Adolescent-Focused Therapy (AFT) : a guide to the joint runner-up treatment for anorexia

What’s adolescent-focused therapy?

Adolescent-focused therapy is an individual psychotherapy for teenagers suffering from anorexia. AFT focuses on the young person’s ability to change his or her own behaviors with the support of the family and therapist. Whereas in a family-based approach the parents are central to treatment, with AFT they only have a supporting role .

In a previous post:

• I introduced you to AFT and its alternative name in England (AFP-AN: ‘adolescent-focused psychotherapy for anorexia nervosa’)
• I summarised how AFT performs in comparison to Family-Based Treatment (FBT): FBT works roughly twice better.
• I explained that a family-based approach is the first-line treatment for most adolescents.
• And England’s NICE guideline lists AFT as a go-to treatment if (and only if) a family-based approach turns out to be ‘unacceptable, contraindicated or ineffective’
• I appealed to clinicians to not dismiss a family-based approach too hastily.
• And I also pointed out that there could be a place for AFT after a family-based approach has brought about the main improvements.

Now I’m going to tell you more about how adolescent-focused psychotherapy is delivered. I hope this will be useful to both parents and clinicians, as there’s not much published on the subject.

James Lock, who wrote the manual for AFT and delivers training in the approach, kindly checked everything I write here, so you can trust it’s accurate. Yes, it’s the same James Lock who co-wrote the Family-Based Treatment (FBT) manual. When he and colleagues set up a randomised controlled study to compare a family-based approach with an individual psychotherapy approach, they needed to write a protocol for each.

It says a lot about the rigours of science that people like James Lock, Daniel Le Grange, Kara Fitzpatrick, who have made FBT the powerhouse treatment it is, also have the openness of mind to train therapists in AFT. Even though, as you will see, the approaches have major differences.

The official description of adolescent-focused therapy

Here’s the manual for AFT.

There are two earlier articles on AFT which describe the approach. One is the 2010 randomised controlled study I previously mentioned, which compared AFT and FBT: Lock, L., Le Grange, D., Agras, W.S., Moye, A., Bryson, S.W., and Jo, B., ‘Randomized Clinical Trial Comparing Family-Based Treatment to Adolescent-focused Individual Therapy for Adolescents with Anorexia’ in Arch. Gen. Psychiatry (October 2010), 67(10), pp. 1025-1032

The other is a 2010 paper describing the approach: Kara K Fitzpatrick, Ann Moye, Renee Hoste, James Lock, Daniel Le Grange, ‘Adolescent focused psychotherapy for adolescents with anorexia nervosa’, in J Contemp Psychotherapy (2010) 40:31-39

That’s the paper I will quote from.

The origins of adolescent-focused therapy

James Lock, Daniel Le Grange and colleagues wrote the AFT manual based on an approach developed and validated throughout the 1990s by Robin and colleagues. It was then called ego-oriented individual therapy. It was the most promising of individual therapies, which is why they chose it as the control in their randomised controlled study on FBT.

It’s a psychotherapy, so you must be an experienced child psychotherapist

For an experienced psychotherapist, adolescent-focused therapy doesn’t involve new skills or strategies. What it does do is give therapists a model of the illness, applied to adolescents. The relationship between therapist and youngster is seen as the key therapeutic intervention.

To deliver adolescent-focused therapy you need to be an experienced child-and-adolescent psychotherapist, you need a strong background in child and adolescent development and experience in working with families. And you need excellent knowledge and experience of anorexia nervosa.

Adolescent-focused therapy needs to be delivered in the context of a multidisciplinary team. The young person will have one main psychotherapist but there should also be medical nutritional inputs where required

How long, how often?

Adolescent-focused therapy typically 32 sessions over one year. The young person meets with the therapist for 45 minutes once a week – possibly less in the third and final phase.

The model in a nutshell

If you’re familiar with FBT, you will be in familiar territory with these principles of adolescent-focused therapy.

• AFT does not come with pre-formed theories of what caused the anorexia,
• The parents are not blamed, nor is the child
• To help avoid the blame-game, the illness is ‘externalised’ – it’s the illness that’s responsible for unwelcome behaviours, not the person
• The focus is on symptoms and behaviours that affect the person in the present moment, rather than on what might have caused the illness.
• Weight gain (if it’s needed) is non-negotiable.

The main differences are:

• In AFT it’s the young person, empowered by the therapist, who problem-solves and decides what behaviours to change and how. In the first phase of FBT, the therapist empowers parents to make these decisions and the young person is given little choice.
• In AFT, parents are involved – but only to support the changes that the young person is willing to make.
• AFT focuses on emotions and coping strategies, so that the young person doesn’t need to use harmful behaviours (like restricting, over-exercising and maintaining a low weight). FBT asks parents to stop the harmful behaviours.

