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.