It was a Saturday morning. The office was quiet. I had decided to start seeing clients in private practice on the weekend. I figured I'd dabble and see if I liked it. Efforts to prepare for that day could never have fully prepared me for the complexity of eating disorders.
My first patient arrived and I immediately felt in over my head. As a young clinician, it was intimidating to encounter a middle-aged woman with anorexia nervosa who was visibly malnourished and emaciated. She had never received treatment and knew that her life was in danger. Not knowing what else to do, I proceeded as planned and performed an assessment of her eating and exercise behaviors, medical history, and the reasons she was seeking treatment at this time. She described the litany of rituals around preparing her food for the day and keeping her caloric intake below her self-prescribed threshold of acceptability. The time not spent planning, preparing and (barely) eating food was spent in constant motion, standing, walking, fidgeting and riding her bicycle. I couldn't wrap my mind around how somebody taking in so little food could seemingly have so much energy to devote to this daily regimen.
Standing toe to toe with an eating disorder this strong can be intense, which is an interesting dichotomy in a woman whose body appeared so fragile. I explained the dangers of anorexia and the risks associated with nutritional rehabilitation (often referred to as "refeeding," a term I dislike because it sounds so fattening and thus threatening to patients). I could sense her ambivalence and knew that I had met my match in challenging her eating disorder. After all, as the RD I am a threat to the illness that is both her friend and foe.
I knew I must seek counsel on how to proceed. This was way more intense than I had expected right off the bat. Due to her level of physical compromise and risk of medical complications it was suggested that I refer her to inpatient treatment which she was adamantly opposed to. "I don't need that. I'm fine. I've been this way for years. Can't you just help me?" She pleaded with me in the kindest, sweetest way. I could see the pain and fear in her eyes. Part of me wanted to agree to try and help her in the way she was requesting, and another part of me wanted to run away as fast as I could.
The firmer I held the boundary, the more angry she got. "Well, fine! I will just find somebody else!" She walked out of my office the day of her second appointment and never came back. I heard from her a few years later that she was discharging from her second or third inpatient stay. I like to think that I may have saved her life by refusing to treat her outpatient, because it ultimately led to her getting inpatient care. But who knows. She had obviously relapsed following inpatient treatment. Yet she was still showing up, still fighting for life against this deadly disease.
It's a unique disposition – to want to recover while simultaneously wanting to cling to the illness. Eating disorders are complicated, complex, and intricate. The professionals that specialize in the treatment of eating disorders still don't have a clear understanding of what works, what doesn't work, and why. Treatment is based on some evidence and a lot of clinical intuition.
Clinically, we easily agree that AN is an intimidat-ing challenge and that therapists who take it onshould have the highest level of skill dev elopmentto help patients battle its emotional sway. But thisis hardly the prevailing ideology in our professionaldialogue. Instead, many in the ﬁeld are attemptingto reduce complex challenges to rudimentary ideaswhich then quickly take on such broad signiﬁcancethat a treatment model is born impromptu—someeven insisting it should be adopted as our treat-ment of choice. Why? If complexity is bluntlyetched not only in the psychopathology of AN butalso in the challenges it creates, shouldn’t this verysame notion be a constant thread in the ideas weintroduce during treatment? And if narrow ideassufﬁced, why does the treatment of AN often veeroff course and prove disappointing? As an example,consider the notion that eating and restoringweight to normal weight while preventing compen-satory behaviors models extinction learning; in themost rudimentary sense this is true, but to thinkthis rises to the level of an explanatory paradigm isshort-sighted. — Strober and Johnson, 2012
This article by Strober and Johnson is well worth your time because it addresses some of the challenges in treating eating disorders.