Why Are Eating Disorders So Difficult to treat?

My colleagues often ask me why I chose to specialize in the treatment of eating disorders. The point they are making is that an eating disorder (ED) is probably the most difficult type of psychological problem to treat. Why? Because your patient does not want to get better by definition. 

That is correct. Individuals with anorexia, or bulimarexia, a new version of the disorder, do not wish to recover. It’s not like treating depression or anxiety where the patient is desperate to rid themselves of the painful symptoms that are turning their lives upside down, threatening their job or academic security and isolating them from loved ones. 

The ED does all of these things in spades. It also threatens the victim’s medical well-being and has a good chance of shortening their lives. In fact anorexia kills 1/3 of all of its victims. Yet still they cling to it. The newest version of anorexia, bulimarexia, is even more dangerous as it includes bingeing and purging in addition to the restricting. 

Despite these incredibly negative consequences, the anorexic/bulimarexic is psychologically unable to give up the disorder. Indeed, they will protect it at all costs, often going from honest individuals with great integrity and many gifts, to individuals who lie with ease to keep parents and loved ones at bay. Once in treatment, which usually requires coercion, they will do anything to sabotage it, up to and including throwing their practitioner under the bus if necessary. If you look at it from the side of the patient, the therapist is a real threat and the better s/he is at the job, the more of a threat. 

I view anorexia as an anxiety disorder with a focus which is what makes it so unique. The victims are completely bought-in to the idea that restricting will alleviate their anxiety. It makes sense when you understand how anxiety works. Anxiety is terribly uncomfortable because it is amorphous and free floating. Fear is easier to manage because it is focused. Many people experiencing high levels of anxiety choose to focus on a specific fear for that reason. In the case of anorexia, it is the fear of gaining weight or getting fat. 

In other words, the fear provides focus and direction; Eat less and lose weight. The added benefit is all of the attention, some of which is positive and some of which is not. Irrespective of how people react, the rewards are built-in as the individual suffering from anorexia quickly learns that she can excel at something that is easy to define and simple to put into motion. Over time it becomes easier and easier to restrict which leads to relentless weight loss. Body dysmorphia prevents her from understanding how thin she has become or how dangerous it is.

Losing weight in a society that worships thinness makes the anorexic feel powerful, in control, accomplished even. At some point, what started out as a way to manage anxiety, becomes full-blown anorexia or bulimarexia, and that changes every aspect of the anorexic’s life. When this happens s/he will do anything to protect the disorder.

That is why asking the anorexic to give up the anorexia makes no sense to them. The patterns of behavior, the rituals, and the isolation quickly become addicting because they are so comforting. The issue then is how to treat a patient who does not wish to “get well.” This is where the rubber meets the road for parents and therapists. In order to help the child/patient both the parent and the practitioner have to stay in their own lanes, but they also have to work closely together for treatment to be effective. 

Most treatment for these disorders fails. The only approach shown to be effective is a family systems based approach that recognizes the importance of these two roles (parent and practitioner) and the need to keep them separate. It is called the Maudsley approach. It is one in which the parents mandate eating and treatment, while the therapist supports the patient as well as the parents in their journey.

That sounds easy enough, right? Not really. Remember, individuals suffering from anorexia do not want to get well. To the contrary, they will protect the eating disorder at all costs. In order to do so, they have to be vigilant, always staying two steps ahead of their parents, significant others, and therapists. Their stance, which is one of full cooperation for everything and anything except gaining weight, is often misunderstood by a naïve therapist or by someone who really doesn’t understand the anorexic mindset. The key is to appear very compliant, while simultaneously restricting and losing weight. If the therapist is onto them, then the goal is to get rid of the therapist. 

