AN is explored

m
through the use of metaphors describing unhelpful behaviors from others (e.g., depiction of
overinvolved, accommodating/enabling care through the image of a kangaroo with a joey in its
pouch; Treasure, Smith, & Crane, 2007). Written information is available for close others prior to
attending a session. In general, our principle is that close others are invited to participate flexibly
in sessions as necessary, with greater involvement the iller the patient. In the joint session with the
close other(s), the mutual (patient/close other) contributions to these behavioral cycles can be
discussed without apportioning blame and by jointly setting goals on how to alter them.
Working on nutrition: A key aim of MANTRA is to help patients regain a healthy weight and
nutrition. Work on nutrition is flexibly woven into the therapy. The way this is done depends on
how ready the patient is to tackle this. However, nutrition is always considered right from the begin-
ning of therapy. An integral part of this is a medical risk assessment that is shared with the patient
[Maudsley Body Mass Index Chart and Risk Assessment in Anorexia Nervosa; www.eatingresearch.
com; section for health professionals/service providers]. Based on this, patients are asked to reflect
on and rate how competent they are to care for their nutritional needs and how independent from
others they are in terms of their nutritional safety. They are also asked to rate what close others and
their therapist would say about these points. If there is a big discrepancy (e.g., patient thinks they
can care for their nutrition totally independently, whereas others think they can’t), there is then
some discussion about what this means and whether the anorexia is playing tricks on the person.
Throughout therapy, patients are weighed at the beginning of each session by the t herapist. The
rationale for this is presented in several different ways: first, in terms of the importance of ongoing
monitoring of the patient’s physical health risk and to ensure that outpatient therapy proceeds
safely; second, weight gain or its absence is one key measure of judging how well the therapy is
going; and third, where a patient has intense fears about gaining weight rapidly in an out-of-con-
trol fashion, regular weekly weighing can help to manage these fears. Patients are encouraged, if
at all possible, to tolerate knowing their weight and not to weigh themselves b etween sessions,
because avoidance or excessive checking both keep anorexic fears going. Weighing patients at the
beginning of a session ensures that there is sufficient time to discuss the patient’s weight and the
patient’s emotional response to this as necessary and to collaboratively think of the implications
for their physical and emotional health and need to make changes to their eating.
Patients are given education about daily energy needs for maintaining weight and for gaining
weight and education about the consequences of starvation, in particular in relation to the impact
on their brain and the biology of bingeing/overeating. They are also given education about what
to eat on a day-by-day basis and what is healthy eating. Supports and blocks to safeguarding nutri-
tional health are considered and a template for a nutritional change plan is available for patients to
complete. All of this is couched in terms of thinking about the bigger picture of better health that
will allow the person to have “a bigger life.” Most patients are able to “sign up” to the aspiration of
wanting to have a bigger life, that is, want to feel physically and emotionally better and have better
relationships. Some patients, upon reflecting on this and using the information from the nutrition
section, are able to begin to increase their food intake relatively easily and straightforwardly. Others
may need a lot of week-by-week encouragement from their therapist to allow themselves to carry
out carefully planned small behavioral experiments (e.g., for 1 week to exchange a zero-fat low-
calorie yoghurt that is part of their usual intake against one that is slightly more nutritious) and thus
to take very gradual steps toward making nutritional change and to build up momentum for change
over time. Where possible and appropriate, patients are also e ncouraged to involve parents, partners,
or friends in giving them practical and emotional support with food preparation and at meal times.
Of note, in contrast to CBT for EDs, we do not encourage patients with AN to complete
a food diary. The reason for this is that because of their detail-focused thinking style (see the
following text), these patients often diligently comply with self-monitoring and record all the
inutiae of their meagre and predictable daily diet; however, they often do so without engaging in
m
these activities in a meaningful way and without leading to any helpful learning points or change.
Some patients, especially early on in therapy, are very reluctant to make any nutritional
changes and the therapist may feel that having conversations about nutrition is like “flogging a
dead horse.” Usually, developing a good case formulation (see the following text) helps to clarify
and acknowledge what the patient’s reluctance is all about and from this understanding, the ther-
apist can develop a strategy on how best to proceed. Often, the topic of nutrition can be revis-
ited in the context of working on the patient’s thinking style (see the following text) or helping
patients to become more self-compassionate (see the following text). Thus treatment moves on
to these other topics, but the therapist’s task is to look for opportunities to raise the issue of
improving nutrition as it fits in with different therapy content and in this context continues to
discuss out-of-session tasks related to improving nutritional health.
Formulation and Treatment Planning (Sessions 5–8). In this phase, the key therapeutic task is
to build a collaborative case formulation and to develop a treatment plan with goals for therapy.
Specifically, this involves (a) getting a good understanding of the patient’s current difficulties
in light of earlier experiences and current environment; (b) understanding and sharing the key
maintaining factors with the patient and, if appropriate, his or her family; (c) developing a col-
laborative diagrammatic case formulation; (d) supplementing this with a formulation letter; and
(e) agreeing on treatment goals and plans for change. Many patients with AN find goal setting
very difficult, in part this may be because they are not ready to set goals around their nutrition
or weight or they may feel that they are too used to setting themselves too many (and often
unobtainable) goals. Thus an important step prior to setting goals is often to get the patient to
identify areas of difficulty and think about their broad aspirations in this area. From this, SMART
(specific, measurable, achievable, realistic, tangible) goals can often follow.
Working for Change (Sessions 9–18). In the middle sessions, the key is to work for lasting
