Eating disorders are often difficult to treat, due in part to many patients being ambivalent about recovery. In a recent article published in the International Journal of Eating Disorders, practitioners are cautious about being too optimistic or invested in patients’ motivation.1The authors suggest that motivational methods alone show little evidence of being effective. Motivational techniques need to be operationalized, and behavioral change is crucial. While verbal expressions of motivation are relatively unhelpful, it is important and moderately helpful to assess the patient’s level of motivation upon entry to treatment.
Embracing two additional premises also can be useful when considering facilitating a patient’s motivation to recover from an eating disorder. First, eating disorders are adaptive; they serve many purposes. Second, engaging in and sustaining a positive therapeutic alliance based on empathy, trust and respect is necessary for sustained motivation. Attachment theory can provide a framework for this to occur.
The causes of eating disorders are complex and unique to the individual. Seeking help is generally fraught with conflict and ambivalence, because often the person is in significant emotional despair by the time he/she is ready to take steps toward recovery. Other times, seeking help comes as a result of medical necessity. What contributes to motivation for recovery can vary among individuals. Their reasons for beginning treatment may stem from reaching their own psychological, symptomatic and relational bottom to perhaps being on the verge of death as a result of starvation or purging.
Helping patients find their motivation for recovery can sometimes be hampered by the circumstances under which they “accepted” the need for treatment. Was it from their own will to recover? Perhaps treatment was sought because of terrified family members watching their loved one fade away. In all cases, helping patients discover their own reasons to begin the recovery process contributes to creating and sustaining motivation. Viewing eating disorders as an effort to adapt to a life that is out of control, and integrating a relational approach in treatment, can help them on this road.
The functions of eating disorders
Biological underpinnings as well as familial, environmental and cultural elements all can contribute to the development of an eating disorder. While research into genetic links continues, treatment options are plentiful and usually include combinations of relational approaches, cognitive-behavioral treatment, family treatment and psychiatric medication.
Eating disorders can act as replacements for relationships. Often, they coexist with other issues such as depression, anxiety, personality disorders and substance abuse. Eating disorders with substance use are especially associated with the highest mortality risks across all mental disorders.2Alcohol and stimulants are most commonly abused among patients with eating disorders, and substance use disorders are reported more frequently in patients with bulimia than anorexia.3
Yet, whatever the root cause, eating disorder symptoms and behaviors provide calming effects, such as the thought, “If I don’t eat, I don’t feel.” Purging provides the release of painful and negative emotions, and has a physiological calming effect over mood. Symptoms are also “affect enabling” in that individuals physically feel through the act of purging or hunger in lieu of psychologically experiencing emotion.
Symptoms also serve to regulate affect in that the person projects feelings and conflicts onto the symptom (feeling guilt or shame because of purging rather than perhaps thinking about what in the person’s life causes feelings of guilt or shame).
Eating disorders also are metaphors. They represent symbols that individuals are unable to express and experience emotionally, verbally and relationally. For instance, the rejection of food can symbolize the rejection of other appetites in life such as joy, sex, emotional attunement, relationships and work fulfillment. Food, much like shopping, also can be a replacement for what is unfulfilling in life. The taking in and purging out of food can be a statement of ambivalence about intimacy. Not eating can represent a need to control or an act of separation/individuation (i.e., “You cannot control my eating”).
Eating disorders have a high rate of psychiatric comorbidity. The most common secondary diagnoses, depression and anxiety, typically precede the emergence of the eating disorder and are subsequently managed through the symptoms of disorder. Substance use, trauma, obsessive-compulsive disorder and Axis II disorders such as borderline personality disorder also can occur with an eating disorder. Comorbidity can greatly affect a person’s motivation in recovery. Depression and anxiety often are more powerful motivators for change than the feelings of, “I want help for my eating disorder.”4
Facilitating patient motivation
Seeing eating disorders as adaptive can facilitate motivation in patients to accept recovery. If eating disorders represent an adaptation to life, then their insidious symptoms are attempts to cope with life’s stressors. Helping patients view their symptoms through this lens can reduce shame, self-reproach and self-disgust, and the belief that they are crazy.
Eating disorders keep a person emotionally and relationally safe. They take on a life of their own and become increasingly absorbed in the relationship with food and body obsession. For these individuals, it is safer to engage in eating disorder symptoms than to feel bad or risk the disappointments, resentments, loss, hurt, anger and rejection that can and usually do come with relationships.
The reality, of course, is that eating disorders are not safe and can never provide the fulfillment and satisfaction that relationships can. Helping patients understand that their eating disorder is not functioning independently of their internal and relational world can help make sense of the disorder. Psychoeducation provides perspective and contributes to maintaining motivation.
