The Hard Line in Eating Disorder Treatment

The refrain from clinicians who treat patients with chronic eating disorders is that there aren't any standard effective treatment options or any useful literature to read. Without a method to rely on, clinicians have turned to the field of addiction for guidance. The accepted approach for a therapist in that realm is rigid and punitive. The eating disorder version of the hard line is as follows. Present the patient with viable treatment options along with meal plans to follow and weight guidelines. If the patient can follow these rules then treatment can proceed. If not, then come back when you're ready. Outside of this simplistic, punitive approach, therapists are on their own.

The premise behind this kind of therapy is that engaging a patient in unsuccessful work will enable worsening of the disease. The eating disorder symptoms will persist without any immediate change in behaviors. More to the point, responsibility for any deterioration will now lie on the clinician's head.

It's no wonder there appears to be so many people with chronic eating disorders not in treatment. The unspoken agreement to hold the hard line among eating disorder professionals lets us all off the hook. No one needs to worry about the chronically ill. They have brought their desperate state upon themselves by refusing the correct course for recovery. Let them think about it and come back in time.

But people come to treatment for help. A one size fits all approach to treating eating disorders is not only reductive but cruel. These are complex, misunderstood illnesses with moderately effective treatments at best and few viable options at worst. How can we as therapists say we have the answer when there is no evidence behind the rigid approach to treatment?

The fear of enabling the illness can easily mask the fear of the therapist to take on such a challenging case. Working through a complex chronic eating disorder takes a lot of time and energy for the patient and therapist. There is certainly no guarantee of success and a high likelihood of managing serious medical problems that stem directly from the eating disorder. It would be more honest for a clinician to say he doesn't have time or expertise for a complex case than to place the blame on the patient. 

What happens when this patient does find a therapist? Things don't get easier. It's just as hard to assemble a team or find a program willing and able to confront the therapeutic challenge of treating someone with a chronic eating disorder, yet these options are clearly more effective than individual therapy alone.

If the patient agrees to more intensive care, most outpatient programs or residential programs cater best to younger patients earlier in the course of the illness. For someone not yet ready for more involved help, it's often a long, uncharted road to understand the eating disorder and institute behavioral changes with food. No manual exists to explain the baby steps in this type of recovery. No map points to paths to success. And no role models offer hope for the chronically ill. It's no wonder many of these patients stop seeking help.

Yet those are the available resources. Any work towards recovery either stays isolated to just individual therapy or expands into a team and/or program. The team offers more chance of full recovery because a patient need different providers to focus on all aspects of treatment and more time and energy to compete with the ever-present psychological and behavioral symptoms. Even the best therapy cannot accomplish all components of treatment. But assembling a team or involving a program also means accepting the misunderstanding and confusion that affects even experienced professionals in facing a complex, chronic illness. Although regular communication among team members and with the patient improves outcome, the patient will have to endure many challenges along the way. Being so resilient while dealing with an eating disorder isn't easy for anyone.

If we assume that treatment has begun and a team of seasoned clinicians assembled, the steps in treatment are still hard to determine. More than with people earlier in their illness, the treatment of chronic eating disorders has two critical components for success. First, it's essential for the team and patient to agree upon reasonable markers of progress and a reasonable timeframe for each step. Balancing the severity of the illness and barriers to progress is not uniform so each patient needs an individualized program. These markers fundamentally represent hope for change and recovery, a sentiment that can be hard believe after a patient has been sick for years. Yet without hope, the treatment is even more challenged from the start. I'll start with these two points in the next post.


  1. This comment has been removed by the author.

  2. As a clinician, I can't tell you how much I appreciate this entry. It validates the experience and profound frustration/sadness that I and so many of my clients experience. I hear your point about the suggestion of the higher level of care being perceived as a rejection. This is something that I've tried work on with my clients. I find that if a client is stepped up to a residential level of care, facilities that allow me to keep in brief and appropriate contact with my clients...well it helps a bit. It alleviates their feelings of, 'she couldn't wait to get rid of me. I was too much to handle.' But... still, no great strategy as of yet. The idea of a program devoted to treating more chronically ill patients is brilliant. Thank you for this very thought provoking entry, I look forward to your expanding on these thoughts!

  3. As a client, I like this. I wouldn't say I have a "chronic" issue... but I will say this. The hard line may work for some people. But then there are people like me who hate the idea of having to be around other people, let alone "bare your soul" to a therapist, and risk being scrutinized for things at more than skin depth. For those, like me... all the hard line does, is make us more angry at them, and then ourselves, and then them again, and to feel as if truly, there is no hope, truly, it is MY fault for getting here, and MY responsibility to get out, and that actually... I was just dumped by my therapist. I come to you for help with something I myself cannot overcome. If you tell me to come back when I figure out what I really want... don't you think I would have done that before I came to see you? I don't expect babying, but I expect gentleness, and patience for things to unravel in time and not in 6 weeks when program time is up. I expect strategies, not rules. And I expect that you will try as hard to research methods that work, as I will in turn try hard to make them work, until together we find something that does.