Adolescent-Focused Therapy for Eating Disorders

Adolescent-Focused Therapy (AFT) is an individual therapy approach designed specifically for adolescents with restrictive eating disorders. The aim of AFT is to support the adolescent to develop a stronger sense of self and identity that does not depend on self-starvation and eating disordered thoughts and behaviours to cope with personal and developmental challenges. 

That is, the therapist works with the client to:
- Develop a healthy sense of self through connecting with hobbies and interests and developing and maintaining healthy friendships
- Develop autonomy by taking ownership of their challenges through increased coping skills, problem solving skills, emotion regulation skills, and communication skills 
- Reduce dependence on and engagement with eating disorder thoughts and behaviours as sense of self and coping skills increase 
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What Causes Eating Disorders in Adolescents?

According to AFT, eating disorders develop when the adolescent is facing such overwhelming challenges that they avoid them by retreating from them through becoming consumed by food and their body. As distressing as living with the eating disorder is, it can give a false sense of control and a pseudo-identity, and ultimately appear preferable to addressing overwhelming feelings and life challenges.

Seeing your teenager withdraw from friends, family, and previous interests, can be incredibly confusing, frustrating, and scary for parents. It can creep up on the family, and leave you at a loss trying to understand when and how it happened. 

As detrimental as eating disorders are, it is important to understand the function of the eating disorder. Eating disorders are very good at ‘protecting’ adolescents from things they are afraid of or want to avoid. When an adolescent focuses exclusively on eating and weight concerns, the rest of life becomes unimportant, dismissed, and not engaged with. In this sense, the eating disorder requires a passionate exclusivity unto itself.

This often starts slowly and secretly. Diet culture is readily available, and control of what goes into our body and how it looks is often equated with success, self-control, and accomplishment. In this way, by limiting food and/or increasing exercise, the adolescent will feel as though they they are are doing something difficult and meaningful. It is well established that adolescents at risk of developing Anorexia Nervosa are prone to having a high external achievement drive. They tend to be over-achievers, particularly in concrete areas like grades and measurable athletic markers such as running or swimming times leads to a focus on weight, calories, exercise minutes, and food rules. Keeping the focus on these issues instead of the very real problems the person needs to be working on can provide respite and escapism.

Thus the eating disorder services as a way to protect the adolescent from perceived threats related to their physical, emotion, psychological, and social development.

It is also worth adding, that while adolescents with eating disorders are highly pre-occupied with their appearance, eating disorders are ultimately not about appearance. In the words of James Lock, who developed the manual for AFT - People with Anorexia Nervosa seldom care about what others think of their appearance and do not use extreme dieting and exercise to be beautiful or attractive for others. Instead, they use these behaviours to avoid strong feelings, avoid developing or retreat from a sexual body, and to reinforce an isolating internal focus without reference to others but rather to a scale, mirror, or timer. 

The Four Goals of Adolescent Focused Therapy 

1. Development of the therapeutic relationship

The therapist works hard to deeply understand the adolescent and to develop trust. Through their work together, the therapist balances an authoritative-nurturing stance. On the authoritative side, the therapist uses the firm aspects of the therapeutic stance, whose purpose is containment of risky behaviours that are dangerous to the physical and emotional well-being of the adolescent. On the nurturing side, the therapist is exploring alternative behaviours, thoughts, and emotional management instead of exploring eating disorder related ones.

2. Limiting the impact of eating disorder thoughts and behaviours on health and development

This involves developing a healthy sense of self and increasing coping skills, while simultaneously working in reducing and challenging eating disorder thoughts and behaviours.

3. Renegotiating the adolescent-parental relationship to meet the adolescent developmental needs

The therapist supports the adolescent to take ownership over their problems and their recovery. They are also encouraged to communicate directly and openly with their parents (rather than using their eating disorder to communicate their needs). The adolescent is also supported with the difficult transition of going through puberty and transitioning from a child to a young adult (and what this means in relation to their role in the family).

4. Promoting the development of appropriate peer relationships 

This includes communication skills and support to help the adolescent develop and maintain healthy friendships, as well as generally navigate the interpersonal difficulties that occur in schooling and other adolescent social contexts.

The Three Phases of Adolescent Focused Therapy

AFT has three phases. As we tend to work with complex clients with co-occuring conditions (eg. neurodivergence, anxiety, depression, trauma), the time period of each phase will depend on the presenting issues.

Phase 1

The therapist works to develop a relationship with the adolescent to get to know them as a person and to better understand how the symptoms of the eating disorder are affecting the adolescent and their family. By doing this, the therapist works to develop a clear understanding about why the eating disorder is being maintained, identifying what function eating disorder is serving the adolescent. 