The model is psycho-dynamically and developmentally based

Adolescent-focused therapy has at its core a model called ‘psychology of self’. Roughly-speaking, the idea is that each of us needs a healthy sense of self to help us self-regulate and self-soothe. The view underlying the approach is based on the idea that adolescents with anorexia do not feel sufficiently competent or efficacious to manage the social, personal, familial, and developmental challenges of adolescence. They use self-starvation, obsessive thinking and restricting behaviours to manage these anxieties and fears. Through the relationship with the therapist and with parental support, AFT aims to help the adolescent safely explore these anxieties, test and challenge them, and learn new skills to build self-confidence and self-esteem.

Case formulation: the hypothesis that drives the treatment

In the first phase of treatment, the therapist prepares a ‘case formulation’. Case formulations are common in psychology and are a hypothesis which provides a framework for the treatment.

From the 2010 article: ‘The physical, social, familial, and cultural environments are hypothesized to present particular challenges, resulting in the development of anorexia nervosa.’

This might sound like AFT is concerned with what might have caused the anorexia, but James Lock has made it clear that AFT focuses on current symptoms, not on etiology.

Back to the article: ‘Anorexia nervosa serves to help regulate emotion, usually by promoting avoidance, while also providing an alternative emotional, behavioural and cognitive focus (i.e. eating, food and weight). In this regard, the adolescent with anorexia nervosa often confuses a control of emotion with a control of biological needs, such as hunger.’

So here’s the model. When the young person is under stress, the best coping strategy they currently have is to starve. The therapist helps identify stressors and teaches the young person healthier ways of coping.

Here are the challenges which, according to the model, patients may be facing:

• Avoiding developmental challenges of adolescence
• Child and family conflict (these would be current conflicts – remember that AFT does not consider the family to be ‘pathogenic’)
• Grief/loss
• Abuse/neglect (again, there is no assumption that a young person with anorexia has suffered abuse or neglect)

The psychological work

The 2010 article gives the example of a 16-year old girl, E.J. In her case, ‘a key goal was to attend to and identify physical signs of emotional responses and develop a richer language for emotional expression’. ‘Once E.J. understood the role her eating disordered behaviour played in her family conflict, treatment focused on finding appropriate ways to express herself’.’ E.J also learned to use her feelings to guide appropriate limit setting with others. That way, when she did not like someone’s actions, she had an alternative to her normal response of ‘passivity and extreme politeness that belied the intensity of her anger’.

There was also work on improving her social relationships, some of it with structured exposure ‘homework’ exercises. The therapist also taught relaxation techniques to help her manage anxiety. This way, E.J. found new ways to engage with others and found it easier to eat with peers in an environment that was more peaceful and enjoyable than at home.

Three phases

Adolescent-focused therapy follows three phases:

• Phase 1: establish rapport, assess motivation, develop a case formulation, actively encourage weight gain
• Phase 2: ‘encourage separation and individuation’: encourage ‘exploration of individuation issues of adolescence (self-efficacy, school and work goals, social identity) with an emphasis on establishing developmentally appropriate independence from the family’; increase the ability to tolerate negative emotions
• Phase 3: ‘coping strategies for adolescent problems (sex, drugs, school stress, etc.)’ and encouraging behaviours or strategies that will lead to independence

Externalising: the child and the anorexia are separate

Like in FBT, adolescent-focused therapy encourages everyone to see the illness as a separate entity which is currently taking over the adolescent, but the real person is still there. This helps the therapist demonstrate ‘unconditional positive regard’ for the person: we don’t blame the teen for their behaviour even while we request that the behaviour changes.

Adolescent-focused therapy is into a ‘sense of self’, and the therapist wants the young person to see themselves as existing apart from issues of food, shape or weight.

What about eating and weight?

Adolescent-focused therapy aims to normalise eating and other behaviours, and therapists will be working on weight restoration. ‘The therapist actively encourages the patient to stop dieting and to gain weight by setting weight goals and emphasizing the need to change these behaviours. The importance of weight gain is discussed and actively encouraged throughout treatment until the patient is weight-restored.’

There are weekly weigh-ins and the therapist helps the person manage any resulting stress. If the young person is skipping meals, the therapist will investigate which stressors are involved and will help the person develop better coping strategies.

A clarification from James Lock:

“AFT encourages weight gain and the therapist will not continue to work on other issues if the patient isn’t trying to eat and gain weight. Because weight gain is not the sole focus, weight recovery is usually slower with AFT than with FBT, and adolescents need to be hospitalised more often.

But based on our studies, for those adolescents who are less severely ill from a psychological point of view, those treated with AFT may do just as well as with FBT.”

The rate of improvement

If you read the case of E.J in the article, you will see that her weight gain was slow, and that it took a while for her to change her diet and to eat with her family. According to the study’s stringent criteria for ‘full remission’, she did not fully recover by the end of treatment.

James Lock comments: “Many cases treated with AFT fully recover, so this example isn’t really the best one.”

Remember that AFT works best with those who are not too ill in psychological terms. E.J is an example of someone who, in spite of her low weight, was able to engage with psychotherapy and to make changes I am used to parents doing the work of rescuing their child. All kudos to the girl and the therapist for managing what they did manage.

Where do parents fit in?

If you’ve spent time with my website or my book, you’ll be used to parents being direct agents of change. In the first phase of FBT treatment, clinicians are busy supporting the parents to get their child to eat, gain weight, and normalise behaviours. We don’t wait for a person with anorexia to want to do any of this. It’s a steep learning curve for parents but the pay-off is big when our children are very unable or lack the motivation to help themselves.

Remember that if parents are willing and able to do this, then a family-based approach is the first choice. We’re only looking at AFT for those where this is not possible, or not effective, or contra-indicated. Or where a family-based approach has run its course and we want to complete treatment with some psychological help.

With adolescent-focused therapy, parents are involved but they are not the drivers of change. They do not intervene if their child skips a meal, nor do they stop exercising or purging. They do not monitor that the child is eating. . The parent’s role is to support their child’s efforts at changing his or her behaviour and help them as they experiment with normal adolescent interests (so that their life isn’t all about dieting and exercise) . Or more precisely, ‘the primary aim’ of sessions with parents ‘is to help parents to support their child to take on the challenges of adolescent development’.

So the parents’ role is supportive, and a lot more hands-off than in FBT.

A clarification from James Lock: “The therapist helps the parents understand how best to help their son or daughter succeed. This may include many hands on things – just not taking charge of re-nourishment directly.”

Eating is the responsibility of the person with anorexia, not of the parents: ‘The therapist interprets behavior, emotions, and motives, and helps the patient distinguish emotional states from bodily needs and asks the patient to accept responsibility for food related issues as opposed to relinquishing authority to others (e.g. parents)’.

AFT is an individual psychotherapy, so parents are not involved in most of the interactions between therapist and the young person. Much of what goes on will be governed by confidentiality rules. But parents are invited to up to eight sessions without their child.

The aim of these ‘collateral’ sessions with the family include:

• For the therapist to get a sense of what family life is like, how family members interact with the teenager and how parents currently deal with the eating disorder behaviours To educate the parents about the illness
• To help parents understand weight gain, nutrition and medical concerns
• To give the parents ‘realistic’ expectations about the rate of improvement and update parents on progress
• To improve communication between family members

During the second phase of treatment, as the young person tries to adopt more ‘normal’ behaviour, parents may be helped to:

• Understand the challenges their child is facing
• Encourage appropriate adjustment and activities in their child
• The therapist ‘advocates for the patients’ developmental needs’

And in the final phase, the focus is on autonomy and relapse prevention. It looks pretty similar to phase three of FBT.

• Address any worries the parents have.
• Work towards developmentally appropriate independence (note that the giving of independence must be ‘developmentally-appropriate’ and must not be rushed’)
• Help parents predict and respond to potential areas of setback
• Help with ordinary, developmentally-appropriate challenges of adolescence

How adolescent-focused therapy is described in the NICE guideline

Here is the relevant text from the NICE guideline for eating disorders (for England):

In summary

• Give a family-based approach (like FBT) your best shot first.

• If a family-based approach hasn’t worked for a particular person, thank goodness there is something else to try.
• For some people, adolescent-focused therapy will work just as well as FBT.
• But if a person’s eating-disorder beliefs and compulsions are very strong, the probability of adolescent-focused therapy working is pretty low. Or to put it differently, if anorexia has hijacked the individual to the extent you hardly ever see a glimpse of the real person, then there isn’t enough of the healthy person there to do the psychological work and to make efforts to change.
• For some, AFT might be a good therapy to use after a family-based approach has yielded the main health and behavioural improvements.

The best we can do

We have one study on 121 youngsters that show adolescent-focused therapy working almost as well as FBT. That’s not to be sniffed at. At the same time, nobody would choose a cure for cancer based on one study of 121 patients.

But this is the world of eating disorders, and most studies involve even smaller numbers. This is the best we have to inform our choices at present. I also pay attention when James Lock, who you’d think is heavily invested in FBT, tells me that adolescent-focused therapy has helped many of his patients when FBT was not an option for the parents, or when it was tried and didn’t work.

I urge therapists to proceed with caution and keep themselves updated.

Totally opposite principles – please do not blend FBT with AFT

Many therapists are only just getting to grips with a family-based approach to treating eating disorders. The strengths of such an approach include:

• parent-empowerment… because parents see what is really going on and can support their child 24/7
• focus on rapid weight gain
• focus on rapid behavioural changes
• health and behavioural improvements are rapid — there is no waiting for insight or motivation

If you are also trained to deliver adolescent-focused therapy, you will be soaking up principles that could be quite the opposite. Please take care not to lose the strengths of family-based treatment when you deliver adolescent-focused therapy.