change. This includes (a) an ongoing focus on nutrition as appropriate and (b) using the manual
(thinking style and emotional & social mind modules) to work on key identified problem areas.
Working on thinking style: In this module, we ask people to reflect on their thought p rocesses
rather than the content of their thinking and how their thinking style impacts on life. The typical
AN thinking style is characterized by extreme focus on detail at the expense of the bigger picture
and cognitive rigidity/set-shifting inefficiencies, that is, a difficulty with being able to switch be-
tween different thoughts, rules, tasks, and perspectives (e.g., Lopez, Tchanturia, Stahl, & Treasure,
2008; Tchanturia et al., 2012; Tchanturia et al., 2011).
At initial assessment, patients undergo neuropsychological tests which assess set-shifting
abilities (i.e., the ability to switch between tasks and task demands) and central coherence (i.e.,
a preference for processing detail over bigger picture).4 Normative feedback (comparing their
performance against that of age- and sex-matched healthy controls) is given to patients. However,
only a proportion of patients show inefficiencies in their neuropsychological performance, but
a much larger number of patients clinically show cognitive rigidity (e.g., in the form of extreme
black and white thinking) and inability to see the bigger picture. We therefore supplement the
neuropsychological assessment with a number of workbook exercises to get people to consider
their particular thinking style, how this may have changed as a result of AN, and how it impacts on
their life. This is explored in terms of the impact of the person’s preferred thinking style (e.g., rule
bound, detail focused) on different domains of his or her life (including work/study, homelife,
and leisure and eating and weight/shape-related areas), the function of this in his or her life (e.g.,
to make things safe and predictable and to avoid mistakes), and the pros and cons of trying to alter
this and how to adapt one’s environment to one’s preferred style (Lopez, Roberts, et al., 2008).
Behavioral aspects that follow from the AN thinking style are that the person feels a need to
get things absolutely right and to avoid mistakes at all cost. We therefore get people to think about
58 Schmidt et al.
the trade-off between speed and accuracy or effort in any task they perform. This also leads to
discussions about standards the person sets themselves and whether these might be unobtainably
high and about their views on making mistakes. All in all, we try to help people to find a way to
make most of their thinking style and to strengthen bigger picture thinking and cognitive flexibility
where appropriate. We also try to strengthen an attitude of “good enough rather than perfect.”
In contrast to cognitive remediation therapy (Lock et al., 2013; Tchanturia, Lloyd, & Lang,
2013), here, the information on thinking style is taken into illness-related and emotionally salient
areas (food, body image, interpersonal relationships). Quite often, there are discussions on
unhelpful and rigid rules about food and eating, calorie content, weighing foods, and types of
food the person allows himself or herself to eat. For some patients, discussions center on how
their detail focus in relation to focusing on parts of their body, for example, the perceived flabbi-
ness of their upper arms prevents them from seeing themselves as a whole person.
For many, these factors (rigidity, detail focus, fear of making mistakes, and unobtainable
standards) are also played out in the interpersonal domain. By their very nature, social situa-
tions are often uncertain or ambiguous, which is something that patients with AN significantly
struggle with (Sternheim, Konstantellou, et al., 2011; Sternheim, Startup, & Schmidt, 2011). This
then makes patients extremely worried about, for example, saying the wrong thing and then being
judged on the basis of some very minor comment or action.
We may ask people where these standards come from (e.g., family culture; parents who are
overly critical or rule-bound) and what the impact of this is on the person’s life. Usually, it spoils
spontaneity and enjoyment.
We work with people to become better at identifying all their rules and to distinguish b etween
those that are helpful and those that are unhelpful (i.e., those that are rigid and set the person up
to fail, and often contradictory) and to learn to become “rule-busters” and to set small experi-
ments of breaking rules. For some patients, it is helpful to practice making deliberate mistakes.
For problems in the interpersonal domain, it can be helpful to focus on the bigger picture of
(one’s own) good intentions (and those of others). We also teach people to tolerate—and if pos-
sible, even embrace—ambiguity, uncertainty, imperfection, and mess in their life.
Working on emotional and social mind: Emotional and social processes and behaviors
are intertwined and we therefore address them together. Evidence from qualitative, self-report,
and experimental studies converges to show that patients with AN have difficulty with differ-
ent aspects of emotions (recognizing/understanding, allowing/tolerating, regulating, expressing
[e.g., Davies, Schmidt, Stahl, & Tchanturia, 2011; Davies, Swan, Schmidt, & Tchanturia, 2012;
Hambrook et al., 2011; Oldershaw et al., 2012; Oldershaw et al., 2011; Oldershaw, Hambrook,
Tchanturia, Treasure, & Schmidt, 2010]) and social interactions (ambiguity, uncontrollability,
potential for being judged negatively, and sensitivity to rejection [e.g., Cardi, Matteo, Corfield, &
Treasure, 2013; Sternheim, Konstantellou, et al., 2011; Sternheim, Startup, et al., 2011; Sternheim,
Startup, Saeidi, et al., 2012; Sternheim, Startup, Pretorius, et al., 2012]). However, as mentioned
earlier, much of these difficulties initially are often hidden behind a bland exterior and the asser-
tion that everything is fine. To investigate what is beneath this enigmatic exterior, a useful start-
ing point is a therapeutic exercise called the “Hidden Parts of Me” where patients are asked to
write about “the things others don’t see, hear, or notice about me” (Johnston, Startup, Lavender,
Godfrey, & Schmidt, 2010). This exercise often gives very poignant and moving insight into key
difficulties patients have in the socioemotional domain. Table 2 shows the themes that typically
emerge from this. Most patients with AN hide their negative emotions (e.g., anger, jealousy, re-
sentment) that they see as either potentially damaging to others or their relationship with them.
They also often hide their tremendous feelings of loneliness and fears of loss of or abandonment
by close others. Needs or desires (e.g., for intimacy/closeness or to be noticed) also get hidden,
as do potentially shameful secrets (e.g., in relation to bulimic or other symptoms, such as obses-
sive–compulsive disorder [OCD] symptoms). Some patients describe a sense of having a hidden
TABLE 2. Qualitative Themes From the Exercise “The Things That Others Do Not See
About Me”
Emotions
