One often-overlooked aspect of recovery from adolescent anorexia is the need for both child and parent to shake off negative, established patterns of coping. For the adolescent, the illness can play the valuable role of masking or numbing feelings of fear, anxiety, low-self esteem, loneliness or boredom. It can also be away to avoid experiences that are threatening or scary: unwanted attention, new social situations or challenges of any type.
For parents, another form of avoidance can come in the form of accommodation: aiding a child in her ritualistic eating behaviors and self-starvation in order to avoid the immediate distress that results in opposing those behaviors.
These would be the parents who stock their fridge with non-fat foods, no-calorie lettuce, “acceptable” energy bars and other such staples, who avoid providing “challenging” foods in order to maintain calm in the home or because they can’t bear to see their child in any more anguish.
A group of researchers has devised a treatment called Acceptance-based Separated Family Treatment for Adolescent Anorexia Nervosa (ASFT), which they hope will help both parents and adolescents learn to replace their rigid and avoidant behaviors with more accepting, flexible behaviors driven by long-term values and goals.
One of these researchers, C. Alix Timko, PhD, explains that AFST is broadly based on a form of psychological treatment called Acceptance and Commitment Therapy (ACT). ACT itself is an increasing popular form of “acceptance-based” Cognitive Behavioral Therapy, one that interprets psychological problems as rooted in emotional and experiential avoidance.
A National Institute of Health-funded pilot project begun in 2008 yielded promising enough preliminary results to spur Dr. Timko and her colleages Rhonda M. Merwin, PhD and Nancy Zucker PhD, to continue their research, which they describe in this article in the latest edition of the Renfrew Center Foundation’s journal Perspectives.
AFST incorporates key concepts of Family Based Treatment (FBT), the current gold-standard approach to refeeding adolescent anorexia patients, but supplies a psychological component that FBT has heretofore not stressed. It involves 20 90-minute sessions of treatment spread over 24 weeks, divided evenly between adolescent and parents. For the first 16 sessions, adolescent and her or his parents are seen separately. Joint sessions are held during the last four every-other-week sessions.
Three phases of treatment take place. In the first, therapists prepare patient and parents for the tough work ahead, stressing the importance of being willing to experience some difficult thoughts and feelings. Parents are encouraged to recognize their own importance as healthy role models, and are given a workbook with information on authoritative parenting, the psychological aspects of eating disorders and behavior management. All this happens as they are taking control of their child’s eating according to FBT protocol.
In the next phase, the therapist conducts a “functional analysis,” during which the patient comes to see how the disorder has both helped and harmed her. Parents are encouraged to think about how they may have over- or under-reacted to the disorder, and how they can improve their lives in other areas to make them better caretakers. As part of this phase, explains Dr. Timko, therapists create a timeline with the adolescent to help him visually graph factors that may help maintain the disorder.
“We ask, ‘When is the eating disorder loud?’ ‘When do you have urge to exercise or restrict?’ ‘What were your thoughts and feelings in this situation?’ Throughout the course we look for patterns,” explains Dr. Timko.
The third phase is the heart of AFST, when the real work of changing attitudes and behaviors takes place. The catch-words “open,” “centered,” and “engaged” are used to help patient and parents accept difficult thoughts and feelings nonjudgmentally, and to distance themselves from these subjective experiences. The joint parent-adolescent sessions focus on communication and relapse prevention.
Drs. Timko, Merwin and Zucker plan to eventually create a treatment manual for therapists based on AFST. For now, though, they’re collecting more data on its effectiveness compared to FBT. A manualized version of Dr. Zucker’s parent skills program Off the C.U.F.F. program—which I wrote about in this blog post, is, however, available from Gürze Books.