Anorexia nervosa is one of the more difficult psychiatric conditions to treat. The illness is often defined by ambivalence about recovery in large part because the classic dieting and associated weight loss of anorexia can feel rewarding and reinforcing to the afflicted. Denial of the severity of illness is common, even when there is severe malnutrition, health consequences and significant concern from loved ones. Research review reveals dramatic statistics for dropout ratesfor patients with anorexia nervosa: in specialized inpatient eating disorder programs, dropout rates range from 20.2% to 51%.[i] It was reported in one literature review that up to 70% of ED patients drop out of outpatient treatment.[ii]
Given the medical risks and high rates of mortality, it’s natural for providers to want to immediately confront and take a highly directive stance surrounding nutrition and weight restoration with their anorexic clients. In other words, the emaciated frame of an anorexic patient can trigger anxiety in the provider and can push a provider into a highly directive and confrontation stance, immediately jumping into the mode of “we have to work on weight gain.”
Studies have found that a confrontational style doesn’t lead to lasting change. Decades of research in the substance abuse field, reveal not a single clinical trial in which a confrontational stance leads to a positive outcome. Actually, studies show that using a collaborative approach results in improved outcomes. [iii] In a collaborative approach, the client – not the therapist – drives the treatment. The client is central in outlining the problem, clarifying the treatment objectives and setting up treatment goals.
Over the course of my career, my colleagues and I have implemented the following strategies to collaborate with our patients and enhance their intrinsic motivation to change:
Establish allegiance with the patient. It’s natural to feel so concerned with the patient’s health, that we want to start with weight restoration right away. It’s essential, however, to first get to know and understand the patient’s concerns. We ask the patient about what brought them into treatment and about what is most concerning to them about their eating. We ask about all areas of life to get a sense of the impact of the illness in all domains. When our clients can outline the things about the illness that simply don’t work for them, then we have an opportunity and window in to support change.
The client is central in setting goals. It is key to empower the patient to drive change. A patient’s goals should be as clear as possible and should include short-term goals and also broader life aspirations. During this time, the therapist may begin to bridge how improved nutrition and perhaps, weight restoration, may mesh with these personal goals.
The provider should clearly communicate limits. We work to set the patient up for success from the beginning by clarifying non-negotiable limits. For example, at our program, we have a clear weight threshold for participation in our outpatient services. If a patient falls below that threshold, a higher level of care will be recommended. Additionally, patients have to remain medically stable. If malnutrition leads to medical complications, the individual will need to promptly transition to an inpatient setting.
Periodically check-in on status. Ideally, the patient will set up clear goals along with a time frame for achieving these goals. Then you can set up a time frame for periodic check ins to see how things are progressing. It’s helpful to collaboratively anticipate problems before they arise. For example, “ok, so over the next 3 months, I understand that you want to be able to go out to eat with friends and order your meal off the menu. What should we do if the time comes and you’re not there yet?”
The provider takes a neutral, but empathic stance. While it can be challenging, it’s important that as a provider, we don’t become too invested in our patients’ weight gain. Ideally, improved nourishment and weight restoration will start from the patient. The provider is there to provide education, feedback, and overall support throughout the process. As much as possible, we bring attention to any discrepancy between current behavior and bigger picture goals so the patient can feel empowered to drive resolution to issues as they arise.
At Columbus Park Treatment Center in New York City, we’ve assembled a team of experts, exclusively focused on treating eating disorders and their co-occurring conditions, such as depression and anxiety. Working with clients of all ages – our active, skilled and engaging therapists deliver the best evidence-based treatments available. For additional resources, sign up for our newsletter.
[i]Wallier J, Vibert S, Berthoz S, Huas C, Hubert T, Godart N: Dropout from Inpatient treatment for Anorexia Nervosa: critical review of the literature. Int J Eat Disord. 2009
[ii]Swan-Kremeier LA, Mitchell JE, Twardowski T, Lancaster K, Crosby RD: Travel distance and attrition in outpatient eating disorders treatment. Int J Eat Disord. 2005, 38: 367-370. 10.1002/eat.20192.
[iii]White, W. & Miller, W. (2007). The use of confrontation in addiction treatment: History, science and time for change. Counselor, 8(4), 12-30.