Adolescent-focused therapy (AFT) for anorexia: how does it compare with family-based treatment?

Should you consider adolescent-focused therapy if you can use a family-based approach?

A huge thank-you to James Lock for contributing to this piece. Jim co-authored the manuals and research for both of the approaches discussed here: adolescent-focused therapy (AFT) and family-based treatment (FBT).

On this page:

• I introduce you to adolescent-focused therapy
• I outline  how it compares with a family-based approach
• I explain how adolescent-focused therapy and cognitive-behaviour therapy are to be used if (and only if) a family-based approach turns out to be ‘unacceptable, contraindicated or ineffective’
• And how it might have a useful role, for some people, towards the end of treatment

And here’s the executive summary:

If you can use a family-based approach like FBT or FT-AN, that’s what you should do. It’s twice as effective as an individual therapy.

Adolescent-focused therapy matters

Also on this site: adolescent-focused therapy (AFT): a guide to the joint runner-up treatment for anorexia

Most of us had only heard of Adolescent-Focused Therapy (AFT) in the context of a 2010  randomised controlled study comparing AFT with Family-Based Treatment (FBT).

FBT came out better. And as AFT was the most promising of individual psychotherapies, a generalisation from this study was that youngsters get better results with family, rather than individual, approaches.

After this study, AFT was little-heard-of, while FBT grew, underwent more research, and eventually became the number one therapy recommended by most governments or professional organisations. This website, and my book, follow principles of FBT.

So why am I suddenly telling you about adolescent-focused therapy (AFT)?

Because in England, the NICE guideline (that’s the National Institute for Clinical Excellence) was updated in May 2017. After reviewing all the evidence for the treatment for under-18s, it recommended:

• A family-based approach (NICE calls it ‘anorexia-nervosa-focused family therapy for children and young people (FT-AN)’)

and if that turns out to be ‘unacceptable, contraindicated or ineffective’ then the health service may follow one of two options:

• individual CBT-ED –that’s cognitive-behaviour therapy specifically for eating disorders

• or adolescent-focused therapy for anorexia nervosa (AFP-AN)

AFP-AN is the catchy new name for adolescent-focused therapy

Note that various names exist for approaches that share common principles or are variants of each other. Sadly this can cause confusion and there’s a risk that vague and untested treatments can slip in.

For instance, NICE doesn’t specifically recommend family-based treatment (FBT) and its manual, but ‘anorexia-nervosa-focused family therapy for children and young people (FT-AN)’. And rather than talking of adolescent-focused therapy (AFT) it talks of adolescent-focused psychotherapy for anorexia nervosa (AFP-AN).

I will make the bold decision of using the term ‘adolescent-focused therapy (AFT)’ on this page. And wherever I talk about Family-Based Treatment (FBT) on this website or in my book I mean the precise method described in the FBT manual. Otherwise I use more general terms like ‘a family-based approach’, or ‘family therapy for eating disorders’.

It’s good to have options

For most youngsters FBT works better than AFT — twice as well. But it doesn’t work for everyone. Sometimes, FBT yields great benefits fast, but our children seem to need more psychological help. Then there’s the issue that  some parents really don’t want to do FBT, or truly can’t. So practitioners need another evidence-based treatment in their toolkit.

Should you choose adolescent-focused therapy or cognitive-behaviour therapy?

If a family-based approach isn’t indicated, NICE doesn’t say if it’s better to try adolescent-focused therapy or cognitive behavioural therapy . NICE probably found it very hard to compare AFT and CBT because there’s not that much research, and because the small amounts of research there is uses different criteria to define full remission (AFT’s criteria are more ambitious).

Note that both cognitive behaviour therapy (CBT) and adolescent-focused therapy(AFT) perform less well on severely ill people. Fairburn’s manual on cognitive behaviour therapy lists criteria for which CBT is not appropriate. And whenever I’ve been in communication with Glenn Waller about his work on CBT he’s stressed that for adolescents a family-based approach is the first thing to try. So even the champions of methods 2 and 3 are saying that method 1 is your best bet.

As a parent I would consider three factors:

• First, James Lock points out that the data for CBT for adolescents is very small whereas there are two encouraging randomised controlled trials for adolescent-focused therapy.
• Second, I would read up on both approaches and try and work out which is most likely to suit my child.
• Third, I would find out more about the training and supervision of the therapist offering each of these therapies, because a good therapy delivered in an amateurish way can do harm.

How does adolescent-focused therapy compare with FBT?

The conclusion drawn from the 2010 trial on 121 youngsters with anorexia was that ‘both treatments led to considerable improvements’.

But AFT was not as successful. As James Lock summarised it for me:

‘The percentage of patients who recovered with adolescent-focused therapy was about half that of family-based treatment. Also, FBT started working faster: the weight gain, beliefs and behaviours improved sooner. Finally, there were fewer youngsters who relapsed after recovery in the FBT group.’