This is where the relationship between the parent and the practitioner becomes critical. For starters the parents and the therapist must be on the same team in order to be effective in fighting the anorexia. Notice I’m not saying in order to fight the anorexic, I’m saying the anorexia. I make this distinction because anorexia creates a mindset that is psychotic-like, ergo the diagnosis “anorexia nervosa psychosis” and therefore very difficult to understand. However, never underestimate this anorexia mindset because it wields great power. Often the patient manipulates everyone in the family as well as healthcare providers in truly masterful ways to prevent them from getting in the way of losing more weight.

Speaking of healthcare providers, it really helps if the patient’s doctor has a clue, which ordinarily isn’t the case. It’s your job as the therapist or parent to educate the pediatrician or the family doctor so that they can be part of the team because you will need them.

Back to the anorexia mindset. It is spectacularly well focused: Eat as little as possible, lose as much as possible and lie lie lie when necessary. Treatment must be equally as well focused. With parents, physician, and therapist working closely together, as a team, in order to prevail. Stabilize medically, mandate eating, increase quality nutrients, slowly increase calories. 

Here’s where things get tricky and other therapeutic approaches get derailed. Each part of Team Treatment has a role. The role of the therapist is one of support, education and empathy. The therapist is on the side of the patient. The role of the parents is to mandate eating and treatment. In this scenario, do the parents have to be the heavy? Yes. They have to parent. Insisting that their child eats and stays in therapy is a part of parenting. This is very hard to do and some parents struggle with being able to do it. Those who struggle are more at risk for getting sucked into putting their child in a residential or daytime treatment center where the treatment team takes on the parenting role. This is a very bad idea.

When the agency/treatment center takes on the role of parenting and mandating eating, and the parents try to be supportive and empathic, which may involve agreeing with their child that the treatment team is being mean, guess what happens? The patient drops out of treatment, goes back home, and immediately stops eating again. As a result the recidivism rate for residential and daycare centers is very high. 

But even worse is how the treatment centers mandate compliance. They are under the gun. They need to get results in a month, as most insurance runs out at that point. Too often they resort to using shame, isolation and punishment (or bad parenting strategies) that are nothing short of damaging and in some instances, frankly disturbing. 

I have had patients who were basically put in isolation because they refused to eat. One teenager was in her room by herself for 30 days ingesting only boost and when representatives of the “treatment” team entered her room they were instructed that they should not make eye contact with or speak to her. You don’t get that kind of isolation in a prison. 

But don’t get me started on the problems with most of the treatment for these disorders. It’s abysmal. With only a 30-40% success rate, these institutions still have the nerve to charge $1500/day for their “treatment”. 

A few other important things to consider if you are the parent. The longer your child has an ED without receiving treatment, the more deeply ingrained the belief is that they cannot live without it. Indeed, they will fight to keep it, irrespective of what they must give up in order to do so. Please try not to blame yourself, as blaming yourself can and often does delay treatment. 

In closing, people come to their ED for many different reasons. The triggers can be very complicated having to do with family dynamics, social pressure, and/or a society that just values thinness or something else altogether. Recently, COVID has been a major instigator as we have seen an uptick in EDs since it began. I believe the isolation caused by COVID created higher levels of anxiety in a society that was already fairly anxious. As I mentioned earlier in the article, the ED gives the anxiety focus, and in so doing, a way to cope. Just not an effective way to cope. We are also seeing this dynamic play out with those who gained weight during COVID. 

Irrespective of how they end up here, this group of patients is unique in that they are highly intelligent, hard workers, organized and determined. Ordinarily these traits would be a benefit. However, when applied to being a good anorexic or bulimarexic they can be deadly. I have a 94% success rate with this population. My patients have gone on to be exceptional parents, doctors, lawyers, artists and humanitarians. My family systems based approach works. 

If you or a loved one is struggling with disordered eating please reach out to me. I am the Eating Disorder Pro and I can help. 

Does someone you love suffer from an eating disorder?

Dr. Renae Norton specializes in the treatment of eating disorders. Located in Cincinnati, Ohio. Call 513-205-6543 to schedule an appointment or fill out our online contact form for someone to call you to discuss your concerns. Tele-therapy sessions available. Individual and family sessions also available.

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