According to AFT, there are four basic functions eating disorders serve for adolescents:

1. To manage anger and control issues

Eating disorders can be used by some adolescents as a strategy to avoid, covertly express, or attempt to otherwise manage strong negative emotions, especially anger and hostility, and especially in the context of families. This anger may also be self-directed so that the eating disorder is experienced as a kind of deserved punishment for having these hostile feelings. In addition, by routinising behaviours and thoughts, and narrowing and intensifying their focus to food, weight, shape, and related but highly constricted issues, the illusion of control of these strong feelings is perpetuating. This gives the false impression that these emotions are now controlled and managed, but the reality is they are avoided and unresolved. 

2. To manage depressive feelings

In these instances, food restriction, rigid eating, excessive exercise, and other weight and eating related thoughts and concerns are conceptualised as a way to avoid or distract from feelings of depression and as a way of trying to manage these feelings indirectly. Depressive moods are often accompanied by feelings of worthlessness, guilt, helplessness, and sadness. 

3. To manage poor self-esteem

Diet culture readily provides a solution to those with low self-esteem through suggesting that control over food and the body leads to sense of worth and accomplishment. In some cases, adolescents with severely low self-esteem believe they are weak and deserve punishment for their inadequacies. Thus, for some, Anorexia Nervosa is a form of self-abnegation or self-torture. This self-torture is embraced by the adolescent because they belief themselves to be deserving of it. 

Adolescents with a very low self-esteem often feel they do not deserve to recover, and such patients report feeling like a burden on family, friends, and even to the therapist.

4. To serve as a pseudo-identity

Controlling food and the body as a means of constructing a pseudo-identity is attractive to some adolescents as an alternative to taking on the tasks of shaping their own identify because they feel inadequate, unsupported, or unable to do so. When used as a pseudo-identity,  it can mask anxiety about adolescent development and perpetuate avoidance of individuation. These adolescents do not tend to express depressed or angry feelings or try to use the eating disorder to block awareness of them. Instead, they may appear to be reasonably happy or indifferent while still being dependent and more childlike than their chronological age.

By focusing on food, calories, weight, and shape, they can avoid seeing how empty their life is. In some cases where the eating disorder has been a pseudo-identity there as been a history of abuse or neglect.

Phase 2

The therapist and patient, with support from the parents, begin to work on actively limiting the self-destructive aspects of the eating disorder while promoting the exploration of healthier and more developmentally appropriate activities that will facilitate growth and efficacy. This is done through techniques such as:

• Psychotherapy and psychodynamic interpretations
• Role play
• Appropriate self-disclosure
• Behavioural experiments
• Emotion regulation skills training
• Communication skills

Phase 3

The therapist continues to support individuation and identifies potential developmental challenges in the future as well as addressing the possibility of relapse.

Who Does AFT Help and What Is the Role of the Family?

Why Use AFT?
In many cases, Family Based Therapy (FBT) is recommended to adolescents with Anorexia Nervosa. While FBT is highly effective in terms of leading to weight restoration, it has the following limitations:

• Requires the participation of the whole family
• The focus is on food and weight restoration (it doesn’t aim to address the underlying issues)
• The parents are given the role of managing the food (a huge responsibility and places the parents in the role of ‘bad cop’)
• If not done skilfully and if the family is not a cohesive unit, it can lead to a breakdown in the relationship between the adolescent and parent/s
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AFT is a good option when:

• The family prefers not to do family therapy or family therapy has not been effective
• The parent/s does not want to be in charge of managing renourishment
• The adolescent is neurodivergent
• The adolescent has complex co-occuring conditions such as a mood disorder, trauma etc.
• The adolescent is struggling with motivation to change
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The Role of the Parents
Parents play an essential role in AFT. Unlike FBT where the parents are in control of the food, in AFT, the therapist works with the adolescent to support them to take ownership over their recovery and to influence the way the renourishment takes place. Parents are then included in this plan so they can support the adolescent reach the goals they have set with the therapist. Practically, the parents are involved in the following ways:

1. Arranging regular appointments with an eating disorder dietitation
2. Arranging regular appointments with an eating disorder trained GP
3. Attending an initial appointment with the psychologist to provide their perspective
4. Attending periodic sessions with the psychologist to again, to provide their perspective, and to be updated on progress and included in therapy and renourishment goals
5. Encouraging the adolescent to be open and honest about their true feelings
6. Modelling a healthy relationship with food and exercise

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