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 restriction and eating disorder 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 

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 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 harmful as eating disorders can be, 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 may feel as though they are doing something difficult and meaningful. Many adolescents at risk of developing Anorexia Nervosa have a strong drive to achieve. They often push themselves hard, particularly in concrete areas like grades and measurable athletic markers such as running or swimming times, and this can lead to a focus on weight, calories, exercise minutes and food rules. Keeping the focus on these things instead of the challenges underneath can provide respite and escape.

In this way the eating disorder serves to protect the adolescent from perceived threats related to their physical, emotional, psychological and social development.

It is also worth adding that while adolescents with eating disorders are often highly preoccupied with their appearance, eating disorders are ultimately not about appearance.

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 to contain behaviours that put the adolescent's physical and emotional wellbeing at risk. 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 at the same time working on reducing and challenging eating disorder thoughts and behaviours.

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

The therapist supports the adolescent to take ownership of their challenges and of the process of getting better. 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 often work with young people with co-occurring conditions (eg. neurodivergence, anxiety, depression, trauma), the length of each phase will depend on each young person's needs.

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 eating disorder is 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 the eating disorder is serving for the adolescent. 

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

1. To manage anger and a need for control

Eating disorders can be used by some adolescents as a strategy to avoid, covertly express, or attempt to otherwise manage strong, difficult 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 over these strong feelings is maintained. This gives the false impression that these emotions are now controlled and managed, but in reality 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 low 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 very low self-esteem believe they are not good enough and deserve to be punished. For some young people, restriction becomes a way of punishing themselves, because they believe they deserve it. 

Adolescents with very low self-esteem often feel they do not deserve to get better, and these young people often say they feel like a burden on family, friends and even 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 identity because they feel unsure of themselves, 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 relying on others more than peers their age might.

By focusing on food, calories, weight, and shape, they can avoid painful feelings about what seems missing in their life. In some cases where the eating disorder has been a pseudo-identity, there has been a history of abuse or neglect.

Phase 2

The therapist and adolescent, with support from the parents, begin to work on actively limiting the harmful aspects of the eating disorder while exploring activities that fit their stage of life and help them grow in confidence. 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 planning for possible setbacks.

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

Why Use AFT?

In many cases, Family Based Therapy (FBT) is recommended for adolescents with Anorexia Nervosa. While FBT has good evidence for 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 work on what sits underneath)
• 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

AFT is a good option when:

• The family prefers not to do family therapy or family therapy has not been a good fit
• The parent/s does not want to be in charge of managing renourishment
• The adolescent is neurodivergent
• The adolescent has co-occurring conditions such as depression, trauma etc.
• The adolescent feels unsure about change

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 of their progress and to influence the way the renourishment takes place. Parents are then included in this plan so they can support the adolescent to 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 dietitian
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, 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