Difficult emotions: P02: “Anger, jealousy, and regret are feelings I regularly feel but
do not express them as they are too powerful to share and may be too upsetting for
others.”
P03: “That sometimes I feel full of resentment but have never admitted that to anyone.”
Difficult to understand emotions: P01: “If only I could see what all these mixed emotions
mean.”
Fear of being overwhelmed by emotions: P01: “The fear of letting go and giving into my
feelings deep within is more than I can handle.”
Desires, Needs, and Secrets
Intimacy and connection: P03: “That although I can never cry in front of someone,
I sometimes would love to just be held whilst I bawl my eyes out.”
P04: “At the same time, however, I still crave reassurance and intimacy yet fear that it
will never happen. I do not deserve. I see my friends (not all but some) getting into
relationships and although I am happy for them, I am also jealous and wish for that kind
of intimacy and connection with another person.”
Making an impact in life: P05: “That I’d love to think more creatively and be original. I would
really like my strengths to be in strategy, innovation, and creation.”
P04: “I tend to feel it is stupid to obsess over these things and am jealous of others,
often wishing I could trade lives with other people and be ‘normal’ but then also feel
guilty/unappreciative/spoilt and self-obsessed for not being thankful for what I have.
I want to do something with my life, something significant; I am scared of being
forgotten.”
Excessive desires: P05: “My addictive relationship with food. They see a restrictive
relationship for the most part and this makes me feel a lot safer. I am ashamed of
the relationship I genuinely have with food and it’s extremely important for me to
cover it.”
Death as relief: P07: “Sometimes I think an odd thought: I imagine a friend looking, when say
50 years old, at a photo of a group of friends and showing to someone, and pointing at me
and saying ‘she’s the one who died young.’ Sometimes, I feel keenly that I don’t wish to die
young; other times, like now, I feel that I don’t really care.”
Good things that nobody values: P02: “I brush off and devalue the things I can do because no
one else sees them as an achievement, so I can’t either.”
Other secrets: P06: “I am pretty sure she (Mum) suspects that I’m queer but we never talk
about that either.”
P04: “I am actually quite superstitious about silly things which I know have no logical/
rational basis such as seeing magpies, walking under ladders, etc.”
P07: “I’m a bit of a mess. I stay up late. I buy food, steal food (from the welfare cupboard), eat
it, and throw it up.”
Bits of self that got lost or overshadowed: P04: “There are several aspects of me that I
feel have got a bit lost/overshadowed by my condition. . . . I used to be quite flirty
and enjoyed the chase . . . I feel ashamed almost to say it but I was very aware that I
used to be attractive and could manipulate that to play around with boys, not in a
serious way.”
Continued
60 Schmidt et al.
TABLE 2. Qualitative Themes From the Exercise “The Things That Others Do Not See
About Me” (Continued)
Flawed or Defective Self
Self as different or unacceptable: P02: “Emma, real Emma, is far too boring and talentless
for anyone to really like.”
P03: “That I’m not strong like you think, that I feel I’m always one step away from
completely falling apart.”
P04: “ . . . have spend many hours worrying about what people see in me or get overnervous
about social situation because I worry I will bore people and they don’t enjoy my
company; I then tend to feel guilty for the self-indulgence.”
Exterior mask or pretend self: P02: “The real Emma is hidden behind a mask to everyone
around me.”
P03: “That I feel like I am pretending all the time, that I’m fine/happy/better etc., I pretend
so much that I’ve forgotten who I really am or what I really want. It’s just easier to do
that because I don’t want to upset or worry you and I can’t admit that everything actually
isn’t fine.”
P01: “People think that I am a kind person but in fact I am horrible and that I hate myself.”
Self and Others
Loneliness, abandonment, rejection and loss: P03: “I expect friends to disappear because they
can see that I’m not worth bothering with and so I push them and push them and they do
what I expect and disappear.”
P05: “How completely alone I feel. I think people see I can be reserved and that I isolate
myself at times. I don’t think they know how frustrated I am when I do this. I want to relax
around people but I’m so scared of negative impressions, rejections, and disruption to my
routines that I can’t bring myself to.”
P02: “I am worried about my family all the time especially my dad because of his condition;
although they say it’s under control, I do not trust it! I worry about them dying and
becoming ill, leaving me alone.”
The Function of a Hidden Self
Subjugating own needs/pleasing others: P02: “ . . . because my emotions in the scheme of
things are not important, other people’s happiness and well-being are more important.”
P07: “I care so much for other people. I wish to give my life to other people, to encourage and
enable them to enjoy life.”
P02: “The things I hide behind my face which I wear are hidden to please everyone and to
prevent me from becoming a burden or a bother. If I let my true self show, there is no way
anyone would stay and help me in the way that I have helped others.”
Protecting self against negative evaluation: P03: “I don’t want them to laugh at me for saying
something stupid because this will show everyone that I am not perfect, and sometimes
dizzy so I don’t say anything.”
P06: “I often feel shy and anxious, but when I tell people this, they laugh because I am
confident and chatty with friends. They don’t understand how much I dislike myself and I
don’t want to draw attention to myself or be seen to be fishing for compliments by saying
what I really feel.”
Protecting others: P01: “Things I would like to tell people but don’t as not to offend them.”
P03: “That I’m not happy because this appears ungrateful; you have always given me
everything that I want in an effort to make me happy and the fact that I’m still not satisfied
makes me so ungrateful so I pretend that I am.”
defective, unacceptable, or broken self. The perceived function of hiding parts of oneself is usually
so as to not attract disapproval and lack of understanding or rejection from others; sometimes,
it is to protect others. Some patients are aware of actively suppressing certain emotions and/or
describe having an external pretend mode, mask, or facade that feels false to them (e.g., appearing
overly independent, or kind and cheerful) and/or pleasing/submitting to others’ wishes and sub-
jugating their own emotions and needs.
Module sections build on each other and progress from more educational to more experiential
tasks or from less to more emotionally “hot” topics in a graded fashion. Homework tasks include
narrative writing tasks and a range of other tasks and behavioral experiments relevant to the topic.
We teach people about the function of emotions taking an evolutionary perspective. We ed-
