Diverging Paths of Eating Disorder Treatment: How to Treat the Chronic Eating Disordered Patient

A recent conversation with a colleague reached a sticking point: what options are there for an undernourished patient who is not able to go to a program and become nourished?

She said that she cannot work with someone who is malnourished. Since a starved brain doesn’t work, any form of therapy is ineffective and meaningless. Until the patient is ready to seek help, therapy is pointless.

I said that although that may be true, how can a clinician reject a patient because she is so stuck in her illness? Isn’t it the obligation of the treater to stand by the patient and shepherd her into beneficial care?

This conversation reflects a larger issue with eating disorder treatment. What is to be done about the people with chronic eating disorders who are unable to seek more intensive help?

Standing one’s ground about becoming nourished has its merits. Treatment will be challenging for someone who is working hard to follow a meal plan, but there will inevitably be progress. Creating new thought and behavior patterns around food naturally evolve from actively working on a meal plan. And for the clinician, it is easy to feel secure in the direction and goals of treatment. There is little risk for the therapist.

Working with someone unable to start a meal plan is a different, challenging and potentially dangerous endeavor. The risks of serious medical consequences are high. The effects of being malnourished or compensatory behaviors such as purging or laxatives are concerning. And there is no guarantee the patient will find a way to start to eat more regularly again.

This path demands patience from a therapist to tolerate a high level of illness and the brutal honesty of seeing what someone in an active eating disorder looks like. Yet the potential rewards of taking the more dangerous route are great.

The effect of standing by someone too sick to begin a path towards recovery is significant. The patient feels heard and understood. She realizes she is not a pariah but instead someone with an illness who wants and needs to get help. She starts to see that she can be cared for in her illness and she won’t be alone in the process of recovery either.

Those messages are necessary to create the trust that opens a heretofore invisible road to wellness.

So it’s not that I disagree completely with my colleague. But maybe there are multiple ways to help someone with an eating disorder see the opportunity to get better. Flexibility and the willingness to find that road are sometimes more important than anything.