[More details on the study’s results at the bottom of this page]

James Lock also wrote to me, ‘It is important to note that AFT worked at its best with less severely ill children (lower EDE scores, lower eating-related obsessive compulsions, and no purging).  For those who were more severely ill, AFT worked less well.’ (EDE scores, in case you’re wondering, refer to a validated Eating Disorder Examination questionnaire, which rates the person’s behaviours and beliefs.)

When would we choose adolescent-focused therapy over FBT?

Generally a therapist should not choose it because family-based treatment is the first-line treatment. They would be even more unlikely to choose it with a very ill child or adolescent.

What a parent chooses may be different. No judgement should be placed on any parent who does not want to use FBT. Having a child you love dearly suffer from an eating disorder is hugely challenging and it may come at a time we truly cannot stretch any further. We each do the best we can with the cards in our hands.

The NICE guideline allows the health service to go for adolescent-focused therapy if family-based treatment is ‘unacceptable, contraindicated or ineffective’.

When would FBT be “ineffective”? When it’s been tried and there’s been no progress for several weeks or months, I guess. The main thing is, therapists have to give it a try. They shouldn’t say  (and this does happen), ‘Oh, family-based treatment is not for you’ if they haven’t tried – as long as the parents are willing to give it a go.

When would FBT be “unacceptable” or “contraindicated”? If parents were unwilling to be actively involved in treatment. A history of parental abuse would also be a contra-indication. Family-based treatment requires parents to take a central role in their child’s care. They have to be willing to come to appointments and in a first phase, to work to get their child to eat and gain weight. If the parents don’t want to do that then it’s a non-starter.

All this to appeal to all therapists reading this: don’t discount family-based treatment (or anorexia-focused family therapy, or whatever you want to call it) ‘just’ because the family is in difficulty. It may work even though:

• The family members are all fighting each other
• The young person bitterly complains about their parents and rejects their support
• The parents are divorcing
• There’s just a single parent, who’s working full-time

You’d expect these factors to make the job impossible but for some, a family-based approach still works very well. Lock and Le Grange themselves say (episode 19 of podcast ‘Maudsley Myths‘) that after all their years of doing FBT, they cannot predict which families FBT will or will not work for.

So I am appealing to therapists to develop their family-based treatment skills and work with parents to get through difficulties, rather than dismissing a family approach and going straight to cognitive behavioural therapy or to adolescent-focused therapy. Please don’t be too hasty in guessing what parents can do, especially when they have expert support.

In my work supporting parents, I meet mothers and fathers who are exhausted, scared, fed up or furious. Sometimes they say that there is no way they will do FBT and it’s time their child took responsibility for their recovery. Yet after one or two sessions of being truly heard, or of receiving practical tips, or of having a support team help with mealtime skills, these parents seem to acquire superpowers to guide their child, as their energy, dedication and love surface.

Conversely, sometimes I speak with parents who are very frustrated because therapists are refusing to provide FBT and will only give the child individual therapy. Reasons given are sometimes that the child is too underweight, or too resistant, or has been ill for too many years. Sure, these things make treatment harder and longer, but there is no evidence to justify these therapists’ decisions – and often the evidence points the opposite way.

Could it be "both-and" rather than "either-or"?

I attended an engaging talk on AFT by London-based Cathy Troupp, child and adolescent psychotherapist. You can hear her in a podcast here.

I could see the sense in her suggestion that AFT could be useful as well as a family-based approach, once the family-based approach has run its course. It appeals to me because parents often worry that psychological issues and the eating disorder mindset are staying put, even while behaviours and weight are pretty well sorted (and the young person may even have been discharged). Re-nourishment, good habits, compassion, time and repetition bring huge improvements, but some of us sense that our kids would benefit from expert psychological work focused on adolescent development .

AFT might be a great way to go at this stage. As long as it doesn’t disempower parents, because it’s too soon to remove the safety net.

In the next page I will tell you everything I know about adolescent-focused therapy, with the help of James Lock.

* More on the results of the 2010 randomised controlled study: FBT versus AFT *

For those of you going through the article with a fine-tooth comb, the following details may help (and they come directly from James Lock):

The rates for recovery (‘full remission’) using AFT were roughly half of FBT’s at end of treatment, and at 6 and 12-month follow-ups.

The differences were statistically significant at 6 and 12-month follow up, but not at end of treatment. The lack of statistical difference is likely only because the sample size was not quite large enough.

In fact even at end of treatment there was statistical significance on weight and change in EDE scores (which concern beliefs and behaviours). And the difference in the recovery rate was very close to being statistically different.

In short you can safely say that the recovery rate with AFT was roughly half of FBT’s.