ucate them about what are emotions and why we have them. We get them to think about the
function of difficult emotions and what they tell us about our needs. We look at emotions in the
social context of particular relationship patterns that are commonly found in AN, such as being
submissive and pleasing. We also get people to think about their “emotional rule book,” that is,
look at whether they have rules that suggest that it is bad to express emotions and work with them
to express their emotions and needs appropriately. We teach them how to manage extreme and
overwhelming emotions. We also get them to see the world from other people’s perspective to
help them get a more balanced bigger picture of interpersonal/emotionally distressing situations.
Much of this work is done with the help of writing exercises (see the following text) that prepare
people for altering their behaviors in the real world. Finally, we also introduce patients to the idea
of developing self-compassion (see the following text).
Self-compassion as the link between the different strands of MANTRA: As patients move
through therapy, therapists need to think of how to link different strands of treatment, with the
core strands being nutrition, thinking style, and emotional and social mind. Often, as people try
to make changes in these different areas, their inner critic will “kick in” strongly and fear of criti-
cism, negative evaluation, or rejection from others will also get stronger. Self-criticism may be in
the form of an anorexic voice attacking nutritional changes and weight gain. Often, self-criticism
extends to other areas, too, attacking any small changes the person is trying to make, for example,
if the person is trying to alter any of their rule-bound behavior or they e xpress their needs and
emotions more openly and assertively. We teach patients to become more aware of their inner
critic, the double standards they often have (judging themselves much more harshly than others);
we get them to challenge the common belief that such harsh self-criticism is necessary for their
survival or to at least help them to be “good enough” and also challenge their belief that others
will always judge them harshly and critically. Instead, we teach them to become more aware of
the kind intentions of others and to become more self-compassionate, including in terms of their
nutritional needs. Self-compassion is a way of positively relating to oneself that does not involve
self-evaluations or social comparisons. Neff (2009) proposes that there are three components to
self-compassion: (a) self-kindness, that is, thinking about oneself with warmth and understanding
rather than in an attacking, critical, or judgmental way; (b) a sense of common humanity, that
is, being aware that all human beings are fallible, that things will go wrong, be suboptimal, and
that mistakes, suffering, and unfairness are part of the human condition; and (c) mindfulness of
one’s present moment experience so that one neither ignores nor ruminates on disliked aspects
of oneself or one’s actions/life. A recent meta-analysis showed that self-compassion is linked to
psychopathology with a large effect size (MacBeth & Gumley, 2012).
Ending, Relapse Prevention (Sessions 19–20), and Follow-Up (Sessions 21–24). In this phase,
the focus is on ending therapy and the implications for the patient. This will involve going
through relapse prevention strategies and therapist and patient exchanging good-bye letters to
reflect on what has been achieved in the treatment and what are remaining areas of work or con-
cern for the future. If done well, the therapist’s letter will be an example of a compassionate other
62 Schmidt et al.
making sense of the person’s predicament and struggles. The patients’ letter often gives them an
opportunity to express complex positive emotions (e.g., gratitude to their therapist, hope for
the future) and those related to ending (fear of abandonment and anxiety, disappointment).
The follow-up sessions are a period of overlearning some of the helpful changes that have
been achieved in therapy. For some patients, this can also involve thinking about and working on
building a new identity separate from anorexia.
Features of MANTRA That Go Across Treatment Phases
Use of Experiential Writing Tasks. Throughout treatment, we use experiential writing tasks
as part of homework. There is a large and sound body of research supporting the use of writing
either about traumatic or negative life events and conflicts or about hopes, aspirations, needs,
and wished-for outcomes as a tool for processing these inner events and with benefits in a range
of areas, including improved psychosocial and physical outcomes (e.g., see Pennebaker, 2004;
Wade & Schmidt, 2009). Recent studies suggest that taking different perspectives in writing may
be helpful (Andersson & Conley, 2013) and that writing may be helpful for coming to terms with
ambivalence (Kelly, Wood, Shearman, Phillips, & Mansell, 2012).
We have developed a range of structured narrative writing tasks based on ideas from Pennebaker
(2004). Many of these tasks are in letter form. These letters are written either to anorexia itself (e.g.,
write a letter to AN as a friend or enemy), to supportive real or imaginary audiences (e.g., such as
writing to a good friend or a fair or compassionate other [who is real or imagined]), or written to
people in the person’s life with whom there are current or unresolved past conflicts (e.g., a letter to
a parent who has been neglectful or abusive, telling them what you would have liked from them).
In some of these exercises, the task includes writing back from the perspective of the other person.
These tasks thus encourage perspective shifting; practicing evaluating one’s difficulties in a fairer,
more compassionate way; and practicing identifying and expressing one’s emotions and needs
while also keeping in mind the perspective of others. Thus, these exercises address “emotional
communicative intentions” in AN. We usually get patients to read out these letters in their therapy
session which is a safe way of practicing saying these often hidden thoughts and feelings out loud
and to begin to think about how to take them into the their social environment.
Use of Metaphors and Mottos. Metaphors and mottos are evocative shorthand or summa-
ries that meaningfully encapsulate aspects of patients’ predicaments and ways of resolving them.
Both foster bigger picture thinking. Good mottos and metaphors are personal and say something
about the individual patient. The MANTRA manual contains a few such mottos of relevance to
AN and a list is provided in Table 3. Mottos and metaphors are useful at any stage of therapy but
can be particularly helpful in terms of helping patients keep in mind what they need to focus on
once therapy finishes. For therapists, too, it can be very useful to try to summarize their patient’s
struggle (and the solution to it) in a motto, because like their patients, they sometimes have diffi-
culties seeing “the wood for the trees.”
Reflections by the Developers

