A Full Assessment of the Hard-Line Approach to Eating Disorder Treatment

The frustration and confusion in treating people with eating disorders allows clinicians to adopt a wide range of therapeutic approaches. Yes, patients do get better and recover, but there is little consensus or evidence of a reliable and effective treatment to get them there. Instead, therapists cobble together a mixture of available options to find a personal style that works. The lack of effective standard guidelines and an accredited subspecialty leaves patients at a loss to find expert clinicians and to assess their competence.

One resulting dilemma among treaters is the theoretical difference between compassion and even love as a source of recovery versus the hard line, best described as "eat or else." These two theories hold sway in the clinical community and often divide a treatment team and limit effective care.

The philosophy of compassion is one I have written about extensively in this blog. The psychological thought process of an eating disorder relies heavily on an internal, critical monologue. The thoughts berate the patient in every aspect of life and curtail any pleasure from even small parts of daily existence. The criticism focuses primarily on food and weight but can encompass most of one's day and cause endless misery. The theory behind compassion is that kindness, forgiveness and caring counters the psychological underpinnings of the eating disorder and presents the patient with an alternate mindset of how to live. At first confused or even angry at the compassion, the patient gradually begins to accept the connectedness and positivity and to recognize the critical thoughts, once confused with identity, as a core symptom of the illness.

The hard line philosophy originated with the clinical application of theories used to treat people with drug addiction and alcoholism. Viewing eating disorders as a subset of substance abuse, therapists insist on regular meals and a weight goal as a mandatory part of treatment. If a patent cannot reach the goal, the team sets a deadline to either eat meals and stop purging behaviors or reach a specific weight. The punishment of not doing so is termination of treatment until the patient is ready to comply with the recommendations.

There are two important points to support this model. First, outpatient treatment with a patient who is malnourished has significant limitations. When someone remains so sick, the brain cannot function well, and therapy cannot be nearly
as effective, and for some completely useless. The body also physically continues to deteriorate, and many clinicians believe that treating a patient under these conditions is akin to enabling a chronic and often fatal illness.

Second, this line of reasoning implies that recovery and eating will be very hard, and there is no point waiting for an epiphany, in or out of therapy. In order to fully recover and get well, every patient must go through the emotionally and physically painful process of eating again and reacquainting the body with regular meals and snacks every day. Learning to face the food and the feelings and experiences that come with eating will always be hard. The hard line approach emphasizes that recovery must come with nourishment, and there is no better time to start than now.

The difference between these two philosophies, in my opinion, is not related to the course of recovery. Patients who find a treatment team with either approach can get well. However, the message underlying that process leads to two diverging ways to live afterwards.

The hard-line approach certainly encourages autonomy, self-determination and the critical importance of eating. A patient who responds to this thought process will bring to many components of life the urgency just to push through, an admirable trait but one that still condones or at least tolerates the critical thoughts of the eating disorder. What this approach ignores is the patient's need to look inward not for guts and determination, something many eating disorder patients have in spades, but for love and kindness.

The goal of treatment is a full recovery and a full life, but the hard line approach neglects to address what a full life means. It means a generosity of spirit, a desire to help others as well as yourself and an ability to take pleasure in the small things around us every day. It must embrace a positive outlook on the identity of the recovered person and the ability to receive and truly feel compliments and care from others. It must allow the person to depend on others and not feel alone in the world anymore, no longer isolated by the punishing thoughts of a horrible illness.

The compassionate philosophy of treatment of eating disorders remains more murky and thus more complicated. Tolerating the severity of symptoms and the medical and psychological sequelae of chronic illness is no easy feat for patients, families or clinicians. At times, it feels like delay or just treading water for long periods of time. However, staying the course with unlimited caring reinforces the concept that only a turnaround in how the person views oneself will lead to a true recovery. Identifying and healing from the eating disorder thoughts must accompany eating and physical well-being in order to attain a full life. Even though the hard-line can get the job of nourishment and weight restoration done, that just isn't enough to get people well.

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