The average age of onset for most eating disorders sits squarely in early to middle of adolescence. Even with early detection and treatment, many individuals move from adolescence to adulthood with their eating disorder in tow. Many things about the eating disorder shift in this developmental transition. These include the nature of medical risks of the eating disorder, the role of the family in treatment, the tone and content of motivation and ambivalence about change, and the degree to which the individual is free and capable of making their own decisions regarding treatment. But in many ways the eating disorder effectively resists maturation; that is, the symptoms, behaviors, anxieties, and core cognitions remain similar across the developmental range.
There are certainly advantages to structuring intensive treatment programs along developmental lines.
Separating adolescent from adult clients allows programs to tailor clinical content and core treatment interventions. One common rationale in favor of separate programming is that separation allows for more focus on family work and support. These issues are particularly important at the residential level of care. I believe, however, that there are strong arguments in favor of providing opportunities for adolescents and adults to work together in treatment as they move to lower levels of care such as day treatment programs.
Adolescents with eating disorder are generally more overtly resistant to treatment than adults. As a rule, adolescents minimize the impact of the eating disorder on their lives and tend to see the eating disorder as something that enhances them in some important way. This can make treatment engagement particularly challenging because adolescents often see treatment as a process that will take something precious away from them. Adults – by virtue of maturation – may often have developed a greater perspective for what the eating disorder has cost them in terms of their physical and relational wellbeing. Even young adults have a greater capacity to look forward and begin to wrestle with the implications of moving through their lives without fully resolving their eating disorder.
Combining adolescents and adults in day treatment programs helps bridge this motivational divide.
Teen-only groups can coalesce around a negative or resistant view about treatment. Young adult and adult groups are less likely to stay stuck in a defiant stance. This openness to the possibility of recovery and change can have a powerful impact on a adolescent that isn’t sure they are ready to engage. Hearing from an older peer about the impact of their eating disorder can break through the defiance in a way that a therapist or a family member can’t. These moments, where an adult patient connects and emotionally touches an adolescent on this issue of desire for change, can be enormously powerful, even transformative. Mixing adolescents and adults can also minimize group comparisons and competition. These dynamics can flourish in adolescent-only groups and inhibit recovery. Many adolescents and adults tell us that they often feel disconnected or set-apart in their relationships. Treatment environments that provide a range of healthy relationship opportunities, with staff and with fellow clients, increase the chances for a meaningful connection that can help build the momentum for change and recovery.
It takes a strong and experienced treatment team to create and manage these interactions.
Teens do need their own separate spaces to address their unique developmental issues. They need specialized family therapy services and support. The group therapy content in mixed groups requires thoughtful monitoring by staff. Day programs that mix adolescents with adults must provide these separated program elements. Programs that mix adolescents and adults need to have distinct models and goals for family therapy and support. With careful and thoughtful attention to these modifications, mixed day treatment programming for adolescents and adults can take advantage of the power of connection between an adolescent with and eating disorder and an adult who can recognize where that adolescent is now and, perhaps more importantly, provide a glimpse of where they are headed.
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