Treatment for people with eating disorders has adopted much of the language used for addiction, most specifically the confounding term motivation.
Motivational interviewing is a theory of addiction treatment that delineates the stages of the process of recovery. The addict moves from being fully into the addiction to recovery through a series of steps with increasing motivation, an unfortunate choice of words to describe healing from an illness.
The theory accurately recounts these stages and gives structure for a therapist to follow but does not have a clear methodology to create motivation because that is not what enables someone to get well. In the end, this term places blame on the patient for having an illness and not knowing how to get better.
Likewise, therapists can posit that patients do not have the motivation to get well from an eating disorder and absolve themselves of any responsibility for the outcome. This scenario often leads to a stalemate: go to a "higher level of care" or else treatment won't work.
I do not mean to imply that more intensive treatment is ineffective. Much to the contrary, it can make a significant difference. Instead, I want to point out that finding motivation is not the barometer of success or failure for the patient. This paradigm is not conducive to recovery because placing blame on the patient reinforces the idea that recovery is impossible and the need for the eating disorder overwhelming.
If the eating disorder is seen more as a way to approach the world rather than an illness, the process of recovery, and the empathy of the therapist, looks very different. Taking away one's central coping mechanism will lead to a dizzying, disorienting transformation. Only a true sense of unhappiness and despair living in the illness is likely to lead someone with a chronic eating disorder to want to make that change.
However, once the patient sees a path towards wellness, she will have true ownership of her recovery. It is ownership, not motivation, that is the goal of treatment. Ownership implies that the patient has the autonomy to live her life, with or without the eating disorder, no matter how hard that might be.
The purpose of a therapist changes drastically when the goal is to help find ownership rather than motivation. The responsibility lies within the therapy to consider recovery as a viable option, a path not to be forced but to be found. Most importantly the discussions can encompass compassion and collaboration, not ultimatums and blame.