Creating a therapeutic environment that enables patients to understand the adaptive role an eating disorder serves in their lives, and utilizing the relationship between therapist and patient, are fundamental ingredients in establishing and sustaining patient motivation for recovery. Trust, empathy and respect between patient and therapist are hallmarks of attachment theory when treating eating disorders.
Attachment theory relies on the foundation of object relations theory, and according to its pioneer John Bowlby it rests on direct observation of parent-child interaction and attunement of the parent to the child throughout the developing years. Attachment theory succinctly states: “Relationship patterns established in the first year of life continue to have a powerful influence on children’s subsequent behavior, social adjustment, self-concept and auto-biographical capacity. Mother-infant relationships characterized by secure holding (both physically and emotionally), responsiveness and attunement are associated with children who are themselves secure, can tolerate and overcome the pain of separation, and have the capacity for self-reflection.”5
The cornerstones of attachment include:
- A lifelong biologically driven need for affiliation with other individual human beings and/or with groups;
- The need for safety, protection, emotional regulation and soothing, physical contact, companionship, communication, support, and a sense of belonging; and,
- Early attachment patterns become fixed templates for later relationships.
Attachment theory is useful in treating eating disorders since we are able to experience the nature of a patient’s interpersonal relationships via examination and exploration of their attachment to the eating disorder.
Eating disorder etiology is complex. From an attachment theory perspective, relationship impairment is front and center in not just understanding but also maintaining eating disorder development. Food becomes the symbolic friend, while simultaneously body image distortion, obsessions and self-destructive rituals serve as physical manifestations of relational failures and dysfunctional interpersonal patterns and dynamics. The use of the therapeutic relationship, a vehicle to repairing relationships and supporting recovery, enables and sustains patient motivation.
Empathy is the precursor
Empathy is the key to understanding patient motivation, as well as a foundation among prominent object relation theorists and a primary principle of attachment theory. The absence of attunement of the caregiver toward the insecure infant and the developing child is not intended to be insensitive or mean, but rather an inability or difficulty in seeing the world from the child’s point of view. A common theme in eating disorder families is that sometimes the “fit” between parent and child is not there and the child grows up feeling like the square peg in the round hole. Or, the communication among members is limited or they lack an emotional language to express how they are feeling.
The eating disorder, from an attachment theory perspective, can be a response to feeling/being different and can be used as a vehicle to find a way to express behaviorally what cannot be expressed emotionally and verbally.
Psychotherapy informed by attachment theory emphasizes the therapist’s use of empathy toward the patient and family members involved in treatment. There are several goals of empathy for recovery. They include role modeling of empathic responses and behavior for the patient and family members to experience; psychoeducation about the concept and purpose of empathy and instruction of family members on how to utilize empathy with one another;6 and empathic responses from the therapist to enable safety, understanding and ultimately trust in the relationship. The latter can encourage patients to experience self-empathy as a cornerstone in reducing self-destructive behavior.
Some of the factors that need to be considered when assessing a person’s motivation for recovery and helping them to become motivated include:
- Diagnostic factors such as comorbidity and whether the eating disorder is primary;
- Whether the patient/family sees the behavior as limiting or undesirable or whether symptoms are no longer working for feeling OK or combating psychological pain;
- The degree to which the person is medically compromised; and,
- The degree to which the person accepts that the eating disorder is not functioning independent from his/her psychological and mental states.
Steps in motivation
The following is a guide for therapists to help individuals find the motivation to begin recovery:
- Acceptance by both the therapist and patient that there is ambivalence in recovering.
- Actively seek to engage the patient; accept that psychological feeding is likely necessary and that utilizing traditional treatment approaches is not helpful.
- Create a relational space. Help the patient notice that he/she is not the only one in the room.
- Disturb the resistance while respecting the need for the symptoms. Respect the power of the eating disorder and its adaptive purposes. Questions such as, “How is the eating disorder working or not working for you?” are best.
- Do not prescribe too many behavioral changes during the early phase of treatment unless medical risk is heightened or you need to determine if a patient can do the work in an outpatient setting.
- Dependency of the therapeutic relationship (attachment theory) is a good thing and is a vehicle for recovery and maintaining motivation.
- Be co-investigators. Inform the patient about what you are doing and thinking in order to reduce the patient’s fear of loss of control or manipulation.
- Provide psychoeducation about theory and treatment where appropriate. Teach the patient about the adaptive and metaphoric use of the eating disorder as a substitute for relationships.