Motivation for Developing the Approach
We were one of the first ED groups to adopt therapist-guided manual-based self-care approaches
in the treatment of (bulimic) EDs (Schmidt et al., 2007; Schmidt, Tiller, & Treasure, 1993; Schmidt
& Treasure, 1993; Thiels, Schmidt, Treasure, Garthe, & Troop, 1998; Treasure et al., 1994; Treasure
et al., 1996). At the time, we came up against much skepticism about this approach by both c linical
and research colleagues who saw this as somewhat “simplistic,” as interfering with clinical “freedom
and artistry,” and as second best to “proper” therapist-delivered psychological treatment, be it CBT
in adults or family-based treatment in adolescents. However, there is now high-quality evidence
TABLE 3. Mottos and Metaphors for Different Stages in Therapy

Purpose and Source of the Motto,
Traits Underpinning Anorexia Nervosa Metaphor, or Quote
The story of the orchids and the dandelions This helps to introduce the idea that people
with AN by virtue of their trait profile need
to pay close attention to their “growing
requirements” to be able to blossom.
The story of the princess and the pea This fairy tale by Hans Christian Andersen is
about a young woman whose royal identity
is established through a test of her unusual
sensitivity. This is a way of connoting
positively the person with anorexia’s unusual
sensitivity to her environment.
Thinking Style,
If in doubt, zoom out Jingle made by one of our patients to remind
her that when things get difficult, this is
usually because she is focusing down too
much on detail and instead she needs to
zoom out and focus on the bigger picture.
Be a rule breaker Patients with AN have many rules and often
recognize these as unhelpful. The idea of
being a bit of a rule breaker or rebel may
appeal to those who see themselves as too
compliant and as “good girls.”
Good enough rather than perfect Loosely based on Donald Winnicott
Every mistake is a treasure Emphasizes that mistakes should be seen as
important information from which we
can learn rather than as something to be
avoided
There is no such a thing as a wrong note This quote attributed to the jazz musician
Thelonius Monk speaks to the fact that in
jazz improvisation, seemingly shrill or out-
of-place notes or disharmonies can always
be “resolved” over time and integrated into
a musical piece. Speaks to the fact that one
can recover from mistakes or that something
that if looked at in isolation may seem
“wrong” or like a mistake if thought about
in a bigger context may be a useful part of a
whole.
You don’t judge a fish by its ability to Attributed to Albert Einstein. Speaks to the
climb a ladder point that we must not evaluate ourselves
using the wrong criteria/standards
Walking away from something unhealthy Found by one of our patients
is brave even if you stumble on the
way to the door
Continued
64 Schmidt et al.
TABLE 3. Mottos and Metaphors for Different Stages in Therapy (Continued)

