by Michael E. Berrett, Ph.D.
Differences in Treatment Between Adults and Adolescents with Eating Disorders:
In the most general view, those suffering from eating disorders need three major things in treatment: 1) Structure, 2) Love and Care, and 3) A safe place and safe relationship. Since the eating disorder often begins in adolescence, and sometimes in childhood, those suffering are likely to have some emotional developmental delays related to the starting of an addiction, which slows emotional development. Some believe that many adult eating disorder clients are in some ways teenagers developmentally, and that adolescent eating disorder clients are often "parentified" children or premature adults. Despite some emotional overlap between adolescents and adults with eating disorders, adolescents have more acute needs to be addressed in treatment. Compared to adults, adolescents in treatment need:
General And Basic Principles and Guidelines for Treating Eating Disordered Youth:
The following principles, while general and basic in nature, can be clear guides and a reminder of some of the most critical things to remember and embrace in a consistent manner through the treatment process. They are as follows:
1) Involve the family system. It is important to involve the families wherever possible, since they are the primary support system for adolescents. It is important for the client to make emotional connections within the family and learn to understand and utilize the resources available there. Learning to reach out for help is critical for the client, and keeping the family system in mind at all times during treatment is critical for the therapist.
2) Be more directive and specific. It is important for the therapist to take more responsibility in treatment to be active, to create energy, and to direct the process, helping the adolescent client who has less experience to draw upon and whose life focus has been more approval and peer-acceptance based (If they knew what to do and how to do it, they would have already been doing it ).
3) Do more activity-based sessions and less talking ones. Experiential learning is the best teacher. Activity-based sessions allow the therapist to join the client's world and gives the adolescent the opportunity to learn from their own experience, which is what they want. Activity creates true participation rather than simple observation of life. It allows the client to "do" rather than "talk about."
4) Provide structures in therapy that help them feel secure. Adolescents already carry much confusion and feelings of insecurity. Nebulous and unguided therapy can accentuate these already unpleasant emotional states. Giving the adolescent information on the process of therapy, the prediction of struggles, what to anticipate, and reasons for interventions can help them feel more in control, more included, more mature, and eventually more invested. Accurate prediction and client inclusion in treatment direction also increases trust in the therapist, which is crucial.
5) Provide much immediate encouragement and reinforcement. Without hope for overcoming these devastating illnesses, movement in recovery is minimal. Adolescents have difficulty seeing past the current moment, day, or week. They need help in nurturing hope, in remembering that their adversity is temporary, and that small steps are good and will eventually "add up". They need their progress pointed out and processed, and they need us to share our vision about their positive futures when they can't see it themselves.
6) Help them to explore love and acceptance over approval. Those suffering with eating disorders often have incorrectly learned that "approval is everything and disapproval is the end of everything." They need to know that their external appearance and their external accomplishments are not "who they are." They need help in noticing, accepting, and giving love, and in ending the never-fulfilling search for others' approval.
7) Emphasize having their feelings without self-judgment. Helping the adolescent client feel, label, understand, accept, and express their emotion without making emotional judgments about themselves for the emotions they feel is very important. They are frightened of intense emotion and therefore tend to avoid it. They need help to understand feelings are instructive and can be embraced rather than feared. Help these clients with their emotion secondary to their original feelings. These secondary or "self-judgmental" emotions often include guilt, shame, selfishness, or embarrassment.
8) Make honesty and congruence an ongoing theme. Helping clients become more honest and congruent without self-criticism or self-punishment is necessary for recovery. This honesty includes openness, sharing unhealthy "secrets," telling the truth, admitting to mistakes, and decreasing "selectivity" in things shared in session. Telling the truth is freeing and helps to overcome intense feelings of shame and guilt for past behaviors and experiences.
9) Teach them to avoid mainly one thing in life — Avoidance. Eating disorders are disorders of avoidance. Help them understand their fears and face them, help them understand their internal "moral imperatives" and follow them. Help them learn to "feel the fear and do it anyway" rather then attempt to get rid of all fear or become handicapped by it. Help them learn through "pointed out experience" that avoidance keeps low self-esteem alive and well.
10) Persistently show nurturance, kindness, and caring. It has been said, "People don't care how much you know until they know how much you care." So it is with our adolescents. Many with eating disorders have received too little nurturing. Others have received it, yet were unable to accept, internalize, or believe it. Help them see and feel the love, caring, nurturance, and acceptance in their lives. Since they are not used to seeing and feeling it, it may help to point it out and label it for them until they have learned to do that for themselves.
In summary, we see and know many beautiful, bright, kind, and priceless youth out there who have no idea of their value, their goodness, or their potential. We can make a difference to these youth. May we have the courage to face our own fears which get in the way of love and service, and may we also have the courage to "no longer support or enable" those destructive and hurtful messages, trends, and forces in our culture. We can do this through refusal to participate and through striving to replace them with things that are good. We can make an appreciated and well needed difference — one effort and one person at a time, beginning with ourselves and extending throughout the world.