It’s no wonder that an eating disorder is so difficult for any patient to let go of – yet certain patients are still labeled as treatment resistant.
“It’s really the eating disorder itself that is treatment resistant,” says Maggie Moran, MSW, LCSW, Senior Eating Disorders Therapist at Penn Medicine Princeton Center for Eating Disorders. “It’s insidious. From the biological and physiological aspects to the psychological components, it hits from all angles.”
“Treatment means removing that protective layer, which is difficult even for motivated patients,” adds Taylor Riches, MSW, LSW, Eating Disorders Therapist. “To complicate matters, they may not fully understand the damage an eating disorder is inflicting, in part because they’re so malnourished.”
Moran and Riches caution that describing a patient as treatment resistant or untreatable can be a disservice to both the patient and the provider. This frame of mind can set a negative tone for the patient-provider relationship and make any future progress even more difficult.
“These patients have been hearing that they’re too much for their entire lives,” says Riches. “If we think this way or apply terms like resistant, it can add to the stigma. Why not instead describe patients as traumatized, struggling, or facing a barrier?”
Moran and Riches recommend taking a step back and thinking outside the box to collaboratively consider solutions when working with patients who are struggling to make progress in treatment. They offer this advice for behavioral health providers:
Frame it as an opportunity. Challenges are an opportunity for a provider to grow and learn alongside a patient. Dig deeper into what’s worked and what hasn’t worked for a patient in the past and use that as a foundation.
Be curious. Seek a greater understanding of the role and function of a patient’s eating disorder. There could be hundreds of reasons for resistance – but if providers assume or don’t delve into these questions, they’ll never know. Maintaining curiosity is part of solving the puzzle.
Take a less authoritative stance. Therapists typically see patients for just a snapshot of their lives. Lean into the fact that patients know themselves better than anyone else and collaboratively explore what they want to try. Gain consensus on the goals of treatment.
Try motivational interviewing. Embrace empathy and reflective listening in asking questions designed to elicit change talk from patients. This might include what worries them the most, what the eating disorder has taken from them, and what makes them think they may want to consider a change at some point.
Make motivation relatable. Ask the patient how motivated they are to recover on a scale of 1 to 10. If the answer is a 1, explore what changes might get them to a 2.
Allow a safe space. Some patients simply need the creation of a safe space for them to sit in silence. Others may open the door to communication if they can participate in a relatable distraction during a treatment session, such as a puzzle, a game, or a walk outside.
Consider who’s working harder. If a provider feels they’re working harder than the patient, they may be pushing too much too soon. If a patient can’t imagine the next step, it may be too far out of reach. Working alongside a patient yields better outcomes.
“Reflecting on the fact that patients with eating disorders are in a great deal of pain can help us better understand their behaviors and journey,” says Moran.
“Treatment may require repeat efforts, but if we’re a little bit further along each time or they’ve retained more knowledge, it’s still a win,” she adds. “And if patients need a higher level of care, we’re here