Purpose and Source of the Motto,
Traits Underpinning Anorexia Nervosa Metaphor, or Quote
Tackling Avoidance of Emotions and
Their Expression in Social Contexts
Feel the fear and do it anyway Title of a book by Susan Jeffers. Helpful to
encourage the notion that having difficult
feelings is part of learning new ways of
behaving.
Real life begins outside your Source uncertain. Useful for patients who
comfort zone believe that feeling anxious or out of their
depth is noxious
Self-Compassion
Loving yourself isn’t selfish, it is necessary Found by one of our patients
Preventing Relapse
You will always have water lapping Saying by one of our colleagues to connote that
around your ankles there will never be a time when a person is
totally free from hassles, stress, problems, or
challenges. This is to counter the common
idea that the person has to wait for “the right
time” to make changes.
Integrity is doing the right thing when Motto put up on her fridge by one of our patients
nobody is looking when she left home and had to be solely in
charge of her daily eating. Speaks to making
changes for yourself rather than to please others.
One cannot think well, love well, sleep Attributed to Virginia Woolf
well, if one has not dined well
to suggest that this kind of approach is as credible to patients and at least as effective as therapist-
delivered approaches and can be significantly less costly (Crow et al., 2013; Mitchell et al., 2011;
Schmidt et al., 2007). Moreover, the potential of manual-based guided s elf-care for easy and wide-
spread dissemination of specialist care is now widely recognized (Wilson & Zandberg, 2012). It
is with these considerations in mind that we developed MANTRA as a manual-based approach.
Some Misconceptions About the Approach

In training workshops and presentations of our model, we have come across two common miscon-
ceptions about MANTRA. The first of these concerns the motivational style of delivery and what
happens if a patient is severely ambivalent about making nutritional changes and weight gain.
Some therapists erroneously think that being motivational under these circumstances means that
they have to back off totally from the topic of nutritional change and weight gain. We would em-
phatically say that this is not the case: As mentioned earlier, weight gain and normal nutrition are a
key goal of MANTRA. As one of our colleagues put it, “MANTRA is not a picnic in the park of no
weight gain.” In working with a highly ambivalent patient, the essence of being motivational is to
look out for and create “teachable moments” in each session where the patient is more receptive to
new information that may help them shift the balance toward change and recovery. This becomes
easier with growing trust in the therapeutic relationship and growing understanding a therapist has
about a particular patient’s formulation. For some patients, motivation fluctuates depending on
other things in their life and it may be helpful for therapists to ask themselves (and if appropriate
also their patient) in each session: “Is today a day for us to push forward or for going more slowly?”
The second one of these misconceptions concerns the flexibility and individual tailoring of the
approach. This has been interpreted by some as “anything goes” and by others as MANTRA being
overly broad and “woolly.” This is not the case because MANTRA is based on a clear model, distinct
therapeutic style, several core components, and with a clear hierarchy of procedures. However,
there is flexibility on which components of MANTRA are used in what order and with greater or
lesser emphasis. This is analogous to the example of ballroom dancing: If you want to dance a waltz
(e.g., as opposed to a tango), you will need a particular kind of music with a specific rhythm, but it
can be danced fast or slow, clockwise or counter-clockwise, and can include more or less complex
steps (of a certain kind), sequenced in different ways. Especially, if there are several couples on the
dance floor, there may also need to be a good deal of moment-to-moment adaptation of which way
to go. Depending on the age, mobility, and skill of the dancers and their ability to listen and take
cues from each other (i.e., to lead or be lead), this can be either a very simple basic dance or a highly
complex one. Yet, despite all this variation, the dance will unmistakably be a waltz.
Preliminary Evidence Supporting the MANTRA Model/Treatment

Evidence supporting the MANTRA model and treatment and its components comes from several
sources. An analogue study of anorexic behaviors in healthy volunteers (East, Startup, Roberts, &
Schmidt, 2010) examined different therapeutic writing exercises used in MANTRA and found that
both a perspective shifting and a less structured writing task improved scores on an ED symptom
scale significantly more than a control writing task. Two pilot trials of MANTRA have been con-
ducted. A small randomized controlled trial (RCT) (n 5 23) in adults with AN used a dismantling
design comparing MANTRA with or without a therapeutic writing component (Wade, Treasure,
& Schmidt, 2011). The writing component was meant to facilitate greater emotional expression
in general and also included tasks that facilitated mentalizing, perspective shifting, and a more
compassionate view of one’s difficulties. Overall, patients showed significant improvements at
12 months follow-up on ED symptoms, weight, and other variables with large to very large effect
sizes in an intention-to-treat sample. The addition of writing tasks appeared to increase the effect
and in particular reduced perfectionism. A larger pilot RCT of 72 adult outpatients with AN com-
pared MANTRA against specialist supportive clinical management (SSCM), the best available
comparison treatment (McIntosh et al., 2005) and found overall significant improvements on
weight, ED symptoms, depression, anxiety, and other variables with no differences between these
treatments (Schmidt et al., 2012). However, in an exploratory analysis of 53 study participants
with more severe AN (body mass index [BMI] below 17.5), while at 6 months (end of treatment),
there was no difference between groups; at 12 months, MANTRA patients showed further im-
provement in weight, whereas those treated with SSCM did not (Schmidt et al., 2012).
Support for the carer component of the MANTRA model comes from three RCTs of car-
ers’ skills training delivered either via the Internet (Grover, Naumann, et al., 2011; Hoyle, Slater,
Williams, Schmidt, & Wade, 2013) or via a manual with accompanying DVDs (Goddard et al.,
2011). These interventions not only reduce carer depression and anxiety but also high expressed
emotion and accommodation and enabling behaviors. Patients themselves reported decreases
with a large effect size in perceived intrusiveness of the carer (Hoyle et al., 2013).
The Social and Emotional Mind module has also formed the basis for a group intervention
for bulimia nervosa which was compared against CBT for bulimia with similar outcomes in terms
of a reduction of bulimic symptomatology and lower dropout rates (Lavender et al., 2012).
Currently, we are conducting a large multicenter RCT (the MOSAIC trial) evaluating
MANTRA against SSCM (Schmidt et al., 2013) and a large multicenter study in Australia is
66 Schmidt et al.
comparing MANTRA against enhanced cognitive behavioral therapy (CBT-E; Fairburn et al.,
2009) and SSCM (McIntosh et al., 2005). In addition, we are completing an RCT comparing the
use of a relapse prevention version of the MANTRA manual with e-mail support from a therapist
in the posthospitalization treatment of patients with severe AN, compared to treatment as usual.
Finally, a German group is using MANTRA for relapse prevention accompanied by telemedicine
therapy sessions (Giel et al., 2013). Thus, over the next 2–3 years, several studies exploring the ef-
ficacy of this treatment will be completed.
In the context of the MOSAIC trial, we conducted a two-part process evaluation of thera-
pists’ and patients’ qualitative view of MANTRA (Lose et al., 2014; Waterman-Collins et al., 2014).
Both patients and therapists found the flexible structure of MANTRA helpful that allowed tai-
lored use of the manual so as to fit individual patients’ needs. The content of the manual was felt
by both parties to be highly relevant, comprehensive, and useful. Patients particularly valued the
formulation and good-bye letters, which were felt to be very personal and provided a helpful sum-
mary of the work that had been done. Most patients and therapists emphasized the importance of
a good therapeutic relationship, therapists felt that working with the manual could facilitate this,
and most patients felt their therapists achieved this.
Discussion
Our maintenance model of AN has been considerably refined since 2006 in light of new research.
In particular, our understanding of how carers maintain AN not just through expressed emo-
tion but also through enabling and accommodating behaviors has grown. Likewise, significant
progress has been made in understanding socioemotional processing impairments in AN, with
the available evidence suggesting a whole range of factors being involved. The therapy built on
the model has been altered to incorporate a significant number of changes. The treatment is now
undergoing rigorous scrutiny in several RCTs comparing it against other credible therapies of AN.
It is hoped that these trials also will provide improved understanding on which patients might
benefit most or least from this treatment. In addition, the in-depth views of patients and carers
have been obtained about this treatment. It is hoped that this will allow further refinements based
on further scientific progress in the field over the next 5–10 years.
MANTRA was developed for adults with AN; however, given the high readability of the
manual, patient-friendly workbook, and patients’ comments that they would have valued having
the manual available at the onset of their problem, it is likely that this approach could also be useful
to adolescents with AN, in combination with a family-based approach. This still requires testing.
Notes
1. Different theoreticians have used different terminologies (including negative affectivity/neuroticism,
sensory processing sensitivity, fear of punishment, and behavioral inhibition to capture the essence of these
traits (e.g., for review, see Aron, Aron, & Jagiellowicz, 2012; Wilamowska et al., 2010).
2. If the patient has a body mass index of 15 kg/m2, 30–40 weekly sessions of treatment are offered. In
the U.K. MOSAIC trial (Schmidt et al., 2013), 30 weekly sessions were offered to these low-weight patients,
whereas in the Australian Strong Without Anorexia Nervosa (SWAN) trial, 40 weekly sessions were offered
(T. Wade, personal communication, January 6, 2013).
3. This idea fits in with recent empirical evidence showing that many putative risk factors in psychology
and psychiatry be they behavioral (e.g., sensitive temperament), physiological (e.g., high stress r eactivity), or
genetic (e.g., being a carrier of the serotonin transporter gene short allele) are also associated with increased
vantage sensitivity to positive effects of supportive environments and therefore can be c onceptualized as plas-
ticity markers (Belsky et al., 2009; Belsky & Pluess, 2009; Pluess & Belsky 2012).
4. Set-shifting can be assessed, for example, with the Wisconsin Card Sorting Test (Heaton, Chelune,
Talley, Kay & Curtiss, 1993), the Brixton Test (Burgess & Challice, 1997), and the Trail Making Test (Kravariti,
Morris, Rabe-Hesketh, Murray, & Frangou, 2003). Central coherence can be assessed with the Rey-Osterrieth
Complex Figure Test (Osterrieth, 1944).
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Acknowledgments. We thank our patients and colleagues whose predicaments, wisdom, and comments have
informed this work. This article presents independent research commissioned by the National Institute for Health
Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1043). The views
expressed in this publication are those of the author(s) and not necessarily those of the National Health Service
(NHS), the NIHR, or the Department of Health. We thank all the patients whose took part in our treatment
study and whose stories, dilemmas, and work in therapy informed this article. This work was supported by
a grant from the NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS
Foundation Trust and Institute of Psychiatry, King’s College London.
Correspondence regarding this article should be directed to Ulrike Schmidt, MD, PhD, FRCPsych, PO Box 59,
Section of Eating Disorders, Institute of Psychiatry, King’s College London, De Crespigny Park, London, SE5 8AF.
E-mail: Ulrike.Schmidt@kcl.ac.uk

The Maudsley Model of Anorexia Nervosa Treatment For Adults (MANTRA) : Development, Key Features, and Preliminary Evidence

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Journal of Cognitive Psychotherapy: An International Quarterly

Volume 28, Number 1 • 2014

The Maudsley Model of Anorexia Nervosa

Tracey D. Wade, PhD

Janet Treasure, MD, PhD, FRCP, FRCPsych

Keywords: eating disorders; anorexia nervosa; psychological therapy; MANTRA

48 © 2014 Springer Publishing Company

Development of the MANTRA Model and Treatment

Key Features of MANTRA

Structure and Dose of MANTRA

Therapeutic Style of MANTRA

Ongoing Risk Monitoring

Working on Joint Relapse

Figure 1. Treatment phases of MANTRA.

TABLE 1. Treatment Modules of the MANTRA Patient Manual

Facets of the MANTRA Treatment Program

What you bring to AN

Event/challenges/difficulties that have Support:

Mismatch between challenges and resources

Figure 2. MANTRA patient-friendly case formulation. AN 5 anorexia nervosa.

Motivation, readiness, and/or confidence high

Decide jointly with patient Work closely with patient

Low risk High risk

Focus on motivation Work closely with carers

Motivation, readiness, and confidence low

Figure 3. Early treatment decisions: Motivation and physical risk.

­ eetings, the patient’s understanding of close others’ inadvertent maintenance of AN is ­explored

Reflections by the Developers

TABLE 3. Mottos and Metaphors for Different Stages in Therapy

TABLE 3. Mottos and Metaphors for Different Stages in Therapy (Continued)

Some Misconceptions About the Approach

Preliminary Evidence Supporting the MANTRA Model/Treatment

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48 © 2014 Springer Publishing Company

eetings, the patient’s understanding of close others’ inadvertent maintenance of AN is explored