RESEARCH ARTICLE Just One More Bite: A Qualitative Analysis of the Family Meal in Family-based Treatment for Anorexia Nervosa Kate Godfrey 1 , Paul Rhodes 1 * , Jane Miskovic-Wheatley 2 , Andrew Wallis 2 , Simon Clarke 2 , Michael Kohn 2 , Stephen Touyz 1 & Sloane Madden 2 1 Clinical Psychology Unit, The University of Sydney, Sydney, NSW 2006, Australia 2 Eating Disorder Service, Department of Psychological Medicine, Department of Adolescent Medicine, The Children’s Hospital at Westmead, Sydney, NSW 2145, Australia Abstract Objective: The family meal is an integral component of Maudsley family-based treatment for anorexia nervosa. The aim of this study was to determine whether there are different types of family meal, as suggested in the treatment manual, and whether within session processes differ according to meal type. Method: Thirty video-recorded family meal sessions from a randomised controlled trial were transcribed and analysed using thematic analysis. Results: Analyses revealed two types of family meal. In the first, the patient ate one mouthful more than they were willing to eat. This meal type was characterised by processes that were consistent with the Maudsley model. In the second, the patient ate what was asked of them with little to no difficulty. Therapist and family avoidance differentiated this meal type from the first. Discussion: The current findings, along with the existing theory, suggest that avoidance may have reduced the therapeutic impact of the meal for many families. Strategies to challenge therapist and family avoidance are suggested. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association. Keywords family meal; Maudsley family-based treatment; anorexia nervosa; eating disorders; qualitative methodology *Correspondence A/Prof. Paul Rhodes, Clinical Psychology Unit, School of Psychology, University of Sydney, Mackie Building K01, Sydney, NSW 2006, Australia. Tel: +61 2 9351 6708; Fax: +61 2 9351 2984. Email: p.rhodes@sydney.edu.au Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2335 Introduction The family meal has been a key component of family-based interventions for anorexia nervosa (AN) for over 30 years. Devel- oped by structural family therapists in the 1970s, the family meal provides a unique opportunity for clinicians to observe and challenge maladaptive family structures and interactions around eating (Minuchin et al., 1975; Minuchin et al., 1978). The Maudsley model of family-based treatment (FBT) has preserved the importance of the family meal, which takes place during session two of the manualised treatment (Lock & Le Grange, 2013; Lock et al., 2001). The primary aims of this session are to assess the family structure, evaluate the family’s strengths and weaknesses during eating and provide parents with an opportu- nity to successfully refeed their child. In the first stage of the meal, the patient eats the food she is comfortable with, and the therapist and family engage in a conversation about family eating practices at home. At any sign of disordered eating behaviour, conversation is ceased, and the parents are given the task of supporting their child to eat at least one mouthful more than they are willing to eat. This task represents a symbolic victory of the family over the illness. The therapist’s role is to guide the family in this task through the use of direct coaching (i.e. repetitive and insistent suggestions on how to get the patient to eat) and support. Lock and Le Grange (2013) suggest that the parents’ success in convincing their child to eat represents a turning point in therapy, such that it empowers parents to continue with the task of refeeding their seriously ill child. Others, however, argue that the confrontational nature of the family meal is unhelpful for many families and thus no longer utilise this session as a routine part of treatment (Eisler, 2005; Eisler et al., 2000). These opposing positions are reflected in a recent study that investigated carers views on treatment for AN (Whitney et al., 2012). A number of carers viewed the family meal as liberating and beneficial, whereas others perceived it as intense and anxiety provoking. Further- more, Couturier and colleagues (2013) investigated therapist per- spectives on FBT and found that therapists were inconsistent in their implementation of the family meal as a standard part of treatment. The primary reasons for this were lack of a suitable environment, lack of training in the family meal and anxiety. However, recent research has found that adolescent and parent behaviours during the family meal predict early response to Eur. Eat. Disorders Rev. (2014)© 2014 John Wiley & Sons, Ltd and Eating Disorders Association.