Adjusting Cognitive Behavior Therapy for Adolescents with Bulimia Nervosa: Results of Case Series

Article excerpt

This article reviews the types of adjustments needed to an adult protocol of cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) to make it more acceptable to an adolescent population. Employing developmental principles as well as clinical experience as guidelines, these modifications include the involvement of parents, recognition of the interaction of treatment with normal adolescent developmental tasks, and allowances for typical cognitive and emotional immaturity on treatment procedures. Outcomes from a series of adolescents with BN who were treated with this modified-CBT approach show results similar to those expected in adult populations treated using CBT.

INTRODUCTION

Psychological interventions with youth work best when they mesh with normal developmental processes (Holmbeck et al., 2000; Kendall, 1993). However, in a recent review of treatment studies of adolescents, Holmbeck et al. found that relatively few (26%) even mentioned adolescent development and identified only one study that examined age as a moderator of treatment effects (Holmbeck et al., 2000). Cognitive-Behavioral Therapy (CBT) has been modified for use with younger patients with depression and anxiety disorders and appears to be effective for these conditions with patients in this age group (Brent et al., 1997; Kendall, 1994). However, there is no systematic research and no comprehensive descriptions of how best to adjust CBT for adolescents with bulimia nervosa (BN), even though substantial evidence supports the efficacy of this form of therapy for BN in adults (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; C. G. Fairburn et al., 1991). The purpose of this article is to describe how to adjust CBT for adolescents with BN. General principles and illustrations of specific modifications are provided.

BACKGROUND

Both clinical and research data suggest that adolescents differ from adults in a number of ways that might have an impact on the acceptability and efficacy of psychotherapy (Feldman & Elliott, 1990). Because of developmental differences between adults and adolescents, treatments need to be adjusted to better match the needs of younger patients (Shirk, 1999; Kendall, Learner, & Craighead, 1984). Adolescence is a transitional developmental period between childhood and adulthood that is characterized by more biological, psychological, and social role changes than any other stage of life except infancy (Feldman & Elliott, 1990). The three main changes of adolescence are physiologic maturity (puberty), increased cognitive capacity (abstract thinking), and increased social maturity through role redefinition. Compared with adults, adolescents have more limited abstracting abilities and poorer executive functioning, goal-setting, and planning abilities (Sternberg, 1977; Sternberg & Nigro, 1980). This limits their perspectives on the hazards of their behaviors and decreases motivation to seek and participate in treatment. As a result of these differences adolescents may have a more limited capacity to utilize therapies that depend on insight, emotional processing, self-evaluation and goal-setting (Izard & Harris, 1995). In addition, autonomy struggles, as well as the high value placed on peer relationships, can compromise treatment collaboration, treatment adherence, and ultimately treatment effectiveness (Savin-Williams & Bernt, 1990; Trickett & Schmid, 1993). Adolescents may generalize autonomy struggles from parents to other adults, including therapists, thus compromising the development of a productive therapeutic collaboration. In addition, autonomy struggles (which are often severe enough to require therapeutic attention) with parents and other authority figures make focused psychological treatments for BN difficult to maintain. Similarly, adolescents with difficulties in peer relationships (e.g. dating or other problems with social performance and role) can derail a focused treatment by forcing therapeutic attention to these problems at the expense of time spent focused on